Sarcopenia Screening For Mortality In Oncology Patients
Overview
This study evaluated the effectiveness of a sarcopenia screening test in predicting mortality among cancer inpatients. Conducted over five months, 82 patients admitted to an oncology ward in southern Taiwan were assessed and followed for three years. Each participant underwent a comprehensive evaluation at admission, including measurements of ECOG performance status, cognitive function, nutritional status, body mass index, and short physical performance battery (SPPB). Sarcopenia was linked to factors such as age, ECOG status, dementia, SPPB score, and albumin levels. Of the patients enrolled, 53 (64.6%) were diagnosed with sarcopenia. The study found that patients with sarcopenia had significantly worse overall survival (OS) compared to those without (28.8% vs. 82%, p = 0.01). Independent predictors of OS included metastasis (HR: 5.166) and albumin levels (HR: 4.346). Among patients aged 65 and older, age was a significant predictor of two-year all-cause mortality (25.6% vs. 100%, p = 0.04). Overall, the sarcopenia screening was effective in predicting OS and all-cause mortality, offering potential value for patient risk stratification during hospital care.
Introduction
Sarcopenia, defined by the progressive loss of skeletal muscle mass and strength associated with aging, is a condition that affects physical performance and contributes to frailty. Several factors contribute to the development of sarcopenia, including advanced age, physical inactivity, poor nutrition, inflammatory diseases, and hormonal imbalances. Among cancer patients, sarcopenia is particularly prevalent due to the combined effects of aging and the metabolic demands of malignant diseases. Studies show that sarcopenia can affect between 11% to 74% of cancer patients, depending on how it is defined and the specific population studied.
The condition of sarcopenia, often overlapping with cancer cachexia, represents a significant challenge in the treatment of cancer patients. Cachexia is characterized by severe weight loss and muscle wasting due to the underlying illness, and is often irreversible even with aggressive nutritional support. This syndrome, which involves systemic inflammation and significant loss of muscle and fat tissue, is frequently seen in patients with advanced cancers. Sarcopenia, on the other hand, is specifically related to the age-related decline in muscle mass and strength, and has been shown to negatively affect clinical outcomes in cancer patients. Numerous studies have linked the presence of sarcopenia to worse overall survival (OS) in various types of cancer, including lung, gastrointestinal, hepatocellular, esophageal, and renal cell carcinomas. This decline in survival is often attributed to sarcopenia’s contribution to increased treatment complications, frailty, and diminished physiological reserve.
The clinical impact of sarcopenia has been recognized across many cancer types and stages, with sarcopenic patients experiencing significantly poorer prognoses compared to those without muscle loss. However, inconsistent findings have been reported in some cancers, such as colon cancer, where the association between sarcopenia and survival has not been clearly established. Despite this, the detrimental effects of sarcopenia are well-documented, particularly in relation to overall survival, cancer treatment tolerance, and increased susceptibility to complications during therapy.
In clinical practice, sarcopenia is diagnosed using a combination of functional tests and assessments of muscle mass. Current guidelines recommend specific criteria to identify sarcopenia, such as handgrip strength, walking speed, and muscle mass measurements using techniques like bioelectrical impedance analysis (BIA). The Asian Working Group on Sarcopenia (AWGS) guidelines set clear thresholds for diagnosing sarcopenia based on these measures. For example, low muscle strength is defined by a handgrip strength of less than 28 kg in men and less than 18 kg in women. Similarly, physical performance is evaluated using tests like the 6-Meter Timed Walk and the Short Physical Performance Battery (SPPB), with specific cutoffs to classify impaired function. These diagnostic tools are crucial for identifying sarcopenia early, particularly in populations with limited access to advanced imaging technologies.
In light of the rising global cancer burden, which is expected to reach 21.4 million new cases by 2030, the importance of identifying risk factors that impact cancer prognosis cannot be overstated. In Taiwan, where cancer has been the leading cause of death for decades, sarcopenia has emerged as a key prognostic factor for cancer progression and mortality. Recognizing sarcopenia in cancer patients is vital for developing individualized treatment strategies that account for their increased vulnerability to treatment-related complications. Patients with sarcopenia often have a poor prognosis, making early identification and intervention critical for improving clinical outcomes.
The primary aim of the study under review was to assess the prevalence of sarcopenia among hospitalized cancer patients at the time of admission and evaluate the predictive power of sarcopenia screening tests in estimating mortality risk. By using a comprehensive screening tool to identify sarcopenia, the study sought to provide a framework for better patient stratification and individualized care during hospital stays. These findings underscore the need for early and accurate identification of sarcopenia in cancer patients, as it holds significant implications for patient management, treatment planning, and improving survival outcomes.
Also read Sarcopenia And Chronic Kidney Disease
Methods
Inclusion Criteria
- Cancer diagnosis: All adult patients (aged ≥18 years) with a confirmed diagnosis of cancer who were consecutively admitted to the oncology wards during the study period (August 2020 to December 2020).
- Hospital admission: Patients admitted to the participating wards of the oncology department at Chi Mei Medical Center, Taiwan.
- Informed consent: Participants who provided written informed consent to be included in the study.
- Cognitive ability: Patients who demonstrated adequate cognitive function to follow study procedures, as determined by a clinical evaluation.
- Sarcopenia screening: Participants eligible for sarcopenia screening using bioelectrical impedance analysis (BIA) and physical performance assessments (handgrip strength, 6-Meter Walk Test, and Short Physical Performance Battery).
Exclusion Criteria
- Severe cognitive impairment: Patients with advanced cognitive decline, as identified through clinical assessment, rendering them unable to comply with study procedures.
- Delirium: Patients experiencing delirium at the time of admission were excluded due to their inability to participate in the study assessments.
- Clinically visible edema: Patients with significant visible edema, which could interfere with accurate bioelectrical impedance analysis (BIA) measurements.
- Non-consent: Patients who declined to provide informed consent for participation in the study.
- Inability to follow procedures: Patients who were unable to adhere to the study protocols, either due to physical or cognitive limitations, were excluded from further assessment.
Analysis
The descriptive statistics for categorical variables were expressed as absolute numbers and frequencies, while continuous variables with normal distribution were reported as means with standard deviations (SD). Fisher’s exact test and the Chi-square test were utilized to compare categorical variables. Data analysis was conducted using SPSS version 26.0 (SPSS Inc., Chicago, IL, USA), with a significance threshold set at p < 0.05. Survival analysis was performed using univariate and multivariate Cox proportional hazard models to determine the hazard ratio (HR) and 95% confidence interval (CI) for factors associated with sarcopenia occurrence. Variables found to be significant in the univariate Cox model (p < 0.05) were included in the multivariate analysis. Additionally, Kaplan-Meier survival curves were generated and compared through log-rank tests.
Results
Out of 103 participants initially considered, 21 individuals were excluded for reasons such as delirium (nine participants), edema (four participants), or refusal to take part in the study (eight participants). Consequently, the final study cohort included 82 participants, comprising 29 women and 53 men, with a mean age of 62.72 ± 10.7 years. Among this group, 53 individuals (64.6%) were diagnosed with sarcopenia based on clinical and diagnostic criteria.
An analysis of the participants’ baseline characteristics revealed significant differences between the sarcopenia and non-sarcopenia groups. Age was a critical factor, with participants in the sarcopenia group being significantly older than those without sarcopenia (p < 0.01). Despite similarities in common comorbidities between the two groups, other variables highlighted important contrasts. The sarcopenia group demonstrated worse overall health, evidenced by significantly lower ECOG performance status (p = 0.001), which measures patients’ ability to perform daily activities. Additionally, cognitive function, as assessed by the Short Portable Mental Status Questionnaire (SPMSQ), was also notably poorer in the sarcopenia group (p = 0.001). Furthermore, serum albumin levels, a marker of nutritional and inflammatory status, were significantly lower in the sarcopenia group (p = 0.001), suggesting greater nutritional deficits or systemic inflammation.
Physical performance markers were also impacted by sarcopenia. Participants with sarcopenia exhibited significantly weaker handgrip strength (p = 0.001) compared to those without the condition, reflecting their diminished muscle strength. The Short Physical Performance Battery (SPPB), which assesses lower extremity function, also showed significantly lower scores in the sarcopenia group (p = 0.001). These results underline the profound impact of sarcopenia on both physical function and overall health, marking it as a critical factor influencing the clinical outcomes of hospitalized cancer patients.
Survival analyses
The univariate Cox proportional hazard analysis for overall survival (OS) showed that sarcopenic patients aged 65 and older had a higher mortality risk compared to non-sarcopenic patients, though the difference was not statistically significant (HR: 1.77; 95% CI: 0.422–2.392). However, sarcopenic individuals had a significantly worse OS than non-sarcopenic individuals (HR: 3.207; 95% CI: 1.130–9.102). Significant predictors of OS included SPPB score (HR: 3.407; 95% CI: 1.209–9.597), ECOG performance status (HR: 3.207; 95% CI: 1.130–9.102), and albumin levels (HR: 5.264; 95% CI: 2.059–13.455).
In the multivariate analysis, metastasis (HR: 5.166; 95% CI: 1.358–19.656) and albumin levels (HR: 4.346; 95% CI: 1.493–12.654) were identified as independent and significant predictors of OS for the entire study population.
Kaplan-Meier survival curves demonstrated significant differences in survival between sarcopenic and non-sarcopenic patients (p = 0.01), with mean survival time being shorter in the sarcopenia group (18.979 ± 0.365) compared to the non-sarcopenia group (19.733 ± 0.580). Subgroup analysis showed similar trends for both patients aged ≥65 and those <65 years, with age being a predictor for 2-year all-cause mortality in patients aged 65 and above (OS: 25.6% vs. 100%, p = 0.04), but not for those under 65 years.
Conclusions
Sarcopenia, as defined by the 2013 Asian Working Group for Sarcopenia (AWGS) guidelines, refers to age-related loss of muscle mass, diminished muscle strength, and reduced physical performance. The 2019 AWGS guidelines reaffirm this definition and provide specific cutoffs for muscle strength, such as handgrip strength and Short Physical Performance Battery (SPPB) scores. In this study, individuals with sarcopenia were generally older and had notably lower handgrip strength and SPPB scores compared to those without sarcopenia, aligning with findings from previous studies (Phu et al., 2020). The SPPB has shown to be an effective diagnostic tool for sarcopenia in older adults, and it can serve as a screening method in clinical environments where measuring appendicular lean body mass may not be feasible.
Sarcopenia has been recognized as a significant prognostic factor in various cancers, including colorectal, ovarian, gastrointestinal, and esophageal cancers, often indicating a shorter life expectancy. Although this study did not find a statistically significant correlation between sarcopenia and overall survival (OS) after controlling for other factors, trends from Kaplan-Meier and univariate regression analyses indicated a potential association with reduced survival. The impact of sarcopenia may be weaker compared to other major prognostic indicators like serum albumin levels. With a larger study population, the effect of sarcopenia on survival may become more evident, which could explain why some smaller studies did not find a clear link between sarcopenia and mortality. Nonetheless, this study supports the use of sarcopenia as a predictive factor for mortality in older adult inpatients.
