MALNUTRITION IS ASSOCIATED WITH POOR HEALTH-RELATED QUALITY OF LIFE IN SURGICAL PATIENTS WITH GASTROINTESTINAL CANCER

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MALNUTRITION IS ASSOCIATED WITH POOR HEALTH-RELATED QUALITY OF LIFE IN SURGICAL PATIENTS WITH GASTROINTESTINAL CANCER Fernanda de Carvalho Pazzini Maia RD, MsC , ˆ Thales Antonio Silva RD, MsC , Simone de Vasconcelos Generoso RD, PhD , Maria Isabel Toulson Davisson Correia MD, PhD PII: DOI: Reference:

S0899-9007(20)30052-6 https://doi.org/10.1016/j.nut.2020.110769 NUT 110769

To appear in:

Nutrition

Received date: Revised date: Accepted date:

5 December 2019 12 January 2020 14 January 2020

Please cite this article as: Fernanda de Carvalho Pazzini Maia RD, MsC , ˆ Thales Antonio Silva RD, MsC , Simone de Vasconcelos Generoso RD, PhD , Maria Isabel Toulson Davisson Correia MD, PhD , MALNUTRITION IS ASSOCIATED WITH POOR HEALTH-RELATED QUALITY OF LIFE IN SURGICAL PATIENTS WITH GASTROINTESTINAL CANCER, Nutrition (2020), doi: https://doi.org/10.1016/j.nut.2020.110769

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HIGHLIGHTS 

Malnutrition, assessed by various tools, was associated with poor healthrelated quality of life of patients with gastrointestinal cancer in the preoperative period.



Subjective global assessment was able to predict a clinically relevant decrease in health-related quality of life.



The prevalence of malnutrition, according to the SGA and the percentage of weight loss, was close to 70%.

MALNUTRITION IS ASSOCIATED WITH POOR HEALTH-RELATED QUALITY OF LIFE IN SURGICAL PATIENTS WITH GASTROINTESTINAL CANCER

Authors: Fernanda de Carvalho Pazzini Maia1, Thales Antônio Silva1, Simone de Vasconcelos Generoso2, Maria Isabel Toulson Davisson Correia3 1

RD,

MsC,

Food

Sciences

Post

Graduation

Program,

Pharmacy

School,

Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais. 2

RD, PhD, Department of Nutrition, Nursing School, Universidade Federal de Minas

Gerais, Belo Horizonte, Minas Gerais. 3

MD, PhD, Department of Surgery, Medical School, Universidade Federal de Minas

Gerais, Belo Horizonte, Minas Gerais.

Corresponding author: Maria Isabel Toulson Davisson Correia, Department of Surgery, Medical School, Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena, 190, Belo Horizonte, Minas Gerais, Brazil–CEP 30130-100. Tel.: +55 31 991688239; fax: +55 31 3409 9759. E-mail address: [email protected].

ABSTRACT Objective: The aim of this study was to evaluate the association between preoperative nutritional status and health-related quality of life (HRQoL) in gastrointestinal cancer patients admitted for elective surgical treatment. Methods: This was a cross-sectional study in which patients with a diagnosis of gastrointestinal cancer were evaluated before the surgical procedure. The nutritional assessment included subjective global assessment (SGA) and measurements of weight loss percentage, bioelectrical impedance and functional capacity. HRQoL was evaluated by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - Core 30 (EORTC QLQ-C30). Statistical analyses were performed with a significance level of 5%. The sample size was calculated based on a pilot study. Results: A total of 132 patients were evaluated, the majority of whom were males. The median age was 62 years, and the most prevalent tumors were in the colon, rectum and anus (52.3%). The SGA highlighted the high prevalence of malnutrition (69.9%), which was confirmed by the rates of weight loss (73.8%) and the low fat-free mass index (56.8%). Malnourished patients and patients with severe weight loss had worse functional, symptom, global health and quality of life scores (p <0.05). Malnutrition, according to the SGA, decreased the physical function and role performance scores by nine and 20 points, respectively (p <0.05). Conclusion: Malnutrition, assessed by various tools, was associated with poor HRQoL of surgical patients with gastrointestinal cancer.

Key words: malnutrition, nutritional status, quality of life, gastrointestinal neoplasms, surgical procedures.

1

INTRODUCTION Malnutrition is highly prevalent in surgical patients with gastrointestinal cancer.

It negatively interferes with clinical outcomes and health-related quality of life (HRQoL) (1–3). Furthermore, the health-related quality of life of cancer patients is affected by both the disease and the adverse effects of cancer therapy (4,5). Together, malnutrition, cancer and its various therapeutic interventions perpetuate a cycle that affects the patient’s quality of life (6,7). Malnourished

cancer patients

present with

increased

infectious and

noninfectious complications, have longer lengths of hospital and intensive care unit (ICU) stays and have an increased rate of readmissions. Mortality is also increased, and costs are significantly higher (8–10). Gastrointestinal cancer patients are especially susceptible to malnutrition, as the disease frequently interferes with food intake due to obstruction, and may also impair the absorption of nutrients and digestion (1,11). Additionally, gastrointestinal cancer increases the risk of malnutrition 8.1-fold (12). Impaired nutritional status may also play a significant role in the HRQoL of the patients, particularly those undergoing major surgical procedures, which per se, also affects it. HRQoL may further be deteriorated if complications occur or when there is disease progression (13). Reported HRQoL of gastrointestinal cancer patients in the preoperative period is scarce and to our knowledge, no one has assessed the interplay of nutritional status and HRQoL. Most authors have only evaluated HRQoL changes from pre- to postoperative scores or the relationship between preoperative HRQoL and clinical outcomes in various time periods without assessment of the association with the nutrition status (4,14–18). It can be speculated that patients with poor nutritional status have worse preoperative HRQoL, which, together with the clinical factors associated with malnutrition, may negatively impact postoperative outcomes. Therefore, the current study aimed to evaluate the association between preoperative nutritional status and HRQoL in gastrointestinal cancer patients admitted for elective surgical treatment.

2 2.1

METHODS Study design This was a cross-sectional study carried out at Hospital das Clínicas/

Universidade Federal de Minas Gerais (UFMG), Minas Gerais, Brazil, between August 2016 and April 2018. The research protocol was approved by the UFMG Ethics Committee in Research (CAAE 55875316.5.0000.5149), and all patients gave written informed consent. Patients diagnosed with gastrointestinal cancer who were admitted for elective operations and were over 18 years old were invited to participate in the study. The evaluation occurred within 72 hours after hospital admission and completion before the surgical procedure was mandatory. Patients with an unconfirmed diagnosis of cancer, patients who did not undergo surgery within seven days after the evaluation and those who refused to sign the consent form were excluded. A standardized questionnaire was used to collect data, including identification number,

age,

sex,

educational

level,

tumor

location and c.

The

Tumor

Nodes Metastasis staging system (TNM) was used to describe disease staging. 2.2

Study measures

2.2.1 Nutritional status Nutritional status was assessed by different methods, since this has been a matter of controversy in the literature. 2.2.1.1

Subjective Global Assessment (SGA)

SGA was performed according to the protocol (19). Each patient was classified as well-nourished, suspected or moderately malnourished or severely malnourished. Patients suspected or moderately malnourished and those severely malnourished were grouped as malnourished. 2.2.1.2

Weight loss

The weight loss percentage was calculated according to the equation:

Weight loss (%) = usual weight (last six months) – current weight × 100 usual weight The current weight was obtained with the aid of a portable digital scale Tanita Solar Scale® with a maximum capacity of 150 kg. Severe weight loss was considered when 10% or more of the usual weight in the last six months occurred. Weight loss below this percentage was characterized as moderate loss (20). 2.2.1.3

Biolectrical impedance analyses (BIA)

BIA was conducted with the Quantum X model (RJL Systems, Michigan, USA) following guidelines (21,22). Body composition data were used to determine the fat-free mass index (FFMI), which was calculated according to the following equation: FFMI = fat-free mass (kg) / height (m)². The index was classified according to the values defined for men and women (23). The phase angle was converted into a standardized phase angle (SPA) (24). Patients with SPA results below -1.65 were classified as at risk for clinical complications and patients with higher values were classified as no risk. 2.2.1.4

Hand grip strength (HGS)

HGS was measured using the Dynamometer Plus (Jamar, South RD Hilton, South Australia, Australia) according to the protocol (25). Three measures were obtained from the dominant hand with a 1-min interval between each measurement, and the median value was used to determine a normal muscle strength when the HGS was greater than the 5th percentile (26). 2.2.2 Health-related quality of life HRQoL was assessed using the “European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - Core 30” (EORTC QLQ-C30), which has been translated and validated in Portuguese (27). This is a selfadministered 30-item cancer-specific questionnaire that was developed in 1986 by the EORTC. It comprises five functional scales (physical, role, cognitive, emotional and social functions), nine symptom scales (fatigue, pain, nausea and vomiting, dyspnea, insomnia, appetite loss, constipation, diarrhea, and financial difficulties) and

a global health status and quality of life scale (28). All single item scales and measurements range from 0 to 100. A high score for the functional scale and for the global health status and quality of life scale represents a higher HRQoL; on the other hand, a higher score for a symptom scale indicates poor HRQoL. To calculate the scales, the standardized formula by the organization that holds the rights of the EORTC QLQ-C30 questionnaire was used; 5- to 9-point differences in scores represent small changes, 10- to 20-point differences represent moderate changes, and greater than 20-point differences represent highly clinically significant alterations (29). 2.3

Statistical analyses Data were analyzed by the Statistical Package for Social Sciences (SPSS),

version 19.0 (SPSS Inc, Chicago, IL, USA), and a p < 0.05 was considered statistically significant. The Kolmogorov-Smirnov test was used to assess data normality. Descriptive statistics were expressed as the median and interquartile range (IQR). Medians were compared between two independent groups using the Mann-Whitney test. Multiple linear regression was performed to assess the association between nutritional status and HRQoL. The sample size was calculated based on a difference of 9.4 points on the median physical function domain score between the well-nourished and the malnourished patients according to the SGA after the pilot study. In this regard, 16 patients with gastrointestinal cancer who underwent elective surgery between May and July 2016 were assessed. A significance level of 5% and a 95% power test were adopted. Thus, the estimated sample size was 38 patients in each nutritional status group.

3

RESULTS One hundred and thirty-two patients were evaluated, with a median age of 62

years; most of the patients were male (62.1%) and had poor education (50.8%). The median time from disease diagnosis was four months, and the most prevalent tumors were in the colon, rectum and anus (52.3%). Neoadjuvant treatment was performed in 29 patients (22.0%), and 30 (26.1%) had advanced stage disease, as shown in Table 1. Table 1 - Clinical and sociodemographic characteristics of patients with gastrointestinal tract cancer (n=132). Relative Frequency - n (%) or Median (IQR) Age (years)

62 (54 – 69)

Sex Male

82 (62.1)

Female

50 (37.9)

Educational level * Incomplete elementary school

63 (50.8)

Elementary school

25 (20.2)

High school

26 (21.0)

Higher education

10 (8.0)

Time to diagnosis (months)

4 (2 – 8.5)

Tumor localization Head and neck

13 (9.8)

Esophagus, stomach and duodenum

29 (22.0)

Colon, rectum and anus

69 (52.3)

Liver, bile ducts and pancreas

21 (15.9)

Neoadjuvant Chemotherapy

29 (22.0)

Chemoradiotherapy

20 (15.2)

Stage ** I

12 (10.4)

II

36 (31.3)

III

37 (32.2)

IV

30 (26.1)

Abbreviation: IQR = interquartile range. *8 missing data. **17 missing data.

Malnutrition was observed in 91 patients by SGA (68.9%), and 96 had some degree of weight loss (72.7%). The median percentage of weight loss was 8.8% (0.9 - 14.8). Low FFMI was observed in 56.8%, the SPA indicated a risk for clinical complications in 21.8% of patients, and 11.1% of the patients had low muscle strength. The median HRQoL scores according to the EORTC QLQ-C30 are presented in Table 2. Patients had high scores for the functional, global health status and quality of life scale and low scores for the symptom scale. Table 2 - HRQoL of preoperative gastrointestinal cancer patients, according to EORTC QLQ-C30 (n=132). Median (IQR) Functional scale Physical

90 (73.3 – 100)

Role

100 (66.6 – 100)

Emotional

83.3 (58.3 – 91.6)

Cognitive

100 (83.3 – 100)

Social

100 (70.8 – 100)

Symptom scale Fatigue Nausea/ vomiting

33.3 (0 – 83.3) 0 (0 – 83.3)

Pain

0 (0 – 50)

Dyspnea

0 (0 – 0)

Insomnia

0 (0 – 33.3)

Appetite loss

0 (0 – 33.3)

Constipation

0 (0 – 0)

Diarrhea

0 (0 – 0)

Financial difficulty Global health status and quality of life scale

0 (0 – 66.6) 75 (58.3 – 91.6)

Abbreviation: HRQoL = health-related quality of life; EORTC QLQ-C30= European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - Core 30; IQR = interquartile range.

Worse physical function, role performance and overall health and quality of life were observed in malnourished patients (p = 0.000; p = 0.001; p = 0.001, respectively). In addition, malnourished individuals reported more pain and appetite loss (p = 0.000). Worse HRQoL in the physical function, role performance, fatigue, appetite loss, financial difficulties and global health status and quality of life domains

were observed in patients with severe weight loss (p = 0.048; p = 0.039; p = 0.030; p = 0.043; p = 0.043; p = 0.034, respectively). Higher appetite loss and financial difficulty domains were found in patients with muscle strength depletion (p = 0.022; p = 0.003, respectively). The risk for clinical complications according to the SPA indicated worse physical function and more fatigue (p = 0.035; p = 0.040) (Table 3).

Table 3 - Comparison of the HRQoL median (IQR) according to EORTC QLQ-C30 according to nutritional status, functionality and standard phase angle. SGA

%WL

HGS ***

SPA ****

Well-nourished

Malnourished

<10%

≥10%

Normal HGS

Low HGS

No risk

Risk

(n=41)

(n=91)

(n=72)

(n=60)

(n=112)

(n=14)

(n=86)

(n=24) 73.3 (53.3 – 98.3)*

Functional scale Physical

100 (86.6 – 100)

86.6 (66.6 – 100)**

93.3 (73.3 – 100)

86.6 (66.6 – 100)*

93.3 (73.3 – 100)

73.3 (50 – 100)

93.3 (73.3 – 100)

Role

100 (100 – 100)

100 (33.3 – 100)**

100 (83.3 – 100)

100 (37.5 – 100)*

100 (66.6 – 100)

100 (29.1 – 100)

100 (66.6 – 100)

91.6 (0 – 100)

Emotional

83.3 (66.6 – 91,6)

83.3 (50 – 100)

83.3 (58.3 – 91.6)

83.3 (58.3 – 97.9)

83.3 (58.3 – 91.6)

75 (31.2 – 85.4)

83.3 (50 – 91.6)

79.1 (58.3 – 100)

Cognitive

100 (83.3 – 100)

83.3 (66.6 – 100)

83.3 (66.6 – 100)

100 (83.3 – 100)

100 (83.3 – 100)

91.6(12.5 – 100)

83.3 (66.6 – 100)

91.6 (70.8 – 100)

Social

100 (83.3 – 100)

100 (66.6 – 100)

100 (79.1 – 100)

100 (66.6 – 100)

100 (83.3 – 100)

91.6 (50 – 100)

100 (83.3 – 100)

100 (58.3 – 100)

Symptom scale 11.1 (0 – 100)

44.4 (11.1 – 77.7)

22.2 (0 – 79.1)

47.2 (22.2 – 95.8)*

22.2 (0 – 77.7)

50 (22.2 – 100)

22.2 (0 – 83.3)

55.5 (22.2 – 100)*

Nausea/ vomiting

0 (0 – 100)

8.3 (0 – 66.6)

0 (0 – 70.8)

8.3 (0 – 83.3)

0 (0 – 79.1)

50 (0 – 70.8)

0 (0 – 83.3)

50 (0 – 100)

Pain

0 (0 – 16.6)

16.6 (0 – 66.6)**

0 (0 – 33.3)

16.6 (0 – 66.6)

0 (0 – 45.8)

0 (0 – 87.5)

8.3 (0 – 50)

0 (0 – 66.6)

Dyspnea

0 (0 – 0)

0 (0 – 0)

0 (0 – 0)

0 (0 – 0)

0 (0 – 0)

0 (0 – 41.6)

0 (0 – 0)

0 (0 – 0)

Insomnia

0 (0 – 0)

0 (0 – 66.6)

0 (0 – 33.3)

0 (0 – 33.3)

0 (0 – 33.3)

0 (0 – 100)

0 (0 – 8.3)

0 (0 – 91.6)

Appetite loss

0 (0 – 0)

0 (0 – 66.6)**

0 (0 – 0)

0 (0 – 58.3)*

0 (0 – 0)

16.6 (0 – 100)*

0 (0 – 0)

0 (0 – 58.3)

Constipation

0 (0 – 0)

0 (0 – 0)

0 (0 – 0)

0 (0 – 0)

0 (0 – 0)

0 (0 – 8.3)

0 (0 – 0)

0 (0 – 25)

Diarrhea

0 (0 – 0)

0 (0 – 0)

0 (0 – 0)

0 (0 – 0)

0 (0 – 0)

0 (0 – 41.6)

0 (0 – 0)

0 (0 – 0)

Financial difficultiy

0 (0 – 33.3)

0 (0 – 66.6)

0 (0 – 33.3)

0 (0 – 91.6)*

0 (0 – 33.3)

66.6 (0 – 100)*

0 (0 – 66.6)

16.6 (0 – 91.6)

Global health status

83.3 (75 – 100)

75 (50 – 83.3)**

83.3 (66.6 – 91.6)

75 (50 – 89.5)*

83.3 (60.4 – 91.6)

70.8 (50 – 77)

83.3 (66.6 – 93.7)

75.0 (50 – 83.3)

Fatigue

and quality of life scale Abbreviation: HRQoL = health-related quality of life; IQR = interquartile range; EORTC QLQ-C30= European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - Core 30; SGA = subjective global assessment; WL = weight loss; HGS = hand grip strength; SPA = standardized phase angle. *p≤0,05.

**p≤0,001.

***6

missing

data.

****22

missing

data.

Multiple linear regression was performed to evaluate the nutritional parameters associated with HRQoL. In addition to these measures, confounding variables such as sex, age and disease stage were included in the analysis. In the final model, only the SGA and HGS were significant, and the former was able to explain 23.9% of the variance in physical function (p = 0.001). Malnutrition was associated with decrease of 9 and 20 points in the physical function and role performance scores, respectively (Table 4). Table 4 – Multivariate analysis of nutritional parameters associated with HRQoL. R²

Physical function Role

Fatigue

SGA

HGS

β

95%CI

β

95%CI

0.239

-9.5

-17.8 – -1.2

-

-

p=0.001

p=0.024

0.175

-20.8

-37.5 – -2.3

-

-

p=0.008

p=0.027

0.144

-

-

-1.8

-3.6 – -0.3

p=0.05 Pain

Appetite loss

Global health status and

p=0.023

0.149

23.2

p=0.022

p=0.011

0,.53

26.6

p=0,019

p=0.006

0.175

-12.5

p=0.096

p=0.026

5.3 – 41.1

-

-

8 – 45.1

-

-

-23.5 – -1.55

-

-

quality of life scale Abbreviation: HRQoL = health-related quality of life; SGA = subjective global assessment; HGS = hand grip strength.

4

DISCUSSION Malnutrition negatively interferes with the clinical outcomes of cancer patients

undergoing any cancer treatment and can also play a significant role in HRQoL (7,30). In a mixed cancer population, severe weight loss indicated poor global health status and quality of life, poor functional performance, and increased symptom perception, while patients who were able to maintain weight often reported being satisfied with their HRQoL (31). Moreover, the combination of anorexia and early satiety negatively impacted the overall health perception and role functioning of cancer patients (32). Surgical patients are especially vulnerable to malnutrition and worst HRQoL due to the negative impact associated with surgery, and this may persist for longer periods after surgery, which may eventually impact the adjuvant therapies (13,33). HRQoL of patients with gastric cancer was not reestablished until at least three months after the surgical procedure (4). However, most studies have essentially reported postoperative assessments, while in the current study, we evaluated the preoperative HRQoL considering that this aspect may also interfere with how the patients will face the surgical procedure, especially when it is a major operation. Therefore, to our knowledge, this is the first study to evaluate the association between nutritional status and HRQoL prior to surgery in patients with various tumors of the gastrointestinal tract. The assessment of nutritional status included several parameters, as this has been a matter of discussion in the literature (34). We chose to use methods commonly described in the literature, such as the SGA, percentage of weight loss and FFMI. The SPA has been associated with changes in nutritional status, clinical complications and mortality in cancer patients (24,35). Functionality is a determining factor for nutritional status and, therefore, was also assessed by measuring handgrip strength. Malnutrition associated with the disease is highly prevalent in Latin America, as shown by a recent systematic review (8). The included Brazilian studies indicated a higher malnutrition variability, with the largest rate of malnutrition reporting values between 39.3% - 69.7% in hospitalized patients (36). In the present study, the prevalence of malnutrition, according to the SGA and the percentage of weight loss,

was close to 70%, the upper limit observed in the general hospitalized population (8). Given that gastrointestinal cancer patients are more vulnerable to malnutrition due to the particularities of the disease, this result was expected, especially considering that our study population was comprised mainly of patients with a low socioeconomic status, which generally hinders access to medical care, precludes early diagnosis and consequently increases the risk of malnutrition. Overall, we observed that patients with gastrointestinal cancer reported good HRQoL in the immediate preoperative period. Although the EORTC QLQ-C30 does not have cutoff points to classify good HRQoL, the medians of the functional scale, global health status and quality of life scale domains were close to the maximum score. Similarly, the medians of the symptom scale domains were zero, except for the fatigue domain. Similar results were found when evaluating patients with gastrointestinal cancer at different stages of cancer treatment, regardless of therapy (32). On the other hand, higher scores in the symptom scale domains and lower scores in the functional scale, global health status and quality of life domains were reported, which represent worse HRQoL (37). We believe that the differences found by the authors may be related to the study populations, as the last ones included only patients with advanced colorectal cancer, especially in the postoperative period (37). Understanding gastrointestinal cancer patient perception of HRQoL may enable the prevention or control of factors that may negatively influence surgical outcomes and provide the opportunity to plan actions that will help the early reestablishment of quality of life scores. Malnutrition is a factor that, in addition to being associated with postoperative complications, can influence HRQoL. We observed that the various nutritional indicators, such as the SGA, weight loss, the HGS and the SPA, when compared with the EORTC QLQ-C30 domains, indicated a close association between depleted nutritional status and HRQoL in the preoperative period. Clinically relevant changes were observed in several domains. Differences were found regardless of the nutritional assessment method used: moderate and large clinical relevance changes were observed in those who were malnourished according to the SGA and in patients with severe weight loss. Changes in scores with great clinical significance were observed when patients at risk for complications

according to the SPA were compared with those without risk, as well as for patients with a low HGS. Our findings reinforced that malnutrition significantly impacts the HRQoL of patients with gastrointestinal cancer in the preoperative period and confirmed the data from studies of postoperative patients as well as those that included patients in different stages of nonsurgical cancer treatment (6,38,39). A systematic review (26 studies, of which 14 evaluated patients with gastrointestinal cancer) was carried out to investigate the role of nutritional status in predicting HRQoL in cancer patients at different stages of treatment, and it indicated that a better nutritional status was positively associated with improved HRQoL (7). On the other hand, a study reported that malnutrition was not associated with the functional and global health status and quality of life scales in patients with head and neck cancer (40). The authors indicated that the symptom scales were the ones that presented a higher degree of association with nutritional status. It should be highlighted that the authors evaluated patients who generally suffer from more signs and symptoms related to cancer. As other factors may negatively impact HRQoL, a multivariate analysis was performed and confirmed that malnutrition diagnosed by SGA was able to predict a clinically relevant decrease in HRQoL variables. Thus, preoperative nutritional assessment should be a routine practice since malnutrition, in addition to affecting postoperative outcomes, interferes with HRQoL. SGA seems to be an adequate clinical method for the initial evaluation as it is rapidly performed, training the evaluators is simple and it has been validated by various authors in different settings (41,42). The main limitation of the present study is its cross-sectional design, which does not allow us to adequately assess causality between nutritional status and HRQoL. Additionally, the non-application of the QLQ-C30 supplementary modules, which are specific to cancer location, is another aspect that deserves to be highlighted. This was decided upon due to the variety of patients with different tumor sites, which led us to choose a cancer-specific questionnaire that addressed issues pertaining to the disease in general.

5

CONCLUSION Malnutrition, assessed by various tools, was associated with poor HRQoL in

patients admitted for elective surgical treatment of gastrointestinal cancer.

Acknowledgements The authors acknowledge Conselho Nacional de Pesquisa (CNPq) for the scientific grant to M.I.T.D.C.

Conflict of interest All the author´s declare no conflict of interest.

Authors’ contributions F.C.P.M.: Conceptualization, Methodology, Formal analysis, Investigation, Writing - Original Draft. T.A.S.: Investigation. S.V.G.: Writing - Review & Editing. M.I.T.D.C.: Conceptualization, Methodology, Writing - Review & Editing, Supervision.

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