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Longitudinal Dynamic in Weight Loss Impacts Clinical Outcomes for Veterans Undergoing Curative Surgery for Colorectal Cancer

Federal Practitioner. 2023 May;40(1)s:S24-S33 | doi:10.12788/fp.0377
May 9, 2023|Federal Practitioner
Urvashi M. Joshi, MD;David Ratz, MS;Timothy L. Frankel, MD;Irina Dobrosotskaya, MD, PhD
Author and Disclosure Information

Urvashi M. Joshi, MDa,b,c; David Ratz, MSa,b; Timothy L. Frankel, MDa,b; Irina Dobrosotskaya, MD, PhDa,b

Correspondence: Irina Dobrosotskaya (irinad@med.umich.edu)

aUniversity of Michigan Health System, Ann Arbor

bVeterans Affairs Ann Arbor Healthcare System, Michigan

cUniversity of Pittsburgh Medical Center, Pennsylvania

Author disclosures

The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.

Disclaimer

The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.

This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Ethics and consent

This study was approved by the Veterans Affairs Ann Arbor Healthcare System Institutional Review Board.

Background: Definitions of malnutrition imperfectly reflect nutritional status or predict perioperative consequences. We sought to identify predictive nutritional trends by examining the effect of preoperative weight on postoperative outcomes in patients with colorectal cancer (CRC).

Methods: This retrospective review examined 148 patients with CRC treated with curative-intent surgery at the Veterans Affairs Ann Arbor Healthcare System in Michigan from January 1, 2015 to December 31, 2019. We evaluated weight dynamics of patients, starting 1 year before cancer diagnosis until 1 year after surgery. We evaluated the association of these weight dynamics with surgical outcomes. Primary outcomes observed were hospital readmission and length of stay (LOS), chemotherapy completion, and delayed recovery defined as abnormal clinical developments.

Results: There were 115 patients in the colon cancer (CC) cohort and 33 in the rectal cancer (RC) cohort. Low preoperative albumin (< 3.5 g/dL) was present in 25 patients with CC (22%) and 11 patients with RC (33%). Six-month preoperative weight loss of at least 3% occurred in 32 patients with CC (36%). Delayed recovery was observed in 35 patients with CC (30%) and 21 patients with RC (64%). Nutrition consultation rates for the CC and RC groups were 15% and 36%, respectively, before the operation; 95% and 100%, respectively, for postoperative inpatients; and 12% and 73%, respectively, for postoperative outpatients. Six-month preoperative weight loss of ≥ 3% was significantly associated with delayed recovery (P < .001) and 60-day readmissions (P = .015) but not increased LOS or chemotherapy noncompletion.

Conclusions: A ≥ 3% weight loss 6 months preceding curative surgery for CRC was associated with adverse outcomes. An intensive nutrition prehabilitation program initiated at the time of cancer diagnosis is needed and may reduce associated complications.

Analysis

The data were described using mean (SD) for continuous variables and number and percentages for categorical variables. Where appropriate, Fisher exact test, Pearson χ2 test, Spearman ρ, and Mann-Whitney U test were used for tests of significance. SAS (SAS Institute) was utilized for multivariable analysis. The significance level was P = .05 for all tests.

Results

There were 115 patients in the CC cohort and 33 in the RC cohort. The mean (SD) age at diagnosis was 70 (9.1) for CC group and 59 (1.4) for RC group (Table 1). 

table 1
For the CC and RC cohorts, the mean (SD) pathologic tumor stage was 2.3 (0.8) and 1.6 (1.2), respectively; the mean (SD) nodal stages was 0.4 (0.7) for both groups. Most patients (84 [73%] in the CC cohort and 29 [88%] in the RC cohort) had at least 1 recorded comorbidity (ie, diabetes mellitus, peripheral arterial disease, coronary artery disease, or history of cerebral vascular accident/transient ischemic attack). Malnutrition as determined by BMI criteria was not highly prevalent in the patient cohort. At time of diagnosis, none of the patients were underweight (BMI < 18.5); 24 patients with CC (27%) and 5 patients with RC (15%) were overweight (BMI 25.0-29.9); and 43 patients with CC (48%) and 15 patients with RC (45%) were obese (BMI ≥ 30). CC and RC cohorts had a mean preoperative albumin of 3.71 and 3.60, respectively. Low preoperative albumin (< 3.5), was present in 25 patients with CC (22%) and in 11 patients with RC (33%).

Weight Trends

Table 2
At time of diagnosis, the mean (SD) BMI was 29.9 (7.1) for the CC group and 30.9 (7.4) for the RC group. The mean (SD) time in days from diagnosis to the date of surgery for the CC group was 43.9 (26.8) and 172.1 (39.1) for the RC group. Mean changes in BMI ranged from -7.0% to +4.9% (Table 2).

From 1 year to 6 months before diagnosis, 40 of 80 patients lost weight in the CC cohort (mean change, +1.9%) and 6 of 22 patients lost weight in the RC cohort (mean change, + 0.5%). From 6 months before diagnosis to time of diagnosis, 47 of 74 patients lost weight in the CC cohort (mean change, -1.5%) and 14 of 21 patients lost weight in the RC cohort (mean change, -2.5%). From time of diagnosis to time of surgery, 36 of 104 patients with CC and 14 of 32 patients with RC lost weight with a mean weight change of and +0.1% and -0.3%, respectively. In the 6 months before surgery, any amount of weight loss was observed in 58 patients (66%) in the CC group and in 12 patients (57%) in the RC group. In this time frame, in the CC cohort, 32 patients (36%) were observed to have at least 3% weight loss, and 23 (26%) were observed to have at least 5% weight loss (Table 3). 

Table 3
In the 6 months before surgery, 20 of 88 patients (23%) in the CC cohort lost ≥ 10 lb.

In patients who completed adjuvant chemotherapy in the CC group, mean (SD) BMI at the beginning and end of chemotherapy was 32.6 (8.6) and 33.1 (8.7), respectively, and a -0.3% mean change in weight was observed. In the RC group, mean (SD) BMI was 28.2 (5.0) at the initiation of adjuvant chemotherapy and 28.4 (5.0) at its completion, with a +2.6% mean change in weight.

In the immediate postoperative period, most patients were losing weight in both the CC and RC groups (mean, -3.5% and -7.0% at 1 month postoperative, respectively). At 1-year after surgery, patients had modest mean increases in weight: +1.3% for patients with CC and +4.9% for patients with RC.

A relatively large proportion of patients had missing data on weights at various data points (Table 4). 

Table 4
Preoperative weight trends were hampered by this limitation. Of the 115 patients, only 62 (54%) had data available to evaluate weight dynamics from 1 year prior to time of diagnosis, 74 (64%) from 6 months prior to diagnosis, and 73 (63%) for 1 year prior to time of surgery. The trend from 6 months pre-diagnosis until the time of surgery allowed for the most complete analysis: Data were available for 88 of 115 patients (77%). Data were missing in 33 patients with RC as well; thus, data analysis is focused on the CC cohort.

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