Abstract
Background
Head and neck cancer (HNC) and its treatment are associated with muscle weakness and considerable long-term comorbidity. The goal of this study was to determine whether skeletal muscle density (SMD) as quantified from pretreatment computed tomography (CT) scans will correlate with measures of function and strength prior to treatment in physical function in HNC patients.
Patients and methods
A cross-sectional analysis was conducted on 90 HNC patients. SMD (myosteatosis vs. normal) was calculated from pretreatment CT scans using SliceOmatic software. Pretreatment physical function was assessed via handgrip strength (HGS), the timed up and go test (TUG), and the short physical performance battery (SPPB). Demographic, cancer, and social characteristics were also collected as confounders. Linear regression models assessed the association between myosteatosis and measures of physical function.
Results
The 90 patients were predominately White, male, former smokers with an average BMI of 28.7 ± 5.7 kg/m2. Among men, adjusted models indicate, as compared to those with normal muscle density, the total SPPB score of those with myosteatosis was 1.57 points lower (p = 0.0008), HGS was 0.85 kg lower (p = 0.73), and TUG took 1.34 s longer (p = 0.03). There were no differences in women.
Conclusion
Myosteatosis is associated with physical function prior to treatment in HNC patients. Larger studies are needed to examine the importance of exercise programs prior to and during treatment to build lean mass and improve long-term prognosis in HNC.
Keywords: Head and neck cancer, Myosteatosis, Physical function, Handgrip strength, Short performance physical battery, Timed up and go, SCCHN
Introduction
HNC was projected to affect 66,630 incident individuals and result in 14,620 deaths in 2021 [1]. Apart from mortality, HNC is associated with a decline in physical and mental health from cancer itself and from its treatment. Those with greater physical strength before treatment are more likely to withstand the insult of treatment with fewer complications, thus they may be considered to be more resilient to the toxicities of cancer treatment. As indicated previously, regular assessments of older cancer patients may aid in the application of lifestyle interventions that work to sustain lean mass and physical function [2]. A measure of body composition, prior to treatment may, therefore, help to identify and refer patients with low muscle density and/or mass to a rehabilitation/exercise specialist prior to or during treatment, yet strength is not frequently assessed in HNC.
A routine part of both diagnosis and treatment for HNC patients receiving definitive radiation therapy (RT) for HNC is CT imaging, which captures measures of body composition including muscle mass and muscle density. ISMD, as measured through CT, refers to the radiodensity of the muscle fibers as found in muscle tissue; muscle density is inversely proportional to the amount of fatty infiltration into the muscle tissue or myosteatosis. Myosteatosis is not to be confused with low muscle mass nor with sarcopenia, the loss of both muscle mass and function, both of which are better known. Myosteatosis can occur independent of the level of muscle mass but may act synergistically [3]. Since CT is routinely performed on HNC patients receiving definitive RT, SMD, in particular myosteatosis, could be ascertained without causing additional patient burden. By ascertaining myosteatosis, it may be possible to categorize patients according to those who need assistance as they navigate through treatment and beyond. The aim of the study was to evaluate the relationship between myosteatosis and physical function prior to treatment in HNC patients receiving definitive radiation therapy.
Patients and methods
Study design and participants
Data for this cross-sectional study was collected in the Head and Neck Radiation Clinic, Roswell Park Comprehensive Cancer Center (RPCCC). Patients include those over 18 years of age that were treated with definitive RT for primary HNC at RPCCC from June 2017 through January 2020. Only patients who underwent whole-body CT including the third lumbar vertebral body (L3) who also performed functional testing prior to treatment were included. Whole-body CT is a regular part of diagnosis and staging at this facility. Individuals without readable scans of the third lumbar (L3) vertebral body were excluded (2.8%). A study researcher utilized the CT scans to determine measures of body composition as described below. Those without physical function measures were also excluded (2.7%). Demographics, diagnosis, cancer staging, and treatment information were collected from ongoing HNC medical record data capture. The Institutional Review Board at RPCCC approved the medical record review of head and neck cancer patients for this retrospective study.
Marker measurement: muscle and adipose tissue
Imaging software (SliceOmatic Software by TomoVision, version 5.0) was used to quantify the cross-sectional area of muscle (a measure of skeletal muscle mass) and adipose tissue in centimeters squared at L3. The imaging software allows for measurement of skeletal muscle, visceral adipose tissue, subcutaneous adipose tissue, and intermuscular adipose tissue through the use of tissue-specific Hounsfield unit (HU) ranges [4]. The L3 level represents a valid and reliable approach to estimate whole-body volume and body composition [5]. A measure of skeletal muscle mass, skeletal muscle index (SMI), was determined by dividing muscle mass by the patient’s height (calculated by dividing the muscle area at L3 by patient height in meters squared). SMD, as measured by the mean radiation attenuation in HU, was used along with BMI to categorize patients as having either myosteatosis or normal muscle density based on previous studies [6]. Myosteatosis was defined as < 41 Hounsfield units (HU) for those with a BMI in the healthy or under-weight range (≤ 24.9 kg/m2) and < 33 HU for those with a BMI in the overweight or obese range (≥ 25.0 kg/m2) [6].
Intermuscular adipose tissue (adipose tissue that is found within a muscle) produces less radiation attenuation than muscle without adipose tissue; therefore, the adipose tissue causes the muscle to appear less dense resulting in a lower average HU reading.
SliceOmatic was also used to quantify adipose tissue in centimeters squared at the L3 level using the same method as described above [4]. Total adipose tissue (TAT) area at L3 in cm2 was constructed through the addition of visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), and intermuscular adipose tissue (IMAT), and each was reported.
Outcome measurement: physical function
Physical function was measured in three ways: handgrip strength, short physical performance battery, and timed up and go. Physical function was measured objectively by trained research assistants during a patient’s regularly scheduled appointment as we have previously done [7].
The short physical performance battery (SPPB) includes three tests each with the best performance score of 4, for a final score of 0–12 [8]. The tests include balance, five-repetition sit to stand (5-STS), and gait speed. Balance includes standing in three different stances (each increasingly difficult) and holding that position for 10 s. It is important to note that the minimal clinically important difference (MCID) for the SPPB is 1.0, and a score ≤ 10.0 is indicative of mobility issues and predictive of all-cause mortality [9, 10]. During the 5-STS, patients stand from a sitting position 5 times without using their arms, as described previously [11]. The gait speed test required patients to walk at a usual pace over a 4-m course, and time was recorded in seconds. The test score is a continuous variable; the lower the score the more likely to have an impairment, a gait speed of ≤ 0.8 m/s would be considered impaired as would a completion time of ≥ 17 s for the 5-STS [12–14]. Both gait speed and 5-STS were evaluated as a separate subanalysis of SPPB to determine the relationship of those physical function tests with myosteatosis.
Hand grip strength (continuous, kg) will be measured using a Jamar™ dynamometer that is adjusted for hand size. Three tests will be performed with each hand, and the average of the dominant hand will be recorded. This will produce a continuous variable in kilograms; the lower the score, the more likely to have an impairment [12, 15, 16]. Impairment, or probable sarcopenia, is considered at ≤ 16 kg for women and ≤ 20 kg for men [13, 17].
TUG was measured in seconds, a continuous parameter where the higher the number, the more likely to have impairment; an impairment or sarcopenia will be considered if the patient requires ≥ 20 s for completion [18, 19]. The patient begins in a seated; they then rise, walk as quickly and safely as possible to a 3-m mark, return to the starting point, and sit down [20, 21].
Covariates
Demographic and clinical data collected on all patients through retrospective review of the electronic medical record were of interest due to their relationship with muscle density and physical function.
Age in years was parameterized as a continuous variable. Sex was parameterized as a dichotomous variable. Primary tumor site was recorded as oral cavity, nasopharynx, oropharynx, hypopharynx, laryngeal, salivary, or other. Smoking status was categorized as current, former, or never smoker. HPV was categorized as positive or negative. The number of comorbidities (co-occurring medical conditions) was parameterized as continuous and was determined through medical record review. The staging of the tumor was categorized according to overall AJCC staging [22, 23]. TAT area at L3 in cm2 was constructed through the addition of VAT, SAT, and IMAT, and each was reported. The race was self-reported and recorded as White, Black, Asian, and Native American or Alaskan Native, or Unknown.
Statistical analysis
Patient demographic and diagnosis data were summarized using descriptive statistics. Continuous variables were summarized as the mean/median and standard deviation/interquartile range as appropriate, and categorical variables were summarized as frequencies/percentages.
The strength of association between myosteatosis and each test of physical function was established using linear regression models demonstrating the amount of change in physical function between those with myosteatosis compared to those with normal muscle density. The following covariates were considered potential confounders based on the literature: age, sex, BMI, number of comorbidities, SMI, TAT, and smoking status. Others were considered the AJCC stage, tumor site, and HPV status. All potential confounders were tested for inclusion in the final model, where inclusion in the base model changed the measure of association by 10% or more, they were deemed confounders and included in the model. Age was included in all adjusted models regardless of change criteria.
Results
Study cohort characteristics
A total of 90 patients were analyzed for this study. Demographics and physical characteristics of patients stratified by myosteatosis can be viewed in Table 1. The overall age of patients was 64 ± 10.7 years, and the majority were White (95.6%) and male (78.9%). The mean number of comorbidities was nearly 2.6 (1.6). Most patients were former smokers (60%) and overweight (mean BMI = 28.7 kg/m2 ± 5.7). The majority were diagnosed with oropharyngeal cancer (56.7%), followed by laryngeal cancer (17.8%), and more than half were HPV-positive (55.6%). The distribution of AJCC stage from I to IV was 24.4% at stage I, 23.3% at stage II, 21.1% at stage III, and 31.1% at stage IV.
Table 1.
Patient characteristics overall and according to muscle density
| Characteristic | All n = 90 |
Myosteatosis n = 37 (41.1) |
Normal SMD n = 53 (58.9) |
p |
|---|---|---|---|---|
| Age (years) | 64.0 (10.7) | 65.8 (9.7) | 62.7 (11.2) | 0.17 |
| Sex | 0.03 | |||
| Male | 71 (78.9) | 25 (35.2) | 46 (64.8) | |
| Female | 19 (21.1) | 12 (63.2) | 7 (36.8) | |
| Race | 0.16 | |||
| White | 86 (95.6) | 34 (39.5) | 52 (60.5) | |
| Black | 4 (4.4) | 3 (75.0) | 1 (25.0) | |
| BMI (kg/m2) | 28.7 (5.7) | 25.9 (5.5) | 30.7 (5.1) | < 0.0001 |
| SMA (cm2) | 157.2 (36.9) | 134.4 (31.7) | 173.2 (31.7) | < 0.0001 |
| SMI (cm2/m2) | 52.4 (10.4) | 45.4 (8.1) | 57.4 (8.9) | < 0.0001 |
| VAT (cm2) | 177.6 (107.8) | 141.3 (119.4) | 202.9 (91.8) | 0.007 |
| SAT (cm2) | 204.4 (117.8) | 163.9 (105.1) | 232.7 (118.8) | 0.006 |
| IMAT (cm2) | 13.2 (5.8) | 16.0 (6.4) | 11.2 (4.5) | 0.0002 |
| TAT (cm2) | 395.1 (191.0) | 321.1 (194.6) | 446.8 (172.1) | 0.002 |
| SMD (HU) | 37.5 (7.9) | 31.0 (6.4) | 42.1 (5.2) | < 0.0001 |
| Comorbidities | 2.6 (1.6) | 2.4 (1.5) | 2.7 (1.6) | 0.46 |
| Tumor site | 0.03 | |||
| Oral cavity | 8 (8.9) | 5 (13.5) | 3 (5.7) | |
| Nasopharynx | 1 (1.1) | 1 (2.7) | 0 (0.0) | |
| Oropharynx | 51 (56.7) | 14 (37.8) | 37 (69.8) | |
| Hypopharynx | 2 (2.2) | 2 (5.4) | 0 (0.0) | |
| Larynx | 16 (17.8) | 10 (27.0) | 6 (11.3) | |
| Salivary | 2 (2.2) | 0 (0.0) | 2 (3.8) | |
| Other | 10 (11.1) | 5 (13.5) | 5 (9.4) | |
| AJCC stage | < 0.0001 | |||
| I | 22 (24.4) | 5 (13.5) | 17 (32.1) | |
| II | 21 (23.3) | 2 (5.4) | 19 (35.9) | |
| III | 19 (21.1) | 11 (29.7) | 8 (15.1) | |
| IV | 28 (31.1) | 19 (51.4) | 9 (17.0) | |
| Karnofsky performance score | 89.0 (8.6) | 86.5 (9.5) | 90.8 (7.6) | 0.02 |
| HPV | < 0.0001 | |||
| Positive | 50 (55.6) | 11 (29.7) | 39 (73.6) | |
| Negative | 40 (44.4) | 26 (70.3) | 14 (26.4) | |
| Smoking status | 0.26 | |||
| Current | 8 (8.9) | 4 (10.8) | 4 (7.6) | |
| Former | 54 (60.0) | 25 (67.6) | 29 (54.7) | |
| Never | 28 (31.1) | 8 (21.6) | 20 (37.7) | |
| Physical function | ||||
| HGS (kg) | 35.9 (11.2) | 31.4 (10.2) | 39.0 (10.8) | 0.001 |
| SPPB (points 0–12) | 10.5 (1.9) | 9.4 (2.3) | 11.2 (1.1) | < 0.0001 |
| 5-STS (seconds) | 10.1 (4.4) | 9.5 (6.0) | 10.4 (2.9) | 0.4 |
| Gait speed (meters/second) | 1.0 (0.2) | 1.1 (0.2) | 0.9 (0.2) | 0.0009 |
| TUG (seconds) | 7.9 (2.3) | 8.9 (2.6) | 7.2 (1.9) | 0.001 |
| Physical function impairment | ||||
| HGS (≤ 16 kg women; ≤ 20 kg men) | 74 (82.2) | 27 (73.0) | 47 (88.7) | 0.06 |
| Gait speed (≤0.8 m/s) | 10 (11.1) | 3 (8.1) | 7 (13.2) | 0.35 |
| 5-STS (≥ 17 s) | 4 (4.4) | 3 (8.1) | 1 (1.9) | 0.30 |
| TUG (≥ 20 s) | – | – | – | – |
5-STS, 5-times sit to stand; AJCC, American Joint Committee on Cancer; BMI, body mass index; HGS, handgrip strength; HNC, head and neck cancer; HU, Hounsfield units; HPV, human papillomavirus; IMAT, intermuscular adipose tissue; kg, kilograms; SAT, subcutaneous adipose tissue; SMA, skeletal muscle area; SMD, skeletal muscle density; SMI, skeletal muscle index; SPPB, short performance physical battery; TAT, total adipose tissue; TUG, timed up and go; VAT, visceral adipose tissue
Data are presented as frequency (percent), mean (SD)
The overall SMD was 37.5 ± 7.9 HU, and the average SMI was 52.4 ± 10.4 cm2/m2. The total adipose tissue constituted 395.1 ± 191.0 cm2, which was primarily attributable to subcutaneous adipose tissue (51.7%) and visceral adipose tissue (44.9%). The mean short physical performance battery score was 10.5 ± 1.9 points. The average gait speed was 1.0 ± 0.2 m/s, and the average time for 5-STS was 10.1 ± 4.4 s. A total of 11.1% of the population suffered impairment in gait speed, while only 4.4% displayed impairment in 5-STS time. The average grip strength was 35.9 ± 11.2 kg, where 82.2% indicated impairment or sarcopenia. Among those with myosteatosis, the percentage was lower (73.0%) than among those with normal musculature (88.7%); however, the results were not statistically significant (p = 0.06). Mean timed up and go was 7.9 ± 2.3 s, and 0% of the population indicated impairment, or sarcopenia, based on time cutoffs.
In a post hoc analysis, a comparison was made between those with sarcopenia and those with myosteatosis (Supplementary Table 1). For nearly every measure of physical function, those with myosteatosis performed worse than those with sarcopenia (hand grip strength 31.4 ± 10.2 vs. 32.1 ± 7.4 kg; SPPB score 9.4 ± 2.3 vs. 10.1 ± 2.2 points; 5-STS 9.5 ± 6.0 vs. 8.0 ± 5.7 s; gait speed 4.5 ± 1.0 vs. 4.2 m/s; TUG 8.9 ± 2.9 vs. 8.3 ± 2.0 s). The results did not reach the level of statistical significance.
Muscle density and physical function regression
The multivariable analysis was performed on the overall population and stratified by sex due to sex-linked differences in body composition. In the overall population (Table 2), those with myosteatosis compared to those with normal muscle density had a 7.57 kg lower handgrip strength (p = 0.001), 1.83 points lower on their SPPB (p < 0.0001), were 0.16 m/s faster in their gait speed (p = 0.0004), took 0.90 fewer seconds to complete the 5-STS (p = 0.34) and took 1.70 s longer to complete the TUG (p = 0.0005). In adjusted models, the strength of the association was attenuated such that those with myosteatosis compared to those with normal muscle density had a 0.96 kg lower handgrip strength (p = 0.67), 1.49 points lower score on their SPPG short performance physical battery (p = 0.0009), a 0.11 m/s faster gait speed (p = 0.04), a 0.37 s longer 5-STS completion time (p = 0.79), and 1.16 s longer TUG (p = 0.03). Among males, those with myosteatosis compared to those with normal muscle density had a 5.23 kg lower handgrip strength (p = 0.03), 1.82 points lower score on their short performance physical battery (p < 0.0001), 0.16 m/s gait speed (p = 0.001), a 0.58 s shorter 5-STS completion time, and a 1.89 s longer timed up and go (p = 0.002). In adjusted models, the strength of association is attenuated such that those with myosteatosis compared to those with normal muscle density had a 0.85 kg lower handgrip strength (p = 0.73), 1.57 point lower score on the SPPB (p = 0.0008), a 0.11 faster gait speed (p = 0.05), a 0.20 s longer 5-STS completion time, and a 1.34 s longer timed up and go (p = 0.03). There was insufficient evidence to support a link between myosteatosis and the measures of physical function at baseline in females (Table 3).
Table 2.
Linear regression of physical function on myosteatosis—overall population
| Overall | β | 95% CI | p |
|---|---|---|---|
| Hand grip strength | |||
| Crude | −7.57 | −12.07, −3.07 | 0.001 |
| Adjusted | −0.96 | −5.51, 3.59 | 0.67 |
| Short performance physical battery | |||
| Crude | −1.83 | −2.54, −1.12 | < 0.0001 |
| Adjusted | −1.49 | −2.35, −0.63 | 0.0009 |
| Gait speed | |||
| Crude | 0.16 | 0.07, 0.25 | 0.0004 |
| Adjusted | 0.11 | 0.007, 0.22 | 0.04 |
| 5-repetition sit to stand | |||
| Crude | −0.90 | −2.79, 0.98 | 0.34 |
| Adjusted | 0.37 | −2.39, 3.13 | 0.79 |
| Timed up and go | |||
| Crude | 1.70 | 0.77, 2.64 | 0.0005 |
| Adjusted | 1.16 | 0.14, 2.19 | 0.03 |
Table 3.
Linear regression of physical function on myosteatosis—by sex
| Males |
Females |
|||||
|---|---|---|---|---|---|---|
| β | 95% CI | p | β | 95% CI | p | |
| HGS | ||||||
| Crude | −5.23 | −9.83, −0.63 | 0.03 | −2.59 | −8.58, 3.40 | 0.37 |
| Adjusted | −0.85 | −5.86, 4.16 | 0.73 | −3.14 | −13.51, 7.23 | 0.53 |
| SPPB | ||||||
| Crude | −1.82 | −2.61, −1.04 | < 0.0001 | −1.40 | −3.46, 0.65 | 0.17 |
| Adjusted | −1.57 | −2.46, −0.68 | 0.0008 | −0.86 | −3.91, 2.19 | 0.56 |
| Gait speed | ||||||
| Crude | 0.16 | 0.07, 0.25 | 0.001 | 0.15 | −0.11, 0.41 | 0.24 |
| Adjusted | 0.11 | −0.001, 0.22 | 0.05 | 0.14 | −0.44, 0.71 | 0.62 |
| 5-repetition sit to stand | ||||||
| Crude | −0.58 | −2.63, 1.47 | 0.57 | −2.67 | −8.30, 2.95 | 0.33 |
| Adjusted | 0.20 | −2.70, 3.09 | 0.89 | 8.62 | −13.86, 31.10 | 0.38 |
| TUG | ||||||
| Crude | 1.89 | 0.75, 3.03 | 0.002 | 1.06 | −0.80, 2.92 | 0.25 |
| Adjusted | 1.34 | 0.13, 2.55 | 0.03 | 0.41 | −1.62, 2.45 | 0.67 |
HGS, handgrip strength; SPPB, short performance physical battery; TUG, timed up and go
Discussion
The goal of this study was to examine the relationship between SMD and the three measures of physical function: SPPB (including gait speed and 5-STS), HGS, and TUG. The results of the study support that SMD is associated with these measures at baseline though that association is attenuated in females after adjustment for muscle mass. Stratification by sex yielded information on the role of sex-based body composition differences and the differences were more pronounced in men than in women, which is consistent with the literature [24, 25].
The study population was typical of US HNC patient populations, male, non-Hispanic White, with oropharyngeal cancer [26]. The study population at diagnosis was similar to national averages in BMI, which was encouraging given the high rates of sarcopenia prevalent in HNC [27]. It is possible that myosteatosis is a function of the disease process as over half of the population at stage IV had myosteatosis, whereas over two-thirds of the population with normal musculature was in an earlier disease state. Perhaps, similar to the rearrangement driven by fibro-adipogenic progenitors (FAPs) in type II diabetes mellitus, either HNC or its treatment is leading to fatty deposition in the muscle. Unfortunately, it is unable to discern this in a cross-sectional study [28]. A recent study explored the biological connection between myosteatosis and physical function through examination of fatty deposition in human thigh muscle [29]. Justice et al. found that women with higher levels of p16INK4a + adipose tissue had poorer physical function than women with lower levels [29].
Multivariable analysis
Our results indicate that SMD was positively associated with HGS and SPPB and negatively associated with TUG in HNC patients before treatment started prior to adjusting for SMI. There are few studies in head and neck cancer to compare to this study. The direction of association observed was expected with denser (less fatty) muscle associated with better balance/performance, greater grip strength, and shorter walking times. The SPPB finding is particularly significant given that a decrease of greater than 1 point has been associated with all-cause mortality [10]. Further, prior research by this group has found an association between objectively measured physical function and both frailty and patient-reported quality of life [7]. In an older population (non-cancer), stratified by sex, betas for radiodensity regressed on SPPB were 0.34 (95% CI–0.45, 1.14) among men and 0.75 (0.24, 1.26) among women [30], suggesting improved balance with greater muscle density among women. The major difference between Anderson’s study population and the current study is that the proportion of males to females is reversed with 75 males and 117 females. Anderson’s study also had an average age of 81.9 ± 6.4 years, and so it may be that the women in the present study are too young as yet to show a significant difference in musculature.
A study by Barbalho et al. had similar findings to the current study in a sample of gastric cancer patients [31]. Though the study was nearly twice the size of the current study, the results suggested that as SMD increased, handgrip strength also increased; after stratification, the effect was seen only among men (β 0.34; 95% CI 0.13, 0.55; p < 0.001). A study conducted with patients from the Carolina Senior Registry with multiple cancer types supported the finding that SMD is associated with decreased TUG times (RR 0.83; 95% CI 0.71, 0.92) [32]. This finding was similar in magnitude to that found in the current study. Interestingly, the Williams et al. study found no association with SMI and physical function but did find an association with skeletal muscle gauge (an interaction term created through multiplying SMI and SMD, a finding not replicated in this cohort); this would indicate that muscle mass in the Williams study may be an effect modifier. Again, like the Anderson study, the Williams study had more women than men and larger sample size than the current study. The Pittsburgh site of the Healthy, Aging and Body Composition Study also found positive associations between muscle density and SPPB score including STS similar to this study [33].
The study had a number of strengths. Only patients with imaging of L3 were included, which allowed for consistency in the measurement of body composition parameters and served to decrease measurement bias. The only one trained researcher was used to interpret and report on the CT scans, which eliminated laboratory drift. All patients were managed by one radiation oncologist, which allowed for consistency in care decisions.
The study also had limitations. Namely, the study was hampered by the sample size. The low number of patients did not allow for a meaningful examination of stratified differences when it came to females. Future studies may include collaborations with other cancer centers so as to overcome this limitation. The research was based on medical records, which were not collected for research purposes; however, the main limitation is the retrospective, cross-sectional nature of the research, which does not allow for any causal conclusions. The study included a mix of HNC patients with varying sites and stages. In order to account for any potential confounding that this may have introduced, the site was assessed as a confounder and determined not to act as a statistical confounder on the relationship between physical function and muscle density. However, baseline assessments of physical function have previously been associated with longitudinal manifestations of resilience [34].
Conclusions
The aim of this study was to test the association between myosteatosis and physical function as a means of demonstrating that myosteatosis could be associated with features of physical function. Future research should endeavor to include posttreatment outcomes and the relationship, if any, to these findings. As suggested by other researchers, diagnostic and planning CT scans could be utilized to give early and specific body composition and malnutrition information [35]. The job now is to develop the optimal approach to maintain or build lean mass during treatment.
Supplementary Material
Acknowledgements
The authors would like to acknowledge Kelsey Smith, PA, for her tireless efforts to provide excellent care to these patients.
Funding
This work was supported by the National Cancer Institute Cancer Center Support Grant (5P30CA016056-42). ALS was funded by the National Cancer Institute Interdisciplinary Training in Cancer Epidemiology Grant (T32CA113951). Funding source had no role in study design, data collection, data analysis, data interpretation, or writing of the report.
Footnotes
Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s00520-022-06808-x.
Code availability All analyses were completed using SAS version 9.4.
Ethics approval The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of Roswell Park Comprehensive Cancer Center (EDR-103707 2/28/2018 1).
Consent to participate A waiver of consent was obtained from the Institutional Review Board due to the retrospective nature of the study making consent impractical and contacting patients to obtain consent would pose a greater risk than the waiver.
Consent for publication Consent for publication was obtained.
Competing interests The authors declare no competing interests.
Data availability
Shaver, Platek, and Singh had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. The data underlying this article cannot be shared publicly for the privacy of individuals that participated in the study.
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Data Availability Statement
Shaver, Platek, and Singh had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. The data underlying this article cannot be shared publicly for the privacy of individuals that participated in the study.