Non-small cell lung cancer (NSCLC) is the most common cancer and the major cause of cancer-related deaths in China and globally [1]. Systemic chemotherapy is the mainstream treatment for metastatic NSCLC without a driving gene, with an objective tumor response rate of 25–35% [2]. At cancer diagnosis, approximately 50% of patients present with some nutritional deficits [3].This prevalence may even rise depending on the tumor location and stage. The highest prevalence is noted in patients with tumors of the gastrointestinal tract and the lungs [4].

Systemic administration of chemotherapy agents targets rapidly dividing cells, including those in the bone marrow and gastrointestinal tract epithelial lining.These direct effects of chemotherapy agents can result in gastrointestinal toxicities, which in turn affect the nutritional statuses of patients [5]. Chemotherapy-induced nausea, vomiting, diarrhea, constipation, anorexia, taste disorder, and early satiety are the symptoms commonly reported by patients undergoing chemotherapy [6]. A subset of these patients may experience the symptoms to an extent that limits their dietary intake, and their nutritional statuses may be compromised, leading to negative outcomes for patients and treatment facilities [7].Malnourished patients experience decreased quality of life, diminished treatment tolerance, increased number of complications, and prolonged hospital admissions,all of which jeopardize treatment adherence and tumor control and ultimately increase the mortality and healthcare burden [8]. Therefore, detecting malnutrition early in patients with cancer has become increasingly important.

Nutritional screening includes anthropometric parameters [body mass index (BMI) and weight loss percentage] and biochemical parameters [hemoglobin(Hb) and albumin] [9-12]. Gastrointestinal symptoms,weight loss, and Hb and albumin levels often decrease in patients receiving chemotherapy [13]. An easy routine screening of malnutrition in patients with cancer should include these factors.

The current study aimed to assess the reallife nutritional status changes and gastrointestinal symptoms in patients with advanced NSCLC receiving chemotherapy.

Materials and methods

This cross-sectional study was conducted at the Cancer Centre, Tongji Hospital, Tongji Medical College,Huazhong University of Science and Technology,between January 2016 and January 2017. Informed consent was obtained from all participants. Biochemical and clinical data were assessed before the first chemotherapy cycle and after the second chemotherapy cycle.

The selection criteria were as follows: age between 19 and 75 years and pathological diagnosis of stage IV NSCLC. Meanwhile, patients who underwent any surgery or radiotherapy as treatment were excluded from the study. The present research was conducted in accordance with the guidelines in the Declaration of Helsinki, and all procedures involving human subjects/patients were approved by the ethics committee.

Data analysis

Descriptive statistics were used for the qualitative and quantitative variables, frequency, percentage, mean,and standard deviation (SD). The average distance of the groups was compared using the paired-samples t test.Data analysis was performed using the SPSS software,version 18 (SPSS, Inc., USA). P ＜ 0.05 was considered statistically significant.

The mean Hb levels before chemotherapy were 132.73 ± 16.42 g/L, which were significantly decreased relative to those after chemotherapy (117.06 ± 16.67 g/L)(P ＜ 0.05). No significant difference was noted between the mean albumin levels before and after chemotherapy(38.29 ± 4.22 g/L vs 38.17 ± 4.54 g/L; P =0.798) (Table 3).

Table 1 General characteristics (mean values and standard deviations; number of patients and percentage values)

Variables n %Sex Male 70 67.31 Femal 34 32.69 Age (years)Mean 54.57 SD 9.32 Weight (kg)Mean 62.28 SD 10.05 BMI (kg/m2)Mean 22.98 SD 3.19 Weight loss (kg)Mean 2.38 SD 2.85 Weight loss≥ 5 32 30.77≥ 10 13 12.50

Results

General characteristics

In this study, patients with advanced lung cancer showed a high prevalence of weight loss. Gastrointestinal symptoms, such as anorexia (80/104, 76.92%), nausea(53/104, 50.96%), constipation (49/104, 47.12%),vomiting (48/104, 46.15%), taste disorders (40/104,38.46%), and early satiety (32/104, 30.77%), were very common during chemotherapy. Chemotherapy can induce weight loss and Hb level decreases in patients with advanced lung cancer.

Unintentional weight loss before chemotherapy

Over 65.38% (68/104) of the patients experienced unintentional weight loss, whereas 30.77% and 12.50% showed ≥ 5% and ≥ 10% degrees of weight loss, respectively, within 6 months before firstline chemotherapy was administered (Table 1).Unintentional weight loss ＞ 10% in the preceding 6 months was considered a sign of malnutrition.

四大工程:给长城贴瓷砖、给赤道镶金边、给太平洋装栏杆、给喜马拉雅山安电梯间;四小工程:给苍蝇戴手套、给蚊子戴口罩、给蟑螂戴避孕套、给老鼠戴脚镣。

Gastrointestinal symptoms during chemotherapy

The most common gastrointestinal symptoms reported among all the study patients were anorexia(80/104, 76.92%), nausea (53/104, 50.96%), constipation(49/104, 47.12%), vomiting (48/104, 46.15%), taste disorders (40/104, 38.46%), early satiety (32/104,30.77%), diarrhea (13/104, 12.50%), and dysphagia(2/104, 1.92%; Table 2).

Table 2 Gastrointestinal symptoms reported during chemotherapy

Symptoms n %Anorexia 80 76.92 Nausea 53 50.96 Constipation 49 47.12 Vomiting 48 46.15 Taste disorders 40 38.46 Early satiety 32 30.77 Diarrhoea 13 12.50 Dysphagia 2 1.92

Weight loss and BMI changes after chemotherapy

我被她说服了。因为是同代人，很容易理解各自的苦衷。更重要的是，这次交谈使我学会了换位思考。如果你试着站在大妈们的立场上去思考一下，或许就会理解当今老年妇女内心的酸甜苦辣，甚至会对她们忍辱负重、甘于奉献，苦苦支撑着一个个家庭的毅力、韧性和无私，寄予无限同情和敬意了。做儿女的想过吗，母亲们多半辈子都在操劳，与其责怪她们，何不平时善待她们，有空多带她们到各处走一走看一看？见多识广，走过了、见过了、尝过了，她们还会少见多怪么？

Hb and albumin level changes after chemotherapy

在路由器进行数据传输之前，需要在系统中完成注册阶段。首先，路由器将其和传感器的公钥(Kr,Ks)和随机数R2发送给证书中心。然后，证书中心核实2个公钥的身份信息，如果信息真实可靠，则生成路由器和传感器间的会话密钥KKA。最后，使用传感器公钥对会话密钥和路由器公钥进行加密ES，并返回给路由器。

Discussion

Gastrointestinal symptoms are noteworthy components of malnutrition in patients with cancer.Upper gastrointestinal symptoms reported by patients are important because a high prevalence of these symptoms can cause difficulty in feeding, reduction in energy intake, and worsening of nutritional status [21–23].In the current study, the most frequent gastrointestinal symptoms were anorexia (80/104, 76.92%), nausea(53/104, 50.96%), constipation (49/104, 47.12%),vomiting (48/104, 46.15%), taste disorders (40/104,38.46%), early satiety (32/104, 30.77%), diarrhea(13/104, 12.50%), and dysphagia (2/104, 1.92%). A similar prevalence of gastrointestinal symptoms was found in other studies [18–20].

Table 3 Weight, BMI and biochemical parameters change during chemotherapy (Mean ± SD)

Variables Before chemotherapy After chemotherapy P Weight (kg) 62.28 ± 10.46 61.47 ± 10.37 0.001 BMI (kg/m2) 22.98 ± 3.19 22.66 ± 3.34 0.004 Hb (g/L) 132.73 ± 16.42 117.06 ± 16.67 0.000 Albumin (g/L) 38.29 ± 4.22 38.17 ± 4.54 0.798

Serum albumin is the simplest and most effective variable indicating visceral protein function. Therefore,this biomarker is commonly used in assessing malnutrition. Normal serum albumin levels range between 3.5 and 5.0 g/dL in adults. Hypoalbuminemia is defined as serum albumin levels ＜ 3.5 g/dL. Albumin is habitually included among the parameters utilized for nutritional assessment and has recently become further widespread. Serum albumin concentration has also been established as an independent prognostic variable for survival in advanced NSCLC [25]. Nevertheless,scarce data are available to date on the prevalence and clinical significance of hypoalbuminemia in patients with cancer and how such conditions affect cancer treatment. In the present study, the albumin levels did not diminish after chemotherapy, unlike in other studies. The discrepancy may be due to the small sample size and short investigation time in the current work.

Of all patients, 48.08% (50/104) experienced unintentional weight loss after two chemotherapy cycles. The mean body weight after chemotherapy was 61.47 ± 10.37 kg, which was significantly decreased relative to that before chemotherapy (P ＜ 0.05). The mean BMI after chemotherapy was 22.66 ± 3.34 kg/m2, which was also significantly decreased relative to that during the previous chemotherapy cycle (P ＜ 0.05)(Table 3).

Malnutrition affects 20–70% of patients with cancer[14]. Weight loss is an easy measure of diagnosing malnutrition and should be assessed in daily practice.However, slight changes in nutritional status can be overlooked occasionally. Declining nutritional status and weight loss originate from multiple processes and are associated with decreased responses to chemotherapy treatment and reduced survival [15]. Therefore, all patients with cancer must be evaluated for early signsof malnutrition and weight loss to provide adequate nutritional support and improve the quality of life and treatment response in these patients. Clinicians and patients must be aware of the effects of malnutrition on patient outcomes, particularly those in patients receiving chemotherapy. Changes in nutritional status have been associated with altered absorption,metabolism, and elimination of chemotherapy drugs.The prevalence of unintentional weight loss in patients with NSCLC has been reported to be 38% [16]. Moreover,most patients with advanced NSCLC also present with malnourishment [17–19]. The present study observed similar results, and 65.38% (68/104) of the patients experienced unintentional weight loss, whereas 30.77%and 12.5% of the patients manifested ≥ 5% and ≥ 10%degrees of weight loss, respectively, within 6 months before first-line chemotherapy was administered.The etiology of unintentional weight loss is not well understood and may be due to decreased food intake.

本报讯 工业和信息化部日前对申请立项的410项行业标准计划项目和64项国家标准计划项目予以公示并征集意见，其中包括《化肥追溯体系规范》化工推荐性行业标准制定项目。征集意见截止时间为11月28日。

Consistent with other reports, the Hb levels were significantly decreased after chemotherapy in our study. This result may be due to the toxic effects of the chemotherapeutic drugs on hematopoietic cells and gut epithelia that lead to malabsorption [24].

BMI is another very important nutritional index and the most practical and simplest means to assess nutritional status. However, this measure provides little information on the body composition alteration in cachexia [20]. In the present study, the mean BMI of the patients was 22.98 kg/m2.

A total of 104 patients with advanced NSCLC [34(32.69%) women and 70 (67.31%) men] underwent at least two chemotherapy cycles. The mean age was 54.57 (SD 14.8) years. The mean body weight was 62.28± 10.46 kg, and the mean BMI was 22.98 ± 3.19 kg/m2(Table 1).

从表1相关要素对照说明，基础地理信息数据与地理国情要素数据有着密切的关联，但两者之间还是存在许多区别。首先，对于同一要素，两者在表示的方法、选取的指标、属性的要求等多方面存在一定的差异；其次，地理国情数据针对一些要素进一步细化，如果园地细化为乔灌果园、藤本果园、草本果园；再次，地理国情数据根据需要新增了许多要素，是基础地理信息数据不具备的。如主体功能区、流域、城镇开发边界等；最后，基础地理信息数据中许多要素在地理国情数据中也没有体现。

In conclusion, weight loss history, gastrointestinal symptoms, and Hb level decreases are determinant factors of nutritional status in patients with advanced lung cancer and must be included in the screening,evaluation, and treatment of lung carcinoma.

湖南省在治理“新官不理旧事”方面，拿出了很多力度颇大的措施，起到的效果也很明显，这从湖南省从严治党、依法治理方面就可见一斑。比如，记者近日在湖南省高级人民法院采访，就了解到了一起“以新官不理旧事为由拒付货款，村民起诉获得法院支持”的案例。被告某村委会三年时间里在原告田某（某镇邮电局的一名临聘人员）处订阅报纸，三年共欠原告报刊费1409元，并向原告田某出具了一张条据。后来，该村村委会换届，原告多次找被告某村委会催要此款，被告某村委会却以“新官不理旧事”为由拒付款。原告田某向湘阴县人民法院起诉请求法院判令被告某村委会向原告田某支付货款1409元，湘阴县人民法院一审作出了支持原告诉讼请求的判决。

Conflict of interest

The authors indicated no potential conflicts of interest.

References

1. Jemal A, Bray F, Center MM, et al. Global cancer statistics. CA Cancer J Clin, 2011, 61: 69–90.

2. Xue C, Hu Z, Jiang W, et al. National survey of the medical treatment status for non-small cell lung cancer (NSCLC) in China. Lung Cancer,2012, 77: 371–375.

3. Fearon K, Strasser F, Anker SD, et al. Definition and classificatio n of cancer cachexia:an international consensus. Lancet Oncol,2011,12: 489–495.

4. Bovio G, Fonte ML, Baiardi P. Prevalence of upper gastrointestinal symptoms and their influence onnutritional state and performance status in patients with different primarytumors receiving palliative care. Am J Hosp Palliat Care, 2014, 31: 20–26.

5. Gudny Geirsdottir O, Thorsdottir I. Nutritional status of cancer p atients in chemotherapy; dietary intake, nitrogen balance and screening. Food Nutr Res, 2008, 52.

6. Sánchez-Lara K, Ugalde-Morales E, Motola-Kuba D, et al. Gastroint estinal symptoms and weight loss in cancer patients receiving chemotherapy. Br J Nutr, 2013,109: 894–897.

7. Attar A, Malka D, Sabaté JM, et al. Malnutrition is high and und erestimated during chemotherapy in gastrointestinal cancer: an AGEO prospective cross-sectional multicenter study. Nutr Cancer,2012, 64: 535–542.

8. Mohan A, Singh P, Kumar S, et al. Effect of change in symptoms,respiratory status, nutritional profile and quality of life on response to treatment for advanced non-small cell lung cancer. Asian Pac J Cancer Prev, 2008, 9: 557–562.

9. Andreyev HJ, Norman AR, Oates J, et al. Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies? Eur J Cance, 1998, 34: 503–509.

10. Lipkin EW, Bell S. Assessment of nutritional status. The clinician’s perspective. Clin Lab Med, 1993,13: 329–352.

11. Srdic D, Plestina S, Sverko-Peternac A, et al. Cancer cachexia,sarcopenia and biochemical markers in patients with advanced nonsmall cell lung cancer-chemotherapy toxicity and prognostic value.Support Care Cancer, 2016, 24: 4495–5002.

12. Tanriverdi O, Avci N, Oktay E, et al. Pretreatment Serum Albumin Level is an Independent Prognostic Factor in Patients with Stage IIIB Non-Small Cell Lung Cancer: A Study of the Turkish Descriptive Oncological Researches Group. Asian Pac J Cancer Prev, 2015,16:59715–59716.

13. Tisdale MJ. Cachexia in cancer patients. Nat Rev Cancer, 2002, 2:862–871.

14. Tong H, Isenring E, Yates P. The prevalence of nutrition impact symptoms and their relationship to qualityof life and clinical outcomes in medical oncology patients. Support Care Cancer, 2009,17: 83–90.

15. von Haehling S, Anker SD. Cachexia as a major underestimate d and unmet medical need: facts and numbers. J Cachexia Sarcopenia Muscle, 2010, 1: 1–5.

16. Cranganu A, Camporeale J. Nutrition aspects of lung cancer. Nutr Clin Pract, 2009, 24: 688–700.

17. HuhmannMB,CunninghamRS.Importance of nutritional screening in treatment of cancer-related weight loss. Lancet Oncol, 2005, 6:334–343.

18. Chlebowski RT, Palomares MR, Lillington L, et al. Recent implications of weight loss in lung cancer management. Nutrition, 1996,12: 43–47.

19. Buccheri G, Ferrigno D. Importance of weight loss definition in the prognostic evaluation of non-small-cell lung cancer. Lung Cancer,2001, 34: 433–440.

20. Lu Z, Yang L, Yu J, et al. Change of body weight and macrophage inhibitory cytokine-1 during chemotherapy in advanced gastriccancer: what is their clinical significance? PLoS One, 2014,9: e88553.

21. BergkvisK, WengströmY. Symptom experiences during chemotherapy treatment--with focus on nauseaand vomiting. Eur J Oncol Nurs,2006,10: 21–29.

22. Sánchez-Lara K, Sosa-Sánchez R, Green-Renner D, et al. Influence of taste disorders on dietary behaviors in cancer patients under chemotherapy. Nutr J, 2010, 9: 15.

23. Davidson W, Teleni L, Muller J, et al. Malnutrition and chemotherapyinduced nausea and vomiting: implications for practice. Oncol Nurs Forum, 2012, 39: 340–345.

24. Alexandre J, Gross-Goupil M, Falissard B, et al. Evaluation of the nutritional and inflammatory status in cancer patients for the risk assessment of severe haematological toxicity following chemotherapy. Ann Oncol, 2003,14: 36–41.

25. Arrieta O, Michel Ortega RM, Villanueva-Rodríguez G, et al.Association of nutritional status and serum albumin levels with developmentof toxicity in patients with advanced non-small cell lung cancer treated withpaclitaxel-cisplatin chemotherapy: a prospective study. BMC Cancer, 2010,10: 50.