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ONC: Nutrition Status and Outcomes in Adult Oncology Patients (2013)


Shahmoradi N, Kandiah M, Peng LS. Impact of nutritional status on the quality of life of advanced cancer patients in hospice home care. Asian Pac J Cancer Prev. 2009; 10(6): 1,003-1,009.

PubMed ID: 20192573
Study Design:
Cross-Sectional Study
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:

To determine the association between nutritional status and quality of life among advanced cancer patients in hospice home care in peninsular Malaysia.

Inclusion Criteria:

Eligible subjects were screened for their functional status using the Eastern Cooperative Oncology Group (ECOG) performance scale, a six-point measure ranging between zero (fully active) and five (dead).

  • Patients with ECOG zero to three (reasonable functional status) were selected
  • Patients who gave informed consent.
Exclusion Criteria:
  • Patients with ECOG four and five
  • Patients and caregivers who did not give informed consent.
Description of Study Protocol:


Cancer patients were screened by palliative care physician and nurses of the selected hospices. Those who met the inclusion criteria were invited to participate in the study.


Cross-sectional study.

Statistical Analysis

  • All data were analyzed using the Statistical Package for Social Sciences (SPSS) version 16.0
  • Descriptive statistics (mean, standard deviation and frequency) were used for subjects' demographic information, disease characteristics, quality of life score and nutritional status score
  • General Linear Model (GLM) univariate analysis were used to evaluate the association between nutritional status score and total quality life score
  • GLM multivariate analyses were used to assess the association between nutritional status score and three domains of quality of life.
  • P<0.05 was deemed as the significant level.
Data Collection Summary:

Timing of Measurements

All data were collected during a face-to-face interview with the subjects at their house by researcher from November 2008 to April 2009.

Dependent Variables

Subjects' quality of life was assessed with the Hospice Quality of Life Index (HQLI), a 28-item tool which includes three aspects of overall quality of life. Four different scores were used for correlation with nutritional status:

  • Total quality of life (28 items)
  • Psychophysiologic well-being (13 items)
  • Functional well-being (seven items)
  • Social and spiritual well-being (eight items).

Independent Variables

Nutritional status of patients [assessed by the Patient-Generated Subjective Global Assessment (PG-SGA), which covers seven items:

  • Weight
  • Food intake
  • Symptoms
  • Activities and function
  • Disease and its relation to nutritional requirements
  • Metabolic demand
  • Physical examination.

Control Variables

Socio-demographic characteristics including:

  • Ethnicity
  • Education
  • Occupation
  • Household income
  • Cancer type
  • Primary disease stage
  • Duration of cancer
  • Duration of hospice care
  • Types of cancer treatment
  • Caregiver description
  • ECOG.
Description of Actual Data Sample:
  • Initial N: 61 cancer patients [33 women (54%) and 28 men (46%)]
  • Attrition (final N): 61
  • Age: Mean age was 59.2±12.5 years old (range: 18 to 74 years)
  • Ethnicity: Chinese (67.2%), Malay (18%), Indian (14.8%). 

Other Relevant Demographics

  • Most (86.9%) had some form of education
  • Most (47.5%) had retired and were disabled
  • Approximately 80% were in hospice for less than 12 months
  • Breast cancer the most widespread form of cancer among females, rectum cancer the most widespread among males
  • Majority (72.1%) were in stage four
  • About 45.9% had been living with cancer for two or more years
  • Almost 88% had received some types of cancer therapy
  • Majority were cared by their spouses
  • ECOG:
    • ECOG 3: 40%
    • ECOG 2: 34.4%
    • ECOG 1: 24.6%.


Hospice home care facilities in Palau Pinang and Negeri Sembilan in Malaysia.


Summary of Results:
  • Nutritional status was categorized into three groups:
    • Nine subjects (14.7%) were well-nourished
    • 32 (52.5%) were moderately or suspected of being malnourished
    • 20 (32.8%) were severely malnourished.
  • 98.4% of the patients required nutrition triage recommendations
  • The total HQLI mean score was 189.9±51.7, with possible scores ranging from zero (poor quality of life) to 280 (high quality of life). The most problem areas were in the domain of functional well-being and the least problems in the social and spiritual domain.
  • PG-SGA scores significantly correlated with total quality of life scores and the three subscale scores. PG-SGA score is able to explain 38%, 36.9%, 41.8% and 7% of the total variation in total quality of life score, psychophysiological, functional and social and spiritual well-being, respectively. Thus, patients with a higher PG-SGA score or poorer nutritional status exhibited a lower quality of life.

Correlations with PG-SGA Scores

  R Squared P Value
Total quality of life 0.38 0.000
Psychophysiological sub-scale well-being 0.37 0.000
Functional sub-scale well-being 0.42 0.000
Social and spiritual sub-scale well-being 0.07 0.040

Other Findings

  • The item with the lowest score in the functional well-being sub-scale was enjoyable activity
  • The items with the lowest score in the psychophysiological well-being sub-scale were anxiety about what was happening to them and satisfaction with sex life
  • The item with the lowest score in the social and spiritual well-being sub-scale was physical contact.
Author Conclusion:
  • This study confirmed a significant association between poorer nutritional status and impaired quality of life in all three domains
  • The quality of life and nutritional assessment using appropriate tools such as the HQLI and PG-SGA should be carried out on cancer patients in hospice care to plan targeted intervention
  • A potential limitation of the study was the small sample size and exclusion of subjects with emotional, cognitive or physical problems that prevented them from completing the HQLI and PG-SGA questionnaire.
Funding Source:
Reviewer Comments:
  • No anthropometrics data were available (weight was part of the PG-SGA)
  • No blinding (data collected by researcher)
  • No withdrawals
  • Funding source was not described.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) N/A
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) N/A
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? N/A
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? ???
3. Were study groups comparable? N/A
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) No
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? N/A
  4.1. Were follow-up methods described and the same for all groups? N/A
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) N/A
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? No
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) No
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? No
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? No
  6.6. Were extra or unplanned treatments described? No
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? N/A
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? N/A
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? N/A
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? No
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? ???
  10.1. Were sources of funding and investigators' affiliations described? No
  10.2. Was the study free from apparent conflict of interest? ???