Zdr Publ 2008;118(3):291-295
Original Article
ANNA SàOWIK-GABRYELSKA
Wpáyw BMI na wyniki leczenia
The infl uence of Body Mass Index
chorych na anaplastycznego
on the effectiveness of therapy
drobnokomórkowego raka páuc
for small cell lung cancer patients
Streszczenie
Summary
Wstęp. Fakt, że rak płuca rozwija się w wyniku przewle-
Introduction. The fact that lung cancer develops due
kłej ekspozycji na zewnątrzpochodne czynniki toksyczne
to chronic exposure to external toxic agents which derive
o działaniu rakotwórczym, powoduje degradację wszystkich
from carcinogenic backgrounds causes the degradation
narządów. Wykładnikiem tych uszkodzeń jest upośledzenie
of all organs. These damages negatively affect nutritional
stanu odżywienia. To upośledzenie pogłębia się w miarę
state, which deteriorates as lung cancer progresses. Un-
wzrostu nowotworu. Niedożywienie towarzyszące uszkodze-
dernourishment associated with degradation of organs can
niu narządów może w decydujący sposób wpłynąć na lecze-
signifi cantly infl uence treatment against small cell lung
nie chorych na raka anaplastycznego drobnokomórkowego
cancer since the therapy is based on cytostatic medicines.
płuc, gdyż podstawą terapii w tym nowotworze jest skojarze-
The toxicity of this medicines can be very big burden to all
nie chemicznych leków cytostatycznych. Toksyczność tych
cancer patients and can signifi cantly infl uence the process
leków może być zbyt dużym obciążeniem dla tej populacji
of treatment.
chorych i w istotny sposób wpłynąć na wyniki leczenia.
Aim. The aim of the study was to establish the infl uence
Cel. Celem pracy było ustalenie wpływu stanu odżywie-
of nutritional state on the results of small cell lung cancer
nia na wyniki leczenia raka anaplastycznego, niedrobno-
treatment.
komórkowego płuc.
Materials. The material for analysis was based on the
Materiał. Materiał do badań stanowiły obserwacje kli-
observation of 113 patients suffering from small cell lung
niczno-laboratoryjne 113 chorych na raka drobnokomór-
cancer.
kowego płuc.
It was established that 60% of the small cell lung cancer
Wyniki. Ustalono, że u ponad 60% chorych na raka ana-
patients suffered from undernourishment on early discovery
plastycznego drobnokomórkowego już w momencie wykrycia
of the illness. The state of undernourishment increased as
choroby występowało niedożywienie. Liczba i ciężkość nie-
the tumor progressed.
dożywienia wzrastała w miarę wzrostu nowotworu.
Results. A signifi cant dependence of small cell lung can-
Ustalono istnienie istotnej zależności podatności raka
cer on nutritional state was discovered, which was evaluated
drobnokomórkowego od stanu odżywienia, ocenianego przy
by means of BMI. Partial or complete cancer remissions
pomocy BMI.
were observed among people who did not suffer from
Całkowite i częściowe regresje raka uzyskiwano u osób
calorie defi ciencies and among those who suffered form
bez niedożywienia energetycznego i u pojedynczych cho-
considerable undernourishment. Most patients with calorie
rych z miernym niedożywieniem. U większości badanych
defi ciencies were resistant or completely non-responsive to
z niedożywieniem energetycznym występowała oporność na
the medicine used.
stosowane leki lub nietolerancja. Im większe niedożywie-
In all the stages of small cell lung cancer, a statisti-
nie, tym częściej występowała oporność lub nietolerancja
cally signifi cant dependence between the magnitude and
leczenia.
duration of cancer remission and the nutritional state was
We wszystkich stadiach zaawansowania raka anapla-
discovered.
stycznego drobnokomórkowego płuca istniała statystycznie
The smaller the progression of the disease, the bigger the
istotna zależność między wielkością regresji i czasem ich
regression, and the better the nutritional state, a longer was
trwania a stanem odżywienia. Im mniejszy stan zaawanso-
remission time. This had a positive impact on the survival.
wania, większa regresja raka i lepszy stan odżywienia, tym
Only people in this group stood a chance of living 5 more
dłuższy był czas remisji. Rzutowało to pozytywnie na czas
years.
przeżycia. Szanse na 5-letnie przeżycia występowały tylko
w tej grupie chorych.
Słowa kluczowe: BMI, rak płuc, stan odżywienia.
Key words: Body Mass Index, lung cancer, nutritional state.
The Department of Health Promotion and Health Education, Faculty of Natural Sciences of Szczecin University
Zdr Publ 2008;118(3)
Primary lung cancer is a tumor induced by external toxic
The cellular type of cancer was established in accordance
and carcinogenic agents from cigarette smoke [1, 2]. These
with histopathologic classifi cations of lung cancer [7].
factors affect certain parts of, or the whole body.
The stages of cancer in the group of examined patients
Degradation of all organs takes place along with tumor
is presented below in Table 1.
changes in the lungs.
The degradation fi rst causes qualitative undernourish-
TABLE 1. The Cellular Type and Stage of Lung Cancer.
ment and then energy defi ciencies.
Cellular Type
Patients
Stage of Cancer
These defi ciencies are most often observed in the stage
I/II
III
IV
preceding lung cancer [1, 3].
N
%
N
%
N
%
N
%
The development of cancer magnifi es the damage to
organs and intensifi es undernourishment. [2, 4-6].
squamous cell
306
48.0
92
30
200
65.3
14
4.5
carcinoma
The damage of organs plays an important role in small
cell lung cancer treatment, which is mainly based on cyto-
anaplastic large 152 23.8 40 26.3 78 51.3 34 22.3
reductive chemotherapy.
cell carcinoma
Effective treatment requires using an aggressive combi-
anaplastic small
113
17.7
41
36.2
53
46.9
19 16.8
nation of cytostatic drugs. These combinations are a huge
cell carcinoma
burden even on a healthy body.
adenocarcinoma
66
10.3
14
21.2
40
60.6
12 18.1
Many small cell lung cancer patients, due to organ
damage, do not tolerate drug toxicity, which results in lim-
ALL
637 100
187
28
360
57.6
77 12.3
iting medicine intake or even giving up the whole therapy
N – number of patients
[2, 6].
In this situation, it is essential to establish to what ex-
TABLE 2. Therapeutic Programs in Compliance with WHO Standards
[5, 6].
tent the nutritional state measured by means of Quetelet
(Body Mass Index} refl ects the degree of organ damage and
Therapy
Stage of Cancer
whether it can infl uence the effi ciency of treatment.
limited
extensiv
The aim of this study was to evaluate the dependence be-
anaplastic small cell carcinoma
tween nutritional state measured by BMI and the effi ciency
of lung cancer treatment.
chemotherapy
8
35
chemotherapy + Co60
33
37
MATERIALS AND METHODS
Materials for analysis were the preliminary treatment
results of 637 men suffering from primary lung cancer,
Complete remission of cancer was recognized when ma-
who were under medical supervision at Outpatient Clinic
lignant infi ltration was absent for more than 2 months.
(Poradnia Przykliniczna), run by A. Słowik-Gabryelska.
Partial remission lasting more than 2 months was recognized
Prior to treatment, patients underwent a series of diag-
when the tumor was reduced, but to more than half of its
nostic examinations in order to discover the cellular type
original size.
and stage of cancer. Moreover, examinations to evaluate the
Resistance to cancer was considered in these cases when
clinical state were carried out.
the tumor regressed to less than half of its original size.
Routine examinations covered: medical interviews, body
Intolerance was observed when unfavorable symptoms
check-ups, taking height and body weigh, and hematological
made it impossible to continue therapy [1, 9].
and biochemical examinations.
Statistical analysis of the material was carried out by
Diagnostic examinations consisted of taking posteri-
Z. Szych in The Department of Medical Informatics and
or- anterior and lateral images on the side of the tumor,
Education Quality Assessment of Pomeranian Medical
bronchoscopy, histological examinations of biopsy speci-
University in Szczecin.
mens, cytological examinations of the sputum, bronchial
The analysis was carried out by means of the following
washings and swabs, abdominal ultrasonographies and chest
tests:
computer tomographies – CT.
1) The Chi-Square correlation ratio was used to establish:
Nutritional state was assessed by means of Quetelet
– the dependence of nutritional state on stage of lung
– BMI (Body Mass Index) BMI = body mass (kg): height
cancer,
(m)2 in accordance with WHO standards from 2003 [4].
– the infl uence of the nutritional state on the suscepti-
The stage of primary lung cancer was established with
bility of cancer to treatment;
respect to International Classifi cation TNM [3, 7].
2) The UMann-Whithney test was used to assess the in-
To evaluate the stage of primary small cell cancer, the
fl uence of nutritional state on time of survival of lung
classifi cation of WHO (World Health Organization) was
cancer patients.
used, which is based on the following criteria [7, 8]:
– limited form – the changes do not cover more than half of
RESULTS OF THE STUDY
the (with the possibility of pleural effusion), mediastinum
and supraclavicular lymph nodes on the side of the tumor
The body weight of 37% of the patients suffering form
and opposite it
small cell cancer was within a normal range, 63% of the
– extensive form – all changes which cannot be classifi ed
individuals suffered from undernourishment, and 47% were
as limited form
seriously malnourished.
293
It was established that the more the tumor increased
TABLE 4. The Infl uence of Nutritional State on the Effects of Small
the worse the nutritional state became. The number of
Cell Lung Cancer Treatment.
people within their proper weight range decreased. The
Results of
Patients
Nutritional State BMI
Chi-Square test proved that the decrease was not statisti-
Treatment
22 – 24
18.6 – 21
< 18.5
cally signifi cant p> 0.47. With the cancer development the
number of undernourished people increased, including
Number % Number % Number % Number %
cases where serious undernourishment was observed. The
C.Remission
17
15
15
88
2
12
Chi-Square test proved that the increase of number of
P.Remission
32
28
16
50
9
28
7
22
malnourished patients was statistically signifi cant p < 0.02.
Table 3, Figure 1.
Resistance
52
46
9
17
7
13
36
60
Intolerance
12
11
3
25
1
8
8
67
TABLE 3. The Nutritional State of Small Cell Lung Cancer Patients.
C.Remission – Complete Remission; P.Remission – Partial Remission
Stage of Patients
Nutritional State of Patients
Cancer
Body Mass Index BMI
> 25
22 – 24
18.6 – 21
< 18.5
The Response to Treatment
number number % number % number % number %
Total
Partial
Resistance
Intolerance
Limited
41
0
17
41.2
11
26.8
13
31.7
Extensiv
72
0
25
34.7
7
9.7
40
55.5
%
All
113
0
42
37.1
19
16.8
53
46.9
The Nutritional State of Small Cell Lung
22 - 24
18.6 - 21
< 18.5
Cancer Patients. Body Mass Index BMI
Body Mass Index
22-24
18.6-21
< 18.5
0
FIGURE 2. The Relationship between Nutritional State and the Effe-
cts of Treatment.
proper BMI and undernourished patients was not statisti-
cally signifi cant p> 0.14. Table 4, Figure 2.
Susceptibility to small cell lung cancer treatment infl u-
enced by nutritional state was in correlation with the survival
time. The better the nutritional state was, the more frequent
FIGURE 1. The Nutritional State of Small Cell Lung Cancer Pa-
and longer were cancer regressions, which correlated with
tients.
survival time.
Susceptibility to treatment among small cell lung cancer
Resistance and intolerance was associated with shorter
patients was correlated with nutritional state. A high number
survival time.
of promising remissions was observed among patients hav-
The UMann-Whitney Test proved that the observed
ing normal body weight. The remissions in undernourished
differences of survival time in remissions between patients
patients were more rare. The most malnourished patients
with proper BMI and undernourished persons were not
were resistant to treatment and did not tolerate drugs. The
statistically signifi cant, both in complete remissions p>0.14
difference of number of remissions between persons with
and in partial remissions p>0.51. Table 5.
TABLE 5. The Dependence of Survival Time of Small Cell Lung Cancer Patients on Body Mass Index and Reaction to Treatment.
Dependence of Results of Treatment on BMI
BMI kg/m2
22-24
18,6-21
<18,5
CR
PR
R/I
CR
PR
R/I
CR
PR
R/I
LOCALISED
N
9
3
6
1
7
3
4
9
S
17-144
9-22
3-8
26
8-16
4-6
8-15
0.5-10
36
13
6
10
5
10
4
ADVANCED
N
6
13
6
1
4
5
3
34
S
17-98
9-30
2-6
14
8-24
3-8
7-16
0.5-8
32
15
2.5
14
6
13
3
ALL
N
15
16
12
2
11
8
7
43
S
17-144
9-30
2-8
14-26
8-24
3-6
7-16
0.5-8
36
13
5
10
6
11
3
N – number of patients, S – median time of survival, CR – complete remissions, PR – partial remissions, R/I – resistance/intolerance.
Zdr Publ 2008;118(3)
The signifi cant dependence of survival time on nutri-
Percent of Survived Patients
tional state was noted. In all stages of cancer, the worse the
22 - 24
18.6 - 21
< 18.5
ALL
nutritional state, the shorter was the survival time.
The UMann-Whitney Test confi rmed the statistically
signifi cant difference of survival time between patients
%
with proper BMI and patients with sever malnourishment
p<0.0001, the statistically signifi cant was also the difference
of survival between undernourished persons and persons
0
3
6
9
12
18
24
36
48
60
months
with severe malnourishment p<0.0001. The difference of
FIGURE 3. The Survival Time of Small Cell Lung Cancer Patients.
survival between persons with proper weigh and undernour-
ished patients was not statistically signifi cant p > 0.47. The
same statistically signifi cant dependences in localized and
DISCUSSION
advanced cancer were seen. Table 6.
The results of the study show that more than 60% of small
TABLE 6. The Infl uence of Nutritional State and the Stage of Small
cell lung cancer patients were undernourished on discovery
Cell Lung Cancer on Survival Time.
of the disease. The state of undernourishment increased as
Stage of
Number
Dependence of Median Survival
the tumor progressed [1, 2, 5, 6].
Lung
of Patients
on the Nutritional State (BMI):
A signifi cant dependence of the susceptibility of small
Cancer
22-24
18.6-21
<18.5
cell lung cancer to nutritional state was observed, measured
N months
N months N months N months
by means of BMI. Total regressions were observed among
individuals who did not suffer from energy defi ciencies
Localized 41
8
17
19
11
8
13
4.5
1-144
3-144
4-26
1-15
and in individual cases in which undernourishment was
moderate.
Advanced 72
8
25
12
7
10
40
4
Partial regressions were also very commonly observed
0.5-98
2-98
7-24
0.5-16
among patients without body mass defi ciencies. Among most
All
113
8
42
14
18
8
53
3
of the examined patients, energy defi ciencies correlated with
0.5-144
2-144
7-26
0.5-16
resistance or intolerance to treatment.
The more undernourished the patients were, the more
Among small cell lung cancer patients having normal
frequent were cases of resistance and intolerance observed.
body weight, 60% lived up to 1 year, 26% to two years
In all the stages of small cell lung cancer, there proved to be
and about 10% survived to more than 5 years. 39% of the
a statistically signifi cant dependence between the size and
undernourished patients managed to survive one year, and
duration of regression and nutritional state.
5% lived up to 2 years. Those severely undernourished died
The less advanced the stage of the illness was, the big-
within one year.
ger the regression, the better the nutritional state and the
The Chi-Square Test with Yates corrections proved statis-
longer the remission time. This had a positive effect on
tically signifi cant difference in number of one year survival
the survival time. The chances of 5 year survival were only
between patients with proper weigh and malnourished pa-
observed in this group of patients. Complete regressions
tients p<0.0001. The difference between undernourished
were not observed among all the patients whose body mass
persons and persons with proper weigh was not statistically
was within the norm. However, they were only seen among
signifi cant p>0.14, but statistical signifi cance was seen be-
the patients whose BMI was within the norm.
tween undernourished and cachectic patients p<0.03.
The results show that correct body mass did not guar-
The difference of number of patients survived longer
antee successful treatment, but was one of the conditions
than 24 months was statistically signifi cant in patients with
necessary to achieve it. The research shows that nutritional
proper nourishment and undernourished p<0.04. Table 7,
state plays a crucial role in lung cancer treatment. Further
Figure 3.
examinations need to be undertaken in order to establish
the dependence of tumor resistance to treatment among
undernourished patients and to evaluate the relationship
TABLE 7. The Dependence of Survival on Body Mass Index of Small
between undernourishment and to secretory function of
Cell Lung Cancer Patients.
cancer cells [2].
Body Mass Index does not indicate the stage of malnu-
BMI
Patients
The Percent of Survived Lung Cancer Patients
trition in lung cancer patients as precisely as tests, done
Months
earlier [2] like the level of albumins or vitamins in serum,
0
3
6
9
12
18
24
36
48
60
but BMI is not expensive, easy to do and is in close cor-
22-24 Number 42
41
36
31
25
16
11
7
4
4
relation with the stage of cancer and time of survival. That
%
100 97.6 85.7 73.8 59.5 38 26.1 16.6 9.5 9.5
makes BMI useful tool in clinical practice for monitoring
the course and the treatment of cancer.
18.6-21 Number 18
18
14
9
7
2
2
%
100 100 77.7 50 38.8 11
11
0
<18.5 Number 53
25
18
8
6
0
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100 47.1 33.9 15.0 11.3 0
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