# Symptom Burden and Dietary Changes Among Older Adults with Cancer: A Cross-Sectional Study
## 2 Materials and Methods  
_Patients and study design_. The study conducted is an anonymous cross-sectional study. Due to the exploratory character of the study, a timeframe for recruitment (one year) was predefined before starting the project. Data were collected prospectively between December 2022 and December 2023. A total of 300 patients treated as inpatients at the Department of Hematology and Medical Oncology at the University Medical Center Gottingen were included in the study and surveyed. Inclusion criteria were \(\geq\)65 years of age, an underlying oncological disease, an inpatient stay, and the ability to provide information as well as consent to participate. The aim was to offer participation to all inpatients who (1) fit the inclusion criteria and (2) were treated during the predefined recruitment time of one year. A yearlong screening was initiated to take into account seasonal fluctuation of patients. All patients were questioned by a previously trained member of the study group. The study's protocol was approved by the Ethics Committee of the University of Gottingen (approval number 26/8/22). Patients were interviewed using an adapted screening tool. The components of this anannesis questionnaire were the NRS-2002 [8], the Geriatric Screening G8 tool [13], a recently proposed questionnaire that considers dietary changes in cancer patients [14], and a question module on symptom burden. In addition, anthropometric data (age, sex, height, weight, BMI) and clinical data (initial diagnosis versus disease progression, tumor entity, and treatment modality) were collected. The NRS-2002 is suitable for screening patients with or at risk of malnutrition in an inpatient setting. It is recommended by the European Society for Clinical Nutrition and Metabolism for all hospitalized patients [4]. The Geriatric Screening G8 [13] is designed to identify patients who require more detailed geriatric assessment. A score \(\leq\) 14 points is considered suspicious and should lead to reassessment or further investigation. Dietary changes and adherence to a cancer diet were assessed in a set of questions, as previously proposed by [12]. Patients were asked if they avoided or preferred certain foods, if they used dietary supplements, and if they followed a special or cancer diet. In addition to the established screening questionnaires, a symptom burden questionnaire was added. As part of this module, a list of symptoms that may be associated with malnutrition and oncological disease was discussed with the patients. Symptoms queried were as follows: oral mucositis, xerostomia, loss of appetite, dyspeusia, dysphagia, otolynophagia, diarrhea, nausea, emesis, meteoriism, abdominal discomfort, and constipation. Other symptoms could be listed in a free text box. The questionnaire (original German questionnaire, as well as a translated English version) is listed under Appendix A. The study has been reported in accordance with the STROBE guidelines [15], and the corresponding checklist is listed under Appendix B. Statistical analysisDue to smaller group sizes, some entities were summarized as follows: non-small lung cancer (NSCLC) and small-cell lung cancer (SCLC) as lung cancer; tumors of the cervix and vulva as other gynecological tumors; prostate, kidney, and urothelial tumors as urooncological tumors; and solid tumors of the jejunum, ileum, or colon as lower GI cancer. In addition, aggressive lymphoma and acute leukemia cases were grouped together, and chronic leukemia was grouped together with cases of indolent lymphoma, myelodysplastic (MDS), and myeloproliferative (MPN) neoplasms. Similarly, patients undergoing allogeneic or autologous stem cell therapy or CAR-T-cell therapy were considered participants receiving \"cellular immunotherapy\". A treatment modality analysis was performed. A distinction was made between radiological therapy and systemic therapy. The subgroups were also analyzed with regard to different age cohorts. The following patient groups were analyzed: 65-74 years, 75-84 years, and \(\geq\)85 years.