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Integrating calf circumference with nutritional and inflammatory parameters improves short-term survival prediction
Karinne de Sousa Cunha1, Emanuelly Varea Maria Wiegert1, Larissa Calixto-Lima1
1Palliative Care Unit, National Cancer Institute (INCA), Rio de Janeiro, RJ, Brazil.
Background:
Calf circumference (CC) is a simple anthropometric measure used as a proxy for muscle mass within the Global Leadership Initiative on Malnutrition framework and has been associated with adverse outcomes in patients with cancer. However, the prognostic value of CC may be limited.
Aims:
This study aimed to evaluate and compare the predictive role of CC, alone and in combination with nutritional and inflammatory parameters for short-term mortality in outpatients with advanced cancer receiving palliative care.
Methods:
This prospective cohort study included adult patients with incurable cancer followed at a specialized palliative care unit between June 2021 and February 2025. Body mass index-adjusted CC was classified as low or normal and evaluated alone or in combination with nutritional (food intake [FI], appetite loss, tiredness, weight loss [WL], and handgrip strength [HGS]) and inflammatory parameters (albumin, C-reactive protein [CRP], and neutrophil-to-lymphocyte ratio [NLR]). Patients were categorized as having none, one, or both parameters altered. The primary outcome was 90-day all-cause mortality. Survival was analyzed using Kaplan-Meier curves and Cox proportional hazards models, and predictive accuracy performance was assessed using receiver operating characteristic (ROC) curves.
Results:
A total of 370 patients were included. Low CC was independently associated with increased 90-day mortality [Adjusted hazard ratio (HR) 1.58; 95%CI: 1.11-2.26]. The strongest associations with mortality were observed for CC combined with WL [Adjusted HR 2.83; 95% CI: 1.71-4.68], hypoalbuminemia [Adjusted HR 3.10; 95%CI: 1.93-4.99], and elevated CRP [Adjusted HR 3.20; 95%CI: 2.00-5.13]. Discriminatory performance for 90-day mortality increased from an area under the ROC curve of 0.541 for CC alone to 0.612 for CC plus WL, 0.626 for CC plus hypoalbuminemia, and 0.631 for CC plus CRP (all p < 0.001).
Conclusions:
CC is a simple and clinically applicable prognostic marker in outpatients with advanced cancer receiving palliative care. Its prognostic value is incrementally enhanced when combined with nutritional and inflammatory parameters, particularly WL and inflammatory markers, supporting the use of integrated, low-cost assessment strategies for short-term prognostic stratification and individualized nutritional decision-making.
