Quality of life and its relation with nutritional status in patients with incurable cancer in palliative care



Nutritional impairment is common in cancer patients and adversely affects quality of life (QoL). The aim of this study was to investigate the association between nutritional status and QoL in incurable cancer patients in palliative care.


A prospective cohort with incurable cancer patients referred to the specialized Palliative Care Unit of the National Cancer Institute in Brazil was conducted. The nutritional risk (NR) was assessed using the Patient-Generated Subjective Global Assessment short form (PG-SGA SF), and cancer cachexia (CC) was defined according to the international consensus. QoL was evaluated using the Quality of Life Questionnaire Core 15 Palliative (QLQ-C15-PAL). Multivariate linear regressions analyses were performed to assess the relationship between the nutritional status and QoL scores.


A total of 1039 consecutive patients were included. A high prevalence of NR (85.4%) and CC (78.7%) were observed. The patients with worse nutritional status presented significantly poorer physical, emotional, symptoms domains scales, and overall QoL. CC were significantly associated with QoL scores for dyspnea (p = 0.013), insomnia (p = 0.046), and appetite loss (p = 0.015), while NR were associated with all the QoL domains scales covered in QLQ-C15-PAL.


Our findings support that impaired nutritional status was associated with poor QoL in incurable cancer patients. NR assessed by PG-SGA SF better reflects physical, emotional, symptom burden, and overall QoL scores. Thus, this tool may contribute in identifying patients at risk of deterioration QoL.

This is a preview of subscription content, access via your institution.

Fig. 1


  1. 1.

    WHO. World Health Organization (2002) National cancer control programmes: policies and managerial guidelines. 2nd ed. Geneva

  2. 2.

    Haun MW, Estel S, Rücker G, Friederich H-C, Villalobos M, Thomas M, Hartmann M (2017) Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev 6:CD011129. https://doi.org/10.1002/14651858.CD011129.pub2

    Article  PubMed  Google Scholar 

  3. 3.

    WHO. World Health Organization. available in: https://www.who.int/healthinfo/survey/whoqolqualityoflife/en/. Accessed 10 Jan 2020

  4. 4.

    Wallengren O, Lundholm K, Bosaeus I (2013) Diagnostic criteria of cancer cachexia: relation to quality of life, exercise capacity and survival in unselected palliative care patients. Support Care Cancer 21:1569–1577. https://doi.org/10.1007/s00520-012-1697-z

    Article  PubMed  Google Scholar 

  5. 5.

    Kwang AY, Kandiah M (2010) Objective and subjective nutritional assessment of patients with cancer in palliative care. Am J Hosp Palliat Care 27:117–126. https://doi.org/10.1177/1049909109353900

    Article  PubMed  Google Scholar 

  6. 6.

    Aktas A, Walsh D, Galang M, O'Donoghue N, Rybicki L, Hullihen B, Schleckman E (2017) Underrecognition of malnutrition in advanced cancer: the role of the dietitian and clinical practice variations. Am J Hosp Palliat Care 34(6):547–555. https://doi.org/10.1177/1049909116639969

    Article  PubMed  Google Scholar 

  7. 7.

    Thoresen L, Frykholm G, Lydersen S, Ulveland H, Baracos V, Prado CM, Birdsell L, Falkmer U (2013) Nutritional status, cachexia and survival in patients with advanced colorectal carcinoma. Different assessment criteria for nutritional status provide unequal results. Clin Nutr 32(1):65–72. https://doi.org/10.1016/j.clnu.2012.05.009

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Cunha MS, Wiegert EVM, Calixto-Lima L, Oliveira LC (2018) Relationship of nutritional status and inflammation with survival in patients with advanced cancer in palliative care. Nutrition 51–52:98–103. https://doi.org/10.1016/j.nut.2017.12.004

    Article  Google Scholar 

  9. 9.

    Ryan AM, Power DG, Daly L, Bhuachalla ĒN, Prado CM (2016) Cancer-associated malnutrition, cachexia and sarcopenia: the skeleton in the hospital closet 40 years later. Proc Nutr Soc 1–13. https://doi.org/10.1017/S002966511500419X

  10. 10.

    Kasvis P, Vigano M, Vigano A (2019) Health-related quality of life across cancer cachexia stages. Ann Palliat Med 8:33–42. https://doi.org/10.21037/apm.2018.08.04

    Article  PubMed  Google Scholar 

  11. 11.

    Lis CG, Gupta D, Lammersfeld CA, Markman M, Vashi PG (2012) Role of nutritional status in predicting quality of life outcomes in cancer--a systematic review of the epidemiological literature. Nutr J 11:27. https://doi.org/10.1186/1475-2891-11-27

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, Fearon K, Hütterer E, Isenring E, Kaasa S, Krznaric Z, Laird B, Larsson M, Laviano A, Mühlebach S, Muscaritoli M, Oldervoll L, Ravasco P, Solheim T, Strasser F, de van der Schueren M, Preiser JC (2017) ESPEN guidelines on nutrition in cancer patients. Clin Nutr 36:11–48. https://doi.org/10.1016/j.clnu.2016.07.015

    Article  PubMed  Google Scholar 

  13. 13.

    Gagnon B, Murphy J, Eades M, Lemoignan J, Jelowicki M, Carney S, Amdouni S, di Dio P, Chasen M, Macdonald N (2013) A prospective evaluation of an interdisciplinary nutrition-rehabilitation program for patients with advanced cancer. Curr Oncol 20:310–318. https://doi.org/10.3747/co.20.1612

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Baldwin C, Spiro A, Ahern R, Emery PW (2012) Oral nutritional interventions in malnourished patients with cancer: a systematic review and meta-analysis. J Natl Cancer Inst 104:371–385. https://doi.org/10.1093/jnci/djr556

    Article  PubMed  Google Scholar 

  15. 15.

    Laviano A, Di Lazzaro L, Koverech A (2018) Nutrition support and clinical outcome in advanced cancer patients. Proc Nutr Soc 77:388–393. https://doi.org/10.1017/S0029665118000459

    Article  PubMed  Google Scholar 

  16. 16.

    Polański J, Jankowska-Polańska B, Uchmanowicz I, Chabowski M, Janczak D, Mazur G, Rosińczuk J (2017) Malnutrition and quality of life in patients with non-small-cell lung cancer. Adv Exp Med Biol 1021:15–26. https://doi.org/10.1007/5584_2017_23

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Wheelwright S, Darlington AS, Hopkinson JB, Fitzsimmons D, White A, Johnson CD (2013) A systematic review of health-related quality of life instruments in patients with cancer cachexia. Support Care Cancer 21:2625–2636. https://doi.org/10.1007/s00520-013-1881-9

    Article  PubMed  Google Scholar 

  18. 18.

    Shahmoradi N, Kandiah M, Peng LS (2009) Impact of nutritional status on the quality of life of advanced cancer patients in hospice home care. Asian Pac J Cancer Prev 10:1003–1009

    PubMed  Google Scholar 

  19. 19.

    Zhang YH, Xie FY, Chen YW, Wang HX, Tian WX, Sun WG, Wu J (2018) Evaluating the nutritional status of oncology patients and its association with quality of life. Biomed Environ Sci 31:637–644. https://doi.org/10.3967/bes2018.088

    Article  PubMed  Google Scholar 

  20. 20.

    Schag CC, Heinrich RL, Ganz PA (1984) Karnofsky performance status revisited: reliability, validity, and guidelines. J Clin Oncol 2(3):187–193. https://doi.org/10.1200/JCO.1984.2.3.187

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Chumlea WC, Guo SS, Steinbaugh ML (1994) Prediction of stature from knee height for black and white adults and children with application to mobility-impaired or handicapped persons. J Am Diet Assoc 94:1385–1388, 1391; quiz 1389-90. https://doi.org/10.1016/0002-8223(94)92540-2

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Fearon K, Strasser F, Anker SD, Bosaeus I, Bruera E, Fainsinger RL, Jatoi A, Loprinzi C, MacDonald N, Mantovani G, Davis M, Muscaritoli M, Ottery F, Radbruch L, Ravasco P, Walsh D, Wilcock A, Kaasa S, Baracos VE (2011) Definition and classification of cancer cachexia: an international consensus. Lancet Oncol 12:489–495. https://doi.org/10.1016/S1470-2045(10)70218-7

    Article  PubMed  Google Scholar 

  23. 23.

    Heymsfield SB, McManus C, Smith J, Stevens V, Nixon DW (1982) Anthropometric measurement of muscle mass: revised equations for calculating bone-free arm muscle area. Am J Clin Nutr 36:680–690. https://doi.org/10.1093/ajcn/36.4.680

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Ottery FD (1996) Definition of standardized nutritional assessment and interventional pathways in oncology. Nutrition 12(1 Suppl):S15–S19. https://doi.org/10.1016/0899-9007(96)90011-8

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Groenvold M, Petersen MA, Aaronson NK, Arraras JI, Blazeby JM, Bottomley A, Fayers PM, de Graeff A, Hammerlid E, Kaasa S, Sprangers MA, Bjorner JB, EORTC Quality of Life Group (2006) The development of the EORTC QLQ-C15-PAL: a shortened questionnaire for cancer patients in palliative care. Eur J Cancer 42:55–64. https://doi.org/10.1016/j.ejca.2005.06.022

    Article  PubMed  Google Scholar 

  26. 26.

    Nunes NA (2014) The quality of life of Brazilian patients in palliative care: validation of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 PAL (EORTC QLQ-C15-PAL). Support Care Cancer 22:1595–1600. https://doi.org/10.1007/s00520-014-2119-1

    Article  PubMed  Google Scholar 

  27. 27.

    Fayers PM, Aaronson NK, Bjordal K et al (2001) The EORTC QLQ-C30 scoring manual. European Organization for Research and Treatment of Cancer, 3rd editor, Brussels

  28. 28.

    BRASIL. Ministério da Saúde (2017) Instituto Nacional de Câncer José Alencar Gomes da Silva INCA. Estimativa 2018: Incidência de câncer no Brasil. Rio de Janeiro. Available from: http://www1.inca.gov.br/estimativa/2018/estimativa-2018.pdf

  29. 29.

    Thoresen L, Frykholm G, Lydersen S, Ulveland H, Baracos V, Birdsell L, Falkmer U (2012) The association of nutritional assessment criteria with health-related quality of life in patients with advanced colorectal carcinoma. Eur J Cancer Care 21(4):505–516. https://doi.org/10.1111/j.1365-2354.2012.01327.x

    CAS  Article  Google Scholar 

  30. 30.

    Daly L, Dolan R, Power D et al (2019) The relationship between the BMI-adjusted weight loss grading system and quality of life in patients with incurable cancer. J Cachexia Sarcopenia Muscle. https://doi.org/10.1002/jcsm.12499

  31. 31.

    Capuano G, Gentile PC, Bianciardi F, Tosti M, Palladino A, Di Palma M (2010) Prevalence and influence of malnutrition on quality of life and performance status in patients with locally advanced head and neck cancer before treatment. Support Care Cancer 18:433–437. https://doi.org/10.1007/s00520-009-0681-8

    Article  PubMed  Google Scholar 

  32. 32.

    Zhou T, Yang K, Thapa S, Liu H, Wang B, Yu S (2017) Differences in symptom burden among cancer patients with different stages of cachexia. J Pain Symptom Manag 53:919–926. https://doi.org/10.1016/j.jpainsymman.2016.12.325

    Article  Google Scholar 

  33. 33.

    Sadeghi M, Keshavarz-Fathi M, Baracos V, Arends J, Mahmoudi M, Rezaei N (2018) Cancer cachexia: diagnosis, assessment, and treatment. Crit Rev Oncol Hematol 127:91–104. https://doi.org/10.1016/j.critrevonc.2018.05.006

    Article  PubMed  Google Scholar 

  34. 34.

    Isenring E, Bauer J, Capra S (2003) The scored Patient-generated Subjective Global Assessment (PG-SGA) and its association with quality of life in ambulatory patients receiving radiotherapy. Eur J Clin Nutr 57:305–309. https://doi.org/10.1038/sj.ejcn.1601552

    CAS  Article  PubMed  Google Scholar 

  35. 35.

    Araújo CS, de Oliveira RCB, Queiroz AR, Lanes RCR (2015) Patient-generated subjective global assessment and classic anthropometry: comparison between the methods in detection of malnutrition among elderly with cancer. Nutr Hosp 31:384–392. https://doi.org/10.3305/nh.2015.31.1.7543

    Article  Google Scholar 

  36. 36.

    Molfino A, Laviano A, Rossi Fanelli F (2010) Contribution of anorexia to tissue wasting in cachexia. Curr Opin Support Palliat Care 4(4):249–253. https://doi.org/10.1097/SPC.0b013e32833e4aa5

    Article  PubMed  Google Scholar 

  37. 37.

    Vigano AAL, Morais JA, Ciutto L, Rosenthall L, di Tomasso J, Khan S, Olders H, Borod M, Kilgour RD (2017) Use of routinely available clinical, nutritional, and functional criteria to classify cachexia in advanced cancer patients. Clin Nutr 36:1378–1390. https://doi.org/10.1016/j.clnu.2016.09.008

    Article  PubMed  Google Scholar 

  38. 38.

    Blackwood HA, Hall CC, Balstad TR, Solheim TS, Fallon M, Haraldsdottir E, Laird BJS (2019) A systematic review examining nutrition support interventions in patients with incurable cancer. Support Care Cancer. https://doi.org/10.1007/s00520-019-04999-4

Download references

Author information



Corresponding author

Correspondence to Livia Costa de Oliveira.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

de Oliveira, L.C., Abreu, G.T., Lima, L.C. et al. Quality of life and its relation with nutritional status in patients with incurable cancer in palliative care. Support Care Cancer 28, 4971–4978 (2020). https://doi.org/10.1007/s00520-020-05339-7

Download citation


  • Nutritional status
  • Cachexia
  • Malnutrition
  • Incurable cancer
  • Quality of life
  • Palliative care