The incidence of cancer is increasing worldwide and with it the prevalence of malnutrition, which may vary between 40 and 80 % in patients with neoplasia [1, 2]. The cancer is responsible for approximately 13 % of all causes of death worldwide, however the death of almost 20 % of cancer patients occurs as a result of malnutrition and its complications, rather than the malignancy of the disease itself [3, 4]. As a chronic disease responsible for several clinical symptoms or biological disorders, either related to the disease or to its treatment, the cancer patient is exposed to the risk of malnutrition. Malnutrition is therefore a major problem for cancer patients [5].

In Brazil, a multicenter study found a prevalence of malnutrition of 66.3 % and an increased risk of almost three-fold of malnutrition (20.3 %) among cancer patients [6]. A similar result was found in a study conducted in Latin America with hospitalized patients, which showed a prevalence of 65.6 % of malnutrition in individuals with cancer [7].

Patients with malnutrition have reduced tolerance to antineoplastic therapy [8] with more dose-limiting toxicity and treatment interruptions, thus requiring more frequent and longer hospital admissions [9].

The etiology of malnutrition in cancer patients is complex and multifactorial and may be influenced by the location and type of tumor, stage of the disease, side effects of the treatment, socioeconomic status, functional performance, symptoms of nutritional impact, need for fasting and inadequate nutritional therapy, as well as medical staff awareness about the importance of nutritional status for the prognosis and quality of life of cancer patients [6,7,10,11].

The objective of this study was to determine the prevalence and factors associated with malnutrition in cancer patients undergoing chemotherapy, so they can be identified and possible complications from malnutrition avoided.

The incidence of cancer is increasing worldwide and with it the prevalence of malnutrition, which may vary between 40 and 80 % in patients with neoplasia [1, 2]. The cancer is responsible for approximately 13 % of all causes of death worldwide, however the death of almost 20 % of cancer patients occurs as a result of malnutrition and its complications, rather than the malignancy of the disease itself [3, 4]. As a chronic disease responsible for several clinical symptoms or biological disorders, either related to the disease or to its treatment, the cancer patient is exposed to the risk of malnutrition. Malnutrition is therefore a major problem for cancer patients [5].

In Brazil, a multicenter study found a prevalence of malnutrition of 66.3 % and an increased risk of almost three-fold of malnutrition (20.3 %) among cancer patients [6]. A similar result was found in a study conducted in Latin America with hospitalized patients, which showed a prevalence of 65.6 % of malnutrition in individuals with cancer [7].

Patients with malnutrition have reduced tolerance to antineoplastic therapy [8] with more dose-limiting toxicity and treatment interruptions, thus requiring more frequent and longer hospital admissions [9].

The etiology of malnutrition in cancer patients is complex and multifactorial and may be influenced by the location and type of tumor, stage of the disease, side effects of the treatment, socioeconomic status, functional performance, symptoms of nutritional impact, need for fasting and inadequate nutritional therapy, as well as medical staff awareness about the importance of nutritional status for the prognosis and quality of life of cancer patients [6,7,10,11].

The objective of this study was to determine the prevalence and factors associated with malnutrition in cancer patients undergoing chemotherapy, so they can be identified and possible complications from malnutrition avoided.

Out of 87 samples, 85 participated in the study having a response rate of 97.7%. More than half of the sample (73 %) were female. The mean age was 53 ± 12.7 years, with 31.7 % (n = 27) of patients aged ≥60 years. Most individuals (80 %) had a partner. The types of cancers most frequently affected were breast cancer (48.25%), colorectal cancer (22,35%) and head and neck cancer (9,4%). We noted that 50.60% of patients had received any curative treatment, half of them (49.40%) had metastatic tumors. The sample showed the most frequent protocol of chemotherapy during the study was association docétaxel with trastuzumab (20,6%) and folfox (18,3%). Highly emetogenic protocols of chemotherapy were those containing cisplatin and anthracycline. In this study 68% of patients had received 3 to 6 courses of chemotherapy. Biological variables and anthropometric data was resumed in (Table 1). Evaluation of chemotherapy toxicity was resumed in (Table 2). 

Table 1: Biological variables and anthropometric data.

Table 2: Chemotherapy toxicity.

Eating habits during chemotherapy were assessed during chemotherapy, 65% avoided taking some foods and 43% added some others to their habits (Table 3). The mean of the ingesta evaluation score was 6.71 ± 2.84 for 77 patients under 70 years old. In our study, about third of patients avoided the consumption of sweets, milk and derivatives, beef, farmed poultry and lamb meat. Alanda, oilseeds and whole grains were the most added foods.

Table 3: Eating habits of patients under chemotherapy.

The prevalence of malnutrition was 32,9%, 24.7% presented with moderate malnutrition and 8.2% presented with severe malnutrition. In relation to the types of cancer, severe malnutrition was more prevalent in patients with cancer of the Oro-gastrointestinal tract (46,5 %). Eldery patients had more prevalence of malnutrion (40,7%) compared to young patients. the malnutrition rate was higher in cases of metastatic cancer (40,5%). Highly emetogenic chemotherapy protocol exposes to a higher risk of malnutrition (42,1%). Demographic profile malnutrition was resumed in (Table 4).

Table 4: Demographic profile malnutrition.

Screening for malnutrition in cancer patients under CT was carried out through BMI, percentage of weight loss, albuminemia, NRI. The muscle strength test using the dynamometer and the evaluation of ingesta by the SEFI ruler were warning signs for the diagnosis of malnutrition, knowing that a normal status does not exclude potential malnutrition.

According to M. Pressoir et al, in a prospective multicenter study including 1545 patients in 17 French cancer centers, malnutrition was reported in 30.9% of patients and considered severe in 12.2% [3]. Another study by C. Bories et al, carried out on 1460 patients in a digestive oncology center, revealed moderate malnutrition for 36.7% of stays (n = 182), and severe malnutrition for 28.8% (n = 143) [13]. Our results were consistent with the literature. Indeed, our study revealed that malnutrition was present in 32.9% of patients, of whom 8.2% had severe malnutrition.

In a cross-sectional study conducted by Karthikayini et al in 2017 [14] on the analysis of undernutrition in 132 newly diagnosed cancer patients, 44% of patients with severe malnutrition were aged over 60, but advanced age did not was not a factor correlated with the increased prevalence of malnutrition. These results were consistent with those found in our population. Indeed, the elderly are more at risk of developing malnutrition in view of the fragility of the terrain, the presence of comorbidities and the psychological state of these patients who are very susceptible to depression.

According to the type of cancer, in the case of cancers of the aerodigestive tract, 60 to 90% of patients were malnourished. In our population, 46% of patients with oral-digestive cancer had severe to moderate malnutrition, whereas it was diagnosed in only 28% of patients with cancer other than oral-digestive. Indeed, the prevalence of malnutrition according to the type of cancer was distributed as follows: colorectal cancer (16.8%) followed by breast cancer (7.8%) then nasopharyngeal carcinoma (6.7%).

According to M.Pressoir and al,upper digestive tract were associated with an increased risk of malnutrition [3]. Indeed, oral-digestive cancers were more frequently accompanied by digestive symptoms, namely nausea, vomiting, diarrhea and mucositis caused essentially by the disease itself before starting treatment, and which is aggravated by treatments. : Chemotherapy and radiotherapy.

In the advanced stages of cancer, a significant proportion of patients presented with malnutrition [14]. A recent prospective study conducted in Canada on patients with advanced cancer showed an association between the symptoms of nutritional impact (anorexia, gastric fullness, dysgeusia, dry mouth and dysphage) and lower survival rate on its univariate analysis, with dysphagia as an independent factor on its final model [15]. This fact highlights the importance of evaluation and appropriate management of these symptoms, given the large impact that causes on prognosis and quality of life of patients

Malnutrition was higher in metastatic cancer [16]. In our result 40,5% of patients had malnutrition in comparison to the Kenyan study (24.30%). Metastatic cancer is chronic and incurable stage of disease, where patients might have received multiple lines of chemotherapies and also due to chronic illness which might have contributed to malnutrition. As this scoring relies mostly on the dietary habits for two weeks, we need serial measurements during the course of illness as this screening tool stratifies those who are at risk and can be managed accordingly.

Functional autonomy is a factor that deserves attention from health professionals when the point is nutritional risk indicators, considering that individuals with limited functional capacity have difficulties in the preparation and food intake [17, 18]. The results of this study support this statement, because it was observed that the PS ≥2 was a risk factor for malnutrition. Similar results were found by a French epidemiological study that found a chance of being malnourished almost three-fold higher in cancer patients admitted with low functional performance [3]. Similarly a multicenter cohort study showed that this is also a risk factor for ambulatory patients [17].

A Greek prospective study conducted with 173 patients with lung cancer showed an association between the PS and the %WL >5 in the last 3 months (p <0.001), with %WL as an indicative of a considerable deterioration of the nutritional status [19, 20, 21]. Other results have also shown an independent relationship of the performance status with survival and death of patients with cancer [3, 15, 22].

Another characteristic prognostic indicator of the cancer patient is the presence of symptoms of nutritional impact, due to its high prevalence mainly due to the tumor itself, antineoplastic therapy introduced as well as malnutrition [19, 23]. Our results showed that more than half of the sample (67.1 %) had symptoms of nutritional impact, in which the most prevalent were: anorexia (50.5 %), pain (23.1 %), vomiting (19.4 %), constipation, and dysgeusia (17.7 %). These results agree with Brazilian and American cross-sectional studies, which place anorexia and pain among the most prevalent symptoms in their populations [24, 25].

About eating habits, a review of litterature found limited evidence that the consumption of nutritious foods may mitigate side effects and benefit quality of life in patients undergoing cancer treatment. Emerging evidence suggests the possibility that foods may support treatment effectiveness. Future studies should focus on whole foods, rather that nutrient consumption or inadequacies, so that findings are generalizable and dietary recommendations for cancer patients can be clear. In addition, the use of patient-reported outcomes as well as hard endpoints (such as recurrence) should be emphasized [26].

Kisha I and al affirm that’s evident that for many patients, cancer treatment makes it difficult to obtain adequate nutrition [27]. Treatment often alters one's sense of smell and taste decreasing both the desire to eat and the enjoyment of eating, which can lead to weight loss and nutritional deficiencies [28]. Nevertheless, many cancer patients are not routinely receiving nutritional guidance. The large number of patients reporting nutritional concerns supports the need for nutrition counseling as a standard part of care [29]. Clinicians can use the findings from this study to inform patients of possible nutritional issues given their profile and refer them to resources to proactively address these issues.

Malnutrition is common in cancer patients. These patients may be malnourished even if their BMI is within normal limits. Malnutrition can be detected and evaluated using instruments such muscle strength test and determining of albuminemia. We suggest that evaluation for malnutrition should be a standard component of cancer patient care. Malnutrition is a common problem seen in cancer patients. Therefore, early recognition and detection of risk for malnutrition, especially gastrointestinal cancer, through screening followed by comprehensive assessment and timely interventions should be an oncology strategy. Furthermore, nutritional support should be an integral part of cancer care.

Conflict of interest

The authors declare that they have no conflict of interest.

Acknowledgments

The authors have no acknowledgments to declare

Funding

No funds, grants, or other support was received.

1. Instituto Nacional de Câncer José Alencar Gomes da Silva. Consenso Nacional de Nutrição Oncológica. Serviço de Nutrição e dietética. 2015.
2. Wie GA, Cho YA, Kim SY, Kim SM, Bae JM, Joung H. Prevalence and risk factors of malnutrition among cancer patients according to tumor location and stage in the National Cancer Center in Korea. Nutrition. 2010.
3. Pressoir M, Desne S, Berchery D, Rossignol G, Poiree B, Meslier M, et al. Prevalence, risk factors and clinical implications of malnutrition in French Comprehensive Cancer Centre. British Journal of Cancer. 2010; 102: 966-971.
4. Wu BW, Yin T, Cao WX, Gu ZD, Wang XJ, Yan M, et al. Clinical application of subjective global assessment in Chinese patients with gastrointestinal cancer. World J Gastroenterol. 2009.
5. Davies, M. Nutritional screening and assessment in cancer-associated malnutrition. European Journal of Oncology Nursing, 2005.
6. Waitzberg DL, Caiaffa WT, Correia MI. Hospital malnutrition: the Brazilian National Survey (IBRANUTRI): a study of 4000 patients. Nutrition. 2001; 17: 573-580.
7. Correia MI, Campos AC. Prevalence of hospital malnutrition in Latin America: the multicenter ELAN study. Nutrition. 2003.
8. Andreyev HJ, Norman AR, Oates J, Cunningham D. Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies? Eur J Cancer. 1998; 34: 503-509.
9. Bozzetti F, Mariani L. Defining and classifying cancer cachexia: a proposal by the SCRINIO Working Group. JPEN J Parenter Enteral Nutr. 2009; 33 :361-367.
10. González SS, Sobrino PS, Álvarez JAC, Villarroel PG, Fernández CP. Parámetros antropométricos en la evaluación de la malnutrición en pacientes oncológicos hospitalizados; utilidad del índice de masa corporal y del porcentaje de pérdida de peso. Nutr Hosp. 2013.
11. Datema FR, Ferrier MB, de Jong RJ B. Impact of severe malnutrition on short-term mortality and overall survival in head and neck cancer. Oral Oncol. 2011.
12. Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J ClinOncol. 1982;5(6):649-655.
13. Bories, E. Assenat, L. Fouques, L. Vercambre, P. Senesse. Dépistage de la dénutrition en oncologie digestive et prise en charge nutritionnelle, Gastroentérologie Clinique et Biologique, 2009; 33.
14. Karthikayini Krishnasamy, Tang Li Yoong, Chong Mei Chan, Lau Peng Choong, Karuthan Chinna. Identifying Malnutrition: Nutritional Status in Newly Diagnosed Patients with Cancer. CJON 2017; 21: E23-E29.
15. Martin L, Watanabe S, Fainsinger R, Lau F, Ghosh S, Quan H, et al. Prognostic factors in patients with advanced cancer: use of the patientgenerated subjective global assessment in survival prediction. J Clin Oncol. 2010.
16. Opanga Y, Kaduka L, Bukania Z, Mutisya R, Korir A, Thuita V, et al. Nutritional status of cancer outpatients using scored patient generated subjective global assessment in two cancer treatment centers, Nairobi, Kenya. BMC Nutr. 2017; 3: 63.
17. Bozzetti F, Mariani L, LoVullo S. The nutritional risk in oncology: a study of 1,453 cancer outpatients. Support Care Cancer. 2012.
18. Oliveira MR, Fogaça KC, Leandro-Merhi VA. Nutritional status and functional capacity of hospitalized elderly. Nutr J. 2009.
19. Ottery FD. Definition of standardized nutritional assessment and interventional pathways in oncology. Nutrition. 1996;12: S15-S19.
20. Sánchez-Lara K, Turcott J, Sosa-Sánchez R, Green-Renner D. Evaluación del estado de nutrición en pacientes con câncer. Revista de Endocrinología y Nutrición. 2008; 16:165-171
21. Gioulbasanis I, Baracos VE, Giannousi Z, Xyrafas A, Martin L, Georgoulias V, et al. Baseline nutritional evaluation in metastatic lung cancer patients: mini nutritional assessment versus weight loss history. Ann Oncol. 2011.
22. Chang PH, Yeh KY, Huang JS, Lai CH, Wu TH, Lan YJ, et al. Pretreatment performance status and nutrition are associated with early mortality of locally advanced head and neck cancer patients undergoing concurrent chemoradiation. Eur Arch Otorhinolaryngol. 2013.
23. Gonzalez MC, Borges LR, Silveira DH, Assunção MCF, Orlandi SP. Validação da versão em português da avaliação subjetiva global produzida pelo próprio pacientes. Rev Bras Nutr Clin. 2010; 25:102-108.
24. Bauer J, Capra S, Ferguson M. Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer. European Journal of Clinical Nutrition. 2002.
25. Colling C, Durval PA, Silveira DH. Pacientes submetidos a quimioterapia: avaliação nutricional prévia. Revista Brasileira de Cancerologia. 2012;58(4):611-617.
26. Conigliaro T, Boyce LM, Lopez CA, Tonorezos ES. Food Intake During Cancer Therapy: A Systematic Review. Am J Clin Oncol. 2020; 43: 813-819.
27. Coa KI, Epstein JB, Ettinger D, et al. The impact of cancer treatment on the diets and food preferences of patients receiving outpatient treatment. Nutr Cancer. 2015; 67: 339-353.
28. Ravasco P. Aspects of taste and compliance in patients with cancer. European Journal of Oncology Nursing. 2005: S84-S91.
29. Caro MMM Laviano A. Pichard C. Impact of nutrition on quality of life during cancer. Current Opinion in Clinical Nutrition & Metabolic Care. 2007: 480-487.