Abstract
Background & aims: Elderly cancer patients are at particularly high risk for malnutrition because both the disease and the old age threaten their nutritional status. The Global Leadership Initiative on Malnutrition (GLIM) released new universal criteria for diagnosing and grading malnutrition, but the validation of these criteria in elderly cancer population is not well documented. Our objective was to investigate the application of the GLIM criteria in nutrition assessment and survival prediction in elderly cancer patients. Methods: This retrospective cohort analysis was conducted on a primary cohort of 1192 cancer patients aged 65 years or older enrolled from a multi-institutional registry, and a validation cohort of 300 elderly cancer patients treated at the First Affiliated Hospital of Sun Yat-sen University. Patients considered at-risk for malnutrition based on the NRS-2002 were assessed using the GLIM criteria. The association between the nutritional status and patients' overall survival (OS) was then analyzed by the Kaplan-Meier method and a Cox model. A nomogram was also established that included additional independent clinical prognostic variables. To determine the predictive accuracy and discriminatory capacity of the nomogram, the C-index, receiver operating characteristic (ROC) curve and calibration curve were evaluated. Results: The percentage of patients considered “at-risk” for malnutrition was 64.8% and 67.3% for the primary and validation cohorts, respectively. GLIM-defined malnutrition was diagnosed in 48.4% of patients in the primary cohort and 46.0% in the validation cohort. In the primary cohort, patients at risk of malnutrition (NRS-2002 ≥ 3) showed a worse OS than those with a NRS-2002 < 3 (HR 1.34, 1.10-1.64; p = 0.003). Additionally, patients with GLIM-defined severe malnutrition (HR1.71, 1.37-2.14; p < 0.001) or moderate malnutrition (HR1.35, 1.09-1.66; p = 0.006) showed a significantly shorter OS compared to those without malnutrition. The nomogram incorporating the domains of the GLIM with other variables was accurate, especially for predicting the 1- and 2-year overall survival rates. Conclusions: The GLIM criteria can be used in elderly cancer patients not only to assess malnutrition, but also to predict survival outcome. The nomogram developed based on the GLIM domains can provide a more accurate prediction of the prognosis than existing systems.
Abstract from Zhang X, Tang M, Zhang Q, et al.: The GLIM criteria as an effective tool for nutrition assessment and survival prediction in older adult cancer patients. Clin Nutr. 2021;40(3):1224–1232.
Knowledge Transfer of Cecília Medeiros de Morais, PhD (Porto)
Background
Over the last decades, we have observed extraordinary improvements in health care and medical sciences, which have contributed to increased longevity. However, in spite of the amazing advances in health, people aged 65 or more are still a population that suffers from several long-term illnesses, including chronic diseases and cancers [1]. Older adults are also more prone to malnutrition, making them more susceptible to a worse prognosis for various diseases, including malignancies of all types. There still are many uncertainties concerning cancers in older adults, specifically the possible underlying biology of ageing in relation to malignancy [2]. By use of several different tools to assess malnutrition, it was found that malnutrition has an independent association with poor overall survival [3, 4] and quality of life, with subsequent longer hospital stays, higher costs of hospitalization, and hospital readmissions in older cancer patients [4].
However, the association of malnutrition and cancer can be complex, and it may be difficult to distinguish between malnutrition already present in an individual and acting as a cause for poor prognosis versus malnutrition being developed as a consequence of the disease and treatment. The assessment of malnutrition should be the first step towards improving a patient’s nutritional status.
Malnutrition in elderly cancer patients
The scientific community recognizes that older adults as more vulnerable to malnutrition, and several factors, such as biological, psychologic and socio-economic, have been linked with malnutrition in older age. In relation to cancer-related malnutrition, the underlying processes are more complex and poorly understood. While it is known that specific tumors or treatments that carry a higher burden put the patient at higher risk of malnutrition, other factors such as cancer-related symptoms, treatment complications, and psychologic conditions may also play an important role in its development and severity [5]. This complexity occurs because nutritional status in oncologic patients is under the combined impact of various modifiable and non-modifiable tumor- and treatment-related factors [6].
Several tools are used to assess the nutritional status in older adults with cancer, such as the Mini Nutritional Assessment (MNA), Malnutrition Universal Screening Tool (MUST), and Patient Generated Subjective Global Assessment (PG-SGA) [3]. However, since malnutrition, sarcopenia, and cachexia are highly prevalent and either overlapping or occurring separately in this patient cohort, some authors argue that used alone these tools are not able to accurately distinguish between them [7, 8]. Hence, the most adequate tool to screen malnutrition in this population can be difficult to define.
The Global Leadership Initiative on Malnutrition (GLIM) criteria recommend performing a nutritional assessment which includes selected core phenotypic and etiologic criteria already in widespread use throughout the world, namely unintentional weight loss, low body mass index (BMI), reduced muscle mass, food intake, and disease burden. The consensus on this matter considered that each of the criteria is relevant for the diagnosis of malnutrition but none of them alone can predict adverse clinical outcomes. The second step according to the GLIM criteria is to grade the stage of malnutrition as 1/moderate or 2/severe. GLIM has been considered very useful not only for the diagnosis of malnutrition but also as a predictor of overall survival in elderly cancer patients [1]. Despite its value in the diagnosis of malnutrition, the authors believe that more diagnostic strategies need to be developed to enable the identification of overlaps with other conditions such as cachexia and sarcopenia [9].
Practical implications and conclusion
Understanding the importance of assessing malnutrition is essential for the treatment of the elderly cancer patient. While gaps still exist in the tools that are validated for the identification of patients at risk of malnutrition, important steps have been taken in the last decades. The GLIM criteria have proven very useful and should be widely implemented.
Also, while medical treatment must be the main focus, a comprehensive geriatric assessment and multidisciplinary follow-up should be put in place at all relevant health institutions. In this regard, the evaluation of the nutritional status of older adults with cancer should also be a priority, as well as the identification of the risk of malnutrition and underlying factors.
Disclosure Statement
I hereby declare that there are no conflicts of interest with regard to this commentary.
