Percorrer por autor "Ravasco, Paula"
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- Assessment of nutritional status of oncology patients at hospital admission : a Portuguese real-world studyPublication . Trabulo, Carolina; Lopes, Joana; Dias, David da Silva; Gramaça, João; Fernandes, Isabel; Gameiro, Rita; Pina, Idília; Mäkitie, Antti; Ottery, Faith; Ravasco, PaulaBackground: Nutritional status in patients with cancer has a determining role in the evolution of the disease and tolerance to treatments. Severity of undernutrition impacts morbidity and mortality in cancer patients and can limit patient response to the optimal therapies if nutritional issues are not appropriately addressed and managed. Despite the importance of malnutrition for the clinical evolution of oncology patients, there is not yet a universally accepted standard method for evaluating malnutrition in such patients. The aim of this study was to stratify the nutritional status of inpatients at an Oncology Department. Methods: This is an observational study with 561 cancer patients, assessed at admission to a Medical Oncology Department from November 2016 to February 2020. All patients were considered eligible. Non-compliant and/or comatose patients were excluded. Nutritional status was assessed using the PG-SGA, BMI classified with the WHO criteria, and calculation of the percentage of weight loss in the previous 3–6 months. Results: A total of 561 patients (303 F: 258 M; mean age 65 ± 13 years) were included. One-third of the patients, n=191/561 (34%), lost 6% of their weight in the month prior to admission and 297/561 (53%) patients lost 10.2% of weight in the previous 6 months. Mean BMI was 24.1 ± 5.8 kg/m2; N = 280/561 (50%) patients had regular BMI according to the WHO criteria. N = 331/561 (59%) patients reported eating less in the month prior to admission. N = 303/561 (54%) had moderate/severe deficits of muscle and adipose compartments. The PG-SGA identified 499/561 (89%) patients as moderately/severely malnourished, of which 466/561 (83%) patients scored ≥9 points, meeting criteria for a critical need for nutritional support. Fifteen percent of patients scored >4 points, indicating a need for directed therapy for symptom control and only 1% scored <2 points (maintenance nutritional counseling). Conclusion: In this oncological setting, a higher proportion of patients were nutritionally-at-risk or with moderate/severe malnutrition. The large majority of patients in this study presented with a critical need for nutritional intervention. These findings highlight the need for an integrated assessment of nutritional status at patient referral. This will allow early and timely nutrition care, which is recommended to prevent or reverse further deterioration of the condition and to optimize treatment administration.
- Bioelectrical impedance analysis (BIA) for the assessment of body composition in oncology : a scoping reviewPublication . Branco, Mariana Garcia; Mateus, Carlota; Capelas, Manuel Luís; Pimenta, Nuno; Santos, Teresa; Mäkitie, Antti; Ganhão-Arranhado, Susana; Trabulo, Carolina; Ravasco, PaulaBioelectrical Impedance Analysis (BIA) is a reliable, non-invasive, objective, and cost-effective body composition assessment method, with high reproducibility. This scoping review aims to evaluate the current scientific and clinical evidence on BIA for body composition assessment in oncology patients, under active treatment. Literature search was conducted through MEDLINE, CINAHL, Scopus and Web of Science databases, following PRISMA-ScR Guidelines. Inclusion criteria comprised studies reporting the use of BIA for body composition evaluation in adults with cancer diagnosis. Studies including non-cancer pathology or only assessing nutritional status were excluded. This scoping review comprised a total of 36 studies: 25 were original studies including 18 prospective studies, six cross-sectional studies and one retrospective study and 11 were systematic reviews. Population size for the included original articles ranged from 18 to 1217 participants, comprising a total of 3015 patients with cancer with a mean baseline Body Mass Index (BMI) ranging from 20.3 to 30.0 kg/m2 and mean age ranging between 47 and 70 years. Review articles included a total of 273 studies, with a total of 78,350 participants. The current review considered studies reporting patients with head and neck cancer (HNC) (n = 8), breast cancer (BC) (n = 4), esophageal cancer (EC) (n = 2), liver cancer (n = 2), pancreatic cancer (PC) (n = 3), gastric cancer (GC) (n = 3), colorectal cancer (CRC) (n = 8), lung cancer (LC) (n = 1), skin cancer (SK) (n = 1) and multiple cancer types (n = 6). BIA is a suitable and valid method for the assessment of body composition in oncology. BIA-derived measures have shown good potential and relevant clinical value in preoperative risk evaluation, in the reduction of postoperative complications and hospital stay and as an important prognostic indicator in persons with cancer. Future research on the diagnostic value and clinical applications of BIA and BIA-derived phase angle (PhA) should be conducted in order to predict its impact on patient survival and other clinical outcomes.
- Body composition analysis in metastatic non-small-cell lung cancer : depicting sarcopenia in Portuguese tertiary carePublication . Mendes, José Leão; Ferreira, Rita Quaresma; Mata, Inês; Barreira, João Vasco; Rodrigues, Ysel Chiara; Dias, David Silva; Capelas, Manuel Luís; Mäkitie, Antti; Guerreiro, Inês; Pimenta, Nuno M.; Ravasco, PaulaBackground/Objectives: Sarcopenia is an emergent prognostic biomarker in clinical oncology. Albeit increasingly defined through skeletal muscle index (SMI) thresholding, the literature cut-offs fail to discern heterogeneous baseline muscularity across populations. This study assesses the prognostic impact of using cohort-specific SMI thresholds in a Portuguese metastatic non-small-cell lung cancer (mNSCLC) cohort. Methods: Retrospective study including mNSCLC patients treated between January 2017 and December 2022. ImageJ v1.54 g was used to assess cross-sectional CT imaging at the third lumbar vertebra (L3) and calculate L3SMI. Sarcopenia was defined both according to Prado et al. and L3SMI thresholds derived from receiver operating characteristic analysis. Overall survival (OS) was the primary endpoint. Secondary endpoints included first-line (1L) progression-free survival (PFS) and sarcopenia subgroup analysis regarding body mass index impact on OS. Results: The initial cohort included 197 patients. Mean age was 65 years (±11.31). Most tumors were adenocarcinomas (n = 165) and presented with metastasis (n = 154). SMI was evaluable in 184 patients: cohort-specific thresholds (<49.96 cm2/m2 for men; <34.02 cm2/m2 for women) yielded 46.74% sarcopenic patients (n = 86) versus 66.30% (n = 122) per the literature definition. Cohort-specific thresholds predicted both OS (12.75 versus 21.13 months, hazard ratio [HR] 1.654, p = 0.002) and PFS (7.92 versus 9.56 months, HR 1.503, p = 0.01). Among sarcopenic patients, overweight (HR 0.417, p = 0.01) and obesity (HR 2.723, p = 0.039) had contrasting impacts on OS. Conclusions: Amid reclassification of nearly one-fifth of the cohort, cohort-specific thresholds improved sarcopenia prognostication in mNSCLC. Homogeneity regarding both cancer treatment setting and ethnicity could be key to defining sarcopenia based on SMI.
- Get a grip! – Baseline handgrip strength and sarcopenia as predictors of survival in patients with head and neck squamous cell carcinomaPublication . Orell, Helena; Pohju, Anne; Ravasco, Paula; Schwab, Ursula; Osterlund, Pia; Mäkitie, Antti A.Background: Low handgrip strength (HGS) and sarcopenia are common in patients with head and neck squamous cell carcinoma (HNSCC). This study aimed to explore associations between baseline HGS, fat-free mass index (FFMI), nutritional indices, and survival. Methods: This was a prospective observational sub-study of a randomized nutritional intervention trial, including 50 male patients with HNSCC undergoing curative-intent treatment (surgery and/or (chemo)radiotherapy). Sarcopenia was defined as low HGS (<27 kg) and FFMI (<17 kg/m2). Chi-square, Kaplan–Meier, and Cox analyses were used. Results: Low HGS was observed in 16%, low FFMI in 46%, and sarcopenia in 12%. Patients with low HGS had lower body weight, BMI, and FFMI, alongside more malnutrition, elevated CRP, and heavy smoking. Low HGS and sarcopenia were associated with shorter overall survival (HR 3.7, [95% CI 1.5–9.1] and 5.5, [2.2–14.5], respectively); FFMI was not. Adjustment removed significance. Findings should be interpreted cautiously due to the small, all-male cohort size. Conclusion: In this small exploratory cohort HGS may serve as a simple screening surrogate for sarcopenia and survival.
- GLIM in diagnosing malnutrition and predicting outcome in ambulatory patients with head and neck cancerPublication . Orell, Helena Kristiina; Pohju, Anne Katariina; Osterlund, Pia; Schwab, Ursula Sonja; Ravasco, Paula; Mäkitie, AnttiAim: This study aimed to determine the prevalence of malnutrition in a head and neck cancer (HNC) population according to the Global Leadership Initiative on Malnutrition (GLIM) criteria and to assess its relation to survival. The secondary aim was to compare GLIM criteria to Patient–Generated Subjective Global Assessment (PG–SGA) and Nutritional Risk Screening 2002 (NRS 2002) methods. Methods: The assessment was performed in a series of 65 curative patients with newly diagnosed HNC in a nutrition intervention study. Malnutrition was defined as PG-SGA classes BC and nutritional risk as NRS 2002 score ≥3 and was retrospectively diagnosed with GLIM criteria in prospectively collected data at diagnosis. Sensitivity, specificity, and kappa (κ) were analyzed. Predictive accuracy was assessed by calculating the area under curve (AUC) b y receiver operating characteristic (ROC) analysis. Kaplan–Meier and Cox regression analyses were used to evaluate association between malnutrition and overall survival (OS), and disease-free survival (DFS). Results: GLIM-defined malnutrition was present in 37% (24/65) of patients. The GLIM showed 77% sensitivity and 84% specificity with agreement of κ = 0.60 and accuracy of AUC = 0.80 (p < 0.001) with PG-SGA and slightly higher sensitivity (83%) with NRS 2002 (κ = 0.58). Patients with GLIM-defined malnutrition had shorter OS (56 vs. 72 months, HR 2.26, 95% CI 1.07–4.77, p = 0.034) and DFS (37 vs. 66 months, HR 2.01, 95% CI 0.99–4.09, p = 0.054), than well-nourished patients. The adjusted HR was 2.53 (95% CI 1.14–5.47, p = 0.023) for OS and 2.10 (95% CI 0.98–4.48, p = 0.056) for DFS in patients with GLIM-defined malnutrition. Conclusion: A substantial proportion of HNC patients were diagnosed with malnutrition according to the GLIM criteria and this showed a moderate agreement with NRS 2002- and PG–SGA-defined malnutrition. Even though the GLIM criteria had strong association with OS, its diagnostic value was poor. Therefore, the GLIM criteria seem potential for malnutrition diagnostics and outcome prediction in the HNC patient population. Furthermore, NRS 2002 score ≥3 indicates high nutritional risk in this patient group.
- Impact of body composition on prognosis and dose-limiting toxicities on metastatic colorectal cancerPublication . Dias, David da Silva; Machado, Mafalda; Trabulo, Carolina; Gosálbez, Beatriz; Ravasco, PaulaSarcopenia is a progressive skeletal muscle disease, often present in oncological patients, that is associated with multiple adverse events such as worse prognosis, physical performance, and quality of life. Body composition evaluation by CT cross-section at the L3 vertebrae region appears to be a precise method to quantify skeletal muscle. The optimal cut-off for the definition of sarcopenia is not yet established, therefore the incidence of sarcopenia varies according to different studies. The main goal was to evaluate the presence of sarcopenia in patients with metastatic colorectal cancer (mCRC) and its impact on overall survival (OS) and dose-limiting toxicities (DLT). A retrospective cohort study of 178 patients with mCRC under first-line chemotherapy (ChT) in association with target therapy, in two hospital units, between January 2015 and December 2018. Skeletal mass area (SMA) was quantified with the NIH ImageJ software in CT cross-sectional images at the L3 vertebrae region. Statistical analysis was performed with IBM SPSS v25 software https://www.ibm.com/analytics/spss-statistics-software. The median age was 62 (SD ± 11) years old, 65% were men and 62.9% had an Eastern Cooperative Oncology Group (ECOG) performance status of 0. The cut-off value was established based on ROC analysis, with sarcopenia defined as SMI < 49.12 cm2/m2 for men and < 35.85 cm2/m2 for women. Despite the mean body mass index (BMI) of 25.71 (± 4.71) kg/m2, half of the patients presented sarcopenia. In a multivariate analysis using a Cox regression model, an association was observed between OS and higher ECOG PS (p = 0.014; HR 5.46, CI 95% [1.42–21.10]), neutrophil-to-lymphocyte ratio (NLR) >2.80 (p = 0.038; HR 2.20, CI 95% [1,05–4.62]), and sarcopenia (p = 0.01; HR 4.73, CI 95% [1.85–12.09]). Additionally, in a logistic regression model, age (p = 0.014; OR 1.09, IC 95% [1.02–1.16]) and sarcopenia (p= 0.030, OR 4.13, IC 95% [1.15-14.8]) were associated with higher incidence of DLT. The CT evaluation of the body composition at the L3 region allows for the quantification of sarcopenia, providing prognostic information and predictive value of DLT in patients with mCRC, although the establishment of optimal cut-off values are required for implementation in clinical practice. A multimodal strategy to delay muscle waste should be considered in these patients.
- The impact of nutrition on the lives of patients with digestive cancers : a position paperPublication . Vitaloni, Marianna; Caccialanza, Riccardo; Ravasco, Paula; Carrato, Alfredo; Kapala, Aleksandra; Schueren, Marian de van der; Constantinides, Dora; Backman, Eva; Chuter, David; Santangelo, Claudia; Maravic, ZoranaNutritional intervention is an essential part of cancer treatments. Research and clinical evidence in cancer have shown that nutritional support can reduce length of hospitalisation, diminish treatment-related toxicity, and improve nutrient intake, quality of life, and physical function. Nutritional intervention can improve outcomes and help patients in the successful completion of oncological treatments by preventing malnutrition. Malnutrition is a very common hallmark in patients with cancers. Almost one-fourth of cancer patients are at risk of dying because of the consequences of malnutrition, rather than cancer itself. Patients with digestive cancers are at higher risk of suffering malnutrition due to the gastrointestinal impairment caused by their disease. They are at high nutritional risk by definition, yet the majority of them have insufficient or null access to nutritional intervention. Inadequate resources are dedicated to implementing nutritional services in Europe. Universal access to nutritional support for digestive cancer patients is not a reality in many European countries. To change this situation, health systems should invest in qualified staff to reinforce or create nutritional teams’ experts in digestive cancer treatments. We aim to share the patient community’s perspective on the status and the importance of nutritional intervention. This is an advocacy manuscript presenting data on the topic and analysing the current situations and the challenges for nutrition in digestive cancers. It highlights the importance of integrative nutrition in the treatment of digestive cancers and advocates for equitable and universal access to nutritional intervention for all patients.
- The impact of pre-, pro- and synbiotics supplementation in colorectal cancer treatment : a systematic reviewPublication . Moreira, Mariana Melo; Carriço, Marta; Capelas, Manuel Luís; Pimenta, Nuno; Santos, Teresa; Ganhão-Arranhado, Susana; Mäkitie, Antti; Ravasco, PaulaIntroduction: The effectiveness of the supplementation of prebiotics, probiotics and synbiotics as a therapeutic approach in colorectal cancer (CRC) remains unclear. The aim of this systematic review is to critically examine the current scientific evidence on the impact of modulating the microbiota, through the use of prebiotics, probiotics and synbiotics, in patients diagnosed with CRC undergoing treatment, to determine the potential therapeutic use of this approach. Methods: This systematic review was made according to the PRISMA 2020 guidelines. Inclusion criteria were randomized controlled trials (RCT) comparing the impact of pre-, pro-, or synbiotic supplementation with placebo or standard care in patients with CRC undergoing treatment. Exclusion criteria were non-human studies, non-RCTs, and studies in languages other than English or Portuguese. Six databases were consulted, namely, Cochrane Library, Pubmed, Scopus, Cinahl, MedicLatina and Web of Science until May of 2023. RAYYAN software was used to manage the search results and risk of bias was assessed according to the guidelines of the Cochrane Collaboration using the Rob 2.0 tool. Results: Twenty-four RCTs met the inclusion criteria and were included in this review. Administration of pre-, pro-, or synbiotics improved surgical outcomes such as the incidence of infectious and non-infectious postoperative complications, return to normal gut function, hospital length of stay, and antibiotic usage. The supplementation of these microorganisms also alleviated some symptoms from chemotherapy and radiotherapy, mainly diarrhea. Evidence on the best approach in terms of types of strains, dosage and duration of intervention is still scarce. Conclusions: Pre-, pro-, and synbiotics supplementation appears to be a beneficial therapeutic approach in CRC treatment to improve surgical outcomes and to alleviate side-effects such as treatment toxicity. More RCTs with larger sample sizes and less heterogeneity are needed to confirm these potential benefits and to determine the best strains, dosage, and duration of administration in each situation.
- Impact of Sarcopenia on prognosis, treatment toxicity and surgical complications in locally advanced gastric cancerPublication . Dias, David da Silva; Luz, Paulo; Fortuna, Ana; Águas, Ana; Machado, Mafalda; Gosálbez, Beatriz; Farate, Rosa; Pinho, Rita Clemente; Valente, Ana Carmo; Mendes, José Leão; Seladas, Marta Maria; Trabulo, Carolina; Ravasco, PaulaBackground: Weight loss and skeletal muscle wasting are frequent in cancer and may influence treatment tolerance and outcomes. Computed tomography (CT) based body composition analysis at the third lumbar vertebra (L3) is an accurate method to quantify skeletal muscle in routine oncology care. Methods: We performed a multicenter retrospective cohort study including 202 adults with locally advanced (stage IB–III) gastric cancer treated in four Portuguese hospitals (January 2020–December 2022). Skeletal muscle area (SMA) was assessed on baseline CT at the L3 vertebral level, using Data Analysis Facilitation Suite (DAFS) software v3.11.2, and skeletal muscle index (SMI) was subsequently calculated. Patients with low muscle quantity were classified as sarcopenic (below sex-specific SMI mean). We evaluated associations with relapse-free survival (RFS), overall survival (OS), FLOT chemotherapy dose-limiting toxicities (DLTs), and postoperative complications after gastrectomy. Results: Mean age was 69 years, 65% had ECOG PS 0, 53% received FLOT chemotherapy protocol. Mean SMI was 49.6 cm2/m2 in males and 40.9 cm2/m2 in females and correlated positively, though moderately, with BMI (p < 0.01; r = 0.424). Sarcopenia was not significantly associated with RFS (p = 0.186) or OS (p = 0.168) at 30-month follow-up. Although numerical differences were observed (64% vs. 56% of patients did not relapse and 74% vs. 63% were alive, for non-sarcopenic vs. sarcopenic patients). Sarcopenia was associated with a higher risk of DLTs (p = 0.021; OR 2.56, 95% CI 1.15–5.73) and postoperative complications (p = 0.024; OR 2.16, 95% CI 1.11–4.21). Conclusions: Sarcopenia significantly increases the risk of chemotherapy toxicity and postoperative complications in locally advanced gastric cancer. However, its effect on OS and RFS was not statistically significant at 30-month follow-up. Standardization of CT-based sarcopenia cut-offs remains a major barrier to clinical implementation.
- The importance of protein sources to support muscle anabolism in cancer : an expert group opinionPublication . Ford, Katherine L.; Arends, Jann; Atherton, Philip J.; Engelen, Mariëlle P.K.J.; Gonçalves, Thiago J.M.; Laviano, Alessandro; Lobo, Dileep N.; Phillips, Stuart M.; Ravasco, Paula; Deutz, Nicolaas E.P.; Prado, Carla M.This opinion paper presents a short review of the potential impact of protein on muscle anabolism in cancer, which is associated with better patient outcomes. Protein source is a topic of interest for patients and clinicians, partly due to recent emphasis on the supposed non-beneficial effect of proteins; therefore, misconceptions involving animal-based (e.g., meat, fish, dairy) and plant-based (e.g., legumes) proteins in cancer are acknowledged and addressed. Although the optimal dietary amino acid composition to support muscle health in cancer is yet to be established, animal-based proteins have a composition that offers superior anabolic potential, compared to plant-derived proteins. Thus, animal-based foods should represent the majority (i.e., ≥65%) of protein intake during active cancer treatment. A diet rich in plant-derived proteins may support muscle anabolism in cancer, albeit requiring a larger quantity of protein to fulfill the optimal amino acid intake. We caution that translating dietary recommendations for cancer prevention to cancer treatment may be inadequate to support the pro-inflammatory and catabolic nature of the disease. We further caution against initiating an exclusively plant-based (i.e., vegan) diet upon a diagnosis of cancer, given the presence of elevated protein requirements and risk of inadequate protein intake to support muscle anabolism. Amino acid combination and the long-term sustainability of a dietary pattern void of animal-based foods requires careful and laborious management of protein intake for patients with cancer. Ultimately, a dietary amino acid composition that promotes muscle anabolism is optimally obtained through combination of animal- and plant-based protein sources.