Decision tree algorithm to predict mortality in incurable cancer: a new prognostic model.

OBJECTIVES: To develop and validate a new prognostic model to predict 90-day mortality in patients with incurable cancer. METHODS: In this prospective cohort study, patients with incurable cancer receiving palliative care (n = 1322) were randomly divided into two groups: development (n = 926, 70%) and validation (n = 396, 30%). A decision tree algorithm was used to develop a prognostic model with clinical variables. The accuracy and applicability of the proposed model were assessed by the C-statistic, calibration and receiver operating characteristic (ROC) curve. RESULTS: Albumin (75.2%), C reactive protein (CRP) (47.7%) and Karnofsky Performance Status (KPS) ≥50% (26.5%) were the variables that most contributed to the classification power of the prognostic model, named Simple decision Tree algorithm for predicting mortality in patients with Incurable Cancer (acromion STIC). This was used to identify three groups of increasing risk of 90-day mortality: STIC-1 - low risk (probability of death: 0.30): albumin ≥3.6 g/dL, CRP <7.8 mg/dL and KPS ≥50%; STIC-2 - medium risk (probability of death: 0.66 to 0.69): albumin ≥3.6 g/dL, CRP <7.8 mg/dL and KPS <50%, or albumin ≥3.6 g/dL and CRP ≥7.8 mg/dL; STIC-3 - high risk (probability of death: 0.79): albumin <3.6 g/dL. In the validation dataset, good accuracy (C-statistic ≥0.71), Hosmer-Lemeshow p=0.12 and area under the ROC curve=0.707 were found. CONCLUSIONS: STIC is a valid, practical tool for stratifying patients with incurable cancer into three risk groups for 90-day mortality.

Effects of specialised nutritional interventions in patients with incurable cancer: a systematic review.

OBJECTIVE: To evaluate current evidence of the effect of specialised nutritional interventions on nutritional status, survival, quality of life and measures of functionality in patients with incurable cancer. METHODS: Systematic literature review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed/MEDLINE, EMBASE, Scopus, LILACS and Cochrane Library databases. Clinical studies that evaluated different specialised nutritional interventions, such as nutritional counselling, oral nutritional supplementation (ONS), enteral nutrition (EN) and parenteral nutrition (PN), were eligible. Only studies classified as being of high methodological quality (ie, low or moderate risk of bias) were included. RESULTS: A total of 22 studies reporting on 2448 patients were deemed eligible. Five types of specialised nutrition were observed: mixed (multimodal nature, ie, dietary counseling, ONS, physical activity and/or drugs) (n=12), ONS (n=5), PN (n=3), EN (n=1) and multidisciplinary team counselling (n=1). Benefits of any kind from the interventions were reported in 14 (63.6%) studies, mainly resulting from mixed intervention. Nutritional status improved in 12 (60.0%) of 20 studies and quality of life improved in eight (50.0%) of 16 studies. Few studies have evaluated the influence of nutritional interventions on survival and measure of functionality, and have not shown improvement in these outcomes. CONCLUSION: Despite the limited evidence, specialised nutritional interventions can yield positive effects for patients with incurable cancer, mainly in their nutritional status and quality of life.

Development and validation of a grading system for assessing muscle mass phenotype using mid-upper arm muscle area and handgrip strength in patients with incurable cancer.

BACKGROUND: This study aimed to develop and validate a distinct method to evaluate muscle mass phenotype in patients with incurable cancer based on a combination of mid-upper arm muscle area (MUAMA) and handgrip strength (HGS). METHODS: This prospective cohort study was conducted with patients with incurable cancer who were enrolled at the palliative care unit of a cancer institute. The 1,660 patients were randomized into two data sets: training (70%; n = 1162), used to determine the muscle mass phenotype groups, derived from a combination of MUAMA and HGS cutoff points related to 180-days mortality; and validation (30%; n = 498), used to evaluate the relationship of the proposed muscle phenotype grading system with performance status, body composition, nutrition status, and mortality. RESULTS: The training data set resulted in three distinct groups formed by combining the cutoff points of MUAMA and HGS, with the best muscle mass phenotype being group 1, the group with any impairment of muscle mass being the 2, and the worst muscle mass phenotype being group 3. In the validation data set, lower performance status (both sexes p < 0.001), worse skeletal muscle index (both sexes p < 0.001), muscle radiodensity (men, p = 0.001; women, p = 0.008), and nutritional status (men, p = 0.003; women, p < 0.001) were observed as MUAMA and HGS values diminished. Patients in group 3 presented significantly higher risk of 180-day mortality (both sexes p < 0.001). CONCLUSION: The muscle mass phenotype grading system proved to be able to identify patients with lower performance status, worse body composition measurements and nutritional status, and higher risk of death in 180 days.

The Nutritional Approach Challenge of a Patient with Colon Cancer and Leptomeningeal Metastasis in Clinical Practice: Case Report / Desafio da Abordagem Nutricional de uma Paciente com Câncer de Cólon e Metástase Leptomeníngea na Prática Clínica: Relato de Caso / El Reto de la Abordaje Nutricional de una Paciente con Cáncer de Colon y Metástasis Leptomeníngeas em la Práctica Clínica: Relato de Caso

Introduction: Leptomeningeal metastasis is an extremely rare evolution of colon cancer, with reduced survival, requiring early palliative treatment in order to improve the patient's quality of life. The aim of this study was to report the case of a patient with colon cancer with leptomeningeal carcinomatosis, from the perspective of the nutritional approach in exclusive palliative care. Case report: Young female patient with diagnosis of colon cancer, metastatic to leptomeninges, admitted to a Palliative Care Unit, with reduced functionality and nutritional risk. From the 1st to the 8th day of hospitalization, she remained on zero diet. In the few moments when she was more alert, there was an attempt to offer liquid oral diet, which could not be achieved due to high risk of bronchoaspiration. After multiprofessional team discussions and conversations with the patient's family members, it was decided to place the nasoenteric catheter (NEC). The patient alternated periods on zero diet and nutrition by NEC according to clinical and nutritional conditions. Conclusion: It is necessary to reconcile a safe food route for quality of life and death, considering not only the patient, but the feelings and meanings the family members attribute to food

Introdução: A metástase leptomeníngea é uma evolução extremamente rara do câncer de cólon, com sobrevida reduzida, demandando tratamento paliativo precoce no intuito de melhorar a qualidade de vida do paciente. O objetivo deste estudo foi relatar o caso de uma paciente com câncer de cólon com carcinomatose leptomeníngea, sob a perspectiva da abordagem nutricional em cuidados paliativos exclusivos. Relato do caso: Paciente jovem, sexo feminino, com diagnóstico de câncer de cólon, metastático para leptomeninge de rara evolução, admitida na Unidade de Cuidados Paliativos, com funcionalidade reduzida e risco nutricional. Do 1º ao 8º dia de internação, manteve dieta zero. Nos poucos momentos em que esteve mais alerta, houve uma tentativa de oferta de dieta via oral líquida, o que não pôde ser alcançado em virtude do alto risco de broncoaspiração. Após discussões entre a equipe multiprofissional e conversas com familiares da paciente, optou-se pela colocação do cateter nasoentérico (CNE). A paciente alternava períodos de dieta zero e nutrição pela CNE de acordo com suas condições clínicas e nutricionais. Conclusão: É necessário conciliar uma via alimentar segura para qualidade de vida e de morte, contemplando não somente o paciente, como também os sentidos e significados atribuídos à alimentação por seus familiares

Introducción: La metástasis leptomeníngea es una evolución extremadamente rara del cáncer de colon, con supervivencia reducida, requiriendo tratamiento paliativo precoz para mejorar la calidad de vida del paciente. El objetivo de este estudio fue reportar el caso de una paciente con cáncer de colon con carcinometosis leptomeníngea, desde la perspectiva del abordaje nutricional en cuidados paliativos exclusivos. Relato del caso: Paciente joven con diagnóstico de cáncer de colon, metastásico a leptomeninge, ingresado en una Unidad de Cuidados Paliativos, con funcionalidad y riesgo nutricional reducidos. Desde el 1º al 8º día de hospitalización, permaneció con dieta cero. En los pocos momentos en que estuvo alerta, se intentó ofrecer dieta líquida oral, lo que no se pudo lograr por alto riesgo de broncoaspiración. Luego de discusiones entre el equipo multiprofesional y conversaciones con familiares del paciente, se decidió colocar el catéter nasoentérico (CNE). El paciente alternó períodos de dieta cero y nutrición por CNE de acuerdo con sus condiciones clínicas y nutricionales. Conclusión: Es necesario conciliar una ruta alimentaria segura para la calidad de vida y la muerte, contemplando no solo al paciente, sino también los sentidos y significados atribuidos a la alimentación por sus familiares