ESMO Symposium on Cancer and Nutrition 2009 Presentation: … · Title: ESMO Symposium on Cancer...
Transcript of ESMO Symposium on Cancer and Nutrition 2009 Presentation: … · Title: ESMO Symposium on Cancer...
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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
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•• 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
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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
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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
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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
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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
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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!
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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
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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
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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
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Percent Percent ≤≤ 5 5 55--10 10 ≥≥ 10 10
In the lastIn the last33--6 months6 months
Weight lossWeight loss(unintentional)(unintentional)
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)
Percent Percent ScoreScore5 5 0010 10 1110 10 22
In the lastIn the last6 months6 months
Weight lossWeight loss(unintentional)(unintentional)
Malnutrition Universal Screening Tool Malnutrition Universal Screening Tool
Malnutrition AdvisoryMalnutrition AdvisoryGroup. BAPEN 2000 Group. BAPEN 2000
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Percent Percent ≤≤ 5 5 55--10 10 ≥≥ 10 10
In the lastIn the last33--6 months6 months
Weight lossWeight loss(unintentional)(unintentional)
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)
Percent Percent ScoreScore5 5 0010 10 1110 10 22
In the lastIn the last6 months6 months
Weight lossWeight loss(unintentional)(unintentional)
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)
Malnutrition Universal Screening Tool Malnutrition Universal Screening Tool
Malnutrition AdvisoryMalnutrition AdvisoryGroup. BAPEN 2000 Group. BAPEN 2000
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Percent Percent ≤≤ 5 5 55--10 10 ≥≥ 10 10
In the lastIn the last33--6 months6 months
Weight lossWeight loss(unintentional)(unintentional)
Add scoresAdd scores
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)
Percent Percent ScoreScore5 5 0010 10 1110 10 22
In the lastIn the last6 months6 months
Weight lossWeight loss(unintentional)(unintentional)
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 Universal Screening Tool Malnutrition Universal Screening Tool
Malnutrition AdvisoryMalnutrition AdvisoryGroup. BAPEN 2000 Group. BAPEN 2000
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MUSTMUST Malnutrition Universal Screening Tool Malnutrition Universal Screening Tool
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
Malnutrition Advisory Group (MAG UK). BAPEN 2000 Malnutrition 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 yearImplementImplement
Overall risk of malnutritionOverall risk of malnutrition
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MUSTMUST Malnutrition Universal Screening Tool Malnutrition Universal Screening Tool
Malnutrition Advisory Group (MAG UK). BAPEN 2000 Malnutrition Advisory Group (MAG UK). BAPEN 2000
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
Malnutrition Advisory Group (MAG UK). BAPEN 2000 Malnutrition 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)ImplementImplement
Overall risk of malnutritionOverall risk of malnutrition
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MUSTMUST Malnutrition Universal Screening Tool Malnutrition Universal Screening Tool
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
Start nutritional therapyStart nutritional therapy
Overall risk of malnutritionOverall risk of malnutrition
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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
substancialsubstancial
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
substancialsubstancial
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PrePre--Screening: four questionsScreening: four questionsNutrition Risk Screening NRS 2002Nutrition Risk Screening NRS 2002QuestionQuestionIs BMI
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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
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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
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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
Start nutritional therapyStart nutritional therapy
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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)
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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)
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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
49%49%
risk of Malnutrition risk of Malnutrition
NRS 2002NRS 2002 Iff S, Stanga Z. Iff S, Stanga Z. Clin Nutr 2008;3:154 (Abstract)Clin Nutr 2008;3:154 (Abstract)
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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
70%70%
risk of Malnutrition risk of Malnutrition
NRS 2002NRS 2002 Iff S, Stanga Z. Iff S, Stanga Z. Clin Nutr 2008;3:154 (Abstract)Clin Nutr 2008;3:154 (Abstract)
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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
Kyle UG et al. Clin Nutr 2006Kyle UG et al. Clin Nutr 2006
= 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
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ComparisonComparison ofof screeningscreening
Kyle UG et al. Clin Nutr 2006Kyle UG et al. Clin Nutr 2006
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
Kyle UG et al. Clin Nutr 2006Kyle UG et al. Clin Nutr 2006
% % 17 17 %% 1.41.4 0.143 0.143 %% 2929 %% 2.42.4
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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
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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
substancialsubstancial
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
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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
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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
Ottery FD. Nutrition 1996;12:S15Ottery FD. Nutrition 1996;12:S15
To be completed by the patientTo be completed by the patient
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PatientPatient--Generated Subjective Global AssessmentGenerated Subjective Global Assessment
3.3. SymptomsSymptomsTo be completed by the patientTo be completed by the patient
Ottery FD. Nutrition 1996;12:S15Ottery FD. Nutrition 1996;12:S15
Generated Subjective Global AssessmentGenerated Subjective Global Assessment
4.4. Functional capacityFunctional capacityTo be completed by the patientTo be completed by the patient
Ottery FD. Nutrition 1996;12:S15Ottery FD. Nutrition 1996;12:S15
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PatientPatient--Generated Subjective Global AssessmentGenerated Subjective Global Assessment
Ottery FD. Nutrition 1996;12:S15Ottery FD. Nutrition 1996;12:S15
Worksheet 1Worksheet 1Scoring weight lossScoring weight loss
Generated Subjective Global AssessmentGenerated Subjective Global Assessment
Ottery FD. Nutrition 1996;12:S15Ottery FD. Nutrition 1996;12:S15
Worksheet 2Worksheet 2Scoring criteria for conditionScoring criteria for condition
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PatientPatient--Generated Subjective Global AssessmentGenerated Subjective Global Assessment
Ottery FD. Nutrition 1996;12:S15Ottery FD. Nutrition 1996;12:S15
Worksheet 3 Worksheet 3 –– Scoring Physical ExaminationScoring Physical ExaminationGenerated Subjective Global AssessmentGenerated Subjective Global Assessment
Ottery FD. Nutrition 1996;12:S15Ottery FD. Nutrition 1996;12:S15
Scoring Physical ExaminationScoring Physical Examination
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PatientPatient--Generated Subjective Global AssessmentGenerated Subjective Global Assessment
Ottery FD. Nutrition 1996;12:S15Ottery FD. Nutrition 1996;12:S15
Worksheet 4 Worksheet 4 –– Scoring metabolic stressScoring metabolic stress
Worksheet 4 Worksheet 4 –– SGA ratingSGA rating
Generated Subjective Global AssessmentGenerated Subjective Global Assessment
Ottery FD. Nutrition 1996;12:S15Ottery FD. Nutrition 1996;12:S15
Scoring metabolic stressScoring metabolic stress
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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
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•• 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
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•• 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
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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 ↑↑↑↑↑↑↑↑
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ScreeningScreeningRapid, simple identificationRapid, simple identification
Nutritional riskNutritional risk
NutritionalNutritional managementmanagementAdmissionAdmission
HospitalHospital
ReRe--ScreeningScreening
AssessmentAssessmentDetailed examinationDetailed examination
Not at nutritional riskNot at nutritional risk
managementmanagement
DischargeDischargeHospitalHospital
ScreeningScreening
Nutritional riskNutritional risk
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NutritionalNutritional managementmanagementAdmissionAdmission
HospitalHospital
NutritionalNutritional
planplan
NutritionalNutritional
therapytherapy
TherapyTherapy
monitoringmonitoring
ReRe--ScreeningScreeningScreeningScreeningRapid, simple identificationRapid, simple identification
Nutritional riskNutritional risk
Not at nutritional riskNot at nutritional risk
AssessmentAssessmentDetailed examinationDetailed examination
managementmanagement
DischargeDischargeHospitalHospital
TherapyTherapy
monitoringmonitoring
ScreeningScreening
NS stable or NS stable or ↑↑↑↑↑↑↑↑
-
NutritionalNutritional managementmanagementAdmissionAdmission
HospitalHospital
NutritionalNutritional
planplan
NutritionalNutritional
therapytherapy
TherapyTherapy
monitoringmonitoring
ScreeningScreeningRapid, simple identificationRapid, simple identification
Nutritional riskNutritional risk
AssessmentAssessmentDetailed examinationDetailed examination
ReRe--ScreeningScreening
Not at nutritional riskNot at nutritional risk
NS stable or NS stable or ↑↑↑↑↑↑↑↑
managementmanagement
TherapyTherapy
monitoringmonitoring
EndEnd
of nutritionalof nutritional
therapytherapy
NS NS ↓↓↓↓↓↓↓↓
ScreeningScreening
NS stable or NS stable or ↑↑↑↑↑↑↑↑
DischargeDischargeHospitalHospital
-
AdmissionAdmissionHospitalHospital
NutritionalNutritional
planplan
NutritionalNutritional
therapytherapy
TherapyTherapy
monitoringmonitoring
ScreeningScreeningRapid, simple identificationRapid, simple identification
Nutritional riskNutritional risk
AssessmentAssessmentDetailed examinationDetailed examination
NutritionalNutritional managementmanagement
ReRe--ScreeningScreening
Not at nutritional riskNot at nutritional risk
NS stable or NS stable or ↑↑↑↑↑↑↑↑
DischargeDischargeHospitalHospital
TherapyTherapy
monitoringmonitoring
EndEnd
of nutritionalof nutritional
therapytherapy
AmbulatoryAmbulatory
follow upfollow up
NS NS ↓↓↓↓↓↓↓↓
managementmanagement
ScreeningScreening
NS stable or NS stable or ↑↑↑↑↑↑↑↑
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•• 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
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•• 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
Take home messageTake home message
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•• 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. .
Take home messageTake home message
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ThanksThanksfor yourfor yourattention !attention !
ThanksThanksfor yourfor yourattention !attention !