The incidence of tumors of the digestive tract is high

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1 Copyright B 2008 Wolters Kluwer Health Lippicott Williams & Wilkis Ju Tia, PhD Zhe-chu Che, PhD Li-fag Hag The Effects of Nutritio Status of Patiets With Digestive System Cacers o Progosis of the Disease K E Y W O R D S Digestive system tumor Follow-up study Nutritio Quality of life Survival rate To assess the associatio betwee utritio status ad progosis of patiets with digestive system cacer, epidemiological ivestigatios were coducted i 2 periods to obtai iformatio about the patiets utritio status, survival time, ad quality of life. Relative risks ad 95% cofidece itervals were estimated by logistic regressio. Amog the patiets with esophagus, stomach, ad colorectal cacers, utritioal idicators at time 1 did ot affect relative risk for survival at time 2. At time 2, relatios betwee quality of life ad albumi, daily itake of calories, ad daily itake of protei were statistically sigificat (P G.05). This study offers evidece that utritio status shortly after operatio does ot affect 1-year survival rate ad that utritioal status at 1 year is associated with quality of life. The icidece of tumors of the digestive tract is high amog Chiese residets. As the livig stadards of the people rose, dietary patters were chaged from high-carbohydrate, low-protei, ad low-fat itake ito highfat ad lowydietary fiber itake, which may cotribute to the high icidece of colo cacer. 1 The progosis for patiets with stomach ad esophagus cacers is poor, ad the 5-year survival rates are about 30%. Of the may ifluecig factors o progosis of the diseases, immue fuctio is a importat factor. It is geerally thought that the utritio status of the patiets may have a impact o their immue fuctios ad outcome of the cacer treatmets. 2,3 May researchers have suggested that good utritio i the patiet with cacer may improve quality of life, 4Y10 ad the utritio status of the patiet after diagosis is associated with cacer recurrece ad survival rates. 2,11,12 However, the evidece likig utritio status after cacer to survival is limited or uclear. 13 What have bee cofirmed are that adequate utritio ca miimize the adverse effects of the treatmets, decrease treatmet-related symptoms, ad improve quality of life. 14Y16 I 2004, we reported that the utritioal status of the patiets with stomach cacer who uderwet surgery ca have a impact o their quality of life. 17 I 2005, we reported that chemotherapy-iduced toxicity may be more severe i patiets with preexistig malutritio ad that high-eergy/protei diet ca reduce the adverse effects of chemotherapy. 18 I this study, a follow-up survey was udertake to assess the associatios betwee 1-year survival rate for patiets with stomach, Authors Affiliatios: Departmet of Epidemiology ad Health Statistics, Fujia Medical Uiversity (Dr Tia ad Ms Hag); ad Fujia Cacer Hospital, Fuzhou, Fujia Provice, Chia (Dr Che). Supported by the Natural Sciece Foudatio of Fujia (o. 2007J0090) ad the Foudatio of Educatio Departmet of Fujia (o. JB06223). Correspodig author: Ju Tia, PhD, Departmet of Epidemiology ad Health Statistics, Fujia Medical Uiversity, Fuzhou , Fujia Provice, Chia (tiajufjmu@126.com). Accepted for publicatio February 12, Cacer Nursig TM, Vol. 31, No. 6, 2008 Tia et al

2 Table 1 & Characteristics of the Patiets With Esophagus, Stomach, ad Colorectal Cacer at Time 1 ad Time 2 Age, Mea (SD), y Educatio Level, % Stage of Disease, % Time Me Wome Low Middle High (11.5) 57.1 (11.7) (10.9) 59.8 (12.5) esophagus, ad colo cacer ad the utritio status of the patiets after operatio ad betwee quality of life ad utritio status of the patiets 12 moths after operatio. Our results may provide iformatio for estimatig the effect of utritio o progosis of the disease. Materials ad Methods Materials The study participats were patiets with esophagus, stomach, or colorectal cacers who were admitted ad uderwet operatio i 4 provicial-level hospitals i Fuzhou, Chia, betwee Jauary 2006 ad Jue The eligible patiets were those who resided i Fuzhou city ad did ot rely o pareteral utritio support. There were 113 eligible participats for the study. A writte coset was requested for each participat. The iterviewers were traied physicias ad urses i the hospitals. The study was approved by the relevat istitutioal review boards for huma research i Fujia Provice, Chia. Methods The first i-perso iterviews were performed for the patiets o the 20th day postoperatio (time 1). Their hemoglobi (HB; g/l), albumi (ALB; g/l), ad body mass idex (BMI; BMI = weight/height 2, kg/m 2 ) were measured. The patiet s ALB is regarded as deficiet whe his/her ALB is less tha 35 g/l. A low level of HB is defied as HB less tha 120 g/l for me ad less tha 110 g/l for wome. The food frequecy survey method 19 was used to obtai iformatio about the dietary itake for every patiet durig the last week. Daily itake of calories ad protei for every patiet i the last week was calculated accordig to the Food Compositio Database. 20 O the basis of the referece values proposed by the Chiese Nutritio Society, the utritio itake levels of the patiets were evaluated. A low level of calorie itake is defied as daily calorie itake of less tha 2,400 kcal for me ad less tha 2,100 kcal for wome, ad low level of protei itake is defied as daily protei itake of less tha 70 g for me ad less tha 65 g for wome. The patiet s age, sex, ad stage of disease were also recorded. The secod i-perso iterviews were performed i the patiets homes i the 12th moth postoperatio (time 2). For the patiets who were alive i the secod iterview, their HB, ALB, ad BMI were measured, ad their dietary itake was obtaied usig the food frequecy survey. A questioaire proposed by the Europea Orgaizatio for Research ad Treatmet (EORTC QLQ-C30 V3.0) was used to measure the quality of life of the patiet. 21 A high total score i this scale expresses good quality of life. Ucoditioal logistic model was used to aalyze the associatios betwee 1-year survival rate ad daily protei ad calorie itake, HB, ad BMI at time 1. The relative risks (RRs), adjusted for age, sex, ad stage of disease, ad 95% cofidece itervals (95% CIs) for these utritioal factors were estimated from logistic model ad were used to aalyze the associatio betwee utritio ad survival rate. The effects of the utritioal factors o quality of life durig the 12th moth postoperatio were estimated by meas of multivariate regressio model. The t test was used to compare differeces of the meas. Data were aalyzed usig SAS versio 9.0 software (SAS Istitute, Ic, Cary, NC). All P values preseted were 2-tailed. Results I the first iterview, the sample icluded 113 participats, with 79 (69.91%) me ad 34 (30.09%) wome. Of them, 23 were esophagus cacer patiets, 51 were stomach cacer patiets, ad 39 were colorectal cacer patiets. The mea ages; proportios of the patiets with low, middle, ad high level of educatio; ad stage of disease (1, 2, 3, or 4) at time 1 are show i Table 1. At the time of the secod iterview, 55 patiets were dead ad 58 patiets were still alive. Of them, 16 were esophagus cacer patiets, 17 were stomach cacer patiets, ad 25 were Table 2 & Meas of Daily Itake of Calories ad Protei Durig the Last Week for 113 Patiets at Time 1 Me ( = 79) Wome ( = 34) Nutritio Referece Value Mea (SD) Referece Value Mea (SD) Calories, kcal 2,400 2,120.1 (1,192.57) a 2,100 1,910.9 (1,113.77) a Protei, g (40.23) (38.92) a The differece betwee mea daily itake of utritio ad referece value was statistically sigificat (P G.05). The Effects of Nutritio o Progosis of Cacer Cacer Nursig TM, Vol. 31, No. 6,

3 Site Table 3 & Frequecy Distributio of Body Mass Idex (BMI) by Tumor Site at Time 1 BMI G18 kg/m 2 18Y25 kg/m kg/m 2 Stomach ad esophagus G.001 Colorectal P colorectal cacer patiets. The mea ages; proportios of the patiets with low, middle, ad high level of educatio; ad stage of disease (1, 2, 3, or 4) at time 2 are show i Table 1. Nutritio Status of the Patiets The meas of daily itake of calories ad protei durig the last week at time 1 for 113 patiets are show i Table 2. For me ad wome, both calorie ad protei itakes were lower tha the referece values proposed by the Chiese Nutritio Society, 20 although the differeces for protei itake were ot statistically sigificat. Of 113 patiets, 62 (43 me ad 19 wome) had daily calorie itake lower tha referece value, 61 (45 me ad 16 wome) had daily protei itake lower tha referece value, ad 52 (37 me ad 15 wome) had both kids of utritio lower tha referece values. The mea (SD) levels of HB, ALB, ad BMI of the sample at time 1 were 11.4 (18.12) g/l, (5.30) g/l, ad (3.04) kg/m 2, respectively. Amog the patiets, 49.56% ad 36.36% had low levels of HB ad ALB, respectively. The frequecy distributio of BMI i stomach ad esophagus cacer patiets ad colorectal cacer patiets is show i Table 3. Amog the patiets, 12.39% had BMI less tha 18 kg/m 2 (all of them were stomach ad esophagus cacer patiets), ad 10.62% had BMI greater tha 25 kg/m 2 (all of them were colorectal cacer patiets). The Relatio Betwee Nutritio ad 1-year Survival Rate There were 55 patiets who died withi 1 year after operatio ad 58 patiets who were alive at time 2. The 1-year survival rates of the diseases by 3 tumor sites ad their 95% CIs are show i Table 4. Compared with other sites, stomach cacer had the lowest 1-year survival rate (P G.05). The survival rate of esophagus cacer was higher tha that of colorectal cacer, but the differece was ot statistically sigificat (P 9.05). The associatio betwee utritio ad survival rate was aalyzed by logistic model. Because a high level of BMI might be a risk factor for survival of the patiets with colorectal cacer, whereas a low level of BMI might be a risk factor for survival of the patiets with stomach or esophagus cacer, the 113 patiets were grouped ito 2 groups to fit the logistic model. Amog the 74 patiets with esophagus ad stomach cacers, adjusted RR (95% CI) was (0.408Y3.348) for low level versus ormal level of HB, (0.528Y3.344) for low level versus ormal level of ALB, (0.392Y4.695) for low BMI (G18 kg/m 2 ) versus ormal BMI, (0.256Y4.213) for low itake versus high itake of protei, ad (95% CI, 0.498Y6.322) for low itake versus high itake of calories. Amog the 39 patiets with colorectal cacer, adjusted RR (95% CI) was (0.225Y5.818) for low level versus ormal level of HB, (0.236Y3.351) for low level versus ormal level of ALB, (0.083Y19.384) for high BMI (925 kg/m 2 ) versus ormal BMI, (0.191Y12.820) for low itake versus high itake of protei, ad (0.213Y18.129) for low itake versus high itake of calories. Because all of the 95% CIs icluded 1 (Figure 1), we had the coclusio that HB, ALB, ad BMI shortly after operatio, as well as daily itake of calories ad protei, do ot have a impact o 1-year survival. The Relatio Betwee Nutritio ad Quality of Life Secod visits were coducted for the 58 patiets who were still alive 12 moths after operatio. Compared with those i time 1, mea levels of HB, ALB, daily calorie itake, ad daily protei itake, but ot BMI, at time 2 were sigificatly icreased (Table 5). The stregths of the relatioships betwee the total score of EORTC QLQ-C30 scale ad idepedet variables, icludig HB, ALB, BMI, daily calorie itake, ad daily protei itake were determied by meas of the multiple liear regressio model. After age, sex, ad stage of the disease were adjusted, ALB ad daily itakes of calories ad protei had a effect o quality of life, at a sigificat level of! =0.05(Table6).From the parameter estimates show i Table 4, we could see that the patiet with high daily itakes of calories ad protei, as well as high level of ALB, had a good quality of life. Discussio The study reported i this article has sought to kow whether the utritio status of the patiet with the digestive system Table 4 & 1-Year Survival Rates of Tumors i 3 Sites ad Their 95% Cofidece Iterval (95% CI) Site Deaths 1-Year Survival Rate 95% CI Esophagus Y Stomach Y Colorectal Y Cacer Nursig TM, Vol. 31, No. 6, 2008 Tia et al

4 Figure 1 Relative risks for hemoglobi (HB), albumi (ALB), body mass idex (BMI), ad protei ad calorie itake. tumor at the time of operatio impacted survival ad quality of life at 1 year postoperatio. The HB, ALB, BMI, ad daily itakes of calories ad protei were selected to reflect the utritioal status of the patiet. The results of our follow-up survey showed that there were o associatios betwee the utritio status of the patiets after operatio ad 1-year survival rate. However, daily itakes of calories ad protei at 1 year postoperatio might have a impact o quality of life. For may patiets with tumors of the gastroitestial tract, some adverse effects of cacer treatmets ad surgery make it difficult to eat well. Malutritio ca result, causig the patiet to be weak ad tired. Recet studies have suggested that a high-eergy/protei diet could reduce the adverse effects of chemotherapy ad ehace tolerace to chemotherapy. Thus, patiets gettig eough calories ad protei i the diet might be able to hadle higher doses of treatmets ad have a better progosis. 22Y26 Our previous work showed that poor utritio status before chemotherapy was a idepedet risk factor of severe adverse effects of therapy ad impacted the recovery of physical performace status after therapy. 19 However, results of the studies o the associatio betwee utritio ad survival rate are icosistet. 13,27 Although some results showed that utritioal status of the patiets affected survival rates, 28Y32 few data were available to directly support this associatio. 13 Some research showed that utritioal status did ot seem to ifluece immediate outcomes after operatio for cacer patiets, but it is a predictor of survival i the log-term. 33 I our study, HB, ALB, ad BMI, the variables reflectig the patiet s utritio status, did ot affect 1-year survival rate for the patiets with esophagus, stomach, ad colo cacers, although there was a weak (osigificat) associatio of BMI at time 1 with a icreased risk of death amog colo cacer patiets 1 year later at time 2. May researchers have suggested that the utritio status of a cacer patiet has a impact o quality of life. 14,34,35 Some researchers suggested that although cacer stage was the major determiat of patiets quality of life, utritioal deterioratio combied with deficiecies i utritioal itake might be more importat factors for the quality of life of the cacer patiets. 14 The EORTC QLQ-C30 V3.0 measures ot oly the physical status of the patiets but also their Table 5 & Mea (SD) Levels of HB, ALB, ad Calorie ad Protei Itake Measured i 2 Periods for 58 Patiets Time 1 Time 2 P a Calorie itake, kcal 2, (1,162.68) 3, (990.91) G.01 Protei itake, g (38.50) (47.50) G.01 ALB, g/l (4.10) (3.05) G.01 HB, g/l (17.21) (17.74) G.01 BMI, kg/m (3.37) (3.60).12 Abbreviatios: ALB, albumi; BMI, body mass idex; HB, hemoglobi. a Two-tailed P value obtaied by t test for 2 samples. The Effects of Nutritio o Progosis of Cacer Cacer Nursig TM, Vol. 31, No. 6,

5 Table 6 & Results of Regressio Model Aalyzig the Relatios Betwee Nutritio Status ad Quality of Life at Time 2 Parameter Estimate Stadard Error of Estimate Calorie Protei ALB HB BMI Abbreviatios: ALB, albumi; BMI, body mass idex; HB, hemoglobi. psychological ad social status. Nutriet depletio adversely affects the patiet s ejoyableess ad social iteractios with family ad frieds, which ca further depress appetite ad icrease the risk of havig depressio. 5 Low HB levels were associated with fatigue, poor overall quality of life, ad decreased ability to work. Itervetios that reverse fatigue ad other aemia-related symptoms should have a positive effect o quality of life. 6 Our result was cosistet with theirs. I our research coducted i 2005, results showed that the level of HB, daily calorie itake ad protei itake were associated with the physical performace status of the cacer patiets. 18 I geeral, a patiet who has a good physical performace status will have a good quality of life, so the associatios betwee utritio status ad quality of life may be explaied, i some degree, by the physical performace status of the patiet. There were some limitatios i our study. The small sample size makes the RRs for HB, BMI, calorie itake, ad protei itake have wide 95% CIs. Other variables reflectig the utritioal status of the participats, such as serum pre- ALB ad serum trasferri, were ot measured. Moreover, we did ot follow up the patiets utritioal variables i a period of 2 to 11 moths after operatio, so the associatio betwee utritio ad survival may be cofouded by chages i utritio status durig that period. By comparig levels of HB ad ALB, as well as the daily itakes of calories ad protei, o the 20th day postoperatio with those i the 12th moth postoperatio for the patiets whose survival time were more tha 1 year, we have see that the levels of these variables have icreased very much, which suggests that the patiets tryig their best to improve their utritio status after beig discharged from hospital may be of beefit to prologig their survival time. Further studies, icludig the field trial of utritio itervetio i the commuities, should be coducted to assess the associatio betwee utritio ad progosis of tumors objectively. I summary, our data, obtaied by epidemiological survey combied with follow-up o the patiets, show that for the patiets with esophagus, stomach, ad colo cacers, utritio status i the short-term after operatios does ot affect 1-year survival rate, but utritio status 1 year after beig discharged from hospitals may be associated with their quality of life. P Refereces 1. 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