ESMO Symposium on Cancer and Nutrition 2009 Presentation: … · Title: ESMO Symposium on Cancer and Nutrition 2009 Presentation: Screening tools in daily practice: The focus on cancer

Zeno StangaZeno StangaDivision of Endocrinology,Division of Endocrinology,

Diabetes and Clinical NutritionDiabetes and Clinical NutritionUniversity Hospital / BernUniversity Hospital / Bern

Zeno StangaZeno StangaDivision of Endocrinology,Division of Endocrinology,

Diabetes and Clinical NutritionDiabetes and Clinical NutritionUniversity Hospital / BernUniversity Hospital / Bern

•• normal nutritional statusnormal nutritional status••mild mild MNMN•• moderate moderate MNMN•• severe severe MNMN

Body Mass IndexBody Mass IndexStatic parameterStatic parameter

Sobotka L, et al. ESPEN Book 2004 / Sobotka L, et al. ESPEN Book 2004 / Schols AM et al. Am J Respir Crit Care Med 1995;152:1268 Schols AM et al. Am J Respir Crit Care Med 1995;152:1268 Cabre E et al. Gastroenterology 1990;85:1597 / Bastow MD et al. BMJ 1983;287:1589Cabre E et al. Gastroenterology 1990;85:1597 / Bastow MD et al. BMJ 1983;287:1589

Definition Definition of of

normal nutritional statusnormal nutritional status 20.0 20.0 –– 2525.0.0 kg/m²kg/m²1818.0.0 –– 19.919.9 kg/m²kg/m²16.016.0 –– 17.917.9 kg/m²kg/m²

< 16 < 16 kg/m²kg/m²

Body Mass IndexBody Mass IndexBMIBMI == weightweight [[ kg kg ]]heightheight [ [ m²m² ]]

Static parameterStatic parameter

Schols AM et al. Am J Respir Crit Care Med 1995;152:1268 Schols AM et al. Am J Respir Crit Care Med 1995;152:1268 Cabre E et al. Gastroenterology 1990;85:1597 / Bastow MD et al. BMJ 1983;287:1589Cabre E et al. Gastroenterology 1990;85:1597 / Bastow MD et al. BMJ 1983;287:1589

of of malnutritionmalnutrition

Kondrup J et al. J Hepatol 1997;27:239 / Olin AO et al. JPEN 1996;20:93Kondrup J et al. J Hepatol 1997;27:239 / Olin AO et al. JPEN 1996;20:93Unosson M et al. Clin Nutr 1992;11:134 / Windsor JA et al. Br J Surg 1988;75:880Unosson M et al. Clin Nutr 1992;11:134 / Windsor JA et al. Br J Surg 1988;75:880

Pathological weight loss Pathological weight loss Keele AM et al. Gut 1997;40:303 / Rana SK et al. Clin Nutr 1992;11:337Keele AM et al. Gut 1997;40:303 / Rana SK et al. Clin Nutr 1992;11:337Keys A et al. Science 1950;112:371Keys A et al. Science 1950;112:371Food intake in the preceding weekFood intake in the preceding week

food intake below 25%

Dynamic parametersDynamic parameters

> 5% > 5% bw 1 mtbw 1 mt // > 7.5% > 7.5% bw 3 mtsbw 3 mts

Definition Definition of of malnutritionmalnutrition

Kondrup J et al. J Hepatol 1997;27:239 / Olin AO et al. JPEN 1996;20:93Kondrup J et al. J Hepatol 1997;27:239 / Olin AO et al. JPEN 1996;20:93Unosson M et al. Clin Nutr 1992;11:134 / Windsor JA et al. Br J Surg 1988;75:880Unosson M et al. Clin Nutr 1992;11:134 / Windsor JA et al. Br J Surg 1988;75:880

Pathological weight loss Pathological weight loss (unintentional)(unintentional)Keele AM et al. Gut 1997;40:303 / Rana SK et al. Clin Nutr 1992;11:337Keele AM et al. Gut 1997;40:303 / Rana SK et al. Clin Nutr 1992;11:337Keys A et al. Science 1950;112:371Keys A et al. Science 1950;112:371Food intake in the preceding weekFood intake in the preceding week

food intake below 25% of normal requirement

Dynamic parametersDynamic parameters

bw 3 mtsbw 3 mts // > 10% > 10% bw 6 mtsbw 6 mts

malnutritionmalnutrition

Cancer: disease and nutrition are keyCancer: disease and nutrition are keydeterminants of patientsdeterminants of patientsQoL function scores are determined by:QoL function scores are determined by:

•• cancer location cancer location •• nutritional intakenutritional intake•• weight lossweight loss•• chemotherapychemotherapy•• surgerysurgery•• disease durationdisease duration•• stage of diseasestage of diseaseRavasco P et al. Supp Care Cancer 2004;12:246Ravasco P et al. Supp Care Cancer 2004;12:246

Cancer: disease and nutrition are keyCancer: disease and nutrition are keydeterminants of patientsdeterminants of patients' QoL' QoLQoL function scores are determined by:QoL function scores are determined by:

cancer location cancer location 30 %30 %nutritional intakenutritional intake 20 %20 %

30 %30 %chemotherapychemotherapy 10 %10 %

6 %6 %disease durationdisease duration 3 %3 %stage of diseasestage of disease 1 %1 %Ravasco P et al. Supp Care Cancer 2004;12:246Ravasco P et al. Supp Care Cancer 2004;12:246

Mortality Mortality ↑↑↑↑↑↑↑↑

Morbidity Morbidity ↑↑↑↑↑↑↑↑•• Infections Infections ↑↑↑↑↑↑↑↑••Wound healingWound healing↓↓↓↓↓↓↓↓•• Tolerance to antiTolerance to anti--cancercancer--therapy therapy ↓↓↓↓↓↓↓↓

•• Organ dysfunctionOrgan dysfunction ↑↑↑↑↑↑↑↑•• Complications Complications ↑↑↑↑↑↑↑↑

ConsequencesConsequences of cancerof cancer

Stanga Z et al. Eur J Cli Nutr;62:687 / S. Iff, Stanga Z. Clin Nutr 2008;3:154Stanga Z et al. Eur J Cli Nutr;62:687 / S. Iff, Stanga Z. Clin Nutr 2008;3:154

Length of stay Length of stay ↑↑↑↑↑↑↑↑•• ReRe--Hosp. Hosp. ↑↑↑↑↑↑↑↑•• Convalescence Convalescence ↑↑↑↑↑↑↑↑

of cancerof cancer--related MNrelated MN

Quality of life Quality of life ↓↓↓↓↓↓↓↓•• Physical and mentalPhysical and mentalproblemsproblemsStanga Z et al. Eur J Cli Nutr;62:687 / S. Iff, Stanga Z. Clin Nutr 2008;3:154Stanga Z et al. Eur J Cli Nutr;62:687 / S. Iff, Stanga Z. Clin Nutr 2008;3:154

Cancer outCancer out-- and inpatientsand inpatients•• Cancer outpatients Cancer outpatients (1‘000 pts, NRS(1‘000 pts, NRS•• Cancer inpatients Cancer inpatients (71 pts, PG(71 pts, PG•• Colorectal cancer Colorectal cancer (inpatients, 234 pts, PG(inpatients, 234 pts, PG•• Ovarian cancer Ovarian cancer (inpatients, 132 pts, SGA)(inpatients, 132 pts, SGA)

Bozzetti et al. Support Care Cancer 2009;17:279Bozzetti et al. Support Care Cancer 2009;17:279Bauer et al. Eur J Clin Nutr 2002;56:779Bauer et al. Eur J Clin Nutr 2002;56:779Gubta et al. Eur J Clin Nutr 2004;59:35Gubta et al. Eur J Clin Nutr 2004;59:35

Prevalence of Prevalence of cancercancerand inpatientsand inpatients(1‘000 pts, NRS(1‘000 pts, NRS--2002)2002) 33.8 %33.8 %(71 pts, PG(71 pts, PG--SGA)SGA) 76 %76 %(inpatients, 234 pts, PG(inpatients, 234 pts, PG--SGA)SGA) 41 %41 %(inpatients, 132 pts, SGA)(inpatients, 132 pts, SGA) 50 %50 %

Bozzetti et al. Support Care Cancer 2009;17:279Bozzetti et al. Support Care Cancer 2009;17:279Gubta et al. J Ovar Res 2008;1:5Gubta et al. J Ovar Res 2008;1:5

Bauer et al. Eur J Clin Nutr 2002;56:779Bauer et al. Eur J Clin Nutr 2002;56:779Gubta et al. Eur J Clin Nutr 2004;59:35Gubta et al. Eur J Clin Nutr 2004;59:35

cancercancer--related MNrelated MN

SCREENING at admissionSCREENING at admissionNutritional managementNutritional management

Kondrup J et al. Clin Nutr 2003;22:415Kondrup J et al. Clin Nutr 2003;22:415IdealIdeal

All patientsAll patientsat riskat risk

identified!identified!

SCREENING at admissionSCREENING at admissionNutritional managementNutritional management

Kondrup J et al. Clin Nutr 2003;22:415Kondrup J et al. Clin Nutr 2003;22:415IdealIdeal

All patientsAll patientsat riskat risk

identified!identified!

Quality of a screening toolQuality of a screening toolRequirements Requirements accordingaccording

•• EasyEasy•• EfficienEfficientt•• AvailableAvailable•• InexpensiveInexpensive

Quality of a screening toolQuality of a screening toolaccordingaccording

•• SpecificitySpecificity•• SensitivitySensitivity•• ReliabilityReliability•• PredictivePredictive

validityvalidity

CommunityCommunity

Kondrup J et al. Clin Nutr 2003;22:415Kondrup J et al. Clin Nutr 2003;22:415MUST MUST κκκκκκκκ==0.660.66InterInter--rater reliabilityrater reliability

substancialsubstancial Kondrup J et al. Clin Nutr 2003;22:415Kondrup J et al. Clin Nutr 2003;22:415

MUSTMUST Malnutrition Universal Screening Tool Malnutrition Universal Screening Tool

BMI BMI ScoreScore> 20.0> 20.0 00

18.518.5--20.0 20.0 11< 18.5 < 18.5 22

Body Mass IndexBody Mass Index(kg/m2)(kg/m2)

Malnutrition Universal Screening Tool Malnutrition Universal Screening Tool

Malnutrition AdvisoryMalnutrition AdvisoryGroup. BAPEN 2000 Group. BAPEN 2000

Percent Percent ≤≤ 5 5 55--10 10 ≥≥ 10 10

In the lastIn the last33--6 months6 months

Weight lossWeight loss(unintentional)(unintentional)



18.518.5--20.0 20.0 11< 18.5 < 18.5 22


Percent Percent ScoreScore5 5 0010 10 1110 10 22

In the lastIn the last6 months6 months




Percent Percent ≤≤ 5 5 55--10 10 ≥≥ 10 10





18.518.5--20.0 20.0 11< 18.5 < 18.5 22





There hasThere hasbeen or is nobeen or is no

nutritional intake nutritional intake for > 5 daysfor > 5 daysAdd a scoreAdd a score

of 2of 2

Disease effectDisease effect(acute)(acute)



Percent Percent ≤≤ 5 5 55--10 10 ≥≥ 10 10



Add scoresAdd scores



18.518.5--20.0 20.0 11< 18.5 < 18.5 22





There hasThere hasbeen or is nobeen or is no

nutritional intake nutritional intake for > 5 daysfor > 5 daysAdd a scoreAdd a score

of 2of 2

Disease effectDisease effect(acute)(acute)

Add scoresAdd scores




Malnutrition Advisory Group (MAG UK). BAPEN 2000 Malnutrition Advisory Group (MAG UK). BAPEN 2000

low low →→ ROUTINEROUTINE Hospitals:Hospitals:CLINICAL CARECLINICAL CARE Care Homes:Care Homes:Community:Community:00

ScoreScore Risk Risk MEASUREMEASURE ImplementImplementOverall risk of malnutritionOverall risk of malnutritionMalnutrition Universal Screening Tool Malnutrition Universal Screening Tool


Hospitals:Hospitals: screening every weekscreening every weekCare Homes:Care Homes: screening every monthscreening every monthCommunity:Community: screening every yearscreening every yearImplementImplement

Overall risk of malnutritionOverall risk of malnutrition



low low →→ ROUTINE ROUTINE Hospitals:Hospitals:CLINICAL CARE CLINICAL CARE Care Homes:Care Homes:Community:Community:

mild mild →→ OBSERVEOBSERVE Hospitals & Care Homes:Hospitals & Care Homes:dietary and fluid intake for 3 daysdietary and fluid intake for 3 daysCommunity:Community:1100

ScoreScore Risk Risk MEASUREMEASURE ImplementImplementOverall risk of malnutritionOverall risk of malnutritionMalnutrition Universal Screening Tool Malnutrition Universal Screening Tool


Hospitals:Hospitals: screening every weekscreening every weekCare Homes:Care Homes: screening every monthscreening every monthCommunity:Community: screening every yearscreening every yearHospitals & Care Homes:Hospitals & Care Homes: documentdocumentdietary and fluid intake for 3 daysdietary and fluid intake for 3 daysCommunity:Community: repeat repeat screening (1screening (1--6 mts)6 mts)ImplementImplement



Malnutrition Advisory Group (MAG UK). BAPEN 2000Malnutrition Advisory Group (MAG UK). BAPEN 2000

low low →→ ROUTINE ROUTINE Hospitals:Hospitals:CLINICAL CARE CLINICAL CARE Care Homes:Care Homes:Community:Community:

mild mild →→ OBSERVE OBSERVE Hospitals & Care Homes:Hospitals & Care Homes:dietary and fluid intake for 3 daysdietary and fluid intake for 3 daysCommunity:Community:highhigh →→ TREATTREAT Hospitals, Care Homes & Community:Hospitals, Care Homes & Community:

≥≥≥≥≥≥≥≥ 22

11

00

ScoreScore Risk Risk MEASUREMEASURE ImplementImplement

Start nutritional therapyStart nutritional therapy

Overall risk of malnutritionOverall risk of malnutritionMalnutrition Universal Screening Tool Malnutrition Universal Screening Tool

Malnutrition Advisory Group (MAG UK). BAPEN 2000Malnutrition Advisory Group (MAG UK). BAPEN 2000

Hospitals:Hospitals: screening every weekscreening every weekCare Homes:Care Homes: screening every monthscreening every monthCommunity:Community: screening every yearscreening every yearHospitals & Care Homes:Hospitals & Care Homes: documentdocumentdietary and fluid intake for 3 daysdietary and fluid intake for 3 daysCommunity:Community: repeat repeat screening (1screening (1--6 mts)6 mts)Hospitals, Care Homes & Community:Hospitals, Care Homes & Community:ImplementImplement



CommunityCommunity

HospitalHospitalKondrup J et al. Clin Nutr 2003;22:415Kondrup J et al. Clin Nutr 2003;22:415MUST MUST κκκκκκκκ==0.660.66InterInter--rater reliabilityrater reliability

substancialsubstancial

NRS 2002 NRS 2002

κκκκκκκκ==0.760.76InterInter--rater reliabilityrater reliability


HospitalHospitalKondrup J et al. Clin Nutr 2003;22:415Kondrup J et al. Clin Nutr 2003;22:415NRS 2002 NRS 2002

0.760.76rater reliabilityrater reliability


PrePre--Screening: four questionsScreening: four questionsNutrition Risk Screening NRS 2002Nutrition Risk Screening NRS 2002QuestionQuestionIs BMI

NRS 2002NutritionalNutritionalRisk ScoreRisk Score

Kondrup J et al.Kondrup J et al.Clin Nutr 2003;22;321Clin Nutr 2003;22;321

Impaired nutritional statusImpaired nutritional statusNormal nutritional statusNormal nutritional statusGrade 1 ( mild impairment )Grade 1 ( mild impairment )Weight loss > 5% in 3 monthsORFood intake below 50Grade 2 ( moderate impairment )Grade 2 ( moderate impairment )Weight loss > 5% in 2 monthsORBMI 18.5 to 20.5 + impaired general conditionORFood intake below 25Grade 3 ( severe impairment )Grade 3 ( severe impairment )Weight loss > 5% in 1 monthORBMI < 18.5 + impaired general conditionORFood intake below 0Intermediate ScoreIntermediate ScoreNutritionalNutritional

riskrisk

Impaired nutritional statusImpaired nutritional statusNormal nutritional statusNormal nutritional statusGrade 1 ( mild impairment )Grade 1 ( mild impairment )Weight loss > 5% in 3 monthsFood intake below 50-75% of normal requirement in prec. weekGrade 2 ( moderate impairment )Grade 2 ( moderate impairment )Weight loss > 5% in 2 monthsBMI 18.5 to 20.5 + impaired general conditionFood intake below 25-50% of normal requirement in prec. weekGrade 3 ( severe impairment )Grade 3 ( severe impairment )Weight loss > 5% in 1 monthBMI < 18.5 + impaired general conditionFood intake below 0-25% of normal requirement in prec. weekIntermediate ScoreIntermediate Score

00

11

22

33

??AA

ScoreScore

Severity of diseaseSeverity of diseaseNo illnessNo illnessGrade 1 ( mild )Grade 1 ( mild )• Hip fracture, chronic patients with acute complications:cirrhosis, COPD• Chronic hemodialysis, diabetes, oncologyGrade 2 ( moderate )Grade 2 ( moderate )• Major abdominal surgery• Stroke• Severe pneumonia• Hematologic malignancyGrade 3 ( severe )Grade 3 ( severe )• Head injury• Burns• Bone marrow transplantation• Intensive care patients ( APACHE Score > 10 )Intermediate ScoreIntermediate Score

NRS 2002NutritionalNutritionalRisk ScoreRisk Score

NutritionalNutritionalriskriskKondrup J et al.Kondrup J et al.Clin Nutr 2003;22;321Clin Nutr 2003;22;321

Severity of diseaseSeverity of disease ((≈ ≈ stress metabolismstress metabolism))Hip fracture, chronic patients with acute complications:Chronic hemodialysis, diabetes, oncologyGrade 2 ( moderate )Grade 2 ( moderate )Major abdominal surgerySevere pneumoniaHematologic malignancyGrade 3 ( severe )Grade 3 ( severe )Bone marrow transplantationIntensive care patients ( APACHE Score > 10 )Intermediate ScoreIntermediate Score

00

11

22

33

??BB

ScoreScore

Kondrup J et al. Clin Nutr 2003;22:321 Kondrup J et al. Clin Nutr 2003;22:321

Calculation and interpretation of the scoreCalculation and interpretation of the score1.1. Define severity ( 1Define severity ( 1--3 ) of the 3 ) of the impairmentimpairment

( highest grade ) and then the ( highest grade ) and then the severity of diseaseseverity of disease

2.2. Calculate total score = Calculate total score = AA + + B ? B ? 3.3. If age If age ≥≥ 70 years:70 years: add add 11 to the total score to correct for frailityto the total score to correct for fraility4.4. SScore core ≥≥≥≥≥≥≥≥ 3:3: high risk of malnutrition or mal. patienthigh risk of malnutrition or mal. patient

benefit from nutritional therapybenefit from nutritional therapy

NutritionalNutritional Risk Score 2002Risk Score 2002

Start nutritional therapyStart nutritional therapyKondrup J et al. Clin Nutr 2003;22:321 Kondrup J et al. Clin Nutr 2003;22:321

Calculation and interpretation of the scoreCalculation and interpretation of the scoreimpairmentimpairment of the of the nutritional statusnutritional statusseverity of diseaseseverity of disease ( Stress ( Stress ↑↑ ))

B ? B ? to the total score to correct for frailityto the total score to correct for fraility

high risk of malnutrition or mal. patienthigh risk of malnutrition or mal. patientbenefit from nutritional therapybenefit from nutritional therapy

Risk Score 2002Risk Score 2002


BernBernBernBern

Risk of MN Risk of MN →→→→→→→→

Iff S, Stanga Z. Clin Nutr 2008;3:154 (Abstract)Iff S, Stanga Z. Clin Nutr 2008;3:154 (Abstract)nn = 2= 2''207207mixed populationmixed populationNRS 2002NRS 2002

→→→→→→→→ prevalenceprevalence

Iff S, Stanga Z. Clin Nutr 2008;3:154 (Abstract)Iff S, Stanga Z. Clin Nutr 2008;3:154 (Abstract)

NRS 2002NRS 2002

0%

10%

20%

30%

40%

0 1 2 3

Not at riskNot at riskPrevalencePrevalence →→→→→→→→ risk of Malnutrition risk of Malnutrition

NRS 2002NRS 20024 5 6 7

Malign

Non-Malign

nn==340340nn==17691769At riskAt risk

risk of Malnutrition risk of Malnutrition

Iff S, Stanga Z. Iff S, Stanga Z. Clin Nutr 2008;3:154 (Abstract)Clin Nutr 2008;3:154 (Abstract)

0%

10%

20%

30%

40%

0 1 2 3


NRS 2002NRS 20024 5 6 7

Malign

Non-Malign


49%49%


NRS 2002NRS 2002 Iff S, Stanga Z. Iff S, Stanga Z. Clin Nutr 2008;3:154 (Abstract)Clin Nutr 2008;3:154 (Abstract)

0%

10%

20%

30%

40%

0 1 2 3


NRS 2002NRS 20024 5 6 7

Malign

Non-Malign


70%70%


NRS 2002NRS 2002 Iff S, Stanga Z. Iff S, Stanga Z. Clin Nutr 2008;3:154 (Abstract)Clin Nutr 2008;3:154 (Abstract)

Kyle UG et al. Clin Nutr 2006Kyle UG et al. Clin Nutr 2006

Prosp. study, Prosp. study, nn = 995, hospital admission, mixed population = 995, hospital admission, mixed population

SGASGA©© (reference)(reference) vs MUSTvs MUST©© vs NRS 2002vs NRS 2002= Subjective Global Assessment= Subjective Global AssessmentMUSTMUST

•• Prevalence of MNPrevalence of MN 23 23 •• Sensitivity Sensitivity 6161•• SpecifitySpecifity 7878•• Pos. predictive valuePos. predictive value 6464•• Neg. predictive valueNeg. predictive value

ComparisonComparison ofof screeningscreening


= 995, hospital admission, mixed population = 995, hospital admission, mixed population

vs NRS 2002vs NRS 2002© © in association within association with LOSLOSMUSTMUST©© NRS 2002NRS 2002© © SGASGA©©23 23 % % 24 24 %% 44 44 %%6161 %% 6262 %%7878 %% 9393 %%6464 %% 8585 %%79 79 %% 65 65 %%

screeningscreening toolstools atat admission admission

ComparisonComparison ofof screeningscreening


SGASGA©©•• Moderate MNModerate MN 83 83 % % •• Severe MNSevere MN 7171 %%MUSTMUST©©•• ScoreScore 11 93 93 %%•• Score Score ≥≥≥≥≥≥≥≥2 Punkte 2 Punkte 74 74 %%NRS 2002NRS 2002©©•• ScoreScore 33--44 74 74 %%•• Score Score >>55 64 64 %%

LOS LOS 11--10 d10 d

screeningscreening toolstools atat admission admission


% % 17 17 %% 1.41.4 0.143 0.143 %% 2929 %% 2.42.4

Kyle UG et al. Clin Nutr 2006Kyle UG et al. Clin Nutr 2006The The NRSNRS--20022002©©

a clinical screening tool that bettera clinical screening tool that betterpredicts hospitalpredicts hospital--related outcome,related outcome,(( e.g. LOSe.g. LOS )) than than MUSTMUST

Prosp. study, Prosp. study, nn = 995, hospital admission, mixed population = 995, hospital admission, mixed population ComparisonComparison ofof screeningscreening

ConclusionConclusion

Kyle UG et al. Clin Nutr 2006Kyle UG et al. Clin Nutr 2006©© appears to beappears to be

a clinical screening tool that bettera clinical screening tool that betterrelated outcome,related outcome,MUSTMUST©© or or SGASGA©©

= 995, hospital admission, mixed population = 995, hospital admission, mixed population screeningscreening toolstools atat admission admission

ConclusionConclusion

CommunityCommunity

HospitalHospitalKondrup J et al. Clin Nutr 2003;22:415Kondrup J et al. Clin Nutr 2003;22:415MUST MUST κκκκκκκκ== 0.660.66InterInter--rater reliabilityrater reliability


NRS 2002 NRS 2002

κκκκκκκκ== 0.760.76InterInter--rater reliabilityrater reliability


GeriatricsGeriatricsCare HomesCare Homes

HospitalHospitalKondrup J et al. Clin Nutr 2003;22:415Kondrup J et al. Clin Nutr 2003;22:415NRS 2002 NRS 2002

0.760.76rater reliabilityrater reliability

substancialsubstancialMNA MNA MiniMini Nutritional AssessmentNutritional Assessmentκκκκκκκκ== 0.510.51InterInter--rater reliabilityrater reliability

moderatemoderate

1996 Ottery adapted the SGA to meet more1996 Ottery adapted the SGA to meet morespecifically the needs of the oncological population:specifically the needs of the oncological population:•• patientpatient--generated history sectiongenerated history section•• increased gastrointestinal symptom sectionincreased gastrointestinal symptom section•• scoring and triage components have been addedscoring and triage components have been addedDetsky AS et al. JPEN 1987;11:9 /Detsky AS et al. JPEN 1987;11:9 /

PatientPatient--Generated Subjective Global AssessmentGenerated Subjective Global Assessment1996 Ottery adapted the SGA to meet more1996 Ottery adapted the SGA to meet morespecifically the needs of the oncological population:specifically the needs of the oncological population:

generated history sectiongenerated history sectionincreased gastrointestinal symptom sectionincreased gastrointestinal symptom sectionscoring and triage components have been addedscoring and triage components have been addedDetsky AS et al. JPEN 1987;11:9 /Detsky AS et al. JPEN 1987;11:9 / Ottery FD. Nutrition 1996;12:S15Ottery FD. Nutrition 1996;12:S15

Generated Subjective Global AssessmentGenerated Subjective Global Assessment

PatientPatient--Generated Subjective Global AssessmentGenerated Subjective Global Assessment

1.1.WeightWeight

Ottery FD. Nutrition 1996;12:S15Ottery FD. Nutrition 1996;12:S15

To be completed by the patientTo be completed by the patientGenerated Subjective Global AssessmentGenerated Subjective Global Assessment

2.2. Food intakeFood intake


To be completed by the patientTo be completed by the patient


3.3. SymptomsSymptomsTo be completed by the patientTo be completed by the patient



4.4. Functional capacityFunctional capacityTo be completed by the patientTo be completed by the patient




Worksheet 1Worksheet 1Scoring weight lossScoring weight loss



Worksheet 2Worksheet 2Scoring criteria for conditionScoring criteria for condition



Worksheet 3 Worksheet 3 –– Scoring Physical ExaminationScoring Physical ExaminationGenerated Subjective Global AssessmentGenerated Subjective Global Assessment


Scoring Physical ExaminationScoring Physical Examination



Worksheet 4 Worksheet 4 –– Scoring metabolic stressScoring metabolic stress

Worksheet 4 Worksheet 4 –– SGA ratingSGA rating



Scoring metabolic stressScoring metabolic stress

Several studies have assessed the validity of the PGSeveral studies have assessed the validity of the PGcancer patients:cancer patients:•• PGPG--SGA correlates with sSGA correlates with s--albumin and salbumin and sPerson C et al. Clin Nutr 1999;18:71Person C et al. Clin Nutr 1999;18:71•• PGPG--SGA correlates with weight loss in the previous 6 mthsSGA correlates with weight loss in the previous 6 mthsBauer J et al. Eur J Clin Nutr 2002;56:779Bauer J et al. Eur J Clin Nutr 2002;56:779Isenring E et al. Eur J Clin Nutr 2003;57:305Isenring E et al. Eur J Clin Nutr 2003;57:305•• PGPG--SGA correlates with LOSSGA correlates with LOSBauer J et al. Eur J Clin Nutr 2002;56:779Bauer J et al. Eur J Clin Nutr 2002;56:779•• PGPG--SGA correlates with QoLSGA correlates with QoLIsenring E et al. Eur J Clin Nutr 2003;57:305Isenring E et al. Eur J Clin Nutr 2003;57:305•• PGPG--SGA correlates with energy intake (kcal)SGA correlates with energy intake (kcal)Ravasco P et al. Clin Oncol 2003;15:443Ravasco P et al. Clin Oncol 2003;15:443

PG-SGA represents a good option for assessing nutritional status in various clinical situationsSeveral studies have assessed the validity of the PGSeveral studies have assessed the validity of the PG--SGA inSGA in

albumin and salbumin and s--prepre--albuminalbumin

SGA correlates with weight loss in the previous 6 mthsSGA correlates with weight loss in the previous 6 mthsBauer J et al. Eur J Clin Nutr 2002;56:779Bauer J et al. Eur J Clin Nutr 2002;56:779Isenring E et al. Eur J Clin Nutr 2003;57:305Isenring E et al. Eur J Clin Nutr 2003;57:305Bauer J et al. Eur J Clin Nutr 2002;56:779Bauer J et al. Eur J Clin Nutr 2002;56:779Isenring E et al. Eur J Clin Nutr 2003;57:305Isenring E et al. Eur J Clin Nutr 2003;57:305SGA correlates with energy intake (kcal)SGA correlates with energy intake (kcal)Ravasco P et al. Clin Oncol 2003;15:443Ravasco P et al. Clin Oncol 2003;15:443

SGA represents a good option for assessing nutritional status in various clinical situations

•• Training is required to score the patient generated section,Training is required to score the patient generated section,as well as to complete the clinical assessment portion of the PGas well as to complete the clinical assessment portion of the PGKubrak C et al. Cancer Nurs 2007;30:E1Kubrak C et al. Cancer Nurs 2007;30:E1•• Patients has difficulty recalling their weight in the previous year.Patients has difficulty recalling their weight in the previous year.Persson C. et al. Clin Nutr 1999;18:71Persson C. et al. Clin Nutr 1999;18:71•• Scoring for the PGScoring for the PG--SGA requires training.SGA requires training.Read JA et al. Nutr Cancer 2005;53:51Read JA et al. Nutr Cancer 2005;53:51Training is required to score the patient generated section,Training is required to score the patient generated section,as well as to complete the clinical assessment portion of the PGas well as to complete the clinical assessment portion of the PG--SGA.SGA.Kubrak C et al. Cancer Nurs 2007;30:E1Kubrak C et al. Cancer Nurs 2007;30:E1Patients has difficulty recalling their weight in the previous year.Patients has difficulty recalling their weight in the previous year.

SGA requires training.SGA requires training.Read JA et al. Nutr Cancer 2005;53:51Read JA et al. Nutr Cancer 2005;53:51

•• Training is required to score the patient generated section,Training is required to score the patient generated section,as well as to complete the clinical assessment portion of the PGas well as to complete the clinical assessment portion of the PGKubrak C et al. Cancer Nurs 2007;30:E1Kubrak C et al. Cancer Nurs 2007;30:E1•• Patients has difficulty recalling their weight in the previous year.Patients has difficulty recalling their weight in the previous year.Persson C. et al. Clin Nutr 1999;18:71Persson C. et al. Clin Nutr 1999;18:71•• Scoring for the PGScoring for the PG--SGA requires training.SGA requires training.Read JA et al. Nutr Cancer 2005;53:51Read JA et al. Nutr Cancer 2005;53:51•• SGA does not allow for the categorization of mild malnutrition andSGA does not allow for the categorization of mild malnutrition andfocuses on chronic or established rather than acute nutritional changes.focuses on chronic or established rather than acute nutritional changes.Sungurtekin H et al. Nutrition 2004;20:428Sungurtekin H et al. Nutrition 2004;20:428Christensson L et al. Eur J Clin Nutr 2002;56:810Christensson L et al. Eur J Clin Nutr 2002;56:810•• The SGA might equally likely represent an index of sickness ratherThe SGA might equally likely represent an index of sickness ratherthan nutrition.than nutrition.Jeejeebhoy KN, Philadelphiy:Saunders, W.B. ;1990Jeejeebhoy KN, Philadelphiy:Saunders, W.B. ;1990•• The SGA better identifies established malnutrition than nutritional riskThe SGA better identifies established malnutrition than nutritional riskits sensitivity is suboptimal.its sensitivity is suboptimal.Detsky AS et al. JAMA 1994;271:54 / Kyle UG et al. Clin Nutr 2006;25:409Detsky AS et al. JAMA 1994;271:54 / Kyle UG et al. Clin Nutr 2006;25:409

Training is required to score the patient generated section,Training is required to score the patient generated section,as well as to complete the clinical assessment portion of the PGas well as to complete the clinical assessment portion of the PG--SGA.SGA.Kubrak C et al. Cancer Nurs 2007;30:E1Kubrak C et al. Cancer Nurs 2007;30:E1Patients has difficulty recalling their weight in the previous year.Patients has difficulty recalling their weight in the previous year.

SGA requires training.SGA requires training.Read JA et al. Nutr Cancer 2005;53:51Read JA et al. Nutr Cancer 2005;53:51SGA does not allow for the categorization of mild malnutrition andSGA does not allow for the categorization of mild malnutrition andfocuses on chronic or established rather than acute nutritional changes.focuses on chronic or established rather than acute nutritional changes.Sungurtekin H et al. Nutrition 2004;20:428Sungurtekin H et al. Nutrition 2004;20:428Christensson L et al. Eur J Clin Nutr 2002;56:810Christensson L et al. Eur J Clin Nutr 2002;56:810The SGA might equally likely represent an index of sickness ratherThe SGA might equally likely represent an index of sickness ratherJeejeebhoy KN, Philadelphiy:Saunders, W.B. ;1990Jeejeebhoy KN, Philadelphiy:Saunders, W.B. ;1990The SGA better identifies established malnutrition than nutritional riskThe SGA better identifies established malnutrition than nutritional riskDetsky AS et al. JAMA 1994;271:54 / Kyle UG et al. Clin Nutr 2006;25:409Detsky AS et al. JAMA 1994;271:54 / Kyle UG et al. Clin Nutr 2006;25:409

NutritionalNutritional managementmanagementAdmissionAdmission

HospitalHospital

Not at nutritional riskNot at nutritional risk

ReRe--ScreeningScreeningScreeningScreeningRapid, simple identificationRapid, simple identification

managementmanagement

DischargeDischargeHospitalHospital

ScreeningScreening

NS stable or NS stable or ↑↑↑↑↑↑↑↑

ScreeningScreeningRapid, simple identificationRapid, simple identification

Nutritional riskNutritional risk


HospitalHospital

ReRe--ScreeningScreening

AssessmentAssessmentDetailed examinationDetailed examination




ScreeningScreening



HospitalHospital

NutritionalNutritional

planplan


therapytherapy

TherapyTherapy

monitoringmonitoring

ReRe--ScreeningScreeningScreeningScreeningRapid, simple identificationRapid, simple identification






TherapyTherapy


ScreeningScreening



HospitalHospital


planplan


therapytherapy

TherapyTherapy









TherapyTherapy


EndEnd

of nutritionalof nutritional

therapytherapy

NS NS ↓↓↓↓↓↓↓↓

ScreeningScreening



AdmissionAdmissionHospitalHospital


planplan


therapytherapy

TherapyTherapy





NutritionalNutritional managementmanagement





TherapyTherapy


EndEnd

of nutritionalof nutritional

therapytherapy

AmbulatoryAmbulatory

follow upfollow up

NS NS ↓↓↓↓↓↓↓↓


ScreeningScreening


•• As first line strategy for identifying malnourished cancerAs first line strategy for identifying malnourished cancerpatients patients routine screeningroutine screening is essential.is essential.

Take home messageTake home messageAs first line strategy for identifying malnourished cancerAs first line strategy for identifying malnourished cancer

is essential.is essential.

Take home messageTake home message

•• As first line strategy for identifying malnourished cancerAs first line strategy for identifying malnourished cancerpatients routine screening is essential.patients routine screening is essential.•• The The PGPG--SGASGA is the most studied and widely accepted systemis the most studied and widely accepted system

for an for an accurate nutritional assessmentaccurate nutritional assessmentHoweverHowever-- it is a less simple tool for screening purposes becauseit is a less simple tool for screening purposes because-- it requires that patients are able to read and writeit requires that patients are able to read and write-- is more time consuming andis more time consuming and-- relies on skilled staff to carry out the evaluationrelies on skilled staff to carry out the evaluation

Take home messageTake home messageAs first line strategy for identifying malnourished cancerAs first line strategy for identifying malnourished cancerpatients routine screening is essential.patients routine screening is essential.

is the most studied and widely accepted systemis the most studied and widely accepted systemaccurate nutritional assessmentaccurate nutritional assessment of cancer patients.of cancer patients.

it is a less simple tool for screening purposes becauseit is a less simple tool for screening purposes becauseit requires that patients are able to read and writeit requires that patients are able to read and writeis more time consuming andis more time consuming andrelies on skilled staff to carry out the evaluationrelies on skilled staff to carry out the evaluation


•• As first line strategy for identifying malnourished cancerAs first line strategy for identifying malnourished cancerpatients routine screening is essential.patients routine screening is essential.•• The The PGPG--SGASGA is the most studied and widely accepted systemis the most studied and widely accepted system

for an accurate nutritional assessment of cancer patients.for an accurate nutritional assessment of cancer patients.HoweverHowever-- it is a less simple tool for screening purposes becauseit is a less simple tool for screening purposes because-- it requires that patients are able to read and writeit requires that patients are able to read and write-- is more time consuming andis more time consuming and-- relies on skilled staff to carry out the evaluationrelies on skilled staff to carry out the evaluation•• MUSTMUST or or NRS 2002NRS 2002 combine the question regardingcombine the question regarding

appetite and recent unintentional weight loss with appetite and recent unintentional weight loss with sensivity and specifitysensivity and specifity at predicting the at predicting the Depends less on examiner training than the Depends less on examiner training than the

Take home messageTake home messageAs first line strategy for identifying malnourished cancerAs first line strategy for identifying malnourished cancerpatients routine screening is essential.patients routine screening is essential.

is the most studied and widely accepted systemis the most studied and widely accepted systemfor an accurate nutritional assessment of cancer patients.for an accurate nutritional assessment of cancer patients.

it is a less simple tool for screening purposes becauseit is a less simple tool for screening purposes becauseit requires that patients are able to read and writeit requires that patients are able to read and writeis more time consuming andis more time consuming andrelies on skilled staff to carry out the evaluationrelies on skilled staff to carry out the evaluation

combine the question regardingcombine the question regardingappetite and recent unintentional weight loss with appetite and recent unintentional weight loss with a higha high

at predicting the at predicting the SGASGA score.score.Depends less on examiner training than the Depends less on examiner training than the SGASGA. .


ThanksThanksfor yourfor yourattention !attention !

ThanksThanksfor yourfor yourattention !attention !

Documents

ESMO Symposium on Cancer and Nutrition 2009 Presentation: … · Title: ESMO Symposium on Cancer and Nutrition 2009 Presentation: Screening tools in daily practice: The focus on cancer