The Potential of Phase Angle as a Nutritional Assessment Tool and Prognostic Factor in Patients with Gastrointestinal Cancers

Research Article

Austin J Nutri Food Sci. 2022; 10(1): 1162.

The Potential of Phase Angle as a Nutritional Assessment Tool and Prognostic Factor in Patients with Gastrointestinal Cancers

Mantzorou M¹*, Tolia M², Pavlidou M¹, Vasios GK¹, Papandreou D³, Papadopoulou SK4 and Giaginis C¹*

1Department of Food Science and Nutrition, University of the Aegean, Lemnos, Greece

2Department of Radiation Oncology, University of Thessaly, School of Health Sciences, Faculty of Medicine, Larissa, Greece

3Department of Health Sciences, College of Natural and Health Sciences, Zayed University, Abu Dhabi, United Arab Emirates

4Department of Nutritional Sciences and Dietetics, International Hellenic University, Thessaloniki, Greece

*Corresponding author: Constantinos Giaginis, Associate Professor, Department of Food Science and Nutrition, University of the Aegean, Mitropoliti Ioakim 2, Myrina, Lemnos, 81400, Greece

Maria Mantzorou, Department of Food Science and Nutrition, University of the Aegean, Mitropoliti Ioakim 2, Myrina, Lemnos, 81400, Greece

Received: February 08, 2022; Accepted: March 08, 2022; Published: March 15, 2022

Abstract

Malnutrition is a common finding in patients with cancer and can significantly affect disease progress and patients’ survival. Gastrointestinal Cancers (GIC) are amongst the most common cancer types. In gastroin-testinal cancer patients, the prevalence of malnutrition has been estimated to be around 39-67%. Body composition reflects the nutritional status. Bio-Impedance Analysis (BIA) is a noninvasive, time- and cost-effective technique to analyse body composition.

This review paper aims to critically summarise the currently available clinical data on the efficiency of the easily obtainable BIA measure, Phase Angle (PA), in the evaluation of malnutrition in GIC patients and on disease progression and prognosis.

PubMed database was thoroughly searched, in order to identify clinical studies that explore the role of BIA- derived raw data and weight loss on disease prognosis and progress, as well on assessing malnutrition.

Phase angle may be used as a nutritional screening tool in patients with gastrointestinal cancers. However, it cannot distinguish between stages of cachexia. Concerning the role of PA as a prognostic factor, current studies show that PA may be used as a prognostic factor of survival, yet further studies are needed for firm conclusions regarding post-operative complications and disease characteristics.

Due to the fact that gastrointestinal cancers are a group of various cancers, further studies should be undertaken, in order to evaluate the role of BIA and PA on all gastrointestinal cancer sites and types.

Keywords: Gastrointestinal cancer; Phase angle; Bioimpedance analysis; Malnutrition; Screening tool; Prognostic factor

Abbreviations

BIA: Bioimpedance Analysis; CRC: Colorectal Cancer; ECW/ ICW: Extracellular/Intracellular Water; GIC: Gastrointestinal Cancer; NETs; Neuroendocrine Tumours; OS: Overall Survival; PA: Phase Angle; PG-SGA: Patient Generated-Subjective Global Assessment

Introduction

Malnutrition is a common finding in patients with cancer, even at diagnosis. Its incidence varies between 31- 87%, depending on cancer stage, histopathological type, treatment and patient [1,2]. Malnutrition can significantly affect disease progress and patient survival. Studies have shown that weight loss in cancer is associated with poor prognosis, poor quality of life, increased treatment-related side effects and reduced tumour response to treatment, as well as lower physical activity levels [3].

Weight loss may develop due to either elevated energy requirements, low energy intake or compromised nutrient absorption. In cancer patients, undernutrition may be attributed to various factors. Inflammation and catabolism due to tumour can lead to muscle wasting and body weight loss (4), while tumour gastrointestinal obstruction can compromise both food intake and absorption, as dysphagia, pain, and vomiting can be present. During treatment, eating related side-effects, such as low appetite, early satiety, nausea and/or vomiting, oral and intestinal mucositis with dysphagia, diarrhoea, haemorrhoids, anal fissures, and smell and taste changes may not only affect total energy intake, but also nutrient absorption, negatively affecting nutritional status, while poor patients’ mental health state can affect their food and energy intake [5-7]. Weight loss at diagnosis has been associated with shorter failure-free and overall survival, while being identified as an independent prognostic factor [8].

Gastrointestinal cancers are amongst the common cancer types. Worldwide, colorectal cancer was the third most commonly diagnosed cancer in 2018, while stomach cancer was the 5th and oesophageal cancer was the 7th most common cancer diagnosed that year [9]. The same year, 10.2% of all cancer incidence (including nonmelanoma skin cancer) in both sexes worldwide was due to colorectal cancer, 5.7% was due to stomach cancer and 4.7% was due to liver cancer and 3,2% was due to oesophageal cancer.

Malnutrition and cachexia are quite common in gastrointestinal cancers and early detection and management is important [10]. In fact, malnutrition risk is up to 80% [10], while it varies between gastrointestinal cancer site and stage [11], as well as screening tool [12]. In gastrointestinal cancer patients, the prevalence of malnutrition was estimated to be around 39.3% for colon/rectum cancer patients, 60.2% for oesophagus and/or stomach cancer patients and 66.7% for pancreas cancer patients [11], while in gastrointestinal cancer patients under chemotherapy it is estimated at 52% [13].

An important issue concerning malnutrition is under-diagnosis [13], despite the fact that nutritional status screening is advised to be performed at diagnosis [14], and body composition analysis can lower the risk of treatment toxicity [15], while BMI alone cannot distinguish fat mass from fat-free mass, and cannot take into account weight loss [16].

Body composition reflects the nutritional status. Bio-Impedance Analysis (BIA) is a noninvasive, time- and cost-effective technique to analyse body composition [17]. BIA can be used to assess the body composition of patients of all ages, independently of their physical and mental health status, as this measurement is fast and easily obtainable, with patients just having to step on the scale-analyser and hold the electrodes. BIA results and raw data are obtained immediately. Notably, BIA is currently used in various clinical settings, from hospitals to dietetic clinics; hence, it is easy to find a clinician or dietitian that has access to body composition analysers. Additionally, most body composition analysers are portable.

Due to the fact that the results of BIA are based on regression equations for healthy individuals, it has been proposed that raw data derived by BIA can be useful to this population [18]. Raw BIA parameters are reactance and resistance, from which phase angle (PA / Phase angle = arc - tangent reactance/resistance x 180°/ p) can be retrieved [19]. Both PA reflects both nutritional and hydration status, being also considered as measure of cell membrane function and integrity [18-20]. A high PA score reflects good function of cellular membrane, while a low PA is associated with cellular apoptosis and a decrease in content of cellular matrix [21]. PA is considered to be a useful prognostic tool in various diseases [22], critically ill patients [23], and especially in cancer patients [17,24], while it has been related with body weight changes in cancer patients undergoing radiotherapy [25]. BIA analysis has been used as a means to evaluate the nutritional status, as well as the course of treatment [26,27]. It has also been identified as a prognostic factor in head and neck [28,29] colorectal [30] and lung [31] cancer patients, as well as in advancedstage cancer patients [32,33]. Moreover, current body composition analysers display PA in their results. However the importance of adopting different cutoffs has been highlighted oftentimes [22,34].

In view of the above considerations, this review paper aims to critically summarise and discuss the currently available clinical data on the efficiency of the easily obtainable phase angle in the evaluation of malnutrition in gastrointestinal cancer patients, highlighting its role on disease progression and prognosis.

PubMed database was thoroughly searched using relative keywords (cancer, phase angle, BIA, bio-impedance, gastrointestinal, colorectal, gastric, liver, oesophagus, stomach, liver, gallbladder, pancreas), in order to identify clinical studies that explore the role of phase angle on disease prognosis and progress, on assessing malnutrition. Inclusion criteria were studies in humans with GIC, and papers written in English language.

Results

Phase angle as a nutritional screening and assessment tool in gastrointestinal cancer

Phase Angle has been used as a nutritional screening and assessment tool in cancer patients [17,24,35] and has been previously shown to be able to distinguish between nourished and malnourished patients with oesophageal [34], stomach [34] and colorectal cancer [36]. Recent studies highlight the value of PA on diagnosing malnutrition, while proposing cut-off points for diagnosing malnutrition [34].

Souza et al. [37] conducted a cross-sectional study with 197 Colorectal Cancer (CRC) patients, 29 of whom were later diagnosed with sarcopenia. Multivariable analysis revealed that PA was amongst the independent predictors of sarcopenia in this patient group. Another recent retrospective study explored the use of BIA as a means to evaluate malnutrition in patients with colorectal disease, most of whom had cancer (82.5%). The postoperative evaluation of 40 patients showed that PA was associated with malnutrition. Malnourished patients had lower PA, with an optimal PA cutoff point at 6.0°, where the tool showed 76.5% sensitivity, 87.0% specificity, 81.3% positive predictive value and 83.4% negative predictive value [38]. Data of 73 stage III and IV CRC patients were used in a retrospective study [36], aiming to evaluate the relationship between SGA and BIA measures. Well-nourished patients had a statistically significantly higher median phase angle, compared to those who were malnourished (6.12° vs. 5.18°). A phase angle cut-off point at 5.2° was 51.7% sensitive and 79.5% specific whereas a cut-off of 6.0° was 82.8% sensitive and 54.5% specific in detecting malnutrition. A phase angle cut-off of 5.9° had high diagnostic accuracy in men who did not respond to primary treatment for advanced colorectal cancer.

In another recent study in 153 geriatric GIC patients, PA was lower in those who were malnourished than those who were not malnourished [39]. A study by Ozorio et al. [16] explored the relation of cachexia defined by Fear on and different nutritional assessment tools, namely PG-SGA, PA, and handgrip strength. 101 GIC patients on chemotherapy with mean age 61.8 ± 12.8 years enrolled, of whom 32.6% were malnourished according to their BMI, while 63.3% were severely or moderately malnourished according to PG-SGA, 60.4% had decreased handgrip strength, and 57.4% had low PA. All tools, including PA, were associated with cachexia, however, PA could not identify between different stages of cachexia. At a cutoff of 5.3° the tool showed 72% sensitivity and 77.5% specificity.

In a recent study, 38 patients with stomach, colorectal, and biliary cancer with cachexia (weight loss of ≥ 5% over a 6 month period), under chemotherapy underwent BIA. PA was significantly lower in patients, compared to healthy controls, and significantly lower in females than males. Male cancer patients, who had lower PA, also had lower intracellular water levels compared with healthy controls. A lower Extracellular/ Intracellular Water (ECW/ICW) ratio was highly correlated with increased PA in cancer patients. The authors concluded that ECW/ICW ratios and PA may be suitable markers for gender-specific changes in cell composition and health status [40].

Citation: Mantzorou M, Tolia M, Pavlidou M, Vasios GK, Papandreou D, Papadopoulou SK, et al. The Potential of Phase Angle as a Nutritional Assessment Tool and Prognostic Factor in Patients with Gastrointestinal Cancers. Austin J Nutri Food Sci. 2022; 10(1): 1162.