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ONC: Malnutrition Screening and Nutrition Assessment of Adult Oncology Patients (2012)

Citation:

Li R, Wu J, Ma M, Pei J, Song Y, Zhang X, Han B. Comparisson of PG-SGA, SGA and body-composition measurement in detecting malnutrition among newly diagnosed lung cancer patients in stage IIIB/IV and benign conditions. Med Oncol. 2011; 28: 689-696.

PubMed ID: 20422319
 
Study Design:
Descriptive Study
Class:
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:
  • To assess relationships between malnutrition and clinical, demographic and tumor-related characteristics of patients with both lung cancer and benign lung disease
  • To determine whether patients with lung cancer can be differentiated from patients with benign lung disease
  • Malnutrition was measured using subjective global assessment (SGA) and the scored patient-generated subjective global assessment (PG-SGA) tools.
Inclusion Criteria:
  • None specifically stated
  • Had to provide informed written consent
  • Subjects obtained from Pulmonary Medicine of Shanghai Chest Hospital
  • Diagnosis of lung cancer or benign lung conditions.
Exclusion Criteria:
  • Patients with recurrent cancer or
  • Patients who had received treatment for other cancers within the past five years.
Description of Study Protocol:

Recruitment: 

  • Patients obtained from Pulmonary Medicine of Shanghai Chest Hospital 
  • No mention of sampling methods.

Design

  • Descriptive: Patients assessed using SGA and PG-SGA
  • Demographic and clinical variables (labs, anthros) obtained and compared between those with lung cancer and those with benign lung disorders
  • After stratifying by SGA and PG-SGA categories (ABC), comparisons were made between SGA and PG-SGA scores, labs and anthros across groups
  • Clinical variables were used to predict disease status and severe malnutrition. 

Statistical Analysis

  • Descriptive statistics used to present patient characteristics
  • Univariate tests used to compare differences in continuous clinical and demographic variables between:
    1. Lung cancer patients and patients with benign conditions
    2. Patients in categories A, B, and C, as assessed using PG-SGA and SGA.
  • Kruskal-Wallis H-test used to compare differences in serum albumin between the afore-mentioned two groups (One and Two)
  • Chi-squared test was used to compare differences in cancer stage, number of organs invaded, gender and histology between patients in Categories A B and C
  • Chi-squared test was used to compare differences in SGA grade, PG-SGA grade and the score of PG-SGA (nine or more vs. less than nine) between patents with lung cancer and benign conditions
  • Step-wise regression analysis was used to predict disease status and severe malnutrition
  • Receiver operation characteristic (ROC) was used to examine concordance between nutritional assessment parameters and SGA and to determine the probability of correctly identifying patients who were malnourished, as assessed by SGA.
Data Collection Summary:

Timing of Measurements

  • After patients provided consent, baseline anthropometric (height and weight, BMI) and clinical (serum albumin, total lymphocyte coutn, hemoglobin, transferrin and pre-albumin) measures were obtained
  • Self-reported weight one month and six months prior to baseline measures were recorded.

Key Study Variables

  • Nutritional assessment variables: SGA and PG-SGA, measured by one trained and experienced professional
  • Anthropometric variables: BMI (kg/m2) measured to the nearest 1.0kg and 0.01m, using digital scale and "height measuring instrument"
  • Serum lab values: Serum albumin (g per dL), pre-albumin (mg per dL), total lymphocyte count (x109 per L), hemoglobin (g per dL), transferrin (g per dL).  

 Control Variables

  • Disorders such as pleural effusion and large tumor volumes may interfere with accurate dry weight determination for BMI
  • Patients with lung cancer were significantly older than those with benign disorders.
Description of Actual Data Sample:

Initial and Final N

148 patients: 109 males (74%) and 39 females (26%).

Age

  • Lung cancer diagnosis: 60.5±12.2 years (range, 29 to 80)
  • Benign condition 53.7±12.5 years (range, 20 to 82)
  • P=0.002.

Ethnicity

Not specified.

Other Relevant Demographics

Type of condition

  • Lung cancer: N=96 (64.9%)
  • Benign lung conditions: N=52 (35.1%).

Anthropometrics

BMI

  • Lung cancer: 23.07±4.3kg/m2
  • Benign conditions: 23.67±5.7kg/m2
  • P=0.469.

Location

Shanghai, China.

Summary of Results:

Table One. Comparison Between Patients with Lung Cancer and Patients with Benign Lung Disease

Variables
(Mean±SD)

Patients with Lung Cancer

Patients with Benign Lung Conditions

P-Values
Age
60.5±12.2
53.7±12.5
0.002
Albumin (g/dL)
41.84±4.7
42.48±4.0
0.411
TLC (x109/L)

1.52±0.5

1.63±0.6

0.233
Hemoglobin (g/L)

130.02±17.8

27.79±16.9

0.46
Transferrin (g/L)
2.27±0.48
2.26±0.48
0.883
Pre-albumin (mg/L)
0.28±0.08
0.28±0.07
0.825
PG-SGA score
8.5±6.6
4.7±4.1
<0.0001

Variables
(N)

Patients with Lung Cancer

Patients with Benign Lung Conditions

P-Values

PG-SGA

Category A

16

17

0.021
Category B
41
24
Category C
39
11
Score <9

63

43

0.021
Score ≥9
33
9
SGA

 

 Category A
32
27

0.012
Category B
25
16
Category C

39

9

Table Two. Comparison Between Clinical Variables in Lung Cancer Patients by PG-SGA and SGA Category (A,B,C)

Variables
(Mean±SD)

Group A

Group B

Group C

 P-Value
BMI

SGA
25.29±0.41
22.52±0.68
21.47±0.86
<0.0001
PG-SGA
26.97±4.6
22.69±2.6
21.61±5.89
<0.0001
Albumin (g/dL) SGA
43.44±0.49
42.41±0.59
40.08±0.74
0.004

PG-SGA

44.88±0.45

42.62±3.96

40.16±5.16

0.012
TLC (X109/L)

SGA
1.72±0.06
1.58±0.09
1.35±0.07
0.002
PG-SGA
1.73±0.5
1.61±0.55
1.39±0.51
0.011
Hemoglobin (g/L) SGA
132.85±2.28
129±2.62
125±2.62
0.068

PG-SGA

132.88±14.0

130.69±18.5

124.94±17.3

0.086
Transferrin (g/L)

SGA
2.47±0.07
2.43±0.07
2.11±0.07
0.005
PG-SGA
2.47±0.45
2.28±0.48
2.11±0.45
0.004
Pre-albumin (mg/L) SGA
0.3±0.01
0.29±0.01
0.25±0.01
0.01

PG-SGA
0.3±0.36

0.29±0.36

0.26±0.08

0.011

 

Table Three. Comparison Between Clinical Variables in Patients with Benign Lung Disorders by PG-SGA and SGA Category (A,B,C)

Variables
(Mean±SD)

Group A

Group B

Group C

 P-Value
BMI

SGA
25.34±0.72
21.74±0.72
22.1±3.89
<0.091
PG-SGA
26.25±1.02
22.44±0.57
22.38±3.08
<0.076
Albumin (g/dL) SGA
43.44±0.6
41.75±1.04
40.22±1.67
0.05

PG-SGA

43.71±0.86

42.42±0.72

40.73±1.55

0.153
TLC (X109/L)

SGA
1.7±0.1
1.69±0.17
1.32±0.10
0.196
PG-SGA
1.66±0.11
1.60±0.14
1.46±0.13
0.541
Hemoglobin (g/L) SGA
134.26±3.27
121.38±3.53
125±2.62
0.068

PG-SGA

131.65±3.86

127.13±3.58

123.27±5.24

0.436
Transferrin (g/L)

SGA
2.44±0.1
2.09±0.1
1.97±0.16
0.019
PG-SGA
2.51±0.11
2.12±0.1
2.06±0.15
0.018
Pre-albumin (mg/L) SGA
0.3±0.01
0.28±0.01
0.23±0.03
0.054

PG-SGA

0.3±0.01

0.28±0.01

0.25±0.03

0.219

Other Findings

  • Patients with lung cancer stage IIIB/IV had a higher rate of malnutrition (40.6%) when assessed using SGA or PG-SGA, compared to those with benign lung disease (17.3% per SGA and 21.1% per PG-SGA)
  • Weight or weight loss predicted SGA and PG-SGA ratings in both lung cancer patients and patients with benign lung disease
  • Serum albumin, total lymphocyte count, hemoglobin, transferrin and prealbumin predicted SGA global rating for lung cancer patients
  • Transferrin and hemoglobin predicted SGA global rating for patients with benign lung disease
  • Albumin, total lymph, transferrin and prealbumin predicted PG-SGA for lung cancer patients
  • Transferrin predicted PG-SGA global rating for benign lung disease patients
  • Prealbumin was the only predictor of SGA grade C for both the lung cancer patients and Benign Group. Prealbumin accurately predicted PG-SGA grade C for lung cancer patients only
  • The highest ROC area under the curve (AUC) was found for the PG-SGA score, BMI and weight.
Author Conclusion:
  • Compared with serum albumin, prealbumin, transferrin, hemoglobin, total lymphocyte count, BMI and weight, the scored PG-SGA and SGA are both accurate and simple nutritional assessment tools suitable for clinical practice
  • Lung cancer patients can be differentiated from those with benign conditions by PG-SGA.
Funding Source:
Reviewer Comments:
  • Some of the information provided in the text did not match the information in the tables
  • More information on predictors (e.g., variance explained) may have been helpful 
  • Specific univariate tests used were not specified and differences between groups were not clearly delineated (no post-hoc tests).
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) N/A
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
1. Was the research question clearly stated? No
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? N/A
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? No
2. Was the selection of study subjects/patients free from bias? No
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? No
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? No
  2.4. Were the subjects/patients a representative sample of the relevant population? No
3. Were study groups comparable? N/A
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? N/A
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? Yes
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? N/A
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? No
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? Yes
  6.8. In diagnostic study, were details of test administration and replication sufficient? No
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? N/A
  7.6. Were other factors accounted for (measured) that could affect outcomes? No
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? No
  8.1. Were statistical analyses adequately described and the results reported appropriately? No
  8.2. Were correct statistical tests used and assumptions of test not violated? No
  8.3. Were statistics reported with levels of significance and/or confidence intervals? No
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? No
  8.6. Was clinical significance as well as statistical significance reported? No
  8.7. If negative findings, was a power calculation reported to address type 2 error? No
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes