Malnutrition Poorly Impacts Survival With CCRT in Advanced Cervical Cancer

Nutritional status—including cachexia, sarcopenia, and malnutrition—independently correlated with survival and toxicity outcomes in patients with locally advanced cervical cancer (LACC) receiving concurrent chemoradiotherapy, according to a scoping review published in Clinical Nutrition Open Science.

Clinical Efficacy and Survival Findings

The synthesis of 23 primary studies demonstrated that various forms of nutritional compromise were consistently associated with inferior survival outcomes in this patient population. Malnutrition, identified through a range of screening and diagnostic indices, was associated with a 1.5- to 3.7-fold higher mortality risk compared with well-nourished patients. Specifically, severe unintentional weight loss of 10% or more was associated with a HR for mortality of 2.37 (95% CI, 1.77-7.37; P = .036).

Body composition metrics derived from CT imaging provided some of the strongest prognostic signals, particularly when measured dynamically during the treatment course. A decline in the skeletal-muscle index of 7% or more during chemoradiotherapy was associated with an adjusted HR for mortality of 6.16 (95% CI, 1.38-27.56), while a loss exceeding 10% over a 150-day window carried an HR of 6.02 (95% CI, 3.04-11.93). In patients with squamous-cell carcinoma, the impact of muscle loss was similarly pronounced, with an HR of 5.65 (95% CI, 2.65-12.02). Furthermore, the loss of intermuscular fat area by 15% or more was linked to a significant increase in mortality risk, with a hazard ratio of 8.52 (95% CI, 2.16-33.59).

The review also highlighted the impact of static baseline measurements and nutritional indices on progression-free survival (PFS) and overall survival (OS). Sarcopenic obesity at the start of treatment was associated with an HR for death of 2.65 (95% CI, 1.28-5.49). Laboratory-based indices also proved to be prognostic, as a low pretreatment Prognostic Nutritional Index (PNI) of no more than 49.1 was independently associated with worse PFS (adjusted HR, 1.48; 95% CI, 1.11-1.98), while a high Controlling Nutritional Status (CONUT) score of more than 2 carried a more substantial risk for progression or death (adjusted HR, 2.77; 95% CI, 1.52-5.04).

Expert Commentary

“By clarifying the prognostic weight of each phenotype and exposing measurement heterogeneity, this review aims to provide the evidence base needed for guideline bodies to embed formal nutritional triage within standard LACC management,” lead study author Canio Martinelli, MD, OB/GYN, MSc, PhD, of Sbarro Institute for Cancer Research and Molecular Medicine and Center of Biotechnology in the College of Science and Technology at Temple University, wrote with coauthors in the study. “Malnutrition (either having high risk of malnutrition and diagnosis of malnutrition), sarcopenia, and cachexia are prevalent among women with [LACC] and independently associated with inferior survival, higher toxicity, treatment interruption, and diminished quality of life.”

Trial Breakdown

The scoping review followed the JBI methodology and PRISMA-ScR reporting standards. Investigators searched databases including PubMed, Scopus, and Web of Science for studies published between 1995 and 2025. The analysis included 23 unique studies encompassing a total of 4352 women with LACC.

Eligibility criteria for the study included patients 18 years or older with FIGO 2009 stage IB2 to IVA or FIGO 2018 stage IB3 to IVA disease. All patients underwent standard concurrent chemoradiotherapy, defined as external-beam radiotherapy at 45 to 50 Gy delivered with weekly cisplatin and followed by brachytherapy.

The review assessed several nutritional constructs, including diagnosed malnutrition via GLIM or Patient-Generated Subjective Global Assessment (PG-SGA), nutritional risk via PNI or CONUT, and sarcopenia phenotypes determined by CT-derived skeletal muscle measures.

Safety Results

Nutritional compromise was strongly associated with an increased risk of treatment-related toxicities and interruptions to the planned chemoradiotherapy schedule. Grade 3 or higher toxicities were found to be 1.2 to 2.5 times more frequent in patients who were malnourished or sarcopenic compared with those who were well-nourished. When patients presented with multiple unfavorable body-composition features, the risk of treatment interruption increased by 3- to 5-fold.

Specific assessments using the PG-SGA showed that patients with severe malnutrition had a 3.21-fold higher risk for treatment interruption compared with well-nourished patients. Those with a PG-SGA numerical score of 9 or higher also had an independently elevated risk of both grade 3 or higher events (RR, 1.13; 95% CI, 1.08-1.18) and treatment delays (RR, 1.80; 95% CI, 1.44-2.25). In one analyzed cohort, 44.4% of patients with high nutritional risk required an interruption in their radiotherapy or chemotherapy schedule compared with 24.5% of those at lower risk. These interruptions were clinically significant, as the investigators noted that each additional day of treatment prolongation beyond the 56-day window increased the risk of recurrence by approximately 1%.

Notably, 0 of the 23 included studies had low overall risk of bias, 6 had a moderate risk, and 17 had a high risk.

Reference

Martinelli C, Ercoli A, Alfano L, et al. Cachexia, sarcopenia, malnutrition and their impact on survival, treatment toxicities, and quality of life in locally advanced cervical cancer patients undergoing concomitant chemoradiotherapy: A scoping review. Clin Nutr Open Sci. 2026;65:100620. doi:10.1016/j.nutos.2025.100620