Association of longitudinal changes in nutritional status with survival outcomes in childhood cancer

Malnutrition is common among children with cancer in low- and middle-income countries (LMICs). Although baseline undernutrition has been associated with complications and inferior outcomes, prospective data evaluating how longitudinal nutritional changes relate to survival are limited. In this study we aimed to study the longitudinal changes in anthropometric measures during treatment of childhood cancer and their association with event-free survival (EFS) and overall survival (OS).

Children aged 18 years or younger with a new diagnosis of malignancy between August 1, 2016, and April 30, 2021, were enrolled in this prospective cohort study conducted at a tertiary care hospital in New Delhi, India. Serial measurements of weight, height, and mid-upper arm circumference were obtained at diagnosis and during follow-up visits up to one year after diagnosis. Multivariable Cox regression models adjusted for age, sex, malignancy type, and baseline anthropometric status were used to evaluate associations between longitudinal nutritional changes and survival in a landmark cohort of patients alive and event-free at 6 months after diagnosis.

A total of 1931 children (median [IQR] age, 8 [0.1-18] years; 1374 [71.2%] male) were included, of whom 996 formed the landmark analysis cohort. The 5-year EFS and OS of the overall cohort was of 49.1% and 53.3%, respectively. At diagnosis, 328 children (17.0%) had wasting (body mass index-for-age Z-score < -2 SD), 417 (21.6%) had stunting (height-for-age Z-score < -2 SD), and 979 (55.5%) had mid-upper arm circumference Z-scores < -2 SD. Weight loss greater than 5% was observed in 312 patients (22.1%) at 3 months, 157 (15.1%) at 6 months, 61 (8.6%) at 9 months, and 31 (6.4%) at 12 months among those with available follow-up data. In the landmark cohort, weight loss >5% at or after six months was independently associated with inferior EFS (adjusted hazard ratio [aHR], 1.69; 95% CI, 1.22-2.33; P = 0.002) and OS (aHR, 1.92; 95% CI, 1.37-2.68; P < 0.001). Similarly, children who had wasting at or after six months had inferior EFS and OS compared with those without wasting.

Weight loss >5% after six months is independently associated with inferior overall survival. Ongoing nutritional monitoring is essential to improve outcomes in children with cancer in LMICs.