Evaluation of malnutrition status in hepatocellular carcinoma patients by the patient-generated subjective global assessment in military hospital 103

T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 150 EVALUATION OF MALNUTRITION STATUS IN HEPATOCELLULAR CARCINOMA PATIENTS BY THE PATIENT-GENERATED SUBJECTIVE GLOBAL ASSESSMENT IN MILITARY HOSPITAL 103 Chin Sophea1,4, Nguyen Thi Huong Giang2, Pham Duc Minh3 SUMMARY Objectives: To assess malnutrition status in hepatocellular carcinoma (HCC) patients by Patient-Generated Subjective Global Assessment (PG-SGA) score. Subjects and methods: A prospective study on 80 patients hospitalized at Military Hospital 103 from 9/2019 - 7/2020. The PG-SGA was collected within first 48 hours of admission. Results: The average points of PG-SGA was 16.5. Most of the HCC patients had reduction of food intake in a month (82.5%), moderate/suspected malnutrition (68.8%) and needed critial nutrition treatment (81.25%). Nutrition intake was affected by fatigue and pain (88.8%), lost of appetite (70%), dry mouth (67.5%) and taste change (50%). PG-SGA score of patient at OKUDA stage 1 (15.2) was lower than stage 2 - 3 (18.9) with p < 0.05, Barcelona Clinic Liver Cancer (BCLC) below advanced stage (14.9) was lower than advanced and end stage (19.6) with p < 0.01. HCC patients at OKUDA stage 1 had lower risk of malnutrition (OR = 0.78; p < 0.05) than stage 2 - 3 and BCLC below advanced stage had lower risk of malnutrition (OR = 0.69; p < 0.01) than the rest. Conclusion: Malnutrition is common in HCC population in Military Hospital 103. There are some nutrition impact symptoms (NIS) affecting the patient's food intake such as: Fatigue, pain, loss of appetite, dry mouth and taste change. The severity of the malnutrition inceased at late stage of liver cancer. Both SGA classification and PG-SGA points have close association trends with Barcelona and OKUDA staging, but not Child-pugh liver functional sorting. * Keywords: Nutrition; Screening; Intensive care unit; NUTRIC; NRS-2002; Clinical outcome. INTRODUCTION Patients with cancer have a high risk of malnutrition. The main factors involved in the development of malnutrition in these patients are metabolic abnormalities and nutrition impact symptoms (NIS), which can be related to the tumor itself or can occur side effects of anticancer treatment. Aging promotes changes in body composition, metabolic and physiological, and reduces functional capacity, makes older patients with cancer who are undergoing oncological treatment more vulnerable, resulting in increased morbidity and mortality [1]. 1Internal Gastrology Department, Military Hospital 103, Vietnam Military Medical University 2Medical Oncology Department No.3, Vietnam National Cancer Hospital 3Nutrition Department, Military Hospital 103, Vietnam Military Medical University 4Preah Ket Mealea Hospital, Cambodia Corresponding author: Pham Duc Minh (drminh103@yahoo.com) Date received: 06/10/2020 Date accepted: 15/11/2020 T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 151 Hepatocellular carcinoma and intrahepatic cholangiocarcinoma (ICC) are the most frequently encountered types of primary liver cancer and together are among the most common incident cancers worldwide [2]. The major risk factors of HCC in contemporary clinical practice are becoming increasingly related to sustained virological response after hepatitis C, suppressed hepatitis B virus during treatment, and alcoholic and nonalcoholic fatty liver disease [3]. In multidispline model, prognostic nutritional index (PNI) and systemic inflammation score are prognotic markers of HCC treatment [4, 5]. Early dectection of malnutrition in HCC patients can help appropriately nutrition intervention to improve outcome [6]. Thus, we conducted this study: To assess malnutrition status in HCC patients by PG-SGA score. SUBJECTS AND METHODS 1. Subjects 80 patients with newly diagnosed HCC were hospitalized at Military Hospital 103 from 9/2019 - 7/2020. * Inclusion criteria: Adults (age ≥ 20 years) were admitted to hospital with a confirmed diagnosis of cancer and agreed to participate in the study. * Exclusion criteria: Patients who were admitted to Intensive Care Units, in a coma, mentally handicapped, and unable to independently complete the PG-SGA questionnaire. 2. Methods * Study design: The study was a hospitalbased, singlecenter, cross-sectional study. * Assessment of liver cancer stage: The traditional staging based on the Okuda system (table 1), which was developed 18 years ago [7]. At that time, early diagnosis of HCC was relatively rare, and the staging system was therefore based on data from patients with advanced disease. Table 1: Definition of the Okuda staging system for HCC. Points Characteristics 0 1 Tumour size 50% of liver Ascites No Yes Albumin (g/dL) ≥ 3 < 3 Bilirubin (mg/dL) < 3 ≥ 3 Okuda stage I: 0 points; Okuda stage II: 1 or 2 points; Okuda stage III: 3 or 4 points. A second alternative is BCLC staging system (table 2), which theoritically has certain advantages. Among the prognostic variables considered in BCLC staging are performance status (PST) [8]. T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 152 Table 2: Barcelona Clinic Liver Cancer staging system. Stage 0 (very early) A (early) B (intermediate) C (advanced) D (end stage) Performance status 0 0 0 1 - 2 3 - 4 Liver function Child-Pugh A – B Child-Pugh A - B Child-Pugh A - B Child-Pugh A -B Child-Pugh C Tumor stage Single Single or 3 nodules < 3 cm Multinodular Vascular invasion or extrahepatic spread Any Stages A and B: All criteria should be fulfilled; stage C: At least one criterion and PST 1 - 2 or vascular invasion/ extrahepatic spread; stage D: At least one criterion and PST 3 - 4 or Okuda stage III/Child-Pugh C. * Assessment of malnutrition risk and malnutrition: Nutritional assessment was performed by using the PG-SGA [9, 10] which was translated for use in the Vietnamese setting. The PG-SGA includes 2 components. The first one, which includes 4 boxes (boxes 1 - 4) and is also referred to the PG-SGA short form, addresses recent weight history (maximum score: 5), food intake (maximum score: 4), NIS (maximum score: 24), and activities/function capacity (maximum score: 3) and was completed by the patient. The second component is completed by a trained nutritionist and includes 5 worksheets that address: (1) weight loss percentage and score; (2) disease and age and their relation to nutritional requirements; (3) metabolic stress, including fever and the use of corticosteroids; and (4) physical examination, including a loss/deficit of subcutaneous fat, muscle, and the presence of edema or ascites. Upon completion, the patient was classified as being well nourished (stage A), having moderate or suspected malnutrition (stage B), or being severely malnourished (stage C), as guided by worksheet 5 from the questionnaire. The total PG-SGA numerical score (ie, the sum of all boxes and worksheets) [11] provides a score to guide the nutritional interventions as follows: (1) A score between 0 and 1 indicates that no intervention is required at this time and re-assessment on a routine and regular basis during treatment; (2) A score between 2 and 3 indicates patient and family education by a dietitian, nurse, or other clinicians with pharmacologic intervention as indicated by symptom survey and laboratory values, as appropriate; (3) A score between 4 and 8 indicates the need for intervention by a dietitian in conjunction with a nurse or physician, as indicated by symptoms; and (4) A score ≥ 9 indicates a critical need for improved symptom management and/or nutrient intervention options. T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 153 According to the PG-SGA numerical score, malnutrition risk was categorized as follows: 0 - 3 points: low risk; 4 - 8 points: medium risk; 9 - 36 points: high risk [10]. * Data collection: The PG-SGA was applied during the first 36 hours of hospitalization, including: + History: Ask the patient directly; tapping through patient's family member in case the patient is unable to communicate or is not alert enough. + Collect clinical and subclinical parameters at the time of admission to assess nutrition status and measure weight and height at admission. Other clinical and subclinical indicators were also collected for analysis, including: Age, sex, occupation, cormobidity diseases, stage diagnosis of cancer disease. * Statistics analysis: By using SPSS 20.0 software. * Ethics: The study was approved by the Scientific Board of Vietnam Military Medical University in Decision No.149/QD-HVQY of the President of Vietnam Military Medical University signed on January 09, 2020. RESULTS Table 3: General characteristics. Characteristics X̅ ± SD or n (%) Mean age (years) 61.5 ±11.8 Age ≥ 65, n (%) 39 (48.9) Male, n (%) 72 (90.0) Co-morbility, n (%) HBV 62 (77.5) HCV 4 (5.0) Cirrhosis 75 (93.8) Stage of HCC by Barcelona classification, n (%) Early 8 (10.0) Intermediate 45 (56.2) Advanced 20 (25.0) End stage 7 (8.8) Stage of HCC by Okuda classification, n (%) Stage 1 52 (65.0) Stage 2 24 (30.0) Stage 3 4 (5.0) Child-Pugh classification, n (%) A 57 (71.2) B 16 (20.0) C 7 (8.8) Most of the patients were men (90.0%), the average age was over 60 (61.5 ± 11.8 years). The majority of patients had HBV (77.5%) and cirrhosis (93.8%). Table 4: Gastrointestinal symptoms affected eating and drinking in the past 2 weeks. Symptoms n (%) No appetite 56 (70.0) Nausea 11 (13.8) Vomitting 6 (7.5) Constipation 14 (17.5) Diarrhea 3 (3.8) Mouth sores 3 (3.8) Dry mouth 54 (67.5) Taste change 40 (50.0) Smell bother me 17 (21.2) Swallow difficulty 2 (2.5) Fatigue 71 (88.8) Pain 71 (88.8) Feel fool quickly 20 (25.0) T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 154 There were many symptoms affecting the patient's eating and drinking in the past 2 weeks. The most affected symptoms were fatigue and pain (88.8%), followed by loss of appetite (70.0%), dry mouth (67.5%) and taste change (50.0%). Some patients got dry mouth (3.8%), swallow difficulty (2.5%) and diarrhea (3.8%). Table 5: Nutrition status of HCC patient. Characteristics n (%) Food intake less than usual past month, n (%) 66 (82.5) Weight decrease past 2 weeks, n (%) 56 (70.0) PG-SGA ( ± SD) 16.5 (7.3) PG-SGA, min, median, max 2, 17, 34 PG-SGA classification, n (%) A (Well-nourished) 19 (23.8) B (Moderate/suspected malnutrition) 55 (68.8) C (Severely malnourished) 6 (7.5) PG-SGA-based nutrition triage classification, n (%) Nutrition education 2 (2.5) Nutrition intervention 13 (16.25) Critial management 65 (81.25) There was a reduction of food intake in a past month (82.5%) in most of the HCC patients, followed by moderate/suspected malnutrition (68.8%) and need to apply critial management (81.25%). Table 6: Association of malnutrition status with stage of HCC. SGA class A-BC, n (%) PG-SGA SGA A SGA BC OR (95%CI); p Mean (SD) p Stage 1 16 (30.8) 36 (69.2) 15.2 (7.2) OKUDA Stage 2 - 3 3 (10.7) 25 (89.3) 078 (0.62 - 0.97); 0.056 18.9 (6.7) 0.025 ≤ intermediate 18 (34.0) 35 (66.0) 14.9 (7.2) BCLC > intermediate 1 (3.7) 26 (96.3) 0.69 (0.56 - 0.84); 0.002 19.6 (6.4) 0.006 A 16 (28.1) 41 (71.9) 15.8 (7.1) Child-pugh BC 3 (13.0) 20 (87.0) 0.82 (0.66 - 1.04); 0.245 18.4 (7.5) 0.149 Hepatocellular carcinoma patients at OKUDA stage 1 had lower risk of malnutrition than stage 2- 3 (OR = 0.78; p < 0.05). Similarly, patients at BCLC stage ≤ intermediate had lower risk of malnutrition than the rest (OR = 0.69, p < 0.01). Liver functional classification by Child-pugh did not show clear differrence in malnutrition assessment with p > 0.05. PG-SGA score of OKUDA stage 1 patient was lower than stage 2 - 3 with p < 0.05, BCLC below intermediate stage was lower than above intermediate stage with p < 0.01. T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 155 DISCUSSION Hepatocellular carcinoma is the fourth most common cause of cancer-related death worldwide [12]. Approximately 75% of liver cancer occurs in Asia, especially in China it accounts for over 50% of the world's burden [13]. HCC is closely associated with hepatic cirrhosis, which is present in 80 - 90% of all cases [14]. The leading cause of liver cancer is cirrhosis due to hepatitis B, hepatitis C or alcohol [15]. The most common types are HCC, which makes up 80% of cases, and cholangiocarcinoma [16]. Treatment options may include surgery, targeted therapy and radiation therapy. In certain cases, ablation therapy, embolization therapy or liver transplantation may be used [3]. Our data had the same trend like others with most of patients with HBV (77.5%) and cirrhosis (93.8%). Malnutrition is common, but frequently underdiagnosed condition in patients with liver cirrhosis as well as in patients with liver cancer and has been shown to have a negative impact on survival in these patients. Frequently applied screening tools including anthropometric measurements or laboratory parameters to screen for malnutrition are not suitable for patients with liver cirrhosis with additional pathophysiological mechanisms leading to hypoalbuminemia and edema. Pre- operative nutritional status is reported to be associated with post-operative outcomes in patients with HCC. Controlling nutritional status (CONUT) and score and the prognostic nutritional index (PNI) are predictors of post-operative outcomes after liver surgery [17]. Malnutrition in patients with HCC is a prognostic factor [18]. In “HCC survivors” population, the severity of the systemic inflammation and the poor nutritional status also predict survival and were considered independent prognostic factors. 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