Disparities in Clinical Outcomes and Risk Profiles Among Male and Female Chemotherapy Patients During COVID-19: An Observational Study

Disparities in Clinical Outcomes and Risk Profiles Among Male and Female Chemotherapy Patients During COVID-19: An Observational Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Disparities in Clinical Outcomes and Risk Profiles Among Male and Female Chemotherapy Patients During COVID-19: An Observational Study Giérisson Brenno Borges Lima, Gabriel Santos de Castro e Lima, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4608193/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective To evaluate and describe clinical parameters and risk factors in patients undergoing chemotherapy during the COVID-19 pandemic, comparing men and women. Methods The sample comprised 106 cancer patients, mean age 54.12 (SD 16.18), both sexes (71 women and 35 men), with different types of cancer, all undergoing chemotherapy treatment. Assessments included anthropometric measurements, tetrapolar bioimpedance (phase angle), handgrip dynamometry, and the International Physical Activity Questionnaire (IPAQ). Results After analysis, 49% of the patients showed deviations from the ideal Body Mass Index (BMI) (13% below and 36% above ideal). The waist-hip ratio was adversely altered in 90.9% of patients, indicating a moderate to very high cardiovascular disease risk (27.3% moderate, 36.4% high, and 27.3% very high). Notably, no women exhibited a low risk, unlike men (31%) (p = 0.007). Reduced calf circumference was observed in 76% of patients. Regarding body composition, 62.9% of patients displayed significant changes in body fat percentage. The majority also exhibited inadequate handgrip strength levels (63.6%), with men being approximately four times more likely to have insufficient strength (p = 0.008, OR = 3.910). A phase angle below the recommended level was found in 94.8% of the sample. Physical activity assessment revealed a 100% sedentary lifestyle rate. Conclusion Patients undergoing chemotherapy during the COVID-19 pandemic had insufficient physical activity levels, inadequate handgrip muscle strength, and anthropometric indices and body composition with adverse changes, increasing cardiovascular risk and low phase angle reference values in the majority of the sample, with women displaying the most unfavorable profile. The research project was approved by the institutional review board, no. 5.069.269. chemotherapy cardiovascular risk physical activity Figures Figure 1 Introduction The COVID-19 pandemic has brought significant consequences for cancer patients, including a greater risk of delayed diagnosis, serious events [ 1 ], prolonged hospitalization in the intensive care unit [ 2 ], and increased mortality [ 3 ]. Given this context and the multifaceted effects of the disease and treatments like chemotherapy which can induce approximately 45 physical and 27 non-physical effects a risky scenario has emerged, bringing additional consequences for this population [ 4 ]. Cancer patients, often frequenting hospitals for treatment, became more vulnerable to COVID-19 infection, presenting a significant challenge [ 5 ]. Consequently, self-isolation, though a recommended preventive measure, has inadvertently become a barrier to physical activity, thereby exacerbating sedentary behavior [ 6 ]. Increasing the level of physical activity is a guideline endorsed by most international health bodies as a non-pharmacological cancer treatment approach, effective in mitigating disease effects and treatment side effects, thereby improving clinical parameters and patient prognosis [ 7 , 8 , 9 ]. Among the influential clinical parameters for cancer patients are anthropometric measurements. Body Mass Index (BMI) and its association with obesity levels are linked to an increased risk of most cancer types, and reducing BMI correlates with decreased risk and improved prognosis [ 10 , 11 , 12 ]. The waist-hip ratio (WHR), another critical anthropometric measure, is associated with cardiovascular disease risk and adiposity in patients, correlating with cancer incidence and prognosis [ 13 , 14 , 15 ]. Calf circumference, a non-invasive measure useful for monitoring sarcopenia which is prevalent among cancer patients [ 16 ] is valuable despite not replacing strength and muscle mass monitoring [ 17 ]. Additionally, reduced calf circumference is associated with increased mortality rates [ 18 ]. It is known that the metabolic and morphological state can impact the risk of developing different types of tumors and the response to systemic therapy [ 19 ]. The comparison of anthropometric measurements and adiposity in relation to cancer risk has been previously studied, as well as in our study, showing its clinical relevance [ 20 , 21 ]. Body composition, particularly adiposity and central fat percentage, has been identified as a marker for increased cancer risk, showing a stronger correlation than BMI and WHR [ 22 ]. Handgrip strength is independently linked with vital biological, functional, and quality-of-life characteristics in patients, with loss of handgrip muscle strength marking decreased physical function and increased fatigue symptoms [ 23 , 24 ]. In the clinical monitoring of cancer patients, the phase angle is emerging as a significant parameter; studies have shown that decreased phase angle values may indicate lower cancer survival rates [ 25 , 26 , 27 ]. Nevertheless, the objective of our study was to evaluate and describe clinical parameters and risk factors in patients undergoing chemotherapy during the COVID-19 pandemic, with a comparative analysis between men and women. Our hypothesis posited that a distinct profile, influenced by the pandemic's impact on sedentary behaviors during periods of social isolation, might be identified, diverging from the profiles commonly reported in the scientific literature. Methods This is an observational study carried out at the chemotherapy outpatient clinic collected between May 2021 to June 2022. The research project was approved by the institutional review board, no. 5.069.269. Sample Size Calculation and Post Hoc Power Analysis Initially, the sample size for this study was calculated based on expected differences in key clinical parameters between male and female patients undergoing chemotherapy. The primary outcome for which the sample size was determined involved differences in handgrip strength, a critical measure of physical function and prognostic indicator in cancer patients. Assuming a medium effect size (Cohen's d = 0.5), an alpha level of 0.05, and a power of 80%, the required sample size was calculated to detect statistically significant differences between the two groups. However, due to the constraints imposed by the clinical setting, particularly during the COVID-19 pandemic, the actual sample size was limited to 106 participants 71 females and 35 males. This presented a challenge in achieving the initially planned statistical power for some of the secondary outcomes, which might have smaller effect sizes. To address this limitation and to understand the statistical power our study had with the available sample size, we conducted a post hoc power analysis focused on our primary outcome handgrip strength. The observed means and standard deviations for this measure were 23.53 kg (SD = 5.55) for females and 35.59 kg (SD = 8.35) for males. The calculated pooled standard deviation was approximately 6.60 kg. The resulting effect size (Cohen's d) was 1.83, which is considered a large effect. Our post hoc power analysis revealed that, with these parameters, our study achieved nearly 99% power to detect the observed difference in handgrip strength between males and females. This high level of power confirms that our study was sufficiently robust to detect significant differences in this primary outcome, despite the smaller overall sample size. Inclusion Criteria The following were considered based on the proposed: (1) voluntary and consented participation; (2) being undergoing chemotherapy treatment; (3) not present musculoskeletal and neurological conditions that prevent the performance of tests and evaluations (4) not have any type of medical contraindication that would make collection unfeasible (5) not have cognitive impairment that makes them unable to understand the commands and perform the tests and exams; (6) not undergoing palliative procedures. Analysis Protocols The analysis protocol followed a specific order and was carried out by a previously trained team: anthropometry, bioelectrical impedance (BIA), handgrip strength, physical activity questionnaire (IPAQ). Some patients presented, due to the effects of chemotherapy, symptoms that momentarily made it impossible for them to perform some of the tests, which is why the number (as in Table 1 ) of patients in each analysis varied. The protocol was carried out during the COVID-19 pandemic, which made access to patients difficult and reanalysis impossible, according to hospital standards. Anthropometry Anthropometric and body composition parameters were collected before medication administration. For circumference measurements, an anthropometric tape (Sanny®, Sao Paulo, Brazil, 2011) was used, with a measuring range of 2m, made of flat and flexible steel. Waist, hip and calf circumference measurements were collected. We calculated Body Mass Index (BMI) by dividing the weight by the square of the height. Cardiovascular risk was verified based on the Waist-Hip Ratio (WHR), obtained by dividing the waist (cm) and hip (cm) perimeters. To measure waist circumference, the measuring tape was positioned at the smallest curvature located between the ribs and the iliac crest. To measure the hip perimeter, the measuring tape was positioned in the area with the greatest gluteal protuberance [ 28 ]. Body composition and angle phase (BIA) The tetrapolar Bioimpedance (Sanny, Model 1011, Sao Paulo, Brazil, 2011) with the use of electrodes. For measurements using bioimpedance, the subject remained lying on a non-conductive surface (stretcher), in the supine position, with arms and legs abducted at 45° from the body [ 29 ]. Handgrip strength The assessment of peripheral muscle strength was carried out using a Jamar® dynamometer (Lafayette Instrument, Lafayette, IN, USA), following the current guidelines for handgrip strength [ 30 , 31 , 32 ]. Physical Activity The level of general physical activity was analyzed according to the short format of International Physical Activity Questionnaire (IPAQ) and normal week, version 8, validated and used in Brazil [ 33 ]. Statistical analysis Data were analyzed using R software version 4.2.2 and RStudio. Initially, data distribution was assessed for normality using the Shapiro-Wilk test, chosen for its effectiveness in handling small to medium sample sizes. Homogeneity of variances was tested using Levene's test, which is robust against non-normal distributions, ensuring that the assumptions for subsequent analyses were met. Continuous variables such as handgrip strength, body mass index (BMI), and phase angle were analyzed using the T-test for independent samples. This test was employed to compare the means between two independent groups, specifically males and females in our study, under the assumption that the data within each group were normally distributed and exhibited equal variances as indicated by the Levene’s test results. For categorical variables, including classification of dynapenia and levels of physical activity, Fisher's exact test was utilized. This choice was due to the small sample size in certain categories, which could compromise the validity of the chi-square test. Fisher’s exact test is particularly suitable for small sample analysis, providing accurate p-values even when expected frequencies in one or more cells of a contingency table are low. Statistical significance was predetermined at a p-value less than 0.05. All tests were two-sided. Results The main characteristics of the sample were described in Table 1 . Table 1 Demographic data of the sample Variable n Mean Standard Deviation Maximum Minimum Age (y) 98 54.12 16.18 89 18 Height (m) 89 1.57 0.94 1.79 1.34 Weight (kg) 90 61.02 13.13 111.3 34 BMI (kg m⁻²) 89 24.79 5.09 49.47 13.62 WHR 87 0.89 0.07 1.12 0.72 Calf Circumference (cm) 92 30.66 3.98 43 21 Fat (%) 83 24.09 8.44 43.53 6.77 Phase Angle (°) 78 5.22 1.13 7.98 2.55 Handgrip (kg) 102 27.45 8.5 50 8 BMI: Body Mass Index; WHR: Waist-Hip Ratio; A total of 106 patients participated in the study, comprising 71 (67%) females and 35 (33%) males. The average age was 54.12 years. The most frequent diagnoses among the patients were cancer of the digestive system (n = 24, 23%), hematological cancer (n = 22, 21%), breast cancer (n = 21, 20%), genital cancer (n = 20, 19%), and other types (n = 17, 17%). Regarding body composition, 12 patients (13%) were classified as thin, 45 (51%) as eutrophic, 21 (24%) as overweight, and 11 (12%) as obese. The majority of patients displayed an altered BMI, with 9.1% below the ideal range and 27.3% above it. Notably, women had higher BMIs compared to men. Calf circumference, an indicator of potential sarcopenia and muscle mass loss, was below normal in 47 (51%) women and 23 (25%) men. Cardiovascular risk, assessed by the waist-hip ratio, indicated a moderate to very high risk of developing cardiovascular diseases in the majority of patients (90.9%), as detailed in Table 2 . The highest values of cardiovascular risk were observed in men, which was expected; however, in the risk classification, all evaluated women showed an increase in risk from moderate to very high, with no cases of low cardiovascular risk found among women. The handgrip strength level of most patients (63.6%) was below the recommended level, indicating dynapenia. Only 6% of men had the recommended strength level, compared to 30.4% of women. The phase angle was below the recommended level for most patients, with the lowest averages predominantly found among women. The level of physical activity, assessed by the International Physical Activity Questionnaire (IPAQ), indicated that 100% of the sample did not engage in sufficient physical activity to avoid a sedentary lifestyle. Table 2 illustrates the differences in studied variables between sexes. Women had higher BMIs compared to men. While men displayed higher strength levels, they also exhibited a greater cardiovascular risk than women. Table 2 . Comparison of variables according to gender Variables Female Male P Value Age (y) 52.15 ± 15.58 58.32 ± 17.06 0.08 BMI (kg m⁻²) 25.81 ± 5.38* 22.46 ± 3.59* 0.004* Handgrip (kg) 23.53 ± 5.55* 35.59 ± 8.35* 0.001* WHR 0.87 ± 0.07* 0.94 ± 0.07* 0.007* Calf Circumference (cm) 30.59 ± 4.26 30.81 ± 3.48 0.8 BMI: Body Mass Index; WHR: Waist-Hip Ratio; * P < 0.05 Table 3 compares variables according to dynamometry. Patients with sufficient dynamometry had higher weight, fat percentage, and handgrip strength levels. No significant differences were observed for the other variables. Table 3 . Comparison of variables according to dynamometry Variables Sufficient Insufficient P value Age (y) 53.06 ± 14.55 54.47 ± 17.42 0.688 BMI (kg m⁻²) 26.04 ± 3.99 24.25 ± 5.64 0.120 Fat (%) 27.04 ± 8.24* 22.24 ± 8.12* 0.004* Handgrip (kg) 30.86 ± 7.14* 25.66 ± 9* 0.002* WHR 0.88 ± 0.07 0.91 ± 0.08 0.085 Waist Circumference (cm) 86.37 ± 10.05 85.03 ± 10.65 0.561 Hip Circumference (cm) 98.98 ± 9.65* 94.12 ± 8.7* 0.01* Calf Circumference (cm) 32.26 ± 3.65* 29.73 ± 3.9* 0.003* BMI: Body Mass Index; WHR: Waist-Hip Ratio; * P < 0.05 Figure 1 displays the comparison of categorical variables according to gender. Female patients had a higher frequency of normal force than men, but also a high frequency of low force. Men had a higher frequency of low strength. They were 3.91 times more likely to have an insufficient level of strength compared to women. Both men and women exhibited insufficient strength levels in the majority. The frequency of cardiovascular risk (assessed by WHR) in women indicates increased cardiovascular risks for the entire sample. Most men also exhibited increased cardiovascular risks, although some individuals had no cardiovascular risk. Discussion Our study identified several deviations from recommended values across various clinical measurements. Specifically, we found that Body Mass Index (BMI) was elevated in 49% of cases, while Waist-to-Hip Ratio (WHR) exceeded ideal levels in 90.9% of participants. Additionally, Calf Circumference was below the norm in 76% of individuals, with Fat Percentage exceeding healthy thresholds in 62.9% of the sample. Handgrip Strength was notably diminished, observed in 63.6% of subjects, while Phase Angle measurements indicated deviations in 94.8% of cases. Remarkably, our findings revealed that every participant in the study exhibited a sedentary lifestyle. These results collectively underscore the significance of these clinical parameters and highlight the widespread prevalence of deviations from ideal values within our sample. Chemotherapy, administered with curative intent, has been shown to adversely affect body composition, physical function, insulin resistance, and lipid markers associated with atherosclerotic cardiovascular diseases in women with breast cancer, according to a study [ 11 , 34 ]. The research demonstrated significant changes in adiposity markers, body weight, and BMI among female participants. Notably, these findings align with existing scientific literature, which emphasizes the critical role of BMI as an indicator of cancer incidence and prognosis [ 35 ]. Overweight and obesity have emerged as global concerns, linked to increased cancer incidence, poorer prognosis, and elevated mortality rates among cancer patients [ 36 ]. Furthermore, these conditions are associated with metabolic and inflammatory alterations in adipose tissue, as highlighted in studies [ 37 , 38 ] reported that excess body weight accounted for approximately 3.9% of all cancers in 2012, with the risk varying between genders and impacting both cancer incidence and prognosis. Evidence shows that cancer risk is sex-specific when associated with adiposity [ 39 ]. Central obesity, measured by BMI and WHR, has been consistently associated with higher mortality rates from all causes and cardiovascular diseases, particularly among women, while BMI serves as a reliable marker in men, WHR is regarded as a more accurate indicator of mortality risk in women [ 40 ]. Moreover, research has indicated a strong association between WHR and increased risk of all-cause mortality and cardiovascular disease, as well as its correlation with various cancer types, including breast cancer, prostate cancer, and endothelial cancer [ 41 , 42 , 43 , 44 , 45 ]. The significant cardiovascular risk observed in our study, especially among female participants, contrasts with some findings in the scientific literature, suggesting that women generally exhibit a more favorable cardiovascular risk factor profile than men. However, our study highlights the need for further investigation into these discrepancies. Reduced calf circumference, observed in most patients, is of particular clinical relevance, as it has been associated with elevated mortality rates across all causes, increased risk of cardiovascular diseases, sarcopenia, and cancer [ 46 ]. Notably, low calf circumference serves as an independent predictor of mortality in cancer patients, as demonstrated by [ 47 ]. Another notable finding in our study was the reduced handgrip strength observed in the majority of patients. This finding aligns with previous research indicating that lower handgrip strength is associated with increased risk of all-cause mortality, cardiovascular mortality, and cancer [ 48 ]. Despite being widely studied, handgrip strength remains underexplored in clinical practice [ 49 ]. A retrospective study highlighted the prevalence of low muscle mass, handgrip strength, and gait speed, as well as sarcopenia, among cancer patients [ 50 ]. Additionally, a prospective observational study conducted at the Oncology Inpatient Unit found high rates of malnutrition, low BMI, low muscle strength, and low fat-free mass among patients [ 51 ]. These findings underscore the importance of addressing these issues in clinical practice to improve patient outcomes. Our study identified several indicators of sarcopenia, including decreased skeletal muscle mass, increased fat percentage, reduced handgrip muscle strength, and decreased calf circumference, particularly among female participants. These findings align with previous research linking sarcopenia to worse prognosis in cancer patients [ 52 , 53 , 54 ]. Sarcopenia has also been associated with social isolation, which can exacerbate its effects on health outcomes [ 55 ]. Social isolation, such as that experienced during the COVID-19 pandemic, has been linked to higher mortality rates and decreased quality of life among cancer patients [ 56 ]. Our study revealed a sedentary profile among participants, with 100% of the sample classified as sedentary according to the guidelines of the American College of Sports Medicine for cancer patients. This sedentary behavior may be partially attributed to decreased physical activity levels and increased screen time during periods of social isolation, contributing to worsening lifestyles and increased health risk behaviors [ 57 ]. Physical activity has been shown to improve survival outcomes for cancer patients, regardless of BMI. However, studies have indicated a decrease in physical activity levels, strength, and cardiorespiratory capacity among cancer patients during the COVID-19 pandemic, with potential implications for their health, as highlighted where they were studied cancer patients before and after the COVID-19 pandemic, demonstrating a decrease in the level of physical activity, strength and cardiorespiratory capacity, the authors associate it with the COVID-19 pandemic, drawing attention to the consequences on the health of cancer patients [ 58 ]. We know that physical activity appears to improve survival outcomes for cancer patients, regardless of their BMI [ 59 ]. Previous studies [ 6 , 60 ] already drew attention to the consequences of the level of physical activity caused during the social isolation of the COVID-19 pandemic in cancer patients. A study [ 61 ] shows this phenomenon in practice among breast cancer survivors, decreasing their level of physical activity, increasing sedentary behavior and negatively modifying their body composition. An emerging clinical parameter with promising results is the phase angle, which has been shown to be a good predictor of nutritional status and clinical prognosis in various health conditions, including cancer. However, our study found phase angle values below recommended levels, particularly among female participants [ 62 ]. A low phase angle has been associated with compromised nutritional profile, functional status, decreased quality of life, and increased morbidity and mortality, indicating its potential as a pivotal indicator of health and integrity, especially in cancer patients [ 63 ]. While our study sheds light on concerning trends among chemotherapy patients during the COVID-19 pandemic, we cannot definitively attribute these results solely to the pandemic. Factors such as reduced physical activity due to pandemic-related insecurity and the disease's inherent effects warrant further investigation. Our study faced several limitations, including the lack of control over food intake, variability in medication administration, sample size constraints due to the pandemic, and missing data. Despite these limitations, our findings underscore the importance of continued monitoring to understand the potential influences of the pandemic and their implications for clinical prognosis. In conclusion, patients undergoing chemotherapy treatment during the COVID-19 pandemic exhibited insufficient physical activity levels and deviations from recommended standards in various health indicators, particularly among women. Further research is needed to discern whether these trends result from pandemic-related factors or the natural progression of the disease in conjunction with inadequate healthcare measures. Abbreviations ACMS American College of Sports Medicine ASCVD atherosclerotic cardiovascular diseases BIA tetrapolar bioimpedance BMI body mass index FA bioimpedance phase angle IPAQ International Physical Activity Questionnaire WHR Waist-Hip Ratio Declarations Funding This study was carried out with the authors' own resources. Competing Interests The authors declare no competing interests. Author contributions Giérisson Brenno Borges Lima - Data collection, manuscript writing and data analysis Gabriel Santos de Castro e Lima - Data collection and data analysis Flaviana Santos de Sousa Silva - Data collection and data analysis Luis Felipe Castro Araújo - Data collection and manuscript writing Thaís da Conceição Tavares Pereira - Data collection and manuscript writing Michel Monteiro Macedo - manuscript review and data analysis Thiago dos Santos Rosa - manuscript review and data analysis Hugo de Luca Correa - manuscript review and data analysis Carlos Eduardo Neves Amorim - Study coordination, manuscript review and data analysis Ethics approval The research project was approved by the Ethics and Research Committee of the University Hospital of the Federal University of Maranhão / HU-UFMA, with embodied opinion no. 5,069,269, following the ethical principles established in Resolution no. 466/12 of the Council National Health Service (CNS) and its supplements. 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International journal of cancer 151(3):372–380. doi: 10.1002/ijc.34026 Perez-Cornago A et al (2022) Adiposity and risk of prostate cancer death: a prospective analysis in UK Biobank and meta-analysis of published studies. BMC medicine 20(1):143. doi: 10.1186/s12916-022-02336-x Wu S, Wei-Liang C (2022) Calf circumference refines sarcopenia in correlating with mortality risk. Age and ageing 51(2):afab239. doi: 10.1093/ageing/afab239 Sousa IM et al (2020) Low calf circumference is an independent predictor of mortality in cancer patients: A prospective cohort study. Nutrition (Burbank, Los Angeles County, Calif.) 79–80:110816. doi: 10.1016/j.nut.2020.110816 López-Bueno R et al (2022) Thresholds of handgrip strength for all-cause, cancer, and cardiovascular mortality: A systematic review with dose-response meta-analysis. Ageing research reviews 82:101778. doi: 10.1016/j.arr.2022.101778 Núñez-Cortés R et al (2022) Handgrip strength measurement protocols for all-cause and cause-specific mortality outcomes in more than 3 million participants: A systematic review and meta-regression analysis. Clinical nutrition (Edinburgh, Scotland) 41(11):2473–2489. doi: 10.1016/j.clnu.2022.09.006 de Bree R, Meerkerk CDA, Halmos GB, Mäkitie AA, Homma A, Rodrigo JP, López F, Takes RP, Vermorken JB, Ferlito A (2022) Measurement of Sarcopenia in Head and Neck Cancer Patients and Its Association with Frailty. Front Oncol 12:884988. doi: 10.3389/fonc.2022.884988 . PMID: 35651790; PMCID: PMC9150392. Ruiz-García I et al (2022) The economic cost of not coding disease-related malnutrition: A study in cancer inpatients. Clinical nutrition (Edinburgh, Scotland) 41(1):186–191. doi: 10.1016/j.clnu.2021.11.028 Liu C et al (2024) Association between preoperative sarcopenia and prognosis of pancreatic cancer after curative-intent surgery: a updated systematic review and meta-analysis. World journal of surgical oncology 22(1):38. doi: 10.1186/s12957-024-03310-y Jang MK et al (2023) The Effectiveness of Sarcopenia Interventions for Cancer Patients Receiving Chemotherapy: A Systematic Review and Meta-analysis. Cancer nursing 46(2):E81-E90. doi: 10.1097/NCC.0000000000000957 Surov A, Andreas W (2022) Prevalence of sarcopenia in patients with solid tumors: A meta-analysis based on 81,814 patients. JPEN. Journal of parenteral and enteral nutrition 46(8):1761–1768. doi: 10.1002/jpen.2415 Yang J et al (2023) The association of living alone and social isolation with sarcopenia: A systematic review and meta-analysis. Ageing research reviews 91:102043. doi: 10.1016/j.arr.2023.102043 Wang L et al (2020) Cancer incidence in relation to body fatness among 0.5 million men and women: Findings from the China Kadoorie Biobank. International journal of cancer 146(4):987–998. doi: 10.1002/ijc.32394 Hermelink R et al (2022) Sedentary behavior and cancer-an umbrella review and meta-analysis. European journal of epidemiology 37(5):447–460. doi: 10.1007/s10654-022-00873–6 Gutiérrez-Santamaría B et al (2023) Physiological and mental health changes in cancer patients during the COVID–19 state of emergency. Sport sciences for health 19(1):123–130. doi: 10.1007/s11332-022-01008-w Himbert C et al (2023) Associations of combined physical activity and body mass index groups with colorectal cancer survival outcomes. BMC cancer 23(1):300. doi: 10.1186/s12885-023-10695–8 Avancini A et al (2020) Physical Activity for Oncological Patients in COVID–19 Era: No Time to Relax. JNCI cancer spectrum 4(6):pkaa071. doi: 10.1093/jncics/pkaa071 Gurgel ARB et al (2021) Determinants of Health and Physical Activity Levels Among Breast Cancer Survivors During the COVID–19 Pandemic: A Cross-Sectional Study. Frontiers in physiology 12:624169. doi: 10.3389/fphys.2021.624169 Jiang N et al (2022) The Role of Standardized Phase Angle in the Assessment of Nutritional Status and Clinical Outcomes in Cancer Patients: A Systematic Review of the Literature. Nutrients 15(1):50. doi: 10.3390/nu15010050 Sukackiene D et al (2022) Standardized Phase Angle for Predicting Nutritional Status of Hemodialysis Patients in the Early Period After Deceased Donor Kidney Transplantation. Frontiers in nutrition 9:803002. doi: 10.3389/fnut.2022.803002 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4608193","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":317107836,"identity":"2d7b6531-edc9-4691-a743-9e68025b99e5","order_by":0,"name":"Giérisson Brenno Borges Lima","email":"","orcid":"","institution":"Federal University of Maranhão (UFMA)","correspondingAuthor":false,"prefix":"","firstName":"Giérisson","middleName":"Brenno Borges","lastName":"Lima","suffix":""},{"id":317107837,"identity":"47f8e9f4-0bbc-4661-9f5e-4bfb2680adb6","order_by":1,"name":"Gabriel Santos de Castro e Lima","email":"","orcid":"","institution":"Federal University of Maranhão (UFMA)","correspondingAuthor":false,"prefix":"","firstName":"Gabriel","middleName":"Santos de Castro e","lastName":"Lima","suffix":""},{"id":317107838,"identity":"c15b661e-372b-4c79-80b7-f8a5c8ec42b3","order_by":2,"name":"Flaviana Santos de Sousa Silva","email":"","orcid":"","institution":"Federal University of Maranhão (UFMA)","correspondingAuthor":false,"prefix":"","firstName":"Flaviana","middleName":"Santos de Sousa","lastName":"Silva","suffix":""},{"id":317107840,"identity":"9e63f9f3-9b4e-4591-bd99-fd5d7b763b4c","order_by":3,"name":"Luis Felipe Castro Araújo","email":"","orcid":"","institution":"Federal University of Maranhão (UFMA)","correspondingAuthor":false,"prefix":"","firstName":"Luis","middleName":"Felipe Castro","lastName":"Araújo","suffix":""},{"id":317107842,"identity":"5a0605a3-a4dd-48bf-8633-04b3eadb7502","order_by":4,"name":"Thaís da Conceição Tavares Pereira","email":"","orcid":"","institution":"Federal University of Maranhão (UFMA)","correspondingAuthor":false,"prefix":"","firstName":"Thaís","middleName":"da Conceição Tavares","lastName":"Pereira","suffix":""},{"id":317107843,"identity":"a62be7c2-a4fb-42c0-9b96-b1b97b0acabf","order_by":5,"name":"Michel Monteiro Macedo","email":"","orcid":"","institution":"University Center UniREDENTOR (UniREDENTOR)","correspondingAuthor":false,"prefix":"","firstName":"Michel","middleName":"Monteiro","lastName":"Macedo","suffix":""},{"id":317107844,"identity":"a2389919-8b19-441b-be84-e4667c23e1fd","order_by":6,"name":"Thiago dos Santos Rosa","email":"","orcid":"","institution":"Catholic University of Brasilia (UCB)","correspondingAuthor":false,"prefix":"","firstName":"Thiago","middleName":"dos Santos","lastName":"Rosa","suffix":""},{"id":317107845,"identity":"98851d0c-e6b4-48e9-a665-65a6b0465ad6","order_by":7,"name":"Hugo de Luca Corrêa","email":"","orcid":"","institution":"Catholic University of Brasilia (UCB)","correspondingAuthor":false,"prefix":"","firstName":"Hugo","middleName":"de Luca","lastName":"Corrêa","suffix":""},{"id":317107846,"identity":"e1fb2741-0fd0-48dd-a192-22ba7be668a5","order_by":8,"name":"Carlos Eduardo Neves Amorim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIie3PMQrCMBSA4ReEuihdU4T2BIKh4KKHqRR08QAOIpVCewMRFO/g0rkS6BR0FboYvICj3XyKBRdjRof8Q0iGj/cCYDL9a8HrbEQAM7DxZukSgkSAE2kRqAlJNIi94sVNTsGzN4elrHacdtPcus4UhJbjcD3KgK2Po9hvZ5z2RdBkQjWmnPqAJABBkg7J+KKfB9Zzu695NfGQONUWp5wuatKrSQ8JbUdIzj+mMPwLEsr2gsR+q5ggkSlTEbcMOamyoeeKxkHe5wNcLCykiryjnw+iAUwmk8mk7AH120y0tY08OAAAAABJRU5ErkJggg==","orcid":"","institution":"Federal University of Maranhão (UFMA)","correspondingAuthor":true,"prefix":"","firstName":"Carlos","middleName":"Eduardo Neves","lastName":"Amorim","suffix":""}],"badges":[],"createdAt":"2024-06-19 23:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4608193/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4608193/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60600271,"identity":"259be0e5-a859-47f7-a131-2dd890727d30","added_by":"auto","created_at":"2024-07-18 16:01:23","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":212654,"visible":true,"origin":"","legend":"\u003cp\u003eGender-Specific Comparison of Handgrip Strength, Waist-Hip Ratio, Muscle Mass, and Phase Angle\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4608193/v1/d3b0dba1f0de9c6a529a9ecf.jpeg"},{"id":64198741,"identity":"b6c580b0-9c8e-48ea-97c2-639386c8b304","added_by":"auto","created_at":"2024-09-10 00:31:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":797971,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4608193/v1/41d9a6a3-4cc0-42ae-8958-03739a00772e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Disparities in Clinical Outcomes and Risk Profiles Among Male and Female Chemotherapy Patients During COVID-19: An Observational Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe COVID-19 pandemic has brought significant consequences for cancer patients, including a greater risk of delayed diagnosis, serious events [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], prolonged hospitalization in the intensive care unit [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and increased mortality [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Given this context and the multifaceted effects of the disease and treatments like chemotherapy which can induce approximately 45 physical and 27 non-physical effects a risky scenario has emerged, bringing additional consequences for this population [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCancer patients, often frequenting hospitals for treatment, became more vulnerable to COVID-19 infection, presenting a significant challenge [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Consequently, self-isolation, though a recommended preventive measure, has inadvertently become a barrier to physical activity, thereby exacerbating sedentary behavior [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIncreasing the level of physical activity is a guideline endorsed by most international health bodies as a non-pharmacological cancer treatment approach, effective in mitigating disease effects and treatment side effects, thereby improving clinical parameters and patient prognosis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong the influential clinical parameters for cancer patients are anthropometric measurements. Body Mass Index (BMI) and its association with obesity levels are linked to an increased risk of most cancer types, and reducing BMI correlates with decreased risk and improved prognosis [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The waist-hip ratio (WHR), another critical anthropometric measure, is associated with cardiovascular disease risk and adiposity in patients, correlating with cancer incidence and prognosis [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCalf circumference, a non-invasive measure useful for monitoring sarcopenia which is prevalent among cancer patients [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] is valuable despite not replacing strength and muscle mass monitoring [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Additionally, reduced calf circumference is associated with increased mortality rates [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is known that the metabolic and morphological state can impact the risk of developing different types of tumors and the response to systemic therapy [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The comparison of anthropometric measurements and adiposity in relation to cancer risk has been previously studied, as well as in our study, showing its clinical relevance [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBody composition, particularly adiposity and central fat percentage, has been identified as a marker for increased cancer risk, showing a stronger correlation than BMI and WHR [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Handgrip strength is independently linked with vital biological, functional, and quality-of-life characteristics in patients, with loss of handgrip muscle strength marking decreased physical function and increased fatigue symptoms [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In the clinical monitoring of cancer patients, the phase angle is emerging as a significant parameter; studies have shown that decreased phase angle values may indicate lower cancer survival rates [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNevertheless, the objective of our study was to evaluate and describe clinical parameters and risk factors in patients undergoing chemotherapy during the COVID-19 pandemic, with a comparative analysis between men and women. Our hypothesis posited that a distinct profile, influenced by the pandemic's impact on sedentary behaviors during periods of social isolation, might be identified, diverging from the profiles commonly reported in the scientific literature.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is an observational study carried out at the chemotherapy outpatient clinic collected between May 2021 to June 2022. The research project was approved by the institutional review board, no. 5.069.269.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSample Size Calculation and Post Hoc Power Analysis\u003c/h2\u003e \u003cp\u003eInitially, the sample size for this study was calculated based on expected differences in key clinical parameters between male and female patients undergoing chemotherapy. The primary outcome for which the sample size was determined involved differences in handgrip strength, a critical measure of physical function and prognostic indicator in cancer patients. Assuming a medium effect size (Cohen's d\u0026thinsp;=\u0026thinsp;0.5), an alpha level of 0.05, and a power of 80%, the required sample size was calculated to detect statistically significant differences between the two groups. However, due to the constraints imposed by the clinical setting, particularly during the COVID-19 pandemic, the actual sample size was limited to 106 participants 71 females and 35 males. This presented a challenge in achieving the initially planned statistical power for some of the secondary outcomes, which might have smaller effect sizes.\u003c/p\u003e \u003cp\u003eTo address this limitation and to understand the statistical power our study had with the available sample size, we conducted a post hoc power analysis focused on our primary outcome handgrip strength. The observed means and standard deviations for this measure were 23.53 kg (SD\u0026thinsp;=\u0026thinsp;5.55) for females and 35.59 kg (SD\u0026thinsp;=\u0026thinsp;8.35) for males. The calculated pooled standard deviation was approximately 6.60 kg. The resulting effect size (Cohen's d) was 1.83, which is considered a large effect. Our post hoc power analysis revealed that, with these parameters, our study achieved nearly 99% power to detect the observed difference in handgrip strength between males and females. This high level of power confirms that our study was sufficiently robust to detect significant differences in this primary outcome, despite the smaller overall sample size.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInclusion Criteria\u003c/h2\u003e \u003cp\u003eThe following were considered based on the proposed: (1) voluntary and consented participation; (2) being undergoing chemotherapy treatment; (3) not present musculoskeletal and neurological conditions that prevent the performance of tests and evaluations (4) not have any type of medical contraindication that would make collection unfeasible (5) not have cognitive impairment that makes them unable to understand the commands and perform the tests and exams; (6) not undergoing palliative procedures.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis Protocols\u003c/h2\u003e \u003cp\u003eThe analysis protocol followed a specific order and was carried out by a previously trained team: anthropometry, bioelectrical impedance (BIA), handgrip strength, physical activity questionnaire (IPAQ). Some patients presented, due to the effects of chemotherapy, symptoms that momentarily made it impossible for them to perform some of the tests, which is why the number (as in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) of patients in each analysis varied. The protocol was carried out during the COVID-19 pandemic, which made access to patients difficult and reanalysis impossible, according to hospital standards.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAnthropometry\u003c/h2\u003e \u003cp\u003eAnthropometric and body composition parameters were collected before medication administration. For circumference measurements, an anthropometric tape (Sanny\u0026reg;, Sao Paulo, Brazil, 2011) was used, with a measuring range of 2m, made of flat and flexible steel. Waist, hip and calf circumference measurements were collected. We calculated Body Mass Index (BMI) by dividing the weight by the square of the height. Cardiovascular risk was verified based on the Waist-Hip Ratio (WHR), obtained by dividing the waist (cm) and hip (cm) perimeters. To measure waist circumference, the measuring tape was positioned at the smallest curvature located between the ribs and the iliac crest. To measure the hip perimeter, the measuring tape was positioned in the area with the greatest gluteal protuberance [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eBody composition and angle phase (BIA)\u003c/h2\u003e \u003cp\u003eThe tetrapolar Bioimpedance (Sanny, Model 1011, Sao Paulo, Brazil, 2011) with the use of electrodes. For measurements using bioimpedance, the subject remained lying on a non-conductive surface (stretcher), in the supine position, with arms and legs abducted at 45\u0026deg; from the body [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eHandgrip strength\u003c/h2\u003e \u003cp\u003eThe assessment of peripheral muscle strength was carried out using a Jamar\u0026reg; dynamometer (Lafayette Instrument, Lafayette, IN, USA), following the current guidelines for handgrip strength [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePhysical Activity\u003c/h2\u003e \u003cp\u003eThe level of general physical activity was analyzed according to the short format of International Physical Activity Questionnaire (IPAQ) and normal week, version 8, validated and used in Brazil [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using R software version 4.2.2 and RStudio. Initially, data distribution was assessed for normality using the Shapiro-Wilk test, chosen for its effectiveness in handling small to medium sample sizes. Homogeneity of variances was tested using Levene's test, which is robust against non-normal distributions, ensuring that the assumptions for subsequent analyses were met. Continuous variables such as handgrip strength, body mass index (BMI), and phase angle were analyzed using the T-test for independent samples. This test was employed to compare the means between two independent groups, specifically males and females in our study, under the assumption that the data within each group were normally distributed and exhibited equal variances as indicated by the Levene\u0026rsquo;s test results. For categorical variables, including classification of dynapenia and levels of physical activity, Fisher's exact test was utilized. This choice was due to the small sample size in certain categories, which could compromise the validity of the chi-square test. Fisher\u0026rsquo;s exact test is particularly suitable for small sample analysis, providing accurate p-values even when expected frequencies in one or more cells of a contingency table are low. Statistical significance was predetermined at a p-value less than 0.05. All tests were two-sided.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe main characteristics of the sample were described in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data of the sample\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (m)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e111.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg m⁻\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWHR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCalf Circumference (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFat (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhase Angle (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHandgrip (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eBMI: Body Mass Index; WHR: Waist-Hip Ratio;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA total of 106 patients participated in the study, comprising 71 (67%) females and 35 (33%) males. The average age was 54.12 years. The most frequent diagnoses among the patients were cancer of the digestive system (n\u0026thinsp;=\u0026thinsp;24, 23%), hematological cancer (n\u0026thinsp;=\u0026thinsp;22, 21%), breast cancer (n\u0026thinsp;=\u0026thinsp;21, 20%), genital cancer (n\u0026thinsp;=\u0026thinsp;20, 19%), and other types (n\u0026thinsp;=\u0026thinsp;17, 17%).\u003c/p\u003e \u003cp\u003eRegarding body composition, 12 patients (13%) were classified as thin, 45 (51%) as eutrophic, 21 (24%) as overweight, and 11 (12%) as obese. The majority of patients displayed an altered BMI, with 9.1% below the ideal range and 27.3% above it. Notably, women had higher BMIs compared to men. Calf circumference, an indicator of potential sarcopenia and muscle mass loss, was below normal in 47 (51%) women and 23 (25%) men.\u003c/p\u003e \u003cp\u003eCardiovascular risk, assessed by the waist-hip ratio, indicated a moderate to very high risk of developing cardiovascular diseases in the majority of patients (90.9%), as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The highest values of cardiovascular risk were observed in men, which was expected; however, in the risk classification, all evaluated women showed an increase in risk from moderate to very high, with no cases of low cardiovascular risk found among women. The handgrip strength level of most patients (63.6%) was below the recommended level, indicating dynapenia. Only 6% of men had the recommended strength level, compared to 30.4% of women.\u003c/p\u003e \u003cp\u003eThe phase angle was below the recommended level for most patients, with the lowest averages predominantly found among women. The level of physical activity, assessed by the International Physical Activity Questionnaire (IPAQ), indicated that 100% of the sample did not engage in sufficient physical activity to avoid a sedentary lifestyle.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eillustrates the differences in studied variables between sexes. Women had higher BMIs compared to men. While men displayed higher strength levels, they also exhibited a greater cardiovascular risk than women.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Comparison of variables according to gender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.15\u0026thinsp;\u0026plusmn;\u0026thinsp;15.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e58.32\u0026thinsp;\u0026plusmn;\u0026thinsp;17.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg m⁻\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.81\u0026thinsp;\u0026plusmn;\u0026thinsp;5.38*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e22.46\u0026thinsp;\u0026plusmn;\u0026thinsp;3.59*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.004*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHandgrip (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.53\u0026thinsp;\u0026plusmn;\u0026thinsp;5.55*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e35.59\u0026thinsp;\u0026plusmn;\u0026thinsp;8.35*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWHR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.87\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0.94\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.007*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCalf Circumference (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.59\u0026thinsp;\u0026plusmn;\u0026thinsp;4.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e30.81\u0026thinsp;\u0026plusmn;\u0026thinsp;3.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eBMI: Body Mass Index; WHR: Waist-Hip Ratio; * P\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ecompares variables according to dynamometry. Patients with sufficient dynamometry had higher weight, fat percentage, and handgrip strength levels. No significant differences were observed for the other variables.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Comparison of variables according to dynamometry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInsufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge (y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.06\u0026thinsp;\u0026plusmn;\u0026thinsp;14.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54.47\u0026thinsp;\u0026plusmn;\u0026thinsp;17.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.688\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBMI (kg m⁻\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.04\u0026thinsp;\u0026plusmn;\u0026thinsp;3.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.25\u0026thinsp;\u0026plusmn;\u0026thinsp;5.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.120\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFat (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.04\u0026thinsp;\u0026plusmn;\u0026thinsp;8.24*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.24\u0026thinsp;\u0026plusmn;\u0026thinsp;8.12*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.004*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHandgrip (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.86\u0026thinsp;\u0026plusmn;\u0026thinsp;7.14*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.66\u0026thinsp;\u0026plusmn;\u0026thinsp;9*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eWHR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.91\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.085\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eWaist Circumference (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.37\u0026thinsp;\u0026plusmn;\u0026thinsp;10.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.03\u0026thinsp;\u0026plusmn;\u0026thinsp;10.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.561\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHip Circumference (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.98\u0026thinsp;\u0026plusmn;\u0026thinsp;9.65*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94.12\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.01*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCalf Circumference (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.26\u0026thinsp;\u0026plusmn;\u0026thinsp;3.65*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.73\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.003*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eBMI: Body Mass Index; WHR: Waist-Hip Ratio; * P\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e displays the comparison of categorical variables according to gender. Female patients had a higher frequency of normal force than men, but also a high frequency of low force. Men had a higher frequency of low strength. They were 3.91 times more likely to have an insufficient level of strength compared to women. Both men and women exhibited insufficient strength levels in the majority. The frequency of cardiovascular risk (assessed by WHR) in women indicates increased cardiovascular risks for the entire sample. Most men also exhibited increased cardiovascular risks, although some individuals had no cardiovascular risk.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study identified several deviations from recommended values across various clinical measurements. Specifically, we found that Body Mass Index (BMI) was elevated in 49% of cases, while Waist-to-Hip Ratio (WHR) exceeded ideal levels in 90.9% of participants. Additionally, Calf Circumference was below the norm in 76% of individuals, with Fat Percentage exceeding healthy thresholds in 62.9% of the sample. Handgrip Strength was notably diminished, observed in 63.6% of subjects, while Phase Angle measurements indicated deviations in 94.8% of cases. Remarkably, our findings revealed that every participant in the study exhibited a sedentary lifestyle. These results collectively underscore the significance of these clinical parameters and highlight the widespread prevalence of deviations from ideal values within our sample.\u003c/p\u003e \u003cp\u003eChemotherapy, administered with curative intent, has been shown to adversely affect body composition, physical function, insulin resistance, and lipid markers associated with atherosclerotic cardiovascular diseases in women with breast cancer, according to a study [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The research demonstrated significant changes in adiposity markers, body weight, and BMI among female participants. Notably, these findings align with existing scientific literature, which emphasizes the critical role of BMI as an indicator of cancer incidence and prognosis [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Overweight and obesity have emerged as global concerns, linked to increased cancer incidence, poorer prognosis, and elevated mortality rates among cancer patients [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, these conditions are associated with metabolic and inflammatory alterations in adipose tissue, as highlighted in studies [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] reported that excess body weight accounted for approximately 3.9% of all cancers in 2012, with the risk varying between genders and impacting both cancer incidence and prognosis. Evidence shows that cancer risk is sex-specific when associated with adiposity [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Central obesity, measured by BMI and WHR, has been consistently associated with higher mortality rates from all causes and cardiovascular diseases, particularly among women, while BMI serves as a reliable marker in men, WHR is regarded as a more accurate indicator of mortality risk in women [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Moreover, research has indicated a strong association between WHR and increased risk of all-cause mortality and cardiovascular disease, as well as its correlation with various cancer types, including breast cancer, prostate cancer, and endothelial cancer [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe significant cardiovascular risk observed in our study, especially among female participants, contrasts with some findings in the scientific literature, suggesting that women generally exhibit a more favorable cardiovascular risk factor profile than men. However, our study highlights the need for further investigation into these discrepancies. Reduced calf circumference, observed in most patients, is of particular clinical relevance, as it has been associated with elevated mortality rates across all causes, increased risk of cardiovascular diseases, sarcopenia, and cancer [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Notably, low calf circumference serves as an independent predictor of mortality in cancer patients, as demonstrated by [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother notable finding in our study was the reduced handgrip strength observed in the majority of patients. This finding aligns with previous research indicating that lower handgrip strength is associated with increased risk of all-cause mortality, cardiovascular mortality, and cancer [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Despite being widely studied, handgrip strength remains underexplored in clinical practice [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA retrospective study highlighted the prevalence of low muscle mass, handgrip strength, and gait speed, as well as sarcopenia, among cancer patients [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Additionally, a prospective observational study conducted at the Oncology Inpatient Unit found high rates of malnutrition, low BMI, low muscle strength, and low fat-free mass among patients [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. These findings underscore the importance of addressing these issues in clinical practice to improve patient outcomes.\u003c/p\u003e \u003cp\u003eOur study identified several indicators of sarcopenia, including decreased skeletal muscle mass, increased fat percentage, reduced handgrip muscle strength, and decreased calf circumference, particularly among female participants. These findings align with previous research linking sarcopenia to worse prognosis in cancer patients [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSarcopenia has also been associated with social isolation, which can exacerbate its effects on health outcomes [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Social isolation, such as that experienced during the COVID-19 pandemic, has been linked to higher mortality rates and decreased quality of life among cancer patients [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Our study revealed a sedentary profile among participants, with 100% of the sample classified as sedentary according to the guidelines of the American College of Sports Medicine for cancer patients. This sedentary behavior may be partially attributed to decreased physical activity levels and increased screen time during periods of social isolation, contributing to worsening lifestyles and increased health risk behaviors [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePhysical activity has been shown to improve survival outcomes for cancer patients, regardless of BMI. However, studies have indicated a decrease in physical activity levels, strength, and cardiorespiratory capacity among cancer patients during the COVID-19 pandemic, with potential implications for their health, as highlighted where they were studied cancer patients before and after the COVID-19 pandemic, demonstrating a decrease in the level of physical activity, strength and cardiorespiratory capacity, the authors associate it with the COVID-19 pandemic, drawing attention to the consequences on the health of cancer patients [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe know that physical activity appears to improve survival outcomes for cancer patients, regardless of their BMI [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Previous studies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e] already drew attention to the consequences of the level of physical activity caused during the social isolation of the COVID-19 pandemic in cancer patients. A study [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e] shows this phenomenon in practice among breast cancer survivors, decreasing their level of physical activity, increasing sedentary behavior and negatively modifying their body composition.\u003c/p\u003e \u003cp\u003eAn emerging clinical parameter with promising results is the phase angle, which has been shown to be a good predictor of nutritional status and clinical prognosis in various health conditions, including cancer. However, our study found phase angle values below recommended levels, particularly among female participants [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. A low phase angle has been associated with compromised nutritional profile, functional status, decreased quality of life, and increased morbidity and mortality, indicating its potential as a pivotal indicator of health and integrity, especially in cancer patients [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile our study sheds light on concerning trends among chemotherapy patients during the COVID-19 pandemic, we cannot definitively attribute these results solely to the pandemic. Factors such as reduced physical activity due to pandemic-related insecurity and the disease's inherent effects warrant further investigation. Our study faced several limitations, including the lack of control over food intake, variability in medication administration, sample size constraints due to the pandemic, and missing data. Despite these limitations, our findings underscore the importance of continued monitoring to understand the potential influences of the pandemic and their implications for clinical prognosis.\u003c/p\u003e \u003cp\u003eIn conclusion, patients undergoing chemotherapy treatment during the COVID-19 pandemic exhibited insufficient physical activity levels and deviations from recommended standards in various health indicators, particularly among women. Further research is needed to discern whether these trends result from pandemic-related factors or the natural progression of the disease in conjunction with inadequate healthcare measures.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican College of Sports Medicine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASCVD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eatherosclerotic cardiovascular diseases\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBIA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etetrapolar bioimpedance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebody mass index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebioimpedance phase angle\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIPAQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Physical Activity Questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWaist-Hip Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was carried out with the authors\u0026apos; own resources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGi\u0026eacute;risson Brenno Borges Lima - Data collection, manuscript writing and data analysis\u003c/p\u003e\n\u003cp\u003eGabriel Santos de Castro e Lima - Data collection and data analysis\u003c/p\u003e\n\u003cp\u003eFlaviana Santos de Sousa Silva - Data collection and data analysis\u003c/p\u003e\n\u003cp\u003eLuis Felipe Castro Ara\u0026uacute;jo - Data collection and manuscript writing\u003c/p\u003e\n\u003cp\u003eTha\u0026iacute;s da Concei\u0026ccedil;\u0026atilde;o Tavares Pereira - Data collection and manuscript writing\u003c/p\u003e\n\u003cp\u003eMichel Monteiro Macedo - manuscript review and data analysis\u003c/p\u003e\n\u003cp\u003eThiago dos Santos Rosa - manuscript review and data analysis\u003c/p\u003e\n\u003cp\u003eHugo de Luca Correa - manuscript review and data analysis\u003c/p\u003e\n\u003cp\u003eCarlos Eduardo Neves Amorim - Study coordination, manuscript review and data analysis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research project was approved by the Ethics and Research Committee of the University Hospital of the Federal University of Maranh\u0026atilde;o / HU-UFMA, with embodied opinion no. 5,069,269, following the ethical principles established in Resolution no. 466/12 of the Council National Health Service (CNS) and its supplements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection took place after agreeing to sign the free and informed consent form (TCLE).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of datas and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSalunke AA et al (2020) Impact of COVID \u0026ndash;\u0026thinsp;19 in cancer patients on severity of disease and fatal outcomes: A systematic review and meta-analysis. 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Frontiers in nutrition 9:803002. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fnut.2022.803002\u003c/span\u003e\u003cspan address=\"10.3389/fnut.2022.803002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"chemotherapy, cardiovascular risk, physical activity","lastPublishedDoi":"10.21203/rs.3.rs-4608193/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4608193/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo evaluate and describe clinical parameters and risk factors in patients undergoing chemotherapy during the COVID-19 pandemic, comparing men and women.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample comprised 106 cancer patients, mean age 54.12 (SD 16.18), both sexes (71 women and 35 men), with different types of cancer, all undergoing chemotherapy treatment. Assessments included anthropometric measurements, tetrapolar bioimpedance (phase angle), handgrip dynamometry, and the International Physical Activity Questionnaire (IPAQ).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter analysis, 49% of the patients showed deviations from the ideal Body Mass Index (BMI) (13% below and 36% above ideal). The waist-hip ratio was adversely altered in 90.9% of patients, indicating a moderate to very high cardiovascular disease risk (27.3% moderate, 36.4% high, and 27.3% very high). Notably, no women exhibited a low risk, unlike men (31%) (p = 0.007). Reduced calf circumference was observed in 76% of patients. Regarding body composition, 62.9% of patients displayed significant changes in body fat percentage. The majority also exhibited inadequate handgrip strength levels (63.6%), with men being approximately four times more likely to have insufficient strength (p = 0.008, OR = 3.910). A phase angle below the recommended level was found in 94.8% of the sample. Physical activity assessment revealed a 100% sedentary lifestyle rate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients undergoing chemotherapy during the COVID-19 pandemic had insufficient physical activity levels, inadequate handgrip muscle strength, and anthropometric indices and body composition with adverse changes, increasing cardiovascular risk and low phase angle reference values in the majority of the sample, with women displaying the most unfavorable profile.\u003c/p\u003e\n\u003cp\u003eThe research project was approved by the institutional review board, no. 5.069.269.\u003c/p\u003e","manuscriptTitle":"Disparities in Clinical Outcomes and Risk Profiles Among Male and Female Chemotherapy Patients During COVID-19: An Observational Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 16:01:18","doi":"10.21203/rs.3.rs-4608193/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d90e95d4-1c8b-4abd-a0db-9dd28a301458","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-25T05:38:31+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-18 16:01:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4608193","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4608193","identity":"rs-4608193","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}