Introduction

Malnutrition is seen in 60-90% of patients with hepatocellular cancer (HCC). Many patients with HCC have cirrhosis. Cirrhosis, along with related ascites and hypoalbuminemia can contribute to malnutrition and also make nutritional assessments difficult. Malnutrition is frequently unrecognized and could result in poor treatment tolerance and adverse outcomes. Many malnutrition screening and assessment tools such as Subjective Global Assessment (SGA), Malnutrition Universal Screening Tool (MUST), and the Mini Nutritional Assessment (MNA) are used in practice in addition to the standard anthropometric measurements which have been conventionally used.

Aims & Methods

We conducted a prospective IRB-approved study. The primary aim was to assess the prevalence of malnutrition in HCC. The secondary aims were to study the concordance between SGA and other malnutrition screening and assessment tools and to assess the predictors of malnutrition in HCC. Consecutive untreated patients with HCC were recruited over 1 year at a referral cancer center. Demography and baseline disease-related parameters were noted. Nutritional assessments were done by trained dieticians at baseline and at predefined intervals. We present the baseline data of 200 patients.

Results

The mean age was 56 years (range 20-79 years), and 88% were males. 12.4% were ≤ 40 years of age and could be classified as young HCC. 89% of patients had an Eastern Cooperative Oncology Group-Performance Status (ECOG-PS) of 0 or 1 at baseline. 5% of patients were from upper socioeconomic status (SES), 50% from middle, and 45% from lower SES. The etiology for HCC was Hepatitis B infection in 50%, Hepatitis C infection in 13%, alcohol-related in 7%, and others including cryptogenic in 30%. The common symptoms at presentation were anorexia and or weight loss in 37%, abdominal pain in 25%, jaundice in 17%, and fatigue in 13%. The baseline BCLC stage was 0- 0.5%, A- 7.5%, B- 32%, C-47%, and D-13%. 86% had cirrhosis (Child A-50%, Child B-26%, and Child C-10%). The AFP levels were <10 ng/ml in 14%, 10-400 ng/ml in 30%, and >400 ng/ml in 56%. 44% had invasion of the main portal vein or its branches.
The prevalence of malnutrition in patients with HCC using the SGA was 70%. 51% were SGA-B (moderately malnourished) and 19% of patients were SGA-C (severely malnourished). Using MUST and MNA, 74% and 90% of the patients respectively were malnourished or at significant risk. The kappa coefficient analysis to study concordance between the MUST, the MNA and the gold standard SGA showed moderate agreement between the SGA and MUST (0.520) but only fair agreement between the SGA and MNA (0.294). Sensitivity with MUST and MNA was 88.57% and 97.14% respectively in detecting malnutrition, but the specificity was lower (61.67% and 26.67% respectively).
Body mass index (BMI) <18.5 Kg/m2, low calf circumference, and low mid-upper arm circumference suggestive of malnutrition were seen in 17%, 70%, and 24% of patients respectively. 20% of patients had a BMI ≥ 25. On multivariate logistical regression analysis, AFP levels >400 ng/ml and a Child score of B or C significantly increased the likelihood of malnutrition with an odds ratio of 3.42 (95% CI 1.68-6.97, p=0.001), and 3.86 (95% CI 1.74-8.60, p=0.001) respectively. BCLC stage or symptoms did not show any association with malnutrition.

Conclusion

70% of HCC patients were malnourished at diagnosis. MUST had a better concordance with SGA as compared to MNA. BMI and anthropometry underestimated the prevalence of malnutrition highlighting the need to use standard validated screening tools like SGA to prevent its underdiagnosis. AFP levels >400 ng/ml and a Child score of B or C were significant predictors of malnutrition in HCC. Nutritional assessment using standard tools and targeted nutrition interventions should be integrated into HCC care pathways in an attempt to improve outcomes.