ONC: Malnutrition Screening and Nutrition Assessment of Adult Oncology Patients (2012)


Kwang AY, Kandiah M. Objective and subjective nutritional assessment of patients with cancer in palliative care. Am J Hosp Palliat Care. 2010 Mar; 27 (2): 117-126. Epub 2009 Dec 3.

PubMed ID: 19959839
Study Design:
Cross-Sectional Study
D - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:
  • The objective is to evaluate the nutritional status of patients with cancer in palliative care using objective and subjective nutritional assessments
  • To determine potential inter-relationships between the methods.
Inclusion Criteria:

All consecutive, mentally alert and ambulatory patients with cancer admitted as inpatients and outpatients at a palliative care unit of a Malaysian government hospital and a non-governmental hospice facility between January and April 2005.

Exclusion Criteria:
  • Non-ambulatory patients who had severe edema or ascites, were on enteral or parenteral nutrition support, terminally ill with metastasis and secondary cancers
  • Also re-admitted patients were not assessed a second time.
Description of Study Protocol:


All consecutive, mentally alert and ambulatory patients with cancer admitted as inpatients and outpatients at a palliative care unit of a Malaysian government hospital and a non-governmental hospice facility between January and April 2005. 



Statistical Analysis

SPSS version 15.0 was used for all statistical analyses:

  • Pearson's correlation to determine the relationship between PG-SGA scores and the objective nutritional variables
  • One-way ANOVA test was performed for differences in objective nutritional indices among the three categories of PG-SGA
  • Bonferroni post-hoc multiple comparison test was applied to further investigate significant differences between PG-SGA ratings
  • Effect size was manually calculated to examine the magnitude of difference and interpreted by Cohen's guidelines
  • A statistical probability level of P<0.050 was considered significant.
Data Collection Summary:

Timing of Measurements

Nutritional status was assessed by two different methods

  1. Anthropometric measurements
  2. A scored PG-SGA tool.

Dependent Variables

  • Anthropometrics: Weight, height, body mass index, mid-upper-arm muscle circumference, triceps skinfold thickness and percentage of change in body weight within one month and six months 
  • Patient-Generated Subjective Global Assessment Score: Scoring range from zero to four; after assessment was complete a nutritional staging was given of (a) well nourished, (b) moderately malnourished or (c) severely malnourished.
Description of Actual Data Sample:
  • Initial N: 58 patients (29 male, 29 female)
  • Attrition (final N): 58
  • Age: 20 years to 74 years of age (mean, 58.4±13.1 years)
  • Ethnicity: 64.8% Chinese; 24.1% Malay; 10.3% Indian; 1.7% others.

Other Relevant Demographics

  • 74% of these patients were actively undergoing surgery, radiotherapy, chemotherapy or other alternative traditional treatments
  • 67% of patients were prescribed with opioid analgesic drugs, morphine and other pain-killer medications
  • 62.1% had Stage Four cancer; 24.1% had Stage Three cancer; 8.6% had Stage Two cancer; 5.2% had Stage One cancer
  • 31.0% of patients were "well nourished," 50.0% were "moderately malnourished" and 19.0% were "severely malnourished"
  • Most frequent nutrition impact symptoms were pain (55.2%), xerostamia (44.8%), anorexia (36.2%) and constipation (31.0%)
  • Majority of the patients (41.4%) have three to four nutrition impact symptoms at the same time.


  • Height: 158.85±11.82cm
  • Weight: 52.98±13.13kg
  • Weight loss at one month: 3.09±4.78%
  • Weight loss at six months: 7.49±8.52%
  • BMI (kg/m2): 20.85±3.98
  • Triceps skinfold thickness: 8.04±3.96mm
  • Mid-upper-arm circumference: 24.38±4.56cm
  • Mid-upper-arm muscle circumference: 217.53±37.27mm


Palliative care unit of a Malaysian government hospital and a non-governmental hospice facility.

Summary of Results:

Key Findings

  • A statistically-significant difference at the P<0.050 level in anthropometric measures for the three PG-SGA stages
  • Both mid-upper arm circumference and triceps skinfold thickness showed a moderate negative correlation between these two and PG-SGA score variables (R=-0.32, N=58, P<0.050), with low reading of anthropometric measures associated with higher scores of PG-SGA
  • Anorexia is moderately correlated with problems of chewing and swallowing
  • Nausea has a moderate correlation with vomiting and dysgeusia; xerostamia with mouth sores and early satiety; dysnomia with dysgeusia.
Author Conclusion:
  • The percentage of malnutrition in this study ranged between 31.0% and 69.0%
  • There is still no consensus on which is the most appropriate to be applied in a specific palliative care setting. Weight loss was found to be a dominant characteristic of patients with poor nutritional status.
  • Continuous weight loss has been shown to be a good predictor of negative complications and as part of the classical causes of cachexia
  • A majority of patients with advanced cancer had normal-to-high BMI values
  • Most of the patients with cancer appear to die with normal BMI status, despite significant weight loss
  • This study does not provide a proper validation of the tool, but the initial findings showed that the scored PG-SGA is an undoubtedly convenient choice of nutritional status evaluation, as it was significantly correlated with anthropometric measurements
  • This study suggests that the tool is practical, especially in busy palliative care units and often with fewer human resources
  • A few anthropometric nutritional values, such as triceps skinfold thickness, weight loss in one or six months and BMI were not significantly different across the PG-SGA stages
  • A limitation was the relatively small sample size and exclusion of objective biochemical parameters, such as inflammatory activity biomarkers (serum pre-albumin and high-sensitivity C-reactive protein), restricted a more comprehensive evaluation of the methods used and further understanding of the etiology of malnutrition in these patients.
Funding Source:
University/Hospital: Wyeth (Malaysia)Sdn Bhd and Stream-Line Industries Sdn Bhd
Reviewer Comments:
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? N/A
  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? Yes
  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? Yes
3. Were study groups comparable? Yes
  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? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  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? Yes
  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.) Yes
  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? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  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%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? Yes
  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? N/A
  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? N/A
  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? N/A
  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? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  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? Yes
  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? Yes
  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? Yes
  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? Yes
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)? Yes
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? N/A
  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? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes