The detrimental impact of malnutrition on the clinical outcomes of cancer patients, encompassing complications and survival rates, has been extensively documented. However, the dynamic changes in nutritional status during multi-cycle chemotherapy in ovarian cancer (OC) patients have not been thoroughly explored.
To our knowledge, this study represents the first longitudinal examination where nutritional status served as a primary endpoint to ascertain the prevalence of nutritional risk. Our investigation tracked the three-wave dynamic changes in nutritional and hematological status during chemotherapy among OC women, revealing a sustained decrease in the prevalence of nutritional risk and a continuous improvement in nutritional status from chemotherapy initiation to the completion of cycles.
In our study, the incidence of nutritional risk before initial chemotherapy, and at the first, third, and fifth cycles were 17.0%, 14.7%, 7.4%, and 5.1%, respectively. This downward trend in nutritional risk prevalence among OC women as chemotherapy progressed is noteworthy. Bian et al. [21] reported a similar prevalence of nutritional risk (21.0%) before chemotherapy in cancer patients. The ascending trend observed in our study aligns with research by Gupta et al. [12], who found that the malnutrition prevalence decreased from 53.1% at admission to 35.7% at 3 months in OC women following chemotherapy, indicating an improved nutritional status. Conversely, studies demonstrated a significant deterioration in the nutritional status of head and neck cancer patients [22] and gynecologic cancer women [23] undergoing radiotherapy. Several potential reasons may explain these discrepancies in nutritional risk prevalence. First, diverse measurement tools to assess nutritional risk may contribute to inconsistent results. Second, cultural perspectives on eating habits and dietary structure vary across regions and countries, influencing nutritional status based on cultural background. Third, differences in tumor types, tumor locations, clinical stages, and lymphatic metastasis could also play a role.
Simultaneously, the variation trend of nutritional parameters aligned with that of nutritional risk, both indicating an improved nutritional status. A previous study demonstrated improvements in serum albumin levels and Mini Nutritional Assessment scores in patients with malignant lymphoma after chemotherapy [24]. In contrast, Movahed et al. [25] and Liang et al. [26] observed significant reductions in the levels of total protein and serum albumin in esophageal cancer patients during chemotherapy. Yamano [27] reported significant decreases in BMI and serum albumin levels in rectal cancer patients during and after chemoradiotherapy, with no significant difference in prealbumin levels.
The values of PNI decreased from 51.0 to 38.0 after treatment in head and neck cancer patients undergoing chemoradiotherapy (p < 0.05) [28]. Similarly, PNI decreased in 94.7% of breast cancer patients after neoadjuvant chemotherapy (NAC), with a significant drop from 52.6 ± 3.8 pre-NAC to 46.5 ± 4.4 post-NAC. Our study, however, indicated sustained good levels of nutrition in OC women undergoing chemotherapy. According to Onodera et al [13], the PNI normal value range is 50–60, while 40 is usually considered the cut-off point of malnutrition.
Several reasons contribute to the observed improvement in nutritional status. Chemotherapy typically commences only after reaching a certain BMI and blood test level to manage potential toxicities, emphasizing the importance of a healthy diet for OC women. The dropout rate in our study, with 95 patients dropping out, might exclude severely nutritionally impaired OC women, introducing bias to the results. Nonetheless, nutritional parameter levels decreased after chemotherapy, mainly due to the toxic side effects such as liver and kidney toxicity, and gastrointestinal symptoms. However, these effects were insufficient to alter the upward trend in nutritional parameters during chemotherapy cycles.
Considering the lower level of post-chemotherapy PNI compared with before chemotherapy due to the side effects of chemotherapy, we selected post-chemotherapy PNI as our independent variable. Investigating influencing factors of PNI aims to develop more targeted nutrition strategies to improve the prognosis of OC women undergoing chemotherapy.
This study identified pre-chemotherapy serum albumin, prealbumin, and absolute lymphocyte count as independent predictors of post-chemotherapy PNI. Higher pre-chemotherapy levels of serum albumin, prealbumin, and absolute lymphocyte count indicated higher post-chemotherapy PNI, aligning with previous findings [19]. Chen et al. [19] reported a significant association between high PNI and elevated levels of albumin and lymphocytes in breast cancer patients during chemotherapy. Serum albumin and prealbumin are traditional nutritional and inflammatory markers, while lymphocyte count reflects immune status. Low levels of serum albumin and lymphocytes can promote inflammatory tumor development and cancer spread [29, 30]. Prealbumin, a sensitive marker for malnutrition, holds prognostic importance in OC women [31]. For women with hypoalbuminemia and lymphopenia, pre-chemotherapy nutrition support with monitoring of albumin and lymphocyte levels is warranted.
Furthermore, as a nutritional indicator, body mass index (BMI) is related to cancer patient prognosis. This study reveals that pre-chemotherapy BMI is an influencing factor of PNI in OC women. Higher pre-chemotherapy BMI is associated with higher post-chemotherapy PNI, indicating a better prognosis. This finding is consistent with most previous studies [32–34]. Underweight patients (BMI < 18.5 kg/m2) had worse overall survival than non-underweight patients for all stages of colorectal cancer [32]. However, the role of BMI in different cancers may vary based on disease stage, tumor site, and treatment regimen, as demonstrated by Shepshelovich et al [35], who showed that both underweight and morbidly obese statuses are associated with poor lung cancer survival.
In this study, we revealed that pre-chemotherapy anemia is a potential risk factor for PNI, indicating that OC patients are more susceptible to malnutrition and worse outcomes when anemic before chemotherapy. This result aligns with previous studies [36–38]. Moreover, we observed a continuous reduction in hemoglobin levels over time during chemotherapy, contrasting with findings by Movahed et al. [25] and Liang et al. [26]. The multi-factorial and complex mechanisms of cancer anemia, including malnutrition, make it a recognized independent prognostic factor for poor patient survival [39]. A systematic review of 60 studies demonstrated a 65% higher overall risk of mortality in cancer patients with anemia compared to those without anemia [40]. The impact of anemia on prognosis may be linked to reduced quality of life, and delayed or incomplete chemotherapy regimens. Effective strategies targeting specific etiologies are essential to prevent and treat anemia of OC women.
Compared to patients with the TP regimen, those treated with specific chemotherapy types (BEP, IP, GP, or FOLFOX) tended to have lower PNI scores. Differences in chemotherapy regimens across disease stages and histological types of OC contribute to intrinsic inconsistencies of PNI. Additionally, higher daily defecation frequency per week was associated with higher PNI levels, suggesting a potential link between dietary intake, structure, and nutritional status during chemotherapy. Patients residing in towns exhibited lower PNI than those in rural areas, possibly due to a comparatively unitary dietary structure in rural areas that needs improvement.
Despite the valuable insights gained, the study had limitations. The sample size, constrained by the single-center design, may limit result generalization. Variations in nutrition risk and status based on tumor stage, pathological type, location, and chemotherapy regimen warrant separate investigations. The lack of follow-up data on overall survival, complications, and other clinical outcomes necessitates exploration in future research. Additionally, the focus on nutritional status and risk during chemotherapy calls for future studies examining post-chemotherapy nutritional status over several months.