Defining the clinical condition of cancer patients: it is time to switch from performance status to nutritional status

Excerpt

Performance status (PS) is universally used in oncology to evaluate the clinical condition of the patients. The performance status has been shown to correlate with survival, as well as with acute toxicity following anticancer chemotherapy [1‐5]. To test whether altered performance status is associated with malnutrition, we retrospectively examined data from a 1-day malnutrition prevalence survey, carried out in 154 oncology wards of private or public hospitals in 24 cities in France [6]. Height and present and usual body weights were assessed in outpatients and inpatients who were present that day. The European Society for Clinical Nutrition and Metabolism and the Cachexia Society recently considered pre-cachectic a patient who involuntarily lost 5% of body weight during the previous 12 months [7, 8]. Malnutrition was defined as a body mass index < 18.5 kg/m², <21 kg/m² in patients aged 75 years or over, and/or as a loss of body weight > 10% from diagnosis in our study. The prevalence of malnutrition was studied in the overall population and stratified for the performance status. Amongst 2,068 patients (1,189 men and 879 women) aged 60 ± 13 years, nutritional status was available in 1,903 patients. The performance status was 0 in 338 (19%), 1 in 560 (32%), 2 in 451 (25%), 3 in 249 (14%), and 4 in 129 (7%) patients. Overall, 723 (38%) of the patients were malnourished. The prevalences of malnutrition were 14.4%, 31.4%, 52.3%, 53.6%, and 65.3% in patients with a performance status ranging from 0 to 4, respectively (Fig. 1). In comparison to patients with performance status 0, the relative risk of malnutrition was 2.5 (p < 0.0001) in men with performance status 1, 6.4 in men with performance status 2 (p < 0.0001) and 2.0 (p < 0.0001) in women with performance status 1 and 5, 2 in women with PS2 (p < 0.0001). Malnutrition is strongly associated with performance status and is likely to be the determining factor of its deterioration. Of note, one third of PS1 patients have malnutrition, underlying the limitations of PS assessment. As a consequence, screening of malnutrition in all cancer patients prior to initiating cancer treatment is strongly recommended. Moreover, evaluation of the nutritional status appears as potentially more accurate than performance status to identify patients at risk for anticancer chemotherapy acute toxicity [1, 3]. The effects of early nutritional intervention in malnourished patients starting chemotherapy should be prospectively studied.

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