ORIGINAL

 

Nutritional status of patients with gynecologic and breast cancer

Estado nutritivo de pacientes con cáncer ginecológico o de mama

 

 

R. Zorlini, A. Akemi Abe Cairo and M. Salete Costa Gurgel

Deparment of Gynecology and Obstetrics. School of Medicine. Universidade Estadual de Campinas. UNICAMP and Women's Integrated Healthcare Center (CAISM). UNICAMP. Brasil.

Correspondence

 

 

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ABSTRACT

Objective: To identify the preoperative nutritional status of women with gynecologic or breast cancer, in correlation with disease site and staging as well as previous treatments.
Subjects and methods: A cross-sectional study of 250 women evaluated by Body Mass Index (BMI) and Subjective Global Assessment (SGA). For data analysis, the chisquare test was applied.
Results: Breast cancer was the most frequent cancer, predominating in 56.2%. The median age of the patients was 52 years. In about 57% of these women, the tumor was restricted to clinical stages 0, I and II and 77% of the women had not undergone any other oncologic treatment prior to surgery. Subjective Global Assessment detected 76% of nourished women and 24% undernourished women, while Body Mass Index identified 34% of nourished women, 3.6% undernourished women and 62.4% overweight/obese women. A low level of diagnostic agreement between normal nutrition and malnutrition by both methods was observed (63.8%; kappa (95% CI) = 0.0884 (-0.07-0.24). No correlation between nutritional evaluation and previous treatment and disease staging was observed. Concerning anatomic site, it was subjectively observed that women with cancer of the uterine corpus were more malnourished than the rest (p = 0.02).
Conclusions: The findings suggest that a more careful evaluation should be employed to identify preoperative nutritional status in women with gynecologic or breast cancer.

Key words: Nutritional status. Gynecologic or breast cancer. Disease site. Staging. Obesity. Malnutrition.

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RESUMEN

Objetivo: Identificar el estado nutritivo preoperatorio de mujeres con cáncer ginecológico o de mama, en correlación con la localización de la enfermedad y su estadificación, así como de tratamientos previos.
Sujetos y métodos: Estudio transversal de 250 mujeres evaluadas mediante Índice de masa corporal (IMC) y Valoración global subjetiva (VGS). Se aplicó la prueba de Chi cuadrado para el análisis de los datos.
Resultados: el cáncer de mama fue el tipo más frecuente, predominando en el 56,2%. La edad media de las pacientes fue de 52 años. En cerca del 57% de ellas, el tumor estaba limitado a los estadios clínicos 0, I y II, y el 77% de ellas no habían sido sometidas a ningún otro tratamiento oncológico antes de la cirugía. La valoración global subjetiva detectó un 76% de las mujeres bien nutridas y 24% malnutridas, mientras que el Índice de masa corporal identificó un 34% de las mujeres bien nutridas, un 3,6% de ellas malnutridas, y un 62,4% de mujeres con sobrepeso/obesidad. Se observó un nivel bajó de concordancia para nutrición normal y malnutrición entre ambos métodos (63,8%; kappa (IC 95%) = 0,0884 (-0,07-0,24). No se observó ninguna correlación entre la evaluación nutricional y tratamiento previo o estadificación de la enfermedad. Con respecto a la localización anatómica, se observó subjetivamente que las mujeres con cáncer del cuerpo del útero presentaban mayor desnutrición que el resto (p = 0,02).
Conclusiones: Los hallazgos sugieren que se debería realizar una evaluación más minuciosa para identificar el estado nutritivo de las mujeres con cáncer ginecológico o de mama.

Palabras clave: Estado nutritivo. Cancer ginecológico o de mama. Localización de la enfermedad. Estadificación. Obesidad. Malnutrición.

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Introduction

In Brazil, the incidence of cancer was 470.000 new cases in 2006 and the disease was more frequent among women. The Brazilian reality is similar to that found in the rest of the world. According to WHO, the estimated number of new cancer cases will rise from 10 million diagnosed in 2000 to 15 million in 2020.^1,2

Estimates of the number of new cancer cases for 2006 in the southeast of Brazil suggest that the most frequent cancer site is the breast, followed by the prostate, colon and rectum, lungs/trachea/bronchi, stomach, uterine cervix and other sites.¹ In the State of São Paulo, cancer is the second cause of death, corresponding to 55% in men against 45% in women. Gynecologic and breast tumors are highlighted in women. In 2001-2002, both types of tumor accounted for about 31% of the total number of deaths, with a crude rate of 14.7 for the breast, 4.31 for the uterus, 3.7 for the uterine corpus and 3.4 for the ovary per 100,000 inhabitants.³

Between 1979 and 2003, the mortality rate due to cancer increased 30% in Brazil and federal government expenses with high complexity oncologic care increased 103% between 2000 and 2005.¹ It must be constantly remembered that management of cancer patients is very complex. Treatment involves multiple aspects-physical, psychological, social, cultural, spiritual and economic. A holistic view of the patient and a multidisciplinary approach are mandatory. Along with this ethical view of the human being, it is necessary to consider the specificity of oncologic treatment. Surgery, radiotherapy and/or chemotherapy are the mainstay of cancer treatment.⁴

About 85% of cancer patients are at nutritional risk or develop malnutrition due to the disease or its treatment.⁵ The incidence of malnutrition in this specific group is 30 to 50%.^6-8 The oncologic patient often undergoes several surgical procedures and nutritional status is usually altered during hospitalization, resulting in a worse prognosis.⁸ The association between cancer and malnutrition has many consequences, including increased risk of infection, increased length of hospitalization, poor wound healing, reduction in muscle function and its consequences, thus affecting response to therapy.^5,8-11

In Brazil, the incidence of malnutrition was evaluated by the Brazilian Survey of Nutritional Assessment (IBRANUTRI) of the Brazilian Society of Parenteral and Enteral Nutrition (SBNPE) in 4,000 patients from 25 public institutions in 13 states, using the method of Subjective Global Assessment (SGA). It identified 20.1% of patients with cancer. Of these, 66.4% had malnutrition, which was moderate in 45.1% and severe in 21.3%.^12,13

Nutritional assessment is the first step in identifying and treating malnutrition and should be a part of pretreatment routine.^5,8,14,15 However, the ideal method for this evaluation has yet to be established, an association of various indicators is required to improve the accuracy of nutritional diagnosis.¹⁶

Some nutritional parameters such as Prognostic Nutritional Indixs, serum albumin, total protein, transferrin, haemoglobin and anthropometric measurements including weight have been used to assess the nutritional status in gynecological cancer patients.^17,18 The subjective global assessment is a validated nutritional instrument tool that is commonly used to assess nutritional status in patients who have a number of different conditions.¹⁹

Among the methods used, Body Mass Index (BMI) and Subjective Global Assessment (SGA) are highlighted. BMI is a simple, cost-effective method, used for calculating total body composition. The drawbacks are dehydration, ascitis, edema and muscle hypertrophy that can mask real body weight.²⁰

SGA is a subjective and easily applied method. It assesses the clinical history of the patient, modification of functional capacity, degree of metabolic stress and modifications at physical examination.^15,17,21 SGA has been considered a very efficient method for nutritional evaluation, since its results are equivalent to those obtained by objective methods.^17,22

Thus, the current study was aimed at identifying the preoperative nutritional profile of women with gynecologic and breast cancer using the two methods cited, in correlation with location and staging of the disease as well as previous oncologic therapies.

 

Patients and methods

A cross-sectional study of 250 women admitted for surgery due to gynecologic or breast cancer was conducted in CAISM/UNICAMP from august 2003 to april 2005. Sample size was based on prevalence of 66.4% of malnourished patients hospitalized with cancer⁷, considering a significance level of 5% and a sample error of 6% (estimated 95% CI of 60.4% to 72.4%).

This study was approved by the Research Ethics Committee in the School of Medicine-UNICAMP, following the precepts of the Declaration of Helsinke. All women signed the written informed consent term (WICT), and none refused to participate in the study.

Included in the study were patients admitted for primary surgical cancer treatment of the breast, ovary, vulva, uterine cervix and corpus, confirmed by histopathology exam. Patients with other associated diagnoses, including non-gynecologic primary cancer, AIDS, renal or hepatic failure were excluded from the study.

After signing a written informed consent term (WICT), the patient or her companion was interviewed about age, school education, usual weight, previous treatments (chemotherapy and/or radiotherapy), and associated diseases such as hypertension and/or diabetes using a brief semi-structured questionnaire, administered by the researcher.

Nutritional status was evaluated on the basis of SGA²³ and BMI calculation.²⁴ For BMI, medical charts containing information on weight and height were used. When height and weight were not included in the charts, measurements were taken on the day of the interview, using a calibrated scale (Filizola) with a capacity of 150 kg and accuracy of 100 grams. The woman had to stand at the center of the scale base, barefoot and wearing light clothes. To measure height, a stadiometer attached to a scale was used, with the woman standing, barefoot, with her heels close together, back straight and arms stretched along the body.

BMI was defined as weight (in kilograms) divided by the square of the height (in meters).²⁴ The cut-off points in kg/m², considered for nutritional diagnosis were: < 16.0 kg/m² - grade III malnutrition (severe); 16.0 to 16.99 kg/m² - grade II malnutrition (moderate); 17.0 to 18.49 kg/m² - grade I malnutrition (mild); 18.5 to 24.99 kg/m² - nourished; 25.0 to 29.99 kg/m² - overweight; 30.0 to 34.99 kg/m² - grade I obesity (mild); 35.0 to 39.99 kg/m² - grade II obesity (moderate); and≥ 40.0 kg/m² - grade III obesity (severe).²⁴

The SGA protocol was created by Detsky (1984) and modified by Garavel (1988). It is a clinical technique that rapidly informs about nutritional status by completion of a questionnaire including anamnesis and physical examination. Anamnesis assesses the percentage of weight loss in the past six months, changes in dietary patterns, gastrintestinal (GI) symptoms, loss of vitality or physical functional capacity and a decreased feeling of well-being. Physical examination investigates the presence or absence of malnutrition by palpation of adipose tissue, volume of muscle mass and presence of edema. Nutritional status is defined by the total sum of partial points and is thus classified: normal nutrition ≤ 7; mild malnutrition: > 7 to 17; moderate malnutrition:> 17 to 22; and severe malnutrition: > 22 points.²³

Data was typed in duplicate. For statistical analysis, the chi-square test with Yates correction, with SAS 8.2¹⁰ software was used. The agreement between the diagnoses of normal nutrition and malnutrition was calculated by both methods using kappa coefficient and its 95% confidence interval. The significance level of 5% was adopted.

 

Results

Among the 250 patients evaluated, the most frequent anatomical site of cancer was the breast (56.4%) followed by the uterine cervix (about 30% of the cases). A significantly lower frequency of cancer of the uterine corpus, ovary and vulva was found. The median age of the patients was 52 years, ranging from 15 to 90 years, and 55.2% of the women were 40-59 years of age at the time of assessment. About 80% had complete Junior High School education and only 7% had complete higher education. Forty per cent of the women evaluated had clinical comorbidity associated with underlying oncologic diseases. The most frequent comorbid conditions were diabetes, chronic arterial hypertension and both conditions associated (table I).

About 57% of the patients were in clinical stages 0, I and II (disease restricted to primary organ site), and less than 25% had undergone chemotherapy and/or radiotherapy prior to surgical indication. In 48 patients, the surgery proposed was minor (conization, uterine curettage, biopsy or breast resection, vulva biopsy), while 103 patients had surgery of medium complexity (radical mastectomy, quadrantectomy with axillary dissection) and 99 patients had major surgery (Wertheim-Meigs, radical vulvectomy, laparotomy for staging of ovarian or endometrial cancer) (table I).

The median nutritional evaluation by BMI was 26.8 kg/m² (ranging from 16.2 to 58.5 kg/m²). Thirty-four percent (34%) of the women were considered nourished, 3.2% had mild nutrition 0.4% had moderate malnutrition, 41.2% were overweight and 21.2% were obese (15.2% grade I obesity, 3.6% grade II obesity and 2.4% grade III obesity) (table II). According to the SGA technique, more than two-thirds of the patients (76%) were classified as nourished and the others as malnourished. Of these, 23.6% were mildly malnourished or at nutritional risk and 0.4% were moderately malnourished (table II).

The level of agreement between patients diagnosed as nourished or undernourished by both methods (n = 94) was 63.8%, with a kappa coefficient of 0.0884 and 95%CI from -0.07 to 0.24. Among the 156 patients classified as overweight or obese by BMI, 25 (16%) were considered undernourished by SGA.

More than 60% of the women had reported no weight loss in the past six months before surgical admission. Only 19% reported a change in diet spontaneous, 77% of them were on a low calorie diet. It was verified that 25% of the women had ankle edema, 2% had sacral edema and about 17% had ascitis. Loss of subcutaneous fat was observed in 22% and skeletal muscle depletion in 20% of the women. However, regarding physical capacity, 67% of the women reported normal functioning. Regarding GI symptoms, 63.6% reported a lack of any symptom. Conversely, 15.6% had dysfagia and/or vomiting and/or nausea or the three symptoms associated, and 20.8% reported feeling anorexia and/or bloating and/or diarrhea or the association of these symptoms (table III).

According to SGA classification, women with cancer of the uterine body were significantly more undernourished than those with other types of tumor (p = 0.02). Meanwhile, according to BMI evaluation, there was no association between nutritional status and cancer site (table IV).

 

The nutritional status of patients evaluated both by BMI and SGA was not influenced by disease staging (p = 0.2419 and p = 0.1288, respectively) in all types of cancer, as well as with the oncologic therapies performed prior to surgery (p = 0.2245 and p = 0.7048, respectively).

 

Discussion

There has been growing interest in malnutrition among surgical patients in recent years. It is wellknown that it plays a role in the development of postoperative complications. This is particularly true for oncologic patients. Apart from a higher frequency of malnutrition, these patients are candidates for aggressive and mutilating procedures.^{5,10,12,18,22,25-27}

Diagnosis of malnutrition is vitally important for patient outcome and treatment. The sooner it can be identified and/or corrected, preventing nutritional deficiencies, the sooner it can be treated.^5,8,27-30 Malnutrition has a prognostic value regarding morbidity: a higher risk of pressure ulcers, surgical complications, infections, dependence on mechanical ventilation and prolonged hospital stays.^8,21 Conversely, obesity predisposes to the development of clinical complications, including arterial hypertension, higher surgical risk, and dehiscence in the postoperative period, insuline resistance, sleep apnea and respiratory disorders.^11,31,32

Removal of the primary tumor, and therefore, the underlying cause of malnutrition create adequate conditions for utilizing the nutrients offered. The patient also requires appropriate conditions to undergo treatment, be it surgical, chemotherapy or radiotherapy with the lowest risk of complications.^7,8,33

The most adequate manner to perform nutritional evaluation is highly controversial, since no method is considered the "gold standard". The ideal would be to use a rapid, low-cost, non-invasive method. Simultaneously, it would have to be of high sensitivity and specificity. We sought a simple methodology; capable of reflecting the reality of a Brazilian public university hospital that has limited resources for more specific nutritional evaluations in its daily routine. This study was based on a study of IBRANUTRI,¹² using the SGA technique for nutritional evaluation. SGA is a subjective method, associated with BMI, which is an objective method.

SGA is an easy, low-cost and non-invasive method. It can be performed in a few minutes at the patient's bedside.^13,16,17,27 The method is widely accepted in clinical practice for the surgical patient and may be applied by any healthcare professional (nursing, medical or nutrition). The average time spent applying the questionnaire and physical examination is five to fifteen minutes.^5,17,30,34

BMI is a very common, easy, practical, and virtually inexpensive method. Data on weight and height are normally in the medical chart of the patient. However, it does not detect malnutrition with absolute accuracy, since it does not appraise recent weight loss, changes in diet, GI symptoms and clinical parameters. It is a good method to evaluate young individuals or healthy adults. Body weight may be masked in cancer patients and hydration status influences body composition.^5,16

Other methods for nutritional evaluation include anthropometric measures such as skinfold thickness, measurements of arm and pulse circumference; and evaluations through laboratory tests and bioelectric impedance analysis (BIA).²¹ The professionals who apply these methods require more specialization, more time available, increasing extra costs to the public health system. Since the allotted budget of our healthcare service is limited, we did not adopt these methods for our nutritional evaluations.

SGA detected a frequency of 24% of malnutrition. Virtually all women had mild malnutrition or were at nutritional risk. Only 0.6% was severely undernourished by SGA, while 3.6% were undernourished by BMI. Furthermore, the level of agreement between both methods for diagnosis of normal nutrition and malnutrition was low (63.8%; kappa (95% CI) = 0.0884 (-0.07-0.24), inferring that the parameters used in each method are different and not always complementary.

Even small amounts of weight loss (less than 5% of body weight) may significantly worsen the prognosis.^35,36 Among those interviewed, it was observed that 29.6% had lost 10% or less of weight, while 19.6% had lost more than 10%, in relation to usual weight. Loss of weight should raise the alert for patient prognosis, because recent weight loss (past six months) puts patients at nutritional risk. It would have been possible to detect how much this represented in terms of protein loss, if serum albumin had been performed in these women. Nourished, overweight and obese women, as well as protein depletion could then be detected.

At first, BMI seems to be the most efficient method for diagnosing obesity. In our study, it detected 21.2% of obese and 41.2% of overweight women. Meanwhile, SGA does not distinguish between overweight and obesity, demonstrating that a subjective evaluation alone would not be an efficient method for nutritional evaluation in this specific group of women. However, 16% of overweight or obese women by BMI were considered undernourished by SGA.

Ideally, SGA and BMI should not be applied alone in a nutritional evaluation. These methods should accompany other objective parameters, e.g. measurements of skinfold thickness and midarm circumference, laboratory tests (serum levels of albumin, prealbumin, iron, ferritin, etc.). These parameters provide real measurements of protein loss and may detect women at nutritional risk and/or malnutrition.⁵ Thus, a single method of evaluation is inadequate and limited.

Laky et al. (2007), in a SGA of 145 patients with gynecologic and breast cancer verified that 80% of the women were nourished and 20% were undernourished. Of these undernourished women, 67% had ovarian cancer.³⁷ Our results were very similar to those found by those authors, apart from the incidence of ovarian cancer, which was 28.6% in our study. In the current study, a low incidence of malnutrition (24%) occurred because breast tumor was the most frequent type of cancer (56.4%), followed by cervical cancer (26.8%), while ovarian cancer accounted for only 5.6% of the cases. According to Gómez Candela (2003) and Laky (2007), ovarian cancer compromised their patients most seriously. In the current study, SGA detected 57.1% of malnutrition in cases of cancer of the uterine corpus, 28.6% in ovarian and/or vulvar cancer, 24.3% in breast cancer and 14.9% in cervical cancer, showing results that are different from those in other publications, where ovarian cancer is predominant in cases of malnutrition.^22,37

Therefore, evaluation of candidates for surgery of gynecologic or breast cancer is necessary, as demonstrated in our study and in those of other authors.^18,22,37-39 Results have shown that women who had stage 0, I and II cancer, regardless of cancer type and I were nourished, despite a recent history of weight loss. It is clear that nutritional evaluation and nutritional therapy must be begun before cancer progression.³⁸ Bozzetti et al. (1982) and Tunca (1983) also found an association between malnutrition and cancer site and staging. The more advanced the tumor, the more malnourished the patient.^38,39

Evaluating the nutritional status of women admitted for surgery, we were faced with the most frequent cancer among them:¹ breast cancer with 141 cases against 109 cases of other types of gynecologic cancer. This rate made our sample less susceptible to malnutrition, since breast cancer has a direct relationship with increased weight and/or obesity.^40-42

Minor surgeries and those of medium complexity accounted for 60.4%, since 56.8% of the women were in stages 0, I, and II of the disease. The majority of patients (76.8%) did not need previous radiotherapy and/or chemotherapy treatment, constituting a less aggravating picture for the women studied.

The current study could have obtained more clarifying results if a similar number of cases of all cancer types were determined, or if it had included any other objective nutritional evaluation with some laboratory tests such as albumin. Albumin represents a parameter for protein loss, appraising visceral protein reserve. Furthermore, it is important in the analysis of slow and progressive conditions of tumor cachexia. Patients with low albumin levels have been undernourished for a considerable time, long enough to compromise hepatic cellular mass. Furthermore, serum albumin level is correlated with the appearance of postoperative complications.¹⁰

In an attempt to value nutritional intervention to prevent postoperative complications and consequently reduce hospitalization costs, government regulation number 272 of the Sanitary Vigilance Office of the Ministry of Health dating from april 8, 1998 was designed with normative guidelines for all public and private hospitals. A Nutritional Therapy Multidisciplinary Team was organized and composed of at least one physician, a pharmacist, a nurse and a nutritionist qualified to practice Nutritional Therapy assessment.⁴³

It is necessary for the healthcare system (healthcare professionals and hospital administrators) to understand that diagnosing overweight and/or obesity, as well as malnutrition in the oncologic patient prior to surgical intervention, means treating these patients correctly and reverting possible surgical and clinical complications. The length of hospitalization is reduced, increasing turnover of hospital beds, lowering costs due to hospital admissions, increasing the therapeutic response and consequently improving the prognosis.^12,15

 

Conclusions

According to SGA, 24% of the patients had malnutrition, while only 3.6% were considered undernourished by BMI. There was a low level of agreement between the diagnosis of normal nutrition and malnutrition by both methods (63.8%).

The highest prevalence of malnutrition was found in women with uterine body cancer, according to SGA. There was no correlation between nutritional status and disease stage and other oncologic treatments before surgery.

 

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Dirección para correspondencia:
María Salete Costa Gurgel.
Rua Alexander Fleming, 101.
13083-970 Campinas. SP. Brasil.
E-mail: salete@caism.unicamp.br

Recibido: 19-X-2007.
Aceptado: 15-III-2008.