Validation of nutritional screening tools in patients with cancer undergoing surgery in low-and middle-income countries

Jana Sremanakova¹Stephen Knight^2,3Marie Carmela Lapitan⁴Edwin Yenli⁵Stephen Tabiri⁵Dhruva Ghosh⁶Pamela A Kingsley⁶Apple Valparaiso⁷Ewen Harrison²Maria Thomas⁶Parvez D Hague⁶Sreejit KV⁶Atul Suroy⁶Ashish Choudhrie⁸Rohin Mittal⁹Rajkumar Kottayasamy Seenivasagam¹⁰Bipradas Roy¹¹Debra Jones^1*Burden S¹

• ¹The University of Manchester, Manchester, United Kingdom
• ²University of Edinburgh, Edinburgh, Scotland, United Kingdom
• ³School of Health & Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
• ⁴National Institutes of Health, University of the Philippines Manila, Manila, National Capital Region, Philippines
• ⁵University for Development Studies, Tamale, Northern Region, Ghana
• ⁶Christian Medical College & Hospital, Ludhiana, Punjab, India
• ⁷University of the Philippines Manila, Manila, Philippines
• ⁸Padhar Hospital, Betul, Padhar Buzurg, India
• ⁹Christian Medical College and Hospital, Vellore, Tamil Nadu, India
• ¹⁰PSG Institute of Medical Sciences & Research, Coimbatore, Tamil Nadu, India
• ¹¹Tata Medical Centre, Kolkata, West Bengal, India

A third of patients preoperatively are severely malnourished in low-and middle-income countries (LMICs). Identifying the most appropriate tool for detecting malnutrition is the first step needed to enable treatment interventions. Thus, this study assessed the validity and reliability of nutrition screening tools in patients with cancer scheduled for surgery in LMICs. Participants were adults undergoing curative elective or palliative surgery in Ghana, India, and Philippines. Anthropometric assessments alongside Malnutrition Universal Screening tool (MUST) and Patient Generated Subjective Global Assessment (PG-SGA) were conducted. Data were analysed using Bland and Altman plots with confidence intervals (CI) and intra-class correlation coefficients (ICC). Sensitivity and specificity tests were performed using Area Under the Curve with Receiver Operating Characteristics (AUROC). 167 participants were recruited with a mean age of 53.3 (SD 14.7) years. Body Mass Index was 23.0 (SD 4.9) kg/m 2 . Participants who were at risk of malnutrition using MUST, PG-SGA SF, and PG-SGA were 53.3%, 47.3% and 66%, respectively. MUST and PG-SGA SF compared to PG-SGA had AUROC of 0.78 (95% CI 0.73, 0.87), and 0.76 (95% CI 0.68, 0.83), respectively. MUST sensitivity was 85% and specificity was 25%, and PG-SGA SF sensitivity was 93% and specificity was 42%. There was excellent agreement between hospital staff for anthropometric measures with ICC >0.9 for all assessments. Both, MUST and PG-SGA SF show good sensitivity with PG-SGA compared to PG-SGA. PG-SGA SF has a slightly higher specificity than MUST. Therefore, PG-SGA SF is recommended for preoperative nutritional screening in LMIC.