Effect of Chemotherapy on the Nutritional Status of Egyptian Patients with Breast Cancer

Breast cancer is the commonest cancer in women account for about 23% of all cancer incidences1. Most of the patients who have early-stage disease receive adjuvant chemotherapy, radiotherapy and hormonal treatment before or after surgery with the aim of prevention of disease recurrence2. However, chemotherapy for breast cancer can result in multiple adverse effects such as nausea, vomiting, taste and smell changes, besides, loss of appetite that may interfere with proper dietary intake 3. Changes in food intake can affect the nutritional status of patients and may impact the disease prognosis. Evidence of weight changes from chemotherapy showed a worse prognosis for the cancer patient, both with weight gain and weight loss4, 5. Data are scarce regarding weight changes observed during chemotherapy in Egyptian breast cancer patients. We, therefore, performed this prospective study to evaluate weight changes during chemotherapy and the effect of chemotherapy related symptoms among a group of consecutive women with breast cancer treated at an Egyptian cancer center.


Eligibility criteria
For inclusion in the study, female patients should have stage I-III histologically confirmed invasive duct carcinoma and scheduled to receive neoadjuvant / adjuvant chemotherapy.The patient should be more than 18 years, free of comorbid diseases and have the physical, verbal and cognitive ability needed to respond to the tools necessary to data collection.All -patients were included before starting the first cycle of chemotherapy.

Exclusion criteria
Patients with primary tumor site other than the breast or metastatic disease were excluded.Moreover, patients not planned to receive chemotherapy or those who started first cycle before inclusion in the study were also excluded.

Tools of data collection
To collect data for this research, we used the following tools: 1. Structured questionnaire through interviewing: The first part included socio-demographic variables such as age, occupation, level of education, marital status and income.The second part included medical data sheet which covered variables such as current medical diagnosis, staging of the disease, type of surgery, timing of chemotherapy and number and duration of chemotherapy sessions.

Nutritional assessment tools:
Adopted from Jarvis 6 and modified and translated by El Feky 7 .The modification needed, validity and reliability were done by experts in the field of Medical Surgical Nursing specialty, Faculty of Nursing Cairo University.

Tools of assessment include:
a. Anthropometric measurements that may be relevant measures of a cancer patient's nutritional status 8 including; height, weight, body mass index (BMI), Triceps skin fold (TSF) and Mid-arm muscle circumference (MAMC).
TSF which reflect fat mass was measured at the midpoint between the acromion and olecranon at the triceps muscle.MAMC which indicate the store of muscle protein was calculated using the formula: MAMC (cm) = MAC (cm) -3.14 × TSF (cm)where MAC is Mid-arm circumference (MAC) was measured at the same level as TSF 10 .
The normal ranges of MAMC and TSF in females are as follow: 21.2 -25 cm and 21 -25 mm, respectively 10 1.
Disease characteristics and treatment received are summarized in Table 2. Most of the patients had stage II disease.All the patients received combination chemotherapy with anthracycline based treatment either in the adjuvant setting (78.3%) or in the neoadjuvant one (21.7%).Among the study subjects, who received adjuvant chemotherapy, 43.3% had radical mastectomy and 35% had lumpectomy.Ninety-three percent of the patients received 8 cycles of anthracycline-taxanes containing treatment.
The results of the anthropometric assessments are illustrated in Table 3. Prior to chemotherapy, 97% of patients were either overweight or obese.Moreover, TSF and MAMC parameters, both were above the normal range in the majority of patients.Seventy-one percent of our patients experienced weight loss during their treatment.During chemotherapy patients had progressive reduction in BMI, TSF and MAMC.
A comparison of the anthropometric measurements before versus after chemotherapy is shown in Table 4.The decrease in weight, BMI, TSF and MAMC was highly significant.
Table 5 shows the gastrointestinal toxicities and dietary habits of our patients.
Decreased appetite occurred in 78.3% of the patients in the second assessment, of which 30% experienced decreased appetite for more than 1 week.This percent elevated to 81% in the third assessment.Also, taste alteration was experienced by 73.3% of the study subjects in the second assessment versus 83.3% in the third assessment.
Twenty nine patients representing 48.4% of the study subjects suffered from vomiting > grade II (2-5 episodes of vomiting in a 24-hour) after chemotherapy in the 2 nd assessment.This percent decreased to 26.6% in the 3 rd assessment.In the 2 nd assessment, 61.7% had nausea that decreased to 33.3% in the 3 rd assessment.
Eighty-three percent of the participants had regular daily meals before starting chemotherapy; this percentage decreased to 16.7% in the 3rd assessment.Moreover, the percentage of patients having 3 meals per day decreased from 85% in the 1st assessment to 26.7% at the end of chemotherapy in the 3 rd assessment.
Table 6 shows a highly significant decrease in BMI in patients who experienced alteration in taste sensation.Participants with taste alteration for more than one week were at higher risk of weight-loss and BMI decrease.Loss of appetite had also a significant effect on loss of BMI at the end of the course of chemotherapy.

dISCuSSIoN
There is a debate on the effect of chemotherapy on weight gain in breast cancer patients with scarce data in Egyptians.This cross sectional study shows weight loss in the majority of patients with a significant decrease in BMI and other anthropometric measures after completing the course of chemotherapy.Changes in BW are valuable indicators of nutritional risk.In many cancer types, weight loss is an independent predictor of more toxicity from chemotherapy and shorter overall survival 11 .Another tool for nutrition status assessment of a cancer patient in clinical practice is the BMI-decrease 12 .
Based on the WHO classification of BMI, 97% of our breast cancer patients were overweight/obese at presentation.By the end of chemotherapy, this percentage decreased significantly to 72% with a significant reduction in the mean BMI.Data on weight changes as a consequence of chemotherapy showed different results.Some trials reported weight gain during adjuvant chemotherapy in 50-96% of all breast cancer patients.The median weight increase ranged from 1 to 6 kg along the treatment course and follow-up periods of up to 1 year 13,14,17 .Noteworthy, trials that followed patients only through treatment have observed no weight gain 15,16,18 .
In a similar trial, 18 breast cancer patients were followed-up during chemotherapy and also for 1 year after completion of treatment 19.There was a lack of weight gain and even weight loss among the studied patients 19 .The baseline mean weight of 64.5 kg decreased to 64.3 kg at mid treatment, which may be due to reduction of energy intake during the course of treatment.In a nonrandomized prospective study, Kutynec et al 18 followed the patients up pre and post treatment.Body weight was obtained at baseline and after 12 weeks, whereas chemotherapy didn't result in weight gain 18 .On the other hand, Heideman et al reported significant weight gain during the year after diagnosis with a mean weight gain of +2 kg 13 .Another trial performed by Irwin et al who assessed weight and body fat at baseline and after 2 years found an increase in weight by 1.7 ± 4.7 kg 20 .
The discrepancy between previous researchers' results and ours may be attributed to the fact that previous trials followed the patients for at least one year after the end of chemotherapy.On the contrary, our study had a short follow up (24 weeks) during chemotherapy.Body weight and BMI during chemotherapy may be affected by decreased food intake as a result of chemotherapy related symptoms.Moreover, the majority (90%) of our patients were > 30 BMI at presentation, a group of patients may not be at a risk of developing weight gain.This is consistent with Nissen et al who reported that women of normal BW at the time of their breast cancer diagnosis are more prone to gain weight after chemotherapy than overweight or obese patients 21 .
Regarding other anthropometric measurements, the decrease in the mean TSF and MAMC also were evident at the end of chemotherapy denoting malnutrition among this group of patients.
Our research aimed to study the effect of chemotherapy on weight and BMI.In context, chemotherapy related side effects as nausea, vomiting and taste alteration may be a direct cause of weight loss in cancer patients and contribute to the deterioration of patients' nutritional status 22 .At the end of chemotherapy, the most frequent GI symptoms amongst our patients were decreased appetite (81%), taste alteration (83%) and nausea (33%) and vomiting (27%).A similar prevalence of GI symptoms was found in studies conducted by Lu et al who reported an incidence of taste changes (48.8%) among a group of cancer patients receiving chemotherapy 23 .Alike, Ishikawa et al reported taste sensation affection in 44% of patients receiving chemotherapy and appetite loss in 87% 24 .
Previous studies revealed that patients with cancer experience numerous symptoms, which commonly affect their food intake and many of them may start at the same time 25 .Subsequently, we have expected weight loss and reduced BMI in patients experienced chemosensory symptoms that have been proven in our results.In our study, taste alteration was significantly associated with decreased BMI (p=0.001),whereas taste alteration for more than one week greatly affected nutritional intake and accordingly resulted in reduction of the BMI (p=0.001) calculated at the end of chemotherapy.On the other hand, BMI wasn't significantly affected by nausea and vomiting.Moreover, most of the chemotherapy cycles contained taxane as part of the chemotherapy course, which was previously accused to alter taste sensation 26 .In 2009 Steinbach and colleagues studied taste and smell changes in patients with breast and gynecologic cancer receiving chemotherapy.They found that taste and smell are significantly affected by chemotherapy, which resulted in reduced appetite and weight loss.And Taxanebased chemotherapy caused the most severe disorders 26 .Furthermore, Speck et al evaluated the effect of taxanes on patients received docetaxel or paclitaxel and reported taste alteration as the most common side effect from taxanes 27 .
Our study was limited by the small number of patients and the short follow up of the weight gain after chemotherapy.

rECoMMENdaTIoNS
Based on our findings, the nutritional assessment of breast cancer patients should be carried out prior to chemotherapy.Attention towards nutritional problems related to chemotherapy is needed.To prevent massive weight loss, patients should maintain adequate energy intake during the course of chemotherapy.Besides, a long-term follow-up of weight changes after the end of the course of chemotherapy is also recommended.
Future research on larger number of patients with longer follow up is required to assess the nutritional status of patients receiving chemotherapy for breast cancer to avoid nutritional deficiency.

Table 1 :
Socio-demographic characteristics of patients

Table 2 :
Disease characteristics and treatment.

Table 3 :
Anthropometric measurements along the course of chemotherapy

Table 4 :
Comparison of the anthropometric parameters before versus after chemotherapy

Table 5 :
Gastrointestinal problems and dietary intake before, during and after the course of chemotherapy.

Table 6 :
Correlation between selected variables and the change in body mass index (BMI).