Association Identified Between Malnutrition and Post-Operative Outcomes in Gynecologic Cancer

Nutritional markers such as body mass index, weight loss, and albumin should be assessed to identify pre-operative malnutrition in patients with gynecologic cancers.

Cancer-specific malnutrition criteria may help to personalize pre-operative risk assessment in patients with gynecologic cancer, according to a study published in Gynecologic Oncology

Classifications included severe malnutrition—defined as body mass index (BMI) of less than 18.5 to 22 plus 10% weight loss by European Society for Clinical Nutrition and Metabolism (ESPEN1) criteria, BMI 18.5 to 22 plus 10% weight loss, BMI of less than 18.5 by ESPEN2 criteria—or mild malnutrition—defined as BMI 18.5 to 22, or albumin of less than 3.5 g/dL.

Among patients who had ovarian cancer, ESPEN2 malnutrition was associated with higher readmission rates (risk ratio [RR], 1.69; 95% CI, 1.29-2.20), reoperation (RR, 2.53; 95% CI, 1.70-3.77), and major complications (RR, 1.36; 95% CI, 1.20-1.54). Those with uterine cancer who were malnourished based on American Cancer Society (ACS) criteria were more at risk of readmission (RR, 2.74; 95% CI, 2.09-3.59), reoperation (RR, 3.61; 95% CI, 2.29-5.71), and major complications (RR, 3.92; 95% CI, 3.40-4.53). Additionally, for cervical cancer those with albumin levels of less than 3.5 g/dL had higher rates of readmission (RR, 1.48; 95% CI, 1.01-2.19), reoperation (RR, 2.25; 95% CI, 1.17-4.34), and major complications (RR, 2.59; 95% CI, 2.11-3.17).

Investigators identified a total of 76,290 patients met the inclusion criteria, of whom 68.8% had uterine cancer, 23.3% had ovarian cancer, and 7.9% had cervical cancer. About 60% of patients were under 65 years of age, 2.1% were over 85 years, and the 70.3% of patients were White. The median BMI was 31.3 kg/m2 and 1.7% had lost more than 10% of their body weight 6 months prior to surgery. Additionally, 3.7% of patients were mildly malnourished, 0.1% had severe malnutrition, 0.2% had ESPEN1, 1.1% had ESPEN2, and 1.3% had ACS malnutrition.

Overall, the rate of unplanned readmission rate was 5.5%, the reoperation rate was 1.7%, and the major complication rate was 13.5%. A higher risk of unplaced readmission was observed in patients who met criteria for EPEN2 (adjusted RR [aRR], 1.45; 95% CI, 1.17-1.80) and ACS malnutrition (RR, 1.44; 95% CI, 1.19-1.74). Those who met the criteria for severe malnourition criteria (aRR, 3.79; 95% CI, 2.00-7.15) and ESPEN2 criteria (aRR; 1.93; 95% CI, 1.37-2.72) had increased rates of unplanned reoperation.

The most common major complication was blood transfusion in 9.9% of patients. Those who met the ACS definition of malnutrition had higher rates of minor complications (aRR, 1.28; 95% CI, 1.04-1.58). The overall death rate was 0.3% and 96.9% were discharged.

Those who had low albumin levels (2.0%) had a 10 times higher risk of death within 30 days of surgery compared with those who had normal albumin (0.2%). These patients were also more likely to have major (aRR, 2.14; 95% CI, 2.05-2.25) and minor complications (aRR, 1.48; 95% CI, 1.33-1.65). Additionally, blood transfusion was the most common major complication occurring in 12.0% of patients.

For patients with uterine cancer, those who met ACS criteria had an increased length of stay at 3.50 days (95% CI, 2.80-4.20), and minor complications (aRR 2.03, 95% CI 1.48–2.80). Low albumin levels were correlated with poorer outcomes including increased length of stay (2.83 days, 95% CI 2.58-3.08), increased risk of readmission (aRR 2.38; 95% CI 2.10-2.69), reoperation (aRR 2.56; 95% CI 2.01-3.25), major complications (aRR 3.74; 95% CI 3.48-4.02), and minor complications (aRR 2.17, 95% CI 1.90-2.48).

Among those with ovarian cancer, ESPEN2 was associated with increased length of stay by 0.54 days (95% CI, 0.10-0.98). Those who met the ACS criteria had increased length of stay by 1.81 days (95% CI, 1.34-2.29), a higher risk of readmission (aRR 1.36, 95% CI 1.06-1.75), and major complications (RR 1.67, 95% CI 1.52-1.82). Albumin levels of less than 3.5 g/dL were associated with a longer stay by 2.46 days (95% CI, 2.19-2.73), an increased risk of readmission (aRR 1.28; 95% CI 1.11–1.47), reoperation (aRR 1.31; 95% CI 1.01–1.70), and major complications (aRR 1.74; 95% CI 1.65–1.74). Those with cervical cancer who had albumin levels of less than 3.5 g/dL had an increased stay of 4.02 days (95% CI, 2.52-5.51).


Goins EC, Weber JM, Truong T, et al. Malnutrition as a risk factor for post-operative morbidity in gynecologic cancer: analysis using a national surgical outcomes database. Gynecol Oncol. 2022;165(2):309-316. doi:10.1016/j.ygyno.2022.01.030