The impact of obesity on LADG for early gastric cancer

Background Laparoscopy-assisted distal gastrectomy (LADG) has become a viable alternative treatment for patients suffering with early gastric cancer. Surgeons have long thought that obesity might increase the rate of intraoperative or postoperative complications. We set out to clarify the effect that obesity has on performing LADG for the treatment of early gastric cancer. Methods We retrospectively reviewed 97 patients who had undergone LADG for early gastric cancer between May 1998 and March 2004. We measured the degree of obesity by using the body mass index (BMI; kg/m²), and we compared the surgical outcomes between the normal BMI group (BMI < 23 kg/m²) and the high BMI group (BMI ≥ 23 kg/m²). We further subdivided the patients into four groups: normal BMI males and normal BMI females, and high BMI males and high BMI females, and we analyzed them in terms of operation times, numbers of retrieved lymph nodes, and rates of postoperative complications. Results There were no significant differences between the normal and high BMI groups in terms of the patients' characteristics, surgical outcomes, postoperative courses, postoperative complications, and operation times. There were no statistically significant differences in the number of retrieved lymph nodes or in the rate of postoperative complications among the four groups (P = 0.5030 and P = 0.3489, respectively). However, there was a statistically significant difference in operation times among the four groups (P = 0.004). Specifically, the males in the high BMI group required a longer operation time than did the females with a normal BMI (P = 0.006) and the females with a high BMI (P = 0.019). Conclusions For LADG in patients with early gastric cancer, obesity may affect the operation time, and men with high BMI require a longer operation time than do women with normal or high BMI.     

Obesity as a determinant of perioperative and postoperative outcome in patients following colorectal cancer surgery: A population-based study (2009–2016)

Background

Obesity is an increasing problem worldwide that can influence perioperative and postoperative outcomes. However, the relationship between obesity and treatment-related perioperative and short-term postoperative morbidity after colorectal resections is still subject to debate.

Associations between obesity,metabolic health,and the risk of breast cancer in East Asian women

Background This study examined the associations between metabolic syndrome(MetS), obesity, their combination as a metabolic obesity phenotype, and the risk of breast cancer in East Asian postmenopausal women.Methods A total of 3,095,336 postmenopausal cancer-free women aged 40–79 years who underwent the National Health Insurance Service health examination between 2009 and 2010 were included. The incidence of invasive breast cancer was followed up until 2018. The presence of obesity (body mass index[BMI] ≥25 kg/m²), MetS, and each component of MetS was investigated.Results Obesity and MetS were associated with breast cancer risk, but when the effects of obesity and MetS were mutually adjusted, the associations were attenuated, especially for MetS. Only elevated fasting blood glucose levels and waist circumference increased the risk of breast cancer after adjusting for BMI. Compared to metabolically healthy normal-weight women, metabolically unhealthy normal-weight women, metabolically healthy obese, and metabolically unhealthy obese women had an increased risk of breast cancer.Conclusions Obesity and MetS were independently associated with an increased risk of breast cancer in postmenopausal women, despite the relationship between MetS and breast cancer appearing to result from a partial association with BMI. Postmenopausal women should be encouraged to control their weight and metabolic health.Subject terms: Risk factors, Weight management     

Body Mass Index (BMI), BMI Change,and Overall Survival in Patients With SCLC and NSCLC: A Pooled Analysis of the International Lung Cancer Consortium

IntroductionThe relationships between morbid obesity, changes in body mass index (BMI) before cancer diagnosis, and lung cancer outcomes by histology (SCLC and NSCLC) have not been well studied.MethodsIndividual level data analysis was performed on 25,430 patients with NSCLC and 2787 patients with SCLC from 16 studies of the International Lung Cancer Consortium evaluating the association between various BMI variables and lung cancer overall survival, reported as adjusted hazard ratios (aHRs) from Cox proportional hazards models and adjusted penalized smoothing spline plots.ResultsOverall survival of NSCLC had putative U-shaped hazard ratio relationships with BMI based on spline plots: being underweight (BMI < 18.5 kg/m²; aHR = 1.56; 95% confidence interval [CI]:1.43–1.70) or morbidly overweight (BMI > 40 kg/m²; aHR = 1.09; 95% CI: 0.95–1.26) at the time of diagnosis was associated with worse stage-specific prognosis, whereas being overweight (25 kg/m² ≤ BMI < 30 kg/m²; aHR = 0.89; 95% CI: 0.85–0.95) or obese (30 kg/m² ≤ BMI ≤ 40 kg/m²; aHR = 0.86; 95% CI: 0.82–0.91) was associated with improved survival. Although not significant, a similar pattern was seen with SCLC. Compared with an increased or stable BMI from the period between young adulthood until date of diagnosis, a decreased BMI was associated with worse outcomes in NSCLC (aHR = 1.24; 95% CI: 1.2–1.3) and SCLC patients (aHR=1.26 (95% CI: 1.0–1.6). Decreased BMI was consistently associated with worse outcome, across clinicodemographic subsets.ConclusionsBoth being underweight or morbidly obese at time of diagnosis is associated with lower stage-specific survival in independent assessments of NSCLC and SCLC patients. In addition, a decrease in BMI at lung cancer diagnosis relative to early adulthood is a consistent marker of poor survival.     

The ‘obesity paradox’ and survival after colorectal cancer: true or false?

Body mass index (BMI), as an approximation of general adiposity, is an established risk factor for incidence of several adult cancer types, including colorectal cancer (CRC). There is a common perception that these relationships extrapolate directly as adverse prognostic factors after diagnosis, but evidence for this is lacking. The paper from Sclesinger et al. in this issue of the journal adds a new dimension to this debate focusing on relationships of post-diagnosis BMI (as a marker of the steady-state weight among survivors) and survival, and provides evidence on a decreased mortality risk among overweight (post-diagnosis BMI 25.0–29.9 kg/m²) compared with normal weight (post-diagnosis BMI 18.5–24.9 kg/m²) CRC survivors—an example of an ‘obesity paradox.’ The observation of the ‘obesity paradox’ is well documented in the methodology literature, but perhaps, less familiar to the cancer readership. Three broad classes of explanation are posited: (1) the associations are true and plausible; (2) the associations are false and reflect methodological issues; or (3) the observations represent a specific form of selection bias, known as collider bias. The present author argues that the obesity paradox reflects the latter—a product of a statistical bias—and emphasizes that, while these findings are hypothesis generating, they will not alter clinical practice or recommendations.     

Impact of Frailty on Hospital Outcomes Among Patients with Lymphoid Malignancies Receiving Autologous Hematopoietic Stem Cell Transplantation in the United States

BackgroundFrailty could affect outcomes of autologous hematopoietic stem cell transplantation (aHSCT). This study sought to examine the effects of frailty on hospital outcomes among patients with non-Hodgkin lymphoma (NHL), Hodgkin lymphoma (HL), and multiple myeloma (MM) who received aHSCT.Materials and MethodsThis study was a retrospective analysis of Nationwide Inpatient Sample database, 2005 to 2014. Outcome variables were in-hospital mortality, prolonged length of stay and hospitalization cost. Frail patients were defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator.ResultsThere were 20,573 NHL, 8,974 HL, and 40,750 MM patients. Among them, 5.5% NHL, 3.8% HL, and 4.8% MM patients were frail. Among patients with NHL, there were significant associations between frailty and in-hospital mortality (Odds Ratio [OR], 4.04, 95% CI: 2.11-7.76), and prolonged length of stay (OR, 2.32, 95% CI: 1.56-3.46). Similarly, among HL, there were significant associations between frailty and in-hospital mortality (OR, 1.82, 95% CI: 1.43-2.76), and prolonged length of stay (OR, 1.55, 95% CI: 1.34-2.84). Likewise, for MM, there were significant associations between frailty and in-hospital mortality (OR, 4.28, 95% CI: 2.16-8.48), and prolonged length of stay (OR, 3.00, 95% CI: 2.00-4.51). These associations remained significant after stratifying by age and comorbidities. Significant differences were observed in hospitalization cost between frail and non-frail patients.ConclusionAmong patients with lymphoid malignancies undergoing HSCT, frailty was associated with greater in-hospital mortality, longer length of stay, and higher hospitalization costs. Comprehensive health status assessments for identifying and managing frail patients in this population could improve patient outcomes.     

Is there an association between body mass index and 21-gene recurrence score?

PurposeThe 21-gene recurrence score (RS) is an established predictor of recurrence for early stage, hormone receptor positive breast cancer. The association between RS and other risk factors such as obesity has not been fully explored. We hypothesized that patients with obesity may present with primary breast cancers with higher recurrence scores.MethodsWe identified 1546 patients who have body mass index (BMI) recorded around the time of RS assay. Obesity was classified as per CDC definitions of overweight (BMI 25–30 kg/m²) and obesity (BMI >30 kg/m²). RS was assessed as a continuous variable and according to pre- and post-TAILORx classifications. Kaplan Meier survival analysis was employed to assess the interaction between RS and BMI on overall survival (OS) and disease-free survival (DFS).ResultsIn univariate analyses, the median RS in patients with overweight was 15, which was significantly lower than the median RS (16) of patients with normal weight (p = 0.03). The overall recurrence rate of patients with obesity was 4.1%, which was significantly worse than the overall recurrence rate of patients with normal and overweight of 2.6% and 1.5%, respectively (p = 0.05). In multivariate analyses using the inverse probability weighted regression adjustment (IPWRA) method to adjust for imbalances between subgroups, patients with overweight or obesity had significantly lower RS than patients with normal weight, correlating to an average decrease in RS value of 2.37 and 1.71, respectively (both p < 0.01). A similar relationship was seen between BMI categories and RS as a categorical variable stratified according to pre- or post-TAILORx categories. This inverse effect was predominantly seen in post-menopausal patients. Despite the generally lower RS in patients with obesity, a high RS in these patients is associated with diminished DFS (p = 0.04).ConclusionTumors in post-menopausal women with higher BMI generally have lower RS. DFS is significantly worse in women with obesity whose RS ≥ 30. The reasons for poor outcomes for postmenopausal patients with obesity despite lower presenting RS merits further study.     

Postoperative intensive care unit stay after minimally invasive esophagectomy shows large hospital variation. Results from the Dutch Upper Gastrointestinal Cancer Audit

IntroductionThe value of routine intensive care unit (ICU) admission after minimally invasive esophagectomy (MIE) has been questioned. This study aimed to investigate Dutch hospital variation regarding length of direct postoperative ICU stay, and the impact of this hospital variation on short-term surgical outcomes.Materials and methodsPatients registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) undergoing curative MIE were included. Length of direct postoperative ICU stay was dichotomized around the national median into short ICU stay ( ≤ 1 day) and long ICU stay ( > 1 day). A case-mix corrected funnel plot based on multivariable logistic regression analyses investigated hospital variation. The impact of this hospital variation on short-term surgical outcomes was investigated using multilevel multivariable logistic regression analyses.ResultsBetween 2017 and 2019, 2110 patients from 16 hospitals were included. Median length of postoperative ICU stay was 1 day [hospital variation: 0–4]. The percentage of short ICU stay ranged from 0 to 91% among hospitals. Corrected for case-mix, 7 hospitals had statistically significantly higher short ICU stay rates and 6 hospitals had lower rates. ICU readmission, in-hospital/30-day mortality, failure to rescue, postoperative pneumonia, cardiac complications and anastomotic leakage were not associated with hospital variation in length of ICU stay. Total length of hospital stay was significantly shorter in hospitals with relatively short ICU stay.ConclusionThis study showed significant hospital variation in postoperative length of ICU stay after MIE. Short ICU stay was associated with shorter overall hospital admission and did not negatively impact short-term surgical outcomes. More selected use of ICU resources could result in a national significant cost reduction.     

A meta-analysis of body mass index and esophageal and gastric cardia adenocarcinoma

BackgroundThe incidence rates of esophageal and gastric cardia adenocarcinoma (EGCA) have increased over recent years in several countries, and overweight/obesity has been suggested to play a major role in these trends. In fact, higher body mass index (BMI) has been positively associated with EGCA in several studies.Material and methodsWe conducted a meta-analysis of case–control and cohort studies on the BMI and EGCA updated to March 2011. We estimated overall relative risks (RRs) and 95% confidence intervals (CI) for BMI between 25 and 30 and BMI ≥ 30 kg/m², when compared with normo-weight subjects, using random-effects models.ResultsWe identified 22 studies, including almost 8000 EGCA cases. The overall RR was 1.71 (95% CI 1.50–1.96) for BMI between 25 and 30, and was 2.34 (95% CI 1.95–2.81) for BMI ≥ 30 kg/m². The continuous RR for an increment of 5 kg/m² of BMI was 1.11 (95% CI 1.09–1.14). The association was stronger for esophageal adenocarcinoma (RR for BMI ≥ 30 kg/m² = 2.73, 95% CI 2.16–3.46) than for gastric cardia adenocarcinoma (RR for BMI ≥ 30 kg/m² = 1.93, 95% CI 1.52–2.45). No substantial differences emerged across strata of sex and geographic areas.ConclusionOverweight and obesity are strongly related to EGCA, particularly to espophageal adenocarcinoma.     

Body mass index, tumor characteristics, and prognosis following diagnosis of early-stage breast cancer in a mammographically screened population

Purpose

Many studies suggest increased body mass index (BMI) is associated with worse breast cancer outcomes, but few account for variability in screening, access to treatment, and tumor differences. We examined the association between BMI and risk of breast cancer recurrence, breast cancer-specific mortality, and all-cause mortality, and evaluated whether tumor characteristics differ by BMI among a mammographically screened population with access to treatment.

Methods

Using a retrospective cohort study design, we followed 485 women aged ≥40 years diagnosed with stage I/II breast cancer within 24 months of a screening mammogram occurring between 1988 and 1993 for 10-year outcomes. BMI before diagnosis was categorized as normal (<25 kg/m²), overweight (25–29.9 kg/m²), and obese (≥30 kg/m²). Tumor marker expression was assessed via immunohistochemistry using tissue collected before adjuvant treatment. Medical records were abstracted to identify treatment, recurrence, and mortality. We used Cox proportional hazards to separately model the hazard ratios (HR) of our three outcomes by BMI while adjusting for age, stage, and tamoxifen use.

Results

Relative to normal-weight women, obese women experienced increased risk of recurrence (HR 2.43; 95 % CI 1.34–4.41) and breast cancer death (HR 2.41; 95 % CI 1.00–5.81) within 10 years of diagnosis. There was no association between BMI and all-cause mortality. Obese women had significantly faster growing tumors, as measured by Ki-67.

Conclusions

Our findings add to the growing evidence that obesity may contribute to poorer breast cancer outcomes, and also suggest that increased tumor proliferation among obese women is a pathway that explains part of their excess risk of adverse outcomes.     

Short-Term Outcomes for Laparoscopic Surgery for BMI≥30 Patients with Rectal Cancer

Objective:Obesity is known to be a preoperative risk factor for rectal cancer surgery. This study aimed to investigate the influence of obesity on the surgical outcomes of laparoscopic surgery for rectal cancer. Methods:The clinical data of 356 patients with rectal cancer from Jan 2012 to Dec 2015 were analyzed retrospectively. Perioperative outcomes were compared between 48 patients with a BMI (body mass index) ≥30 kg/m² [obese group ] and 308 patients with a BMI≥30 kg/m² [non-obese group] who underwent laparoscopic surgery.Results:Operation times were significantly longer for the obese group than for the non-obese group (125.2±30.5 min vs. 180.5±58.2 min, P=0.021). There were no statistically significant differences between two groups in terms of intraoperative blood loss, the number of retrieved lymph nodes, postoperative recovery and postoperative complications (P≥0.05). During the follow-up period, the overall survival rates were not significantly different between the two groups [66.7% (32/48) vs 67.2% (207/308), P=0.787]. The differences in recurrence and metastasis between the two groups were not statistically significant. Conclusion:Our analysis revealed that laparoscopic surgery can be safely performed in patients with BMI≥30. The procedure was considered to be difficult but sufficiently feasible.Key Words: Rectal cancer, obese, body mass index, laparoscopy, treatment outcome     

Does high body mass index negatively affect the surgical outcome and long-term survival of gastric cancer patients who underwent gastrectomy: A systematic review and meta-analysis

Background

Whether high body mass index (BMI) was associated with increased postoperative complications and unfavorable prognosis of gastric cancer (GC) patients remain controversial. In the present study, we performed a systematic review and meta-analysis to evaluate the impact of high BMI on surgical outcome, postoperative complications and long-term survival of GC patients.

Obesity is associated with breast cancer in African-American women but not Hispanic women in South Los Angeles

BACKGROUND:

Obesity is considered a risk factor for breast cancer. Modifying life styles that reduce obesity offers the potential for prevention and improved outcomes from cancer. The effects of obesity and breast cancer among African‐American women and Hispanic women have been explored in a limited number of studies. The objective of the current study was to investigate the association of obesity with breast cancer in a minority cohort.

METHODS:

This was a cross‐sectional study of 471 African‐American and Hispanic women with and without breast cancer in South Los Angeles. Data regarding body mass index (BMI) and clinical factors were obtained by medical record abstraction. Data were assessed using logistic regression with multivariate analysis. Kaplan‐Meier survival analysis was used to assess disease‐free survival.

RESULTS:

Women with breast cancer were more likely to be obese (BMI >30 kg/m²) than women without breast cancer (odds ratio [OR], 2.0; P = .01). There was a significant association of being overweight or obese and breast cancer among postmenopausal women (OR, 2.3 [P = .03] and 2.9 [P < .01], respectively). The association between obesity and breast cancer was significant only among African‐American women (OR, 2.70; P < .01) and was especially significant among postmenopausal African‐American women (OR, 4.8; P < .01). There was a borderline significant association between obesity and later disease stage at diagnosis (P = .06). An association also was observed between higher BMI (for cutoff points of both 30 kg/m² and 28 kg/m²) and poorer disease‐free survival (P = .045 and P = .019, respectively).

CONCLUSIONS:

The current data suggested an association between obesity and breast cancer, especially among postmenopausal women and most significantly in the African‐American cohort. Cancer 2011. © 2011 American Cancer Society.     

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for omentectomy – A case series

Background and objectiveTransvaginal natural orifice transluminal endoscopic surgery (vNOTES) has been applied massively in the gynecological field in recent years. The aim of the current study is to present the surgical technique of vNOTES omentectomy and to evaluate the feasibility of this procedure.MethodsA case series study of the first 5 vNOTES omentectomy procedures performed for surgical staging of suspicious early stage ovarian cancer, at Rambam Health Care Campus (Israel) and Imelda Hospital (Belgium) between November 2018 and August 2019. Sociodemographic and clinical data were retrieved from patients’ electronic charts. Primary points of interest included intra-operative bleeding, length of surgery, length of hospitalization, and surgical complications.ResultsThe median age was 61 years (range 50–72), and the median BMI was 27 kg/m² (range 23–33). All the operations were carried out to completion through the vaginal GelPOINT, without insertion of an assistant abdominal trocar or conversion to another surgical approach. The median omentectomy time was 45 min (range: 39–52). The median estimated intraoperative blood loss was 150 ml (range: 20–200). The median hospital stay was 2 days (range: 1–3).ConclusionsvNOTES is a feasible technique for omentectomy in early stage ovarian cancer, with low rates of complications and improved cosmetic results.     

Body mass index and survival in women with breast cancer—systematic literature review and meta-analysis of 82 follow-up studies

BackgroundPositive association between obesity and survival after breast cancer was demonstrated in previous meta-analyses of published data, but only the results for the comparison of obese versus non-obese was summarised.MethodsWe systematically searched in MEDLINE and EMBASE for follow-up studies of breast cancer survivors with body mass index (BMI) before and after diagnosis, and total and cause-specific mortality until June 2013, as part of the World Cancer Research Fund Continuous Update Project. Random-effects meta-analyses were conducted to explore the magnitude and the shape of the associations.ResultsEighty-two studies, including 213 075 breast cancer survivors with 41 477 deaths (23 182 from breast cancer) were identified. For BMI before diagnosis, compared with normal weight women, the summary relative risks (RRs) of total mortality were 1.41 [95% confidence interval (CI) 1.29–1.53] for obese (BMI >30.0), 1.07 (95 CI 1.02–1.12) for overweight (BMI 25.0–<30.0) and 1.10 (95% CI 0.92–1.31) for underweight (BMI <18.5) women. For obese women, the summary RRs were 1.75 (95% CI 1.26–2.41) for pre-menopausal and 1.34 (95% CI 1.18–1.53) for post-menopausal breast cancer. For each 5 kg/m² increment of BMI before, <12 months after, and ≥12 months after diagnosis, increased risks of 17%, 11%, and 8% for total mortality, and 18%, 14%, and 29% for breast cancer mortality were observed, respectively.ConclusionsObesity is associated with poorer overall and breast cancer survival in pre- and post-menopausal breast cancer, regardless of when BMI is ascertained. Being overweight is also related to a higher risk of mortality. Randomised clinical trials are needed to test interventions for weight loss and maintenance on survival in women with breast cancer.     

Weight Gain after Hormone Receptor-Positive Breast Cancer

Obesity following breast cancer diagnosis is associated with poor overall survival. Understanding weight trajectories will help inform breast cancer survivors at greater risk of weight gain, and those who would benefit from earlier anti-obesity interventions. We performed a retrospective chart review of women from the Breast Cancer Program Longitudinal Repository (BCPLR) at Johns Hopkins diagnosed with hormone receptor-positive Stage I-III breast cancer from 2010 to 2020. We investigated obesity (measured by body mass index [BMI]) over time, patient and tumor characteristics, as well as treatment and recurrence. We observed a significant ≥5% increase in BMI from diagnosis to most recent follow-up (p = 0.009), particularly among those who were overweight at diagnosis (p = 0.003). Additionally, among those up to 5 years since diagnosis, there was a significant association between experiencing a ≥0.1 kg/m² increase per year since diagnosis and baseline BMI status (p = 0.009). A ≥0.6 kg/m² decrease in BMI was observed for participants with obesity at diagnosis (p = 0.006). Our study highlights (i) the significant burden of obesity in women with a history of breast cancer and (ii) higher risks for increases in BMI and shifts in class of obesity among women who are overweight at diagnosis.     

Central adiposity,obesity during early adulthood,and pancreatic cancer mortality in a pooled analysis of cohort studies

BackgroundBody mass index (BMI), a measure of obesity typically assessed in middle age or later, is known to be positively associated with pancreatic cancer. However, little evidence exists regarding the influence of central adiposity, a high BMI during early adulthood, and weight gain after early adulthood on pancreatic cancer risk.DesignWe conducted a pooled analysis of individual-level data from 20 prospective cohort studies in the National Cancer Institute BMI and Mortality Cohort Consortium to examine the association of pancreatic cancer mortality with measures of central adiposity (e.g. waist circumference; n = 647 478; 1947 pancreatic cancer deaths), BMI during early adulthood (ages 18–21 years) and BMI change between early adulthood and cohort enrollment, mostly in middle age or later (n = 1 096 492; 3223 pancreatic cancer deaths). Multivariable hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression models.ResultsHigher waist-to-hip ratio (HR = 1.09, 95% CI 1.02–1.17 per 0.1 increment) and waist circumference (HR = 1.07, 95% CI 1.00–1.14 per 10 cm) were associated with increased risk of pancreatic cancer mortality, even when adjusted for BMI at baseline. BMI during early adulthood was associated with increased pancreatic cancer mortality (HR = 1.18, 95% CI 1.11–1.25 per 5 kg/m²), with increased risk observed in both overweight and obese individuals (compared with BMI of 21.0 to <23 kg/m², HR = 1.36, 95% CI 1.20–1.55 for BMI 25.0 < 27.5 kg/m², HR = 1.48, 95% CI 1.20–1.84 for BMI 27.5 to <30 kg/m², HR = 1.43, 95% CI 1.11–1.85 for BMI ≥30 kg/m²). BMI gain after early adulthood, adjusted for early adult BMI, was less strongly associated with pancreatic cancer mortality (HR = 1.05, 95% CI 1.01–1.10 per 5 kg/m²).ConclusionsOur results support an association between pancreatic cancer mortality and central obesity, independent of BMI, and also suggest that being overweight or obese during early adulthood may be important in influencing pancreatic cancer mortality risk later in life.     

Obesity and Cancer Treatment Outcomes: Interpreting the Complex Evidence

A wealth of epidemiological evidence, combined with plausible biological mechanisms, present a convincing argument for a causal relationship between excess adiposity, commonly approximated as body mass index (BMI, kg/m²), and incident cancer risk. Beyond this relationship, there are a number of challenges posed in the context of interpreting whether being overweight (BMI 25.0–29.9 kg/m²) or obese (BMI ≥ 30.0 kg/m²) adversely influences disease progression, cancer mortality and survival. Elevated BMI (≥ 25.0 kg/m²) may influence treatment selection of, for example, the approach to surgery; the choice of chemotherapy dosing; the inclusion of patients into randomised clinical trials. Furthermore, the technical challenges posed by an elevated BMI may adversely affect surgical outcomes, for example, morbidity (increasing the risk of surgical site infections), reduced lymph node harvest (and subsequent risk of under-staging and under-treatment) and increased risk of margin positivity. Suboptimal chemotherapy dosing, associated with capping chemotherapy in obese patients as an attempt to avoid excess toxicity, might be a driver of poor prognostic outcomes. By contrast, the efficacy of immune checkpoint inhibition may be enhanced in patients who are obese, although in turn, this observation might be due to reverse causality. So, a central research question is whether being overweight or obese adversely affects outcomes either directly through effects of cancer biology or whether adverse outcomes are mediated through indirect pathways. A further dimension to this complex relationship is the obesity paradox, a phenomenon where being overweight or obese is associated with improved survival where the reverse is expected. In this overview, we describe a framework for evaluating methodological problems such as selection bias, confounding and reverse causality, which may contribute to spurious interpretations. Future studies will need to focus on prospective studies with well-considered methodology in order to improve the interpretation of causality.     

Perioperative nutritional assessment and interventions in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC): A systematic review

BackgroundPeritoneal carcinomatosis is a catabolic state and cytoreductive surgery (CRS) is a high morbidity operation. Optimising perioperative nutrition is crucial to improve outcomes. This systematic review sought to examine literature describing clinical outcomes related to preoperative nutrition status and nutrition interventions in patients undergoing CRS with hyperthermic intraperitoneal chemotherapy (HIPEC).MethodsA systematic review was registered with PROSPERO (300326). A search of eight electronic databases was undertaken on 8th May 2022 and reported according to the PRISMA statement. Studies reporting nutrition status through use of screening and assessment tools, nutrition interventions or nutrition-related clinical outcomes for patients undergoing CRS with HIPEC were included.ResultsOf 276 screened studies, 25 studies were included for review. Commonly used nutrition assessment tools for CRS-HIPEC patients included Subjective Global Assessment (SGA), sarcopenia assessment with computed tomography, preoperative albumin, and body mass index (BMI). Three retrospective studies compared SGA with postoperative outcomes. Malnourished patients were more likely to have postoperative infectious complications (p = 0.042 SGA-B, p = 0.025 SGA-C). Malnutrition was significantly associated with increased hospital length of stay (LOS) in two studies (p = 0.006, p = 0.02), and with overall survival in another study (p = 0.006). Eight studies analysing preoperative albumin levels reported conflicting associations with postoperative outcomes. BMI in five studies was not associated with morbidity. One study did not support routine nasogastric tube (NGT) feeding.ConclusionsPreoperative nutritional assessment tools, including SGA and objective sarcopaenia measures, have a role in predicting nutritional status for CRS-HIPEC patients. Optimisation of nutrition is important for preventing complications.     

Sarcopenia and obesity among patients with soft tissue sarcoma – Association with clinicopathologic characteristics,complications and oncologic outcome: A systematic review and meta-analysis

Background and aimsSarcopenia and obesity may be associated with negative outcomes in many cancers, but their prevalence and impact in modern regimens for soft-tissue sarcoma (STS) have not been systematically studied. This study summarises and critically evaluates the current evidence-based literature on body mass index (BMI) and body composition among patients with STS, with respect to clinical and pathologic characteristics, treatment-associated morbidity and oncologic outcome.MethodsA systematic literature search of the PubMed, Embase and Cochrane databases was performed. Meta-analysis of the relationship between BMI, body composition and pathologic characteristics, operative morbidity and oncologic outcome was undertaken using RevMan v.5.4 using fixed or random effects methods as appropriate.Results14 studies including 3598 patients met inclusion criteria. Ten studies reported on BMI, two on CT and two on PET-CT assessment of body composition. BMI ranged from 14.6 to 63.7 kg/m², with obesity in 18%–39% of patients. Although some studies demonstrated larger tumours among patients with obesity, this was not significant on meta-analysis (P = 0.31, I² = 99%). There was no significant difference in tumour grade or histologic type according to BMI. Postoperatively, obesity was associated with increased risk of overall morbidity (odds ratio (OR) 2.03 [95% CI 1.41–2.92], P = 0.0001, I² = 22%), and wound morbidity (OR 1.32 [95% CI 1.02–1.71], P = 0.03, I² = 0%). Similar effects were observed in studies of visceral adiposity. No differences in functional outcomes were observed. There was a trend towards reduced local recurrence among patients with obesity (HR 0.64 [95% CI 0.38–1.08], P = 0.10, I² = 0%), but no difference in distant metastasis (HR 1.00 [95% CI 0.76–1.30], P = 0.98, I² = 0%) or overall survival (HR 0.98 [95% CI 0.43–2.22], P = 0.95, I² = 64%). Various measures of sarcopenia were associated with poorer survival outcomes.ConclusionWhile obesity is associated with increased postoperative morbidity, it had no significant association with long-term oncologic outcomes. Sarcopenia may be associated with a poorer long-term prognosis. A greater understanding of the impact of nutritional status on disease characteristics and treatment outcomes is essential to facilitate improvements in clinical care for patients with STS.