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


Amaral TF, Antunes A, Cabral S, Alves P, Kent-Smith L. An evaluation of three nutritional screening tools in a Portuguese oncology centre. J Hum Nutr Diet. 2008; 21: 575-583.

Study Design:
Diagnostic, Validity or Reliability Study
C - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:
  • To evaluate the ability of the Malnutrition Screening Tool (MST) and the Malnutrition Universal Screening Tool (MUST) to identify nutritionally at-risk cancer patients, compared to a reference screening tool (Nutritional Risk Screening 2002)
  • To compare the ability of each screening tool to predict long length-of-stay in nutritionally at-risk oncology patients.
Inclusion Criteria:
  • Male or non-pregnant female
  • Aged at least 18 years
  • Anticipated length of stay over 24 hours
  • Provide informed consent.
Exclusion Criteria:
  • Patients admitted to the following departments:
    • Pediatric units
    • Intensive and intermediate care units
    • Bone marrow transplant units
    • Brachytherapy.
Description of Study Protocol:


  • March through June 2005
  • The first of every two admissions (every other admission) who met study criteria were included until half the department's available inpatient beds were filled.


  • Nutrition screening was completed by the same investigator for each tool in the order below:
    • Malnutrition Screening Tool (MST)
      • Score calculated based on appetite and unintentional weight loss
      • Classified as normal or at-risk.
    • Malnutrition Universal Screening Tool (MUST)
      • Score calculated based on BMI, unintentional weight loss and acute disease effect with potential for no nutrition intake of more than five days
      • Classified as low, medium or high risk.
    • Nutritional Risk Screening (NRS-2002)
      • Score calculated based on BMI, percentage of recent weight loss, recent change in food intake and disease severity
      • Classified as normal, mild, moderate or severe risk.
  • Demographic and anthropometric data were collected.

Blinding Used

Data collected by interviewer not involved with patients' care.

Statistical Analysis

  • Chi-square test was calculated to compare proportions
  • Student's T-test or Mann-Whitney U-test used to compare means
  • Using NRS-2002 as the reference, sensitivity, specificity, positive and negative predictive values were calculated for MST and MUST. Fleiss' kappa coefficient assessed agreement.
  • Multivariate analyses and odds ratios were calculated to assess the association between nutrition risk and length of stay. Adjusted for age and gender.
  • Patients with ascites or edema were excluded from BMI determination (N=4)
  • For the MUST tool, medium and high risk were combined into high risk category, due to small numbers in each nutrition risk category
  • Significance: P<0.05.
Data Collection Summary:

Timing of Measurements

  • Data was collected from the medical record or interview on Day One of admission for surgical patients or Day Two for non-surgical patients
    • Anthropometrics
      • Height or recumbent height
      • Weight
      • Tricep skinfold and arm circumference.
    • Education
    • Clinical diagnosis.

Dependent Variables

  • Nutrition risk identification
    • MST
    • MUST.
  • Long length of stay (median length of stay for the study sample): At least seven days

Independent Variables

Nutrition risk screening tools.

Control Variables

  • Age
  • Gender.
Description of Actual Data Sample:
  • Initial N: 130 (73 males and 57 females)
  • Attrition (final N): 130
  • Age (mean±SD): 57.1±13.5 years (range, 22 to 97 years)
  • Ethnicity: Not described
  • Location: Comprehensive cancer center in Portugal.
Summary of Results:

Key Findings

Nutrition Risk Screening

  • Nutrition risk identification by tool
    • NRS-2002: N=37 (28.5%)
    • MST: N=23 (17.7%)
    • MUST: N=57 (43.8%).
  • Stratified by tumor location
    • All three tools identified head and neck cancer patients as those presenting with the highest risk and showed good agreement identifying patients with peritoneal and gastrointestinal and lympha ganglia tumors
    • No patients with hematopoietic or endothelial reticulum tumors were identified at nutrition risk with any tool
    • Compared with NRS-2002, MST failed to identify patients at nutrition risk in seven tumor location categories
    • MUST failed to identify one patient at nutritional risk, compared to NRS-2002.
  • Agreement of screening tools, compared to NRS-2002
  •   Sensitivity Specificity Positive Predictive Value Negative Predictive Value Agreement Kappa Interpretion
  • Restricting the analysis to the tumor location groups with the highest nutritional risk (head and neck and peritoneal and gastrointestinal, N=52), MST showed good agreement with NRS-2002. MUST maintained a high sensitivity but the other parameters declined with moderate agreement with NRS-2002.

Risk of Long Length of Stay [(OR (95% CI) adjusted for age and gender)]

  • NRS-2002: 2.47 (1.05 to 5.80), P=0.003
  • MST: 2.31 (0.84 to 6.36), not significant
  • MUST: 3.24 (1.50 to 7.00), P=0.038.
Author Conclusion:

MUST agreed with NSR-2002 better than MST in hospitalized cancer patients and also predicted oncology patients at greater risk for longer length of stay.

Funding Source:
University/Hospital: Nutrition & Food Science, University of Porto, Portugal; Instituto Portugues de Oncologia do Porto Francisco Gentil, Porto, Portugal
Reviewer Comments:
  • NRS-2002 may not represent the gold standard to evaluate the nutritional status of oncology patients
  • Length of stay was affected by many non-nutrition-related factors and may not have been a good outcome variable.
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) Yes
  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) Yes
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? 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? N/A
  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? 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")? Yes
4. Was method of handling withdrawals described? Yes
  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? N/A
  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? Yes
5. Was blinding used to prevent introduction of bias? Yes
  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.) Yes
  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? Yes
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? N/A
  6.6. Were extra or unplanned treatments described? N/A
  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? Yes
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? 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? N/A
  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)? Yes
  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? No
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