C-Reactive Protein and C-Reactive Protein-Based Scores to Predict Survival in Esophageal and Junctional Adenocarcinoma: Systematic Review and Meta-Analysis.

BACKGROUND: Esophageal adenocarcinoma (EAC) has a poor prognosis; predictive markers of prognosis would facilitate advances in personalized therapy. C-reactive protein (CRP) and CRP-based scores are increasingly recommended across oncology; however, their role and value in EAC is unclear. This systematic review and meta-analysis examined CRP cut-point and scores and how they may best be applied in predicting survival in EAC. METHODS: A systematic literature search was conducted in EMBASE, Medline, Web of Science, Cochrane, Scopus and CINAHL databases, from inception to 1st October 2020. Studies reporting data from adults with EAC including adenocarcinoma of the gastro-esophageal junction (AEG), pre-treatment CRP or CRP-based score and Hazard Ratio (HR) for survival were included. QUIPS tool assessed risk of bias. Meta-analysis was undertaken. RESULTS: A total of 819 records were screened. Eight papers were included, with data for 1475 people. CRP cut-points ranged from 2.8 to 10 mg/L. The Glasgow Prognostic Score (GPS) and modified GPS were the most commonly reported scores. On meta-analysis, elevated preoperative GPS/mGPS was significantly associated with worse overall survival (hazards ratio [HR] 1.81, 95% confidence interval [CI] 1.25-2.62, p = 0.002); results were similar in subgroup analyses of multimodal treatment, M0 disease, and R0 resection. CONCLUSIONS: This is the first review to evaluate comprehensively the evidence for CRP and CRP-based scores in EAC. Meta-analysis demonstrated that elevated preoperative GPS or mGPS was significantly associated with reduced overall survival in EAC, including AEG. There is insufficient evidence to support use of CRP alone. Future studies should examine GPS/mGPS in EAC prospectively, alone and combined with other prognostic markers.

Late referral of cancer patients with malnutrition to dietitians: a prospective study of clinical practice.

PURPOSE: Malnutrition (MN) in cancer is common but underdiagnosed. Dietitian referrals may not occur until MN is established. We investigated cancer patient characteristics (demographics, nutritional status, and nutrition barriers) on referral to oncology dietitians. We also examined referral practices and prevalence of missed referral opportunities. METHODS: This was a naturalistic multi-site study of clinical practice. Data from consecutive referrals were collected in inpatient and outpatient settings. Demographics, nutritional status (weight, body mass index (BMI), weight loss in the preceding 3-6 months, oral intake, nutrition barriers), referral reasons, and use of screening were recorded. Missed opportunities for earlier referral were also noted. RESULTS: Two hundred patients were included (60% male, 51% inpatients). Half had gastrointestinal and hepatobiliary cancers. The majority were on antitumor treatment. Two-thirds had lost ≥ 5% body weight. Forty percent were overweight or obese. Seventy percent had ≥ 2 nutritional barriers. Most common nutrition barriers were anorexia, nausea, and early satiety. Greater weight loss and lower food intake were associated with ≥ 2 barriers. Weight loss was the most common referral reason. Screening was used in 35%. Referrals should have occurred sooner in nearly half (45%, n = 89). CONCLUSIONS: Cancer patients were referred late to a dietitian, with multiple nutritional barriers. Most referrals were for established weight loss (WL). WL may be masked by pre-existing obesity. Almost half had missed earlier referral opportunities; screening was infrequent. Over one-quarter should have been re-referred sooner. There is a clear need for clinician education. Future research should investigate the optimal timing of dietitian referral and the best nutrition screening tools for use in cancer.

Application of the 2011 international consensus cancer cachexia classification in routine oncology dietetic practice: An observational study.

BACKGROUND: Cancer cachexia (CC) is highly prevalent and associated with significant morbidity and mortality, yet underrecognized. In 2011, an international cachexia consensus (ICC) proposed a definition, assessment framework, and stages for classification: cancer precachexia, cachexia, and refractory cachexia. The authors anticipated that a "more practical classification approach for clinical practice" would be required, which we interpreted as a bedside assessment based on clinical data. We investigated whether the ICC classification could be employed in routine dietetic practice without access to objective muscle mass measures. METHODS: Data from 200 consecutive patients with solid tumors were collected as part of clinical practice by oncology dietitians in five tertiary referral hospitals. Dietitians used information gathered during their routine assessment and applied the ICC framework to assign a stage. When the dietitian was unable to assign a stage, the reason was noted. RESULTS: Based on available data, classification was possible in 177 (88%); 23 (12%) could not be staged. The reasons cited were as follows: unknown C-reactive protein (n = 14), complex clinical situation (n = 5), unknown weight loss (n = 2), and acute illness (n = 2). Thirty (17%) of the 177 participants were judged to be noncachectic.  One hundred twelve (83%) met the criteria for 1 of the 3 ICC stages: 92 (52%) were cachectic; 35 (20%) precachectic, and 20 (11%) refractory. CONCLUSIONS: CC staging based on the ICC classification was feasible and practical in routine dietetic practice even without access to objective muscle mass measures. Once validated and operationalized, expert clinical assessment by a dietitian could be a cost-effective means to identify and stage CC, with more resource-intensive means used when there is clinical doubt.