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CME / ABIM MOC / CE

How Does Malnutrition Affect Postoperative Outcomes in Gynecologic Cancer?

  • Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 7/15/2022
  • Valid for credit through: 7/15/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

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Target Audience and Goal Statement

This activity is intended for obstetricians/gynecologists/women's health clinicians, family medicine and primary care practitioners, nurses, hematologists/oncologists, physician assistants, internists, and other members of the healthcare team for patients undergoing surgery for gynecologic cancer.

The goal of this activity is for learners to be better able to describe the association of various malnutrition definitions, including those of the European Society for Clinical Nutrition and Metabolism (ESPEN) and American College of Surgeons (ACS), with postoperative morbidity in 3 gynecologic malignancies, according to a retrospective analysis using the National Surgical Quality Improvement Program (NSQIP) database to identify patients undergoing resection of ovarian, uterine, or cervical cancer between 2005 and 2019.

Upon completion of this activity, participants will:

  • Describe the association of various malnutrition definitions with postoperative morbidity in 3 gynecologic malignancies, according to retrospective analysis using the NSQIP database
  • Determine clinical implications of the association of various malnutrition definitions with postoperative morbidity in 3 gynecologic malignancies, according to a retrospective analysis using the NSQIP database
  • Outline implications for the healthcare team


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News Author

  • Megan Brooks

    Freelance writer, Medscape

    Disclosures

    Megan Brooks has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has the following relevant financial relationships:
    Formerly owned stocks in: AbbVie Inc.

Editor/Nurse Planner

  • Leigh Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CMSRN, CNE, CHCP, has no relevant financial relationships.

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.


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CME / ABIM MOC / CE

How Does Malnutrition Affect Postoperative Outcomes in Gynecologic Cancer?

Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 7/15/2022

Valid for credit through: 7/15/2023

processing....

Clinical Context

Approximately 40% to 80% of patients with cancer have malnutrition, and tumor- or treatment-induced malnutrition cause ~ 20% of cancer deaths. Nutritional status predicts perioperative morbidity and mortality in patients undergoing cancer surgery.

Multiple definitions and criteria exist for malnutrition. Studies have shown that the most appropriate malnutrition definition and associated risk for morbidity and mortality varies by cancer type among general surgery oncology patients.

Women with gynecologic cancers who meet criteria for malnutrition before surgery face a higher risk for poor postoperative outcomes; however, the value of preoperative malnutrition assessments depends on the definition of malnutrition used as well as the gynecologic cancer type, according to new findings published in Gynecologic Oncology.

Study Synopsis and Perspective

For ovarian cancer, 2 definitions of malnutrition -- European Society for Clinical Nutrition and Metabolism 2 (ESPEN 2) and low albumin -- were associated with the highest number of adverse outcomes, but for uterine cancer, low albumin and American College of Surgeons (ACS) criteria were associated with the most adverse outcomes.

"By identifying the most relevant definitions of malnutrition for each gynecologic cancer, we hope to inform future patient-specific perioperative nutrition management and risk-based counseling," lead author Laura Havrilesky, MD, and colleagues with Duke University, Durham, North Carolina, wrote.

As many as 80% of patients with cancer experience malnutrition. Prior studies have shown that nutritional status affects postoperative outcomes in gynecologic cancers, including mortality, but knowing which definitions of malnutrition are most appropriate for each cancer type remains unclear.

Using the National Surgical Quality Improvement Program (NSQIP) database, the researchers identified 76,290 patients undergoing surgery for uterine (68.8%), ovarian (23.3%), or cervical cancer (7.9%) between 2005 and 2019. The authors then classified patients using the following 6 criteria and definitions of malnutrition.

The ESPEN uses 2 definitions for malnutrition: ESPEN 1 and ESPEN 2.

ESPEN 1 defines malnutrition as a body mass index (BMI) of 18.5 to 20 for persons younger than age 70 years or 18.5 to 22 for persons aged 70 years and older plus unintended weight loss of more than 10% over any period or more than 5% over 3 months.

ESPEN 2 defines malnutrition as a BMI under 18.5.

The ACS defines malnutrition as more than 10% weight loss during the 6 months before surgery for persons with a BMI in the normal or overweight range. A definition for severe malnutrition is a BMI below 18.5 plus 10% weight loss whereas the definition for mild malnutrition is a BMI of 18.5 to 20 for persons younger than age 70 and 18.6 to 22 for persons aged 70 years and older.

Finally, low albumin (< 3.5 g/dL) is a measure for malnutrition.

The authors found that 3.7% of the women met the definition for mild malnutrition, 0.1% for severe malnutrition, 0.2% for ESPEN 1, 1.1% for ESPEN 2, and 1.3% for ACS. For the 61.4% of women with a preoperative serum albumin recorded, 11.1% had an albumin level < 3.5 g/dL.

Patients who met any definition of malnutrition faced a higher risk for major complications regardless of cancer type. Overall, major complications occurred in 13.5% of cases, unplanned readmission in 5.5%, and repeat surgery in 1.7%.

For uterine cancer, malnutrition by the ACS definition and low albumin were associated with the highest number of adverse events. The ACS definition was associated with an increased risk for readmission (adjusted relative risk [aRR] 2.74), reoperation (aRR 3.61), major complications (aRR 3.92), and minor complications (aRR 2.03).

Similarly, for uterine cancer, low albumin was associated with an increased risk for readmission (aRR 2.38), and reoperation (aRR 2.56), as well as major (aRR 3.74) and minor (aRR 2.17) complications.

For ovarian cancer, ESPEN 2 and low albumin were associated with the highest number of adverse outcomes. ESPEN 2 was associated with higher readmissions (aRR 1.69), reoperations (aRR 2.53), and major complications (aRR 1.36). Similarly, low albumin was associated with a higher risk for readmission (aRR 1.28), reoperation (aRR 1.31), and major complications (aRR 1.74). 

"Patients with ovarian cancer have been shown to be the most malnourished population among gynecologic malignancies, possibly due to their frequent diagnosis at stage III-IV," the authors noted.

For cervical cancer, low albumin was associated with an increased risk for readmissions (aRR 1.48), repeat surgery (aRR 2.25), longer length of stay (LOS) (4 days), and major (aRR 2.59), and minor (aRR 1.52) complications. 

In fact, "low albumin is associated with all major poor outcomes across all cancers and should be measured prior to surgery," the authors noted.

Patients with low albumin had a 10-fold higher risk for death within 30 days of surgery compared with patients with normal albumin and were more likely to have major and minor complications and longer hospital stays.

Overall, this study demonstrates how different definitions of malnutrition are associated with different postoperative outcomes for 3 gynecologic cancers.

"Nutritional markers such as BMI, weight loss, and albumin should be evaluated in all gynecologic cancer patients to accurately diagnose preoperative malnutrition," the authors concluded.

The study had no specific funding. The authors reported no relevant disclosures.

Gynecol Oncol. 2022;165:309-316.[1]

Study Highlights

  • Researchers identified patients undergoing resection of ovarian, uterine, or cervical cancer between 2005 and 2019 (N = 76,290) from the NSQIP database.
  • They defined severe malnutrition as BMI < 18.5 plus 10% weight loss over 6 months before surgery; ESPEN 1 as BMI 18.5 to 22 plus 10% weight loss, ESPEN 2 as BMI < 18.5, ACS as normal/overweight BMI plus 10% weight loss, mild malnutrition as BMI 18.5 to 22 or albumin < 3.5 g/dL.
  • Percentages of patients meeting malnutrition definitions were: 0.1%, severe; 0.2%, ESPEN 1; 1.1%, ESPEN 2; 1.3%, ACS; 3.7%, mild; and 11.1%, albumin < 3.5 g/dL.
  • Overall, 5.5% had unplanned readmission, 1.7% reoperation, and 13.5% major complications.
  • For ovarian cancer, ESPEN 2 malnutrition was associated with higher readmissions (aRR 1.69 [95% CI: 1.29, 2.2]), reoperations (2.53 [95% CI: 1.7, 3.77]), and major complications (1.36 [95% CI: 1.2, 1.54]).
  • For uterine cancer, ACS malnutrition was associated with readmissions (2.74 [95% CI: 2.09, 3.59]), reoperations (3.61 [95% CI: 2.29, 5.71]) and complications (3.92 [95% CI: 3.4, 4.53]).
  • For cervical cancer, albumin < 3.5 g/dL was associated with readmissions (1.48 [95% CI: 1.01, 2.19]), reoperations (2.25 [95% CI: 1.17, 4.34]), longer LOS (4.02 [2.52, 5.51] days), major complications (2.59 [95% CI: 2.11, 3.17]), and minor complications (1.52 [95% CI: 1.04, 2.21]).
  • In cervical, ovarian, and uterine cancer, albumin < 3.5 g/dL was associated with adverse outcomes.
  • Patients with low vs normal albumin had a 10-fold increased risk for death within 30 days of surgery and were more likely to have major and minor complications and longer hospital stays.
  • The investigators concluded that in uterine cancer, weight loss and albumin were associated with major complications, reoperation, and readmission; in cervical cancer, only albumin was associated with an increased risk for all adverse outcomes; and in ovarian cancer, weight loss, low BMI, and albumin were associated with postoperative adverse outcomes.
  • Regardless of cancer type, patients meeting any malnutrition definition were at increased risk for major complications.
  • Major complications, readmissions, and reoperations were all associated with the ESPEN 2 definition for ovarian cancer, the ACS definition for uterine cancer, and with albumin < 3.5 g/dL for all cancers.
  • Among patients with gynecologic cancers, persons with ovarian cancer are the most malnourished population, possibly explained by frequent diagnosis at stages III to IV.
  • The association between malnutrition definitions and postoperative outcomes varies by gynecologic cancer type, consistent with differences in tumor biology, predisposing risk factors, and natural history of each cancer.
  • Preoperative risk assessments might be tailored using cancer-specific malnutrition criteria.
  • To accurately diagnose preoperative malnutrition, nutritional markers including BMI, weight loss, and albumin should be evaluated in all patients with gynecologic cancer. The roles of the interprofessional team members, such as dieticians, family medicine providers, and nurses, should be utilized to optimize care coordination in the diagnostic process.
  • As albumin is a marker of malnutrition and cachexia and is modulated by pro-inflammatory cytokines, low albumin may reflect dysregulated immunological status and reduced immune system ability to resist cancer progression.
  • To best counsel patients regarding anticipated operative risks, clinicians should consider using cancer-specific and patient-specific risk estimates to assess for risk for poor outcomes.
  • Study limitations include those inherent in using the NSQIP database; low numbers of patients after stratifying by cancer type and malnutrition definition; and inability to determine functional outcome and quality of life after surgery.
  • Future research should prospectively validate these different models.
  • Previous research has shown that prehabilitation, or preoperative interventions focused on modifiable risk factors to improve physical, nutritional, and mental status, leads to fewer complications and faster postoperative recovery in oncology patients.
  • Further study is needed to determine whether prehabilitation can reduce postoperative morbidity in patients with gynecologic cancer.

Clinical Implications

  • The association between malnutrition definitions and postoperative outcomes varies by gynecologic cancer type.
  • Preoperative risk assessments might be tailored using cancer-specific malnutrition criteria.
  • Implications for the Healthcare Team: The roles of the interprofessional team should be utilized to accurately diagnose preoperative malnutrition by ensuring markers including BMI, weight loss, and albumin are evaluated in all patients with gynecologic cancer.

 

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