Malnutrition: An underrecognized comorbidity in hematologic malignancies in a single institution review of nutrition referrals

Abstract Background: Unintentional weight loss is a common presenting symptom of malignancy. This is often multifactorial, but arises in part due to pain, mechanical obstruction, inflammation, and alterations in metabolism. Symptoms like nausea, constipation, and early satiety are difficult to manage and frequently require a multidisciplinary approach. Malnutrition in this population has been associated with a lower functional status, increased fatigue, and increased mortality. Undiganosed malnutrition on initial presentation poses a threat to a patient's ability to tolerate intensive cancer-directed therapy. Despite this risk, patients are frequently not screened for malnutrition during their initial presentation in the outpatient oncology clinic. Surrogate indices for malnutrition are instead used, such as Body Mass Index (BMI), but this alone does not approximate nutrition. We postulate that patients with new hematologic malignancies at risk for malnutrition are underrecognized in the outpatient setting. We hypothesize that screening for malnutrition in the initial oncology patient visit and referring high-risk patients to the nutrition department may improve outcomes. Methods: We performed a single-institution retrospective review examining all new hematologic malignancy outpatient visits during 2024. Utilizing the Nutritional Risk Index (NRI), we risk stratified patients based on extrapolated data. The NRI has previously been shown to be an effective indicator on prognostic factors in cancer patients. A strength of this model is that it utilizes laboratory data such as serum albumin and weight to calculate a score. The NRI was calculated using the following formula: (1.519 × serum albumin, g/L) + (41.7 × present weight, kg / usual weight, kg). Usual weight was defined as stable body weight for last 6 months. The NRI separated patients into four malnutrition-risk groups: None (score > 100.0), Mild (score 97.6-100), Moderate (score 83.5-97.5), and Severe (score < 83.5). BMI was calculated using the following formula: (weight, kg/ height, m2). Underweight was defined as BMI < 18.5 Results: Out of the 809 new patients seen in the outpatient hematologic malignancy clinics, 101 patients (12.5%) had the necessary data available to utilize the NRI. Within this group, 45 individuals (44.6%) in total were at risk for malnutrition. Results showed that 17 of those at risk were “Mild,” 20 of them were “Moderate,” and 8 of them were “Severe.” Only 1 out of these 45 patients (2.25%) were referred to nutrition during this initial encounter. For BMI, only 3 patients out of the 45 individuals at risk for malnutrition (6.67%) were “Underweight.” Conclusion: These results demonstrate a stark discrepancy between patients at risk for malnutrition and those who received appropriate nutrition referrals. The data showed that relying on BMI alone is not an adequate surrogate for nutritional status. Our quality improvement project aims to close this care gap by implementing a workflow in the hematologic malignancy clinics for patients to be screened for malnutrition routinely as part of the initial visit onboarding process. Should the patient be at risk, an automatic nutrition referral will be pended for approval on behalf of the provider. The interval change in nutritional referrals will be measured and longitudinal outcomes such as functional status, disease-free progression, and overall survival will be collected to evaluate for efficacy of the intervention. Malnutrition is a modifiable risk factor for adverse outcomes in hematologic malignancies and this data showed that it is underrecognized during initial outpatient visits. Therefore, initial malnutrition screening poses a promising, actionable target for improving quality care and outcomes for this population.