1. Special article
Why the oncologist should consider the nutritional status
of the elderly cancer patient
Federico Bozzetti M.D. *
Faculty of Medicine, University of Milan, Italy
Keywords:
Malnutrition and oncologic outcome
Malnutrition and quality of life
Malnutrition and tolerance to
chemotherapy
Malnutrition and efficacy of chemotherapy
Sarcopenia and chemotherapy toxicity
a b s t r a c t
Epidemiologic studies show that malnutrition frequently afflicts elderly cancer patients. Malnu-
trition, (expressed as weight loss, or depletion of some body compartments or alteration of
nutritional clinical or biochemical scores) is associated with higher morbidity/mortality, poor
quality of life, reduced tolerance to oncologic therapy and poor efficacy of chemotherapy. Recently,
sarcopenia, regardless of the presence of weight loss, has been identified as an independent risk
factor for chemotherapy toxicity.
Ó 2015 Elsevier Inc. All rights reserved.
Prevalence of malnutrition
In Europe, about one-third of elderly patients admitted to
hospital are malnourished [1–3], and a recent study on 1767
older patients has shown malnutrition and cancer account for
the highest risk of all-cause mortality [4]. The association be-
tween presence of a malignancy and the consequent malnutri-
tion is well-known for many years [5]. Although many surveys
(except a few) have been performed in a mixed population of
adult cancer patients, it has to be pointed out that elderly pa-
tients represent a high proportion of this population.
Few studies have specifically focused on elderly cancer pa-
tients. According to Pailloud et al., [6] the percentage of elderly
cancer patients with more than 10% of weight loss was 71% and
the percentage of those with body mass index (BMI) < 20 was
44%. In addition, during their stay in hospital, triceps skinfold and
fat mass further decreased in older patients. Lecleire et al. [7]
reported a study including 120 patients with esophageal cancer
(median age 68.8 Æ 9.9 y). The introduction of a therapeutic
prosthesis was associated with a decrease in BMI, serum albumin
level, and Eastern Cooperative Oncology Group, though dysphagia
was improved in 89.1% of the patients. Blanc-Bisson et al. [8] re-
ported nutritional status could be impaired in 66% of elderly pa-
tients with cancer according to Mini Nutritional Assessment
(MNA) questionnaire scores (score < 24) and to a low serum
albumin levels (<35 g/L).
Obviously, the prevalence of malnutrition is related to the
composition of the case. In studies mainly represented by elderly
patients with breast cancer, the nutritional status was reported
to be poor (BMI < 22 kg/m2
) in 5% of the patients [9], whereas
other authors [10] reported 14% of their patients had a
BMI < 18.5 kg/m2
and 7.7% had lost more than 10% of their usual
weight. A French study reported 13.3% of nondigestive and 28.6%
of digestive cancer patients were malnourished according to the
MNA and geriatric syndromes were independent risk factors for
malnutrition [11].
An Italian prospective study on the nutritional status of can-
cer outpatients [12] showed in 689 subjects older than 65 the
mean weight loss was 9.5% (median value 8.2%) and the per-
centage of patients with a weight loss !10% of their usual body
weight was 42.5%.
Effect of malnutrition on the outcome
Clinicians are aware nutrition and nutritional status are
important for elderly people to maintain them in in healthy
conditions and to overcome acute and chronic diseases. This is, of
course, also the case for patients with cancer.
There is abundant literature showing malnutrition of the
cancer patients adversely affects their survival and quality of life
as well as compliance with oncologic treatments and their effi-
cacy. It is noteworthy to consider that the term “malnutrition”
frequently adopted in literature, usually means a significant
weight loss (approximately !10% of the usual body weight) and
F.B. has an honoraria from BAXTER and BBRAUN for scientific lectures at
meetings.
* Corresponding author. Tel.: þ39 3297655385; fax: þ39 0226410267.
E-mail address: dottfb@tin.it
http://dx.doi.org/10.1016/j.nut.2014.12.005
0899-9007/Ó 2015 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
Nutrition
journal homepage: www.nutritionjrnl.com
Nutrition 31 (2015) 590–593

2. only in recent times, more specific definitions of cancer cachexia
have been proposed [13–15]. However, all proposals of defini-
tions of cancer cachexia and several clinical scores that quantify
the risk associated with malnutrition include weight loss in their
formulations.
Malnutrition is an independent negative prognostic factor
Data from literature show malnutrition evaluated as weight
loss [16–37] or low bioelectrical impedance phase angle [38–45]
or depletion of protein [46] of fat [47] or as low prognostic
nutritional index [48,49], poor MNA [50], or severe Glasgow
Prognostic Score [51] or are associated with a poor prognosis
(Table 1). These series generally included patients of any age but
some studies regarded only elderly patients [7,27,43].
A recent prospective study [52] has shown a poor MNA score
was a predictor of early death in cancer patients older than 70 y.
Malnutrition adversely affects the quality of life
Main data from literature concerning the negative effect of
malnutrition on different domains of quality of life in a mixed
adult-old patients’ population are reported in Table 2.
A recent review of 26 papers on this topic [61] has shown that
in over 90% of them the nutritional status was found to be
associated directly with the quality of life of the patients.
Malnutrition is associated with an increased chemotherapy
toxicity
Main data from literature are reported in Table 3. Assuming
fat-free mass represents the volume of distribution of many
cytotoxic chemotherapy drugs, Prado et al. [64] estimated indi-
vidual variation in fat-free mass could account for up to 3 times
variation in effective volume of distribution for chemotherapy
administered per unit body-surface area to cancer patients. They
concluded sarcopenia is a significant predictor of toxicity and
time-to-progression in metastatic breast cancer patients treated
with capecitabine. In a subsequent prospective study of colon
cancer patients treated with 5-FU and Leucovorin, Prado et al.
[65] showed that women who had a low proportion of skeletal
muscle in relation to their body surface area, had a higher inci-
dence of dose-limiting toxicity. In this study, a cut-off point of
20 mg 5-FU/kg of lean body mass was a predictor of 5-FU toxicity.
Similarly, a BMI <25 kg/m2
with diminished muscle mass is a
significant predictor of toxicity in metastatic renal cell carcinoma
patients treated with sorafenib [66]. Recently the number of
authors who have reported that sarcopenia is associated with
interruption of chemotherapy or >20% dose reduction is
increased [67–69], and sarcopenia has been identified to be
associated to a higher mortality [70].
Malnutrition impairs the response (rate and duration) to
chemotherapy
Many studies support this statement [16,20,30,33,53,56,
71–73].
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Table 1
Malnutrition and poor prognosis in cancer patients
Parameter of nutritional status Author
Weight loss Aviles et al. [16], Bachmann et al. [17],
Bosaeus et al. [18], DeWys et al. [19],
DiFiore et al. [20], Edington et al. [21],
Evans et al. [22], Fein et al. [23], Gogos
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MNA, Mini Nutritional Assessment
Table 2
Malnutrition and poor quality of life
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Symptom distress Sarna et al. [60]
Muscular strength and
functional status
Norman et al. [43]
Table 3
Malnutrition and increased toxicity from chemotherapy
Indicator of malnutrition Author
Weight loss and hypoalbuminemia Arrieta et al. [62]
Low total body nitrogen Aslani et al. [63]
Sarcopenia Prado et al. [64,65]
BMI < 25 kg/m2
Antoun et al. [66]
F. Bozzetti / Nutrition 31 (2015) 590–593 591

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