Cancer cachexia syndrome in head and neck cancer patients: part I. Diagnosis, impact on quality of life and survival, and treatment

Investigating the clinical significance of body composition changes in patients undergoing chemoradiation for oropharyngeal cancer using analytic morphomics

Background

The purpose is to investigate the clinical significance of body morphomics changes in stage III–IV oropharyngeal cancer patients during concurrent chemoradiotherapy (CRT).

Methods

Fifty patients who underwent CRT were selected for body composition analyses by either availability of pre/post treatment DEXA scans or a novel CT-based approach of body morphomics analysis (BMA). BMA changes (lean psoas and total psoas area) were compared to total lean body mass changes by DEXA scans using two-sample t tests. Pearson correlation was used to compare the BMA measures to head and neck specific quality of life outcomes. Cox hazards model was used to predict mortality and tumor recurrence.

Results

Clinically significant declines in total psoas area and lean body mass of similar magnitude were observed in both BMA and DEXA cohorts after CRT. Loss of psoas area (P < 0.05) was associated with greater frailty and mobility issues (3 out of 15 UWQOL domains). Total psoas area is more sensitive for local recurrence than weight changes and T-stage on multivariate analyses.

Conclusions

BMA specifically evaluating psoas area appears to correlate with head and neck cancer quality of life physical domains. Pre- and post-treatment total psoas area at L4 appears prognostic for tumor recurrence.

Patient-reported outcomes, body composition, and nutrition status in patients with head and neck cancer: Results from an exploratory randomized controlled exercise trial

BACKGROUND

Patients with head and neck cancer experience loss of weight and muscle mass, decreased functioning, malnutrition, depression, and declines in quality of life during and after treatment. The purpose of this exploratory randomized study was to determine the optimal timing for the initiation of a lifestyle and progressive resistance exercise training intervention (during or after radiation therapy), as determined by intervention adherence and by comparing between-group outcomes across 24 weeks.

METHODS

Sixty patients with head and neck cancer were randomized to engage in a 12-week lifestyle intervention and progressive resistance-training program either during radiation treatment or immediately after completion. The primary outcome of body composition--specifically, lean body mass, body mass index, and body fat--as well as secondary outcomes of fitness, quality of life, depression, and nutrition status were evaluated.

RESULTS

The progressive resistance-training intervention carried out during treatment did not significantly influence the primary outcome of body composition, despite a significant increase in weekly physical activity reported by the intervention group. A small-to-medium intervention effect was noted for some secondary outcomes, including fitness, quality of life, and nutrition status. Regardless of whether patients received the immediate or delayed progressive resistance-training intervention, the analysis revealed a main effect of time on body composition, fitness, quality of life, depression, and nutritional scores.

CONCLUSIONS

Although the intervention during treatment did not reduce the loss of lean body mass, delaying the exercise program until after treatment completion was associated with improved intervention adherence, a finding with important clinical implications.

Impact of cancer anorexia-cachexia syndrome on health-related quality of life and resource utilisation: A systematic review

INTRODUCTION

Cancer anorexia-cachexia syndrome (CACS) negatively impacts patients' quality of life (QoL) and increases the burden on healthcare resources.

OBJECTIVES

To review published CACS data regarding health-related QOL (HRQoL) and its economic impact on the healthcare system.

METHODS

Searches were conducted in MEDLINE, EMBASE, DARE, and NHS EED databases.

RESULTS

A total of 458 HRQoL and 189 healthcare resources utilisation abstracts were screened, and 42 and 2 full-text articles were included, respectively. The EORTC QLQ-C30 and FAACT instruments were most favoured for assessing HRQOL but none of the current tools cover all domains affected by CACS. Economic estimates for managing CACS are scarce, with studies lacking a breakdown of healthcare resource utilisation items.

CONCLUSIONS

HRQoL instruments that can better assess and incorporate all the domains affected by CACS are required. Rigorous assessment of costs and benefits of treatment are needed to understand the magnitude of the impact of CACS.

Post-treatment weight change in oral cavity and oropharyngeal squamous cell carcinoma

PURPOSE

Incidence of head and neck cancer (HNC) due to human papillomavirus (HPV) infection has been increasing. Treatment regimens have evolved. These changes might result in alterations of assumed treatment-related weight changes for HNC patients. We aimed to compare the trajectory of pre- to post-treatment weight changes of oropharyngeal squamous cell carcinoma (OPSCC) versus oral cavity squamous cell carcinoma (OCSCC) patients and to compare weight changes between patients with primary surgery ± adjuvant therapy to patients with primary radiation and/or chemotherapy.

METHODS

This retrospective cohort study examined adult OPSCC and OCSCC patients with initial definitive treatment at the University of Pennsylvania from January 1, 2009 to December 31, 2010. Patient demographics, medical history, treatments, and pre- and post-treatment body weight data were collected from electronic medical records. Mixed-effects modeling was performed.

RESULTS

Among 354 patients who met the inclusion criteria, 290 (82 %) survivors were available for inclusion by 24-month follow-up. More than 70 % OPSCC and OCSCC patients were overweight or obese at all pre- and post-treatment time points. The average weight among OPSCC patients was 6.63 kg higher than OCSCC patients at all time points (mean = 6.63, 95 % confidence interval (CI), 2.46-10.79, p = 0.002). After adjusting for potential confounders, patients with primary surgery had significantly more weight gain from pre-treatment to 12-18 month post-treatment follow-up as compared to patients with primary radiation and/or chemotherapy (adjusted mean = 4.01, 95 % CI, 0.16-7.87, p = 0.041).

CONCLUSION

Overweight and obesity may be a new challenge in OPSCC and OCSCC patient care. Further study is needed to evaluate whether exercise and nutritional interventions can improve their survivorship.

Prevalence and Predictors of Malnutrition in Nasopharyngeal Carcinoma

We assessed the prevalence and predictors of malnutrition in patients with nasopharyngeal carcinoma. Sixty cases and 123 controls matched for age and gender were included. Bio-data, dietary history, height, weight, body mass index (BMI), ideal body weight, and serum albumin levels were recorded. Pretreatment weight loss of >5% was present in 35% of subjects (P < 0.0001). A BMI of < 18.5 kg/m² was present in 13.3% (P < 0.001), percent ideal body weight of <90% was present in 30% (P < 0.001), and serum albumin levels <30 g/dL was present in 23.3% (P < 0.001) of cases. Nasopharyngeal carcinoma increased the likelihood of having a BMI < 18.5 kg/m² (odds ratio, 9.3 (3.4–25.3) P ≤ 0.001). Logistic regression shows that stage IV disease was associated with a decrease in all parameters except protein-calorie intake. Stage IV nasopharyngeal carcinoma is a predictive marker for weight loss and low serum albumin levels. Nutritional management is important for ensuring the patients’ ability to withstand chemoradiation and thus improve survival and quality of life.

Cancer cachexia, mechanism and treatment

It is estimated that half of all patients with cancer eventually develop a syndrome of cachexia, with anorexia and a progressive loss of adipose tissue and skeletal muscle mass. Cancer cachexia is characterized by systemic inflammation, negative protein and energy balance, and an involuntary loss of lean body mass. It is an insidious syndrome that not only has a dramatic impact on patient quality of life, but also is associated with poor responses to chemotherapy and decreased survival. Cachexia is still largely an underestimated and untreated condition, despite the fact that multiple mechanisms are reported to be involved in its development, with a number of cytokines postulated to play a role in the etiology of the persistent catabolic state. Existing therapies for cachexia, including orexigenic appetite stimulants, focus on palliation of symptoms and reduction of the distress of patients and families rather than prolongation of life. Recent therapies for the cachectic syndrome involve a multidisciplinary approach. Combination therapy with diet modification and/or exercise has been added to novel pharmaceutical agents, such as Megestrol acetate, medroxyprogesterone, ghrelin, omega-3-fatty acid among others. These agents are reported to have improved survival rates as well as quality of life. In this review, we will discuss the emerging understanding of the mechanisms of cancer cachexia, the current treatment options including multidisciplinary combination therapies, as well an update on new and ongoing clinical trials.

Cancer cachexia update in head and neck cancer: Pathophysiology and treatment

The pathophysiology of cancer cachexia remains complex. A comprehensive literature search was performed up to April 2013 using PubMed, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and the Google search engine. In this review, we focus on the different mediators of impaired anabolism and upregulated catabolism that alter the skeletal muscle homeostasis resulting in the wasting of cancer cachexia. We present recent evidence of targeted treatment modalities from clinical trials along with their potential mechanisms of action. We also report on the most current evidence from randomized clinical trials using multimodal treatments in patients with cancer cachexia, but also the evidence from head and neck cancer-specific trials. A more complete understanding of the pathophysiology of the syndrome may lead to more effective targeted therapies and improved outcomes for patients.

Correlation between the international consensus definition of the Cancer Anorexia-Cachexia Syndrome (CACS) and patient-centered outcomes in advanced non-small cell lung cancer

CONTEXT

The cancer anorexia-cachexia syndrome (CACS) is common in patients with advanced solid tumors and is associated with adverse outcomes including poor quality of life (QOL), impaired functioning, and shortened survival.

OBJECTIVES

To apply the recently posed weight-based international consensus CACS definition to a population of patients with advanced non-small cell lung cancer (NSCLC) and explore its impact on patient-reported outcomes.

METHODS

Ninety-nine patients participated in up to four study visits over a six-month period. Longitudinal assessments included measures of physical function, QOL, and other clinical variables such as weight and survival.

RESULTS

Patients meeting the consensus CACS criteria at Visit 1 had a significantly shorter median survival (239.5 vs. 446 days; hazard ratio, 2.06, P < 0.05). Physical function was worse in the CACS group (mean Karnofsky Performance Status score 68 vs. 77, Eastern Cooperative Oncology Group Performance Status score 1.8 vs. 1.3, P < 0.05 for both), as was QOL (Functional Assessment of Cancer Therapy-General [FACT-G] Lung Cancer subscale of 17.2 vs. 19.9, Anorexia/Cachexia subscale of 31.4 vs. 37.9, P < 0.05 for both). Differences in the FACT-G and the Functional Assessment of Chronic Illness Therapy-Fatigue subscale approached but did not reach statistical significance. Longitudinally, all measures of physical function and QOL worsened regardless of CACS status, but the rate of decline was more rapid in the CACS group.

CONCLUSION

The weight-based component of the recently proposed international consensus CACS definition is useful in identifying patients with advanced NSCLC who are likely to have significantly inferior survival and who will develop more precipitous declines in physical function and QOL. This definition may be useful for clinical screening purposes and identify patients with high palliative care needs.

Validation and real-world assessment of the Functional Assessment of Anorexia-Cachexia Therapy (FAACT) scale in patients with advanced non-small cell lung cancer and the cancer anorexia-cachexia syndrome (CACS)

PURPOSE

Patients with cancer anorexia-cachexia syndrome (CACS) suffer a significant symptom burden, impaired quality of life (QoL), and shorter survival. Measurement of QoL impairments related to CACS is thereby important both in clinical practice and in research. We aimed to further validate the Functional Assessment of Anorexia-Cachexia Therapy (FAACT) scale in an advanced lung cancer population.

METHODS

We tested the performance of the FAACT and its anorexia-cachexia subscale (ACS) within a dataset of patients with advanced non-small cell lung cancer (aNSCLC), using standard statistical methods. We then compared the performance of commonly used QoL measures stratified by CACS status and by patient self-report of appetite and weight loss.

RESULTS

The FAACT and its ACS demonstrate internal validity consistent with acceptable published ranges for other QoL scales (Cronbach alpha = 0.9 and 0.79, respectively). Correlation coefficients demonstrate moderate correlations in the expected directions between FAACT and ACS and scales that measure related constructs. Comparing patients with and without CACS, the ACS is more sensitive to change than other QoL instruments (mean score 33.1 vs. 37.2, p = 0.011, ES = 0.58).

CONCLUSION

In patients with aNSCLC, the FAACT and its ACS performed well compared with other instruments, further supporting their validity and value in clinical research. FAACT and ACS scores covaried with symptoms and other QoL changes that are typical hallmarks of CACS, lending further support to their use as QoL endpoints in clinical trials among patients with CACS.

Effect of weight loss on short-term outcomes and costs of care after head and neck cancer surgery

OBJECTIVES

Patients with head and neck cancer (HNC) frequently present with weight loss secondary to dysphagia and malnutrition. We sought to determine the relationship between weight loss and in-hospital mortality, complications, length of hospitalization, and costs in HNC surgery.

METHODS

We analyzed discharge data from the Nationwide Inpatient Sample for 93,663 patients who underwent an ablative procedure for malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasms between 2003 and 2008.

RESULTS

Weight loss was significantly associated with dysphagia (relative risk ratio [RRR] = 3.0; p < 0.001), alcohol abuse (RRR = 2.0; p < 0.001), advanced comorbidity (RRR = 1.8; p < 0.001), Medicaid payor status (RRR = 1.6; p = 0.002), urgent or emergent admission (RRR = 1.7; p = 0.015), and major surgical procedures (RRR = 2.3; p < 0.001). Patients with weight loss had increased risks of acute cardiac events, pneumonia, renal failure, sepsis, pulmonary failure (RRR = 2.6; p < 0.001), and postoperative wound healing complications, including fistula, dehiscence, and surgical site infection (RRR = 2.0; p < 0.001). After we controlled for all other variables, weight loss was associated with significantly increased length of hospitalization and hospital-related costs.

CONCLUSIONS

Weight loss is associated with increases in medical complications, surgical complications, length of hospitalization, and hospital-related costs in HNC surgical patients. Aggressive preoperative identification and treatment of underlying dysphagia and malnutrition may reduce the medical and surgical morbidity in this high-risk population.

Echium oil is not protective against weight loss in head and neck cancer patients undergoing curative radio(chemo)therapy: a randomised-controlled trial

BACKGROUND

Therapy-induced mucositis and dysphagia puts head and neck (H&N) cancer patients at increased risk for developing cachexia. Omega-3 fatty acids (n-3 FA) have been suggested to protect against cachexia. We aimed to examine if echium oil, a plant source of n-3 FA, could reduce weight loss in H&N cancer patients undergoing radio(chemo)therapy with curative intent.

METHODS

In a double-blind trial, patients were randomly assigned to echium oil (intervention (I) group; 7.5 ml bis in die (b.i.d.), 235 mg/ml α-linolenic acid (ALA) + 95 mg/ml stearidonic acid (SDA) + 79 mg/ml γ-linolenic acid (GLA)) or n-3 FA deficient sunflower oil high oleic (control (C) group; 7.5 ml b.i.d.) additional to standard nutritional support during treatment. Differences in percentage weight loss between both groups were analysed according to the intention-to-treat principle. Erythrocyte FA profile, body composition, nutritional status and quality of life were collected.

RESULTS

Ninety-one eligible patients were randomised, of whom 83 were evaluable. Dietary supplement adherence was comparable in both groups (median, I: 87%, C: 81%). At week 4, the I group showed significantly increased values of erythrocyte n-3 eicosapentanoic acid (EPA, 14% vs -5%) and n-6 GLA (42% vs -20%) compared to the C group, without a significant change in n-6 arachidonic acid (AA, 2% vs -1%). Intention-to-treat analysis could not reveal a significant reduction in weight loss related to echium oil consumption (median weight loss, I: 8.9%, C: 7.6%). Also, no significant improvement was observed in the other evaluated anthropometric parameters.

CONCLUSIONS

Echium oil effectively increased erythrocyte EPA and GLA FAs in H&N cancer patients. It failed however to protect against weight loss, or improve nutritional parameters.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT01596933.

Clinical utility of the modified Glasgow prognostic score in patients with advanced head and neck cancer

BACKGROUND

The purpose of this study was to evaluate the prognostic potential of the modified Glasgow prognostic score (mGPS), known to reflect the degree of tumor-associated inflammation and cancer cachexia, in patients with advanced head and neck cancer.

METHODS

Patients with advanced head and neck cancer treated at the University of Tsukuba Hospital between January 2002 and December 2011 were retrospectively evaluated. They were categorized by their mGPS.

RESULTS

A total of 210 patients were enrolled in this study. Patients with an mGPS of 0 had better overall survival and disease-free survival than did those with an mGPS of 1 or 2. Multivariate analysis revealed that the mGPS was a significant risk factor for overall survival and disease-free survival.

CONCLUSIONS

Our results suggest that the mGPS is useful for predicting outcome in patients with advanced head and neck cancer and should be included in their routine clinical assessment.

Quality of life in urban and rural settings: a study of head and neck cancer survivors

OBJECTIVE

Urban-rural variation in cancer incidence, treatment, and clinical outcomes has been well researched. With the growing numbers and longer lifespan of cancer survivors, quality of life (QOL) is now a critical issue. The present study investigates the QOL of head and neck cancer (HNC) survivors in Ireland, paying special attention to urban and rural variation.

METHODS

From the population-based National Cancer Registry Ireland, we identified 991 survivors of HNC (ICD10 C00-C14, C32), who were at least eight months post-diagnosis, and invited them to complete a postal survey. We used self-reported data and information from the Registry to create a composite variable classifying respondents' current area of residence as "urban" or "rural." Respondents self-reported QOL using the Functional Assessment for Cancer Therapy with Head and Neck module (FACT-HN). We used bootstrap linear regression to control for confounding variables, while estimating the association of urban and rural residence to FACT-HN domain scores.

RESULTS

We obtained survey and Registry data from 583 HNC survivors. Controlling for demographic and clinical variables, rural survivors reported higher physical (coefficient 1.27, bias-corrected and accelerated 95% confidence interval 0.54, 2.43), emotional (coef. 0.99, 95% CI 0.21, 2.02), and HNC-specific (coef. 1.55, 95% CI 0.32, 3.54) QOL than their urban counterparts. Social and functional QOL did not differ significantly.

CONCLUSIONS

These findings add to growing evidence of important differences in life experiences of cancers survivors in urban and rural settings. Results such as these will allow health professionals, policy makers and service providers to better serve these populations.

Local and systemic pathogenesis and consequences of regimen-induced inflammatory responses in patients with head and neck cancer receiving chemoradiation

Treatment-related toxicities are common among patients with head and neck cancer, leading to poor clinical outcomes, reduced quality of life, and increased use of healthcare resources. Over the last decade, much has been learned about the pathogenesis of cancer regimen-related toxicities. Historically, toxicities were separated into those associated with tissue injury and those with behavioural or systemic changes. However, it is now clear that tissue-specific damage such as mucositis, dermatitis, or fibrosis is no longer the sole consequence of direct clonogenic cell death, and a relationship between toxicities that results in their presentation as symptom clusters has been documented and attributed to a common underlying pathobiology. In addition, the finding that patients commonly develop toxicities representing tissue injury outside radiation fields and side effects such as fatigue or cognitive dysfunction suggests the generation of systemic as well as local mediators. As a consequence, it might be appropriate to consider toxicity syndromes, rather than the traditional approach, in which each side effect was considered as an autonomous entity. In this paper, we propose a biologically based explanation which forms the basis for the diverse constellation of toxicities seen in response to current regimens used to treat cancers of the head and neck.

Complementary therapies and integrative medicine in lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

Physicians are often asked about complementary therapies by patients with cancer, and data show that the interest in and use of these therapies among patients with cancer is common. Therefore, it is important to assess the current evidence base on the benefits and risks of complementary therapies (modalities not historically used in modern Western medicine).

METHODS

A systematic literature review was carried out and recommendations were made according to the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines development methodology.

RESULTS

A large number of randomized controlled trials, systematic reviews, and meta-analyses, as well as a number of prospective cohort studies, met the predetermined inclusion criteria. These trials addressed many different issues pertaining to patients with lung cancer, such as symptoms of anxiety, mood disturbance, pain, quality of life, and treatment-related side effects. The available data cover a variety of interventions, including acupuncture, nutrition, mind-body therapies, exercise, and massage. The body of evidence supports a series of recommendations. An evidenced-based approach to modern cancer care should integrate complementary therapies with standard cancer therapies such as surgery, radiation, chemotherapy, and best supportive care measures.

CONCLUSIONS

Several complementary therapy modalities can be helpful in improving the overall care of patients with lung cancer.

High weight loss during radiation treatment changes the prognosis in under-/normal weight nasopharyngeal carcinoma patients for the worse: a retrospective analysis of 2433 cases

BACKGROUND

Although weight loss is common in nasopharyngeal carcinoma (NPC) patients receiving radiotherapy, the prognostic influence of weight loss and its impact modified by body mass index (BMI) are still unclear.

METHODS

2433 NPC patients receiving radical radiotherapy at Sun Yat-sen University Cancer Center from November, 2000 to December, 2004 were enrolled. Weight change during radiation treatment was categorized into high weight loss (HWL) and low weight loss (LWL). The associations of HWL with overall survival (OS) and disease-specific survival (DSS) were analyzed by Cox regression.

RESULTS

Among underweight patients, HWL was independently associated with poor OS (hazard ratio [HR], 2.06; 95% CI 1.36-3.11) and DSS (HR, 2.27; 95% CI 1.38-3.73), as compared with LWL, after adjusting for covariates. In normal weight patients, the impact of HWL on OS (HR, 1.47; 95% CI 1.19-1.80) and DSS (HR, 1.59; 95% CI 1.24-2.03) was moderate. Among overweight/obese patients, no significant association between HWL and OS (HR, 1.22; 95% CI 0.95-1.55), or DSS (HR, 1.23; 95% CI 0.93-1.64) was found.

CONCLUSION

Except for overweight/obese patients, high weight loss during radiation treatment was independently associated with poor survival in NPC. This impact was more prominent in the underweight patient group.

Survivorship--competing mortalities, morbidities, and second malignancies

Mortality of head and neck cancer has declined in the United States over the past 20 years. This improvement has been linked to use of multimodality treatment of advanced disease. Despite this improvement, disease-specific survival remains low. Patients who survive head and neck cancer are exposed to morbidity and mortality secondary to the same factors as the general population. Factors related to cancer and cancer treatment predispose them to increased risk of mortality. Improvements in head and neck cancer treatment have led to a scenario where an increasing proportion of patients die from causes other than the primary cancer, called competing mortalities.

The role of inflammatory pathways in cancer-associated cachexia and radiation resistance

Dysregulated inflammatory responses are key contributors to a multitude of chronic ailments, including cancer. Evidence indicates that disease progression in cancer is dependent on the complex interaction between the tumor and the host microenvironment. Most recently, the inflammatory response has been suggested to be critical, as both the tumor and microenvironment compartments produce cytokines that act on numerous target sites, where they foster a complex cascade of biologic outcomes. Patients with cancer-associated cachexia (CAC) suffer from a dramatic loss of skeletal muscle and adipose tissue, ultimately precluding them from many forms of therapeutic intervention, including radiotherapy. The cytokines that have been linked to the promotion of the cachectic response may also participate in radiation resistance. The major changes at the cytokine level are, in part, due to transcriptional regulatory alterations possibly due to epigenetic modifications. Herein we discuss the role of inflammatory pathways in CAC and examine the potential link between cachexia induction and radiation resistance.

Cancer cachexia--pathophysiology and management

About half of all cancer patients show a syndrome of cachexia, characterized by anorexia and loss of adipose tissue and skeletal muscle mass. Cachexia can have a profound impact on quality of life, symptom burden, and a patient's sense of dignity. It is a very serious complication, as weight loss during cancer treatment is associated with more chemotherapy-related side effects, fewer completed cycles of chemotherapy, and decreased survival rates. Numerous cytokines have been postulated to play a role in the etiology of cancer cachexia. Cytokines can elicit effects that mimic leptin signaling and suppress orexigenic ghrelin and neuropeptide Y (NPY) signaling, inducing sustained anorexia and cachexia not accompanied by the usual compensatory response. Furthermore, cytokines have been implicated in the induction of cancer-related muscle wasting. Cytokine-induced skeletal muscle wasting is probably a multifactorial process, which involves a protein synthesis inhibition, an increase in protein degradation, or a combination of both. The best treatment of the cachectic syndrome is a multifactorial approach. Many drugs including appetite stimulants, thalidomide, cytokine inhibitors, steroids, nonsteroidal anti-inflammatory drugs, branched-chain amino acids, eicosapentaenoic acid, and antiserotoninergic drugs have been proposed and used in clinical trials, while others are still under investigation using experimental animals. There is a growing awareness of the positive impact of supportive care measures and development of promising novel pharmaceutical agents for cachexia. While there has been great progress in understanding the underlying biological mechanisms of cachexia, health care providers must also recognize the psychosocial and biomedical impact cachexia can have.

Pretreatment dietary patterns, weight status, and head and neck squamous cell carcinoma prognosis

BACKGROUND

Few studies have evaluated the association of diet and weight status with head and neck cancer outcomes.

OBJECTIVE

The purpose of this study was to determine whether pretreatment dietary patterns and weight status are associated with head and neck cancer prognosis.

DESIGN

This was a longitudinal study of 542 patients with newly diagnosed head and neck cancer who completed food-frequency questionnaires and health surveys before treatment. Clinical data were abstracted from medical records and the Social Security Death Index. Dietary patterns were identified by using principal component analysis. Cox proportional hazard models were used to examine the association of derived dietary patterns (fit by quintiles of exposure) and weight status with time to recurrence and survival, with control for covariates.

RESULTS

During the study period, there were 229 deaths and 184 recurrences. Two dietary patterns were identified: a whole-foods pattern (characterized by high intakes of vegetables, fruit, fish, poultry, and whole grains) and a Western pattern (characterized by high intakes of red and processed meats, refined grains, potatoes, and French fries). In multivariable analyses, significantly fewer deaths were observed in subjects most adherent to the whole-foods pattern (HR: 0.56; 95% CI: 0.34, 0.92; P-trend = 0.01). Subjects classified as overweight or obese had significantly fewer deaths (HR: 0.65; 95% CI: 0.49, 0.85; P = 0.001) and recurrences (HR: 0.70; 95% CI: 0.52, 0.95; P = 0.02) than did normal-weight or underweight subjects.

CONCLUSION

Consumption of a diet rich in vegetables, fruit, fish, poultry, and whole grains and being overweight before diagnosis with head and neck cancer are associated with a better prognosis.

Exercise and nutrition for head and neck cancer patients: a patient oriented, clinic-supported randomized controlled trial

Background

Research on physical activity and nutrition interventions aimed at positively impacting symptom management, treatment-related recovery and quality of life has largely excluded head and neck (HN) cancer populations. This translates into a lack of clinical programming available for these patient populations. HN cancer patients deal with severe weight loss, with more than 70% attributed to lean muscle wasting, leading to extended recovery times, decreased quality of life (QoL), and impaired physical functioning. To date, interventions to address body composition issues have focused solely on diet, despite findings that nutritional therapy alone is insufficient to mitigate changes. A combined physical activity and nutrition intervention, that also incorporates important educational components known to positively impact behaviour change, is warranted for this population. Our pilot work suggests that there is large patient demand and clinic support from the health care professionals for a comprehensive program.

Methods/Design

Therefore, the purpose of the present study is to examine the impact and timing of a 12-week PA and nutrition intervention (either during or following treatment) for HN cancer patients on body composition, recovery, serum inflammatory markers and quality of life. In addition, we will examine the impact of a 12-week maintenance program, delivered immediately following the intervention, on adherence, patient-reported outcomes (i.e., management of both physical and psychosocial treatment-related symptoms and side-effects), as well as return to work.

Discussion

This research will facilitate advancements in patient wellness, survivorship, and autonomy, and carve the path for a physical-activity and wellness-education model that can be implemented in other cancer centers.

Trial registration

Current Controlled Trials NCT01681654

Validation of the Head and Neck Patient Symptom Checklist as a nutrition impact symptom assessment tool for head and neck cancer patients

PURPOSE

The purpose of this study was to test the validity of the Head and Neck Patient Symptom Checklist (HNSC).

METHODS

Three hundred and sixty-eight treatment-naive individuals with head and neck cancer prospectively completed the HNSC and the Patient-Generated Symptom Global Assessment (PG-SGA). The predictive validity was determined by comparing the HNSC symptoms interference scores to the PG-SGA scores. Multivariate logistic regression was used to determine the HNSC symptoms scores associated with reduced dietary intake, ≥ 5 % weight loss over 6 months, and reduced functional performance (FP).

RESULTS

HNSC sensitivity (79-98 %), specificity (99-100 %), positive predictive value (92-100 %), and negative predictive value (94-100 %) were excellent, and the Cronbach's alpha coefficient was 0.92. The multivariate logistic regression showed that advanced tumor stage, pain, loss of appetite (LOA), and difficulty swallowing significantly predicted dietary intake. Advanced tumor stage, LOA, and difficulty swallowing were also significant predictors of ≥ 5 % weight loss over 6 months. LOA, difficulty swallowing, feeling full, and lack of energy were significant predictors of reduced FP.

CONCLUSIONS

The HNSC appears to be a valid tool for determining symptoms interfering with dietary intake of head and neck cancer (HNC) patients. This instrument may aid in early identification of symptoms that place HNC patients at risk for reductions in dietary intake, weight, and functional performance.

Understanding cancer-induced cachexia: imaging the flame and its fuel

PURPOSE OF REVIEW

One of the most under explored and yet devastating consequences of cancer is cachexia, a condition in which the body is consumed by deranged carbohydrate, lipid and protein metabolism that is induced by inflammatory cytokines. Cachexia is associated with poor treatment outcome, fatigue and poor quality of life. Because of its multifactorial characteristics, it has been difficult to understand the impact of the tumor on body organs and the sequence of events that leads to cachexia. Such insights are critically important in identifying therapeutic strategies.

RECENT FINDINGS

The ability to understand the interaction between the tumor and normal tissues and to noninvasively image the development of this condition would be invaluable in identifying critical stages when cachexia becomes life-threatening. Current multimodality molecular and functional imaging capabilities provide unique opportunities to study cachexia holistically in preclinical models and clinically. In this review we have provided examples of how state-of-the-art imaging techniques in combination with molecular characterization can be used to understand cancer-induced cachexia.

SUMMARY

Such studies will lead to clinically translatable indices for the early detection of this condition and will identify novel targets to inhibit the cachexia cascade.

Metabolic signatures imaged in cancer-induced cachexia

Cancer-induced cachexia is a complex and poorly understood life-threatening syndrome that is characterized by progressive weight loss due to metabolic alterations, depletion of lipid stores, and severe loss of skeletal muscle protein. Gaining the ability to noninvasively image the presence or onset of cachexia is important to better treat this condition, to improve the design and optimization of therapeutic strategies, and to detect the responses to such treatments. In this study, we employed noninvasive magnetic resonance spectroscopic imaging (MRSI) and [(18)F]fluoro-2-deoxy-D-glucose ((18)FDG) positron emission tomography (PET) to identify metabolic signatures typical of cachectic tumors, using this information to analyze the types and extents of metabolic changes induced by the onset of cachexia in normal tissues. Cachexia was confirmed by weight loss as well as analyses of muscle tissue and serum. In vivo, cachexia-inducing murine adenocarcinoma (MAC)16 tumors were characterized by higher total choline (tCho) and higher (18)FDG uptake than histologically similar noncachectic MAC13 tumors. A profound depletion of the lipid signal was observed in normal tissue of MAC16 tumor-bearing mice but not within the tumor tissue itself. High-resolution (1)H magnetic resonance spectroscopy (MRS) confirmed the high tCho level observed in cachectic tumors that occurred because of an increase of free choline and phosphocholine. Higher succinate and lower creatine levels were also detected in cachectic tumors. Taken together, these findings enhance our understanding of the effect of cancer on host organs and tissues as well as promote the development of noninvasive biomarkers for the presence of cachexia and identification of new therapeutic targets.

Comparison of the prevalence of malnutrition diagnosis in head and neck, gastrointestinal, and lung cancer patients by 3 classification methods

BACKGROUND

Malnutrition is prevalent among patients within certain cancer types. There is lack of universal standard of care for nutrition screening and a lack of agreement on an operational definition and on validity of malnutrition indicators.

OBJECTIVE

In a secondary data analysis, we investigated prevalence of malnutrition diagnosis with 3 classification methods using data from medical records of a National Cancer Institute-designated comprehensive cancer center.

METHODS

Records of 227 patients hospitalized during 1998 with head and neck, gastrointestinal, or lung cancer were reviewed for malnutrition based on 3 methods: (1) physician-diagnosed malnutrition-related International Classification of Diseases, Ninth Revision codes; (2) in-hospital nutritional assessment summaries conducted by registered dietitians; and (3) body mass indexes (BMIs). For patients with multiple admissions, only data from the first hospitalization were included.

RESULTS

Prevalence of malnutrition diagnosis ranged from 8.8% based on BMI to approximately 26% of all cases based on dietitian assessment. κ coefficients between any methods indicated a weak (κ = 0.23, BMI and dietitians; and κ = 0.28, dietitians and physicians)-to-fair strength of agreement (κ = 0.38, BMI and physicians).

CONCLUSIONS

Available methods to identify patients with malnutrition in a National Cancer Institute-designated comprehensive cancer center resulted in varied prevalence of malnutrition diagnosis. A universal standard of care for nutrition screening that uses validated tools is needed.

IMPLICATIONS FOR PRACTICE

The Joint Commission on the Accreditation of Healthcare Organizations requires nutritional screening of patients within 24 hours of admission. For this purpose, implementation of a validated tool that can be used by various healthcare practitioners, including nurses, needs to be considered.

Nerve growth factor links oral cancer progression, pain, and cachexia

Cancers often cause excruciating pain and rapid weight loss, severely reducing quality of life in cancer patients. Cancer-induced pain and cachexia are often studied and treated independently, although both symptoms are strongly linked with chronic inflammation and sustained production of proinflammatory cytokines. Because nerve growth factor (NGF) plays a cardinal role in inflammation and pain, and because it interacts with multiple proinflammatory cytokines, we hypothesized that NGF acts as a key endogenous molecule involved in the orchestration of cancer-related inflammation. NGF might be a molecule common to the mechanisms responsible for clinically distinctive cancer symptoms such as pain and cachexia as well as cancer progression. Here we reported that NGF was highly elevated in human oral squamous cell carcinoma tumors and cell cultures. Using two validated mouse cancer models, we further showed that NGF blockade decreased tumor proliferation, nociception, and weight loss by orchestrating proinflammatory cytokines and leptin production. NGF blockade also decreased expression levels of nociceptive receptors TRPV1, TRPA1, and PAR-2. Together, these results identified NGF as a common link among proliferation, pain, and cachexia in oral cancer. Anti-NGF could be an important mechanism-based therapy for oral cancer and its related symptoms.

Cancer cachexia: traditional therapies and novel molecular mechanism-based approaches to treatment

The complex syndrome of cancer cachexia (CC) that occurs in 50% to 80% cancer patients has been identified as an independent predictor of shorter survival and increased risk of treatment failure and toxicity, contributing to the mortality and morbidity in this population. CC is a pathological state including a symptom cluster of loss of muscle (skeletal and visceral) and fat, manifested in the cardinal feature of emaciation, weakness affecting functional status, impaired immune system, and metabolic dysfunction. The most prominent feature of CC is its non-responsiveness to traditional treatment approaches; randomized clinical trials with appetite stimulants, 5-HT3 antagonists, nutrient supplementation, and Cox-2 inhibitors all have failed to demonstrate success in reversing the metabolic abnormalities seen in CC. Interventions based on a clear understanding of the mechanism of CC, using validated markers relevant to the underlying metabolic abnormalities implicated in CC are much needed. Although the etiopathogenesis of CC is poorly understood, studies have proposed that NFkB is upregulated in CC, modulating immune and inflammatory responses induce the cellular breakdown of muscle, resulting in sarcopenia. Several recent laboratory studies have shown that n-3 fatty acid may attenuate protein degradation, potentially by preventing NFkB accumulation in the nucleus, preventing the degradation of muscle proteins. However, clinical trials to date have produced mixed results potentially attributed to timing of interventions (end stage) and utilizing outcome markers such as weight which is confounded by hydration, cytotoxic therapies, and serum cytokines. We propose that selective targeting of proteasome activity with a standardized dose of omega-3-acid ethyl esters, administered to cancer patients diagnosed with early stage CC, in addition to a standard intervention with nutritionally adequate diet and appetite stimulants, will alter metabolic abnormalities by downregulating NFkB, preventing the breakdown of myofibrillar proteins and resulting in increasing serum protein markers, lean body mass, and functional status.

Pretreatment nutritional status and locoregional failure of patients with head and neck cancer undergoing definitive concurrent chemoradiation therapy

BACKGROUND

This study was carried out to determine if markers of nutritional status predict for locoregional failure following intensity-modulated radiation therapy (IMRT) with concurrent chemoradiotherapy (CCRT) for squamous cell carcinoma of the head and neck (SCCHN).

METHODS

We performed a retrospective chart review of 78 patients with SCCHN who received definitive CCRT. We compared patient factors, tumor characteristics, and nutritional status indicators between patients with and without locoregional failure.

RESULTS

Fifteen of 78 patients (19%) experienced locoregional failure. Median follow-up for live patients was 38 months. On univariate analysis, pretreatment percentage of ideal body weight (%IBW) (p < .01), pretreatment hemoglobin (p = .04), and treatment duration (p < .01) were significant predictors of failure. On multivariate analysis, pretreatment %IBW (p = .04) and treatment time (p < .01) remained statistically significant.

CONCLUSIONS

Although treatment time is an accepted risk factor for failure, differences in outcome for patients with head and neck cancer undergoing definitive CCRT based on pretreatment %IBW should be examined further.

Nutrition impact symptoms: key determinants of reduced dietary intake, weight loss, and reduced functional capacity of patients with head and neck cancer before treatment

BACKGROUND

Our aim was to evaluate the prevalence and relationship of symptoms with reduced dietary intake, weight, and functional capacity in patients with head and neck cancer.

METHODS

Three hundred forty-one patients were prospectively screened with the patient-generated subjective global assessment before treatment. Logistic analysis was used to relate symptoms to reduced dietary intake, weight, and functional capacity. Cumulative hazard analysis was performed to determine the time and risk of weight loss of each symptom. Survival analysis was performed with Cox proportional hazards model.

RESULTS

Anorexia, dysphagia, mouth sores, and others were significant predictors of reduced dietary intake and weight. Symptom presence accelerated the time and probability of weight loss. Body mass index < or = 18.5 related to overall survival (p value = .001).

CONCLUSIONS

Symptoms present before treatment may adversely affect the dietary intake, weight, and functional capacity of patients. Symptom treatment and management is critical to weight loss prevention.

Prophylactic gastrostomy tubes for patients receiving radical radiotherapy for head and neck cancers: a retrospective review

Patients undergoing radical radiotherapy for head and neck cancers often experience significant complications. We sought to evaluate the impact of prophylactic gastrostomy tubes (PGTs) among these patients on four easily evaluable adverse outcomes, namely, absolute weight loss, percentage weight loss, admissions for nutritional reasons and treatment interruptions. A retrospective review was carried out on patients undergoing radical radiotherapy for primary head and neck cancers from September 1999 to October 2005 at the Wellington Blood and Cancer Centre (n = 71). PGTs were placed in 7 (10%) patients. Patients with PGTs were compared with the patients without PGTs (the control group) by univariate and multivariate analyses. By univariate analysis, there was no significant difference in absolute or percentage weight loss between those with PGTs and the control group. By multivariate analysis, those with PGTs lost 5.2% (P = 0.016) less weight than the control group. There were no significant differences between the two groups with regard to admissions for nutritional reasons or treatment interruptions. The use of PGTs can reduce weight loss in patients undergoing radical radiotherapy for head and neck cancers, and its use should be further evaluated in future studies.

Cancer protection of soy resembles cancer protection during pregnancy

It has been established that carrying a pregnancy to full-term at an early age can protect against contracting cancer by up to 50% in later life. The trophoblast theory of cancer states that trophoblast and cancer tissue are very similar. New findings suggest that the loss of fetal cells during pregnancy resemble those cells responsible for causing metastasis in cancer. Fetal cells and spreading cancer cells are highly proliferative. They are similar to stem cells, exhibiting no or low hormone receptor expression, and require a hormone receptor independent mechanism for control. Control of membrane stability during pregnancy is of vital importance for a successful pregnancy and is mediated by androstenediol and 2-methoxyestradiol. 2-Methoxyestradiol has no hormone receptor affinity and elicits strong anticancer effects particularly against cancer stem cells and fetal cells, for which currently no treatment has yet been established. There is a discussion whether pregnancy reduces cancer stem cells in the breast. Soy isoflavones are structurally similar to both hormones, and elicit strong anticancer effects and antiangiogenesis via inhibition of NF-κB, even in hormone receptor independent breast cancers seen in epidemiologic studies. The trophoblast theory of cancer could help to explain why soy baby nutrition formulas have no effect on baby physiology, other than the nutritional aspect, although soy elicits many effects on the adult immune system. To survive the immune system of the mother, the immune system of the fetus has to be separated; otherwise, the reduction of the immune system in the mother, a necessary feature for the blastocyst to grow, would immediately reduce the immunity for the fetus and endanger its survival. Similar to a fetus, newly born babies show immune insensitive to Th1 and Th2 cytokines, which are necessary and crucial for regulating the immune system of the mother, thus raising the risk of the baby of developing allergies and neurodermatitis. Gene expression studies in vitro as well as in circulating tumor cells from patients consuming a fermented soy product support the antiangiogenic as well as antiproliferative effects of soy.

The influence of nursing in head and neck cancer management

PURPOSE OF REVIEW

Nurses can play an essential role in the treatment of head and neck cancer and the care of patients and their families. The role and influence of nursing is dependent on available evidence to fulfill that role and on the sociopolitical and organizational factors that shape the context for nursing and interdisciplinary practice.

RECENT FINDINGS

Nurses influence treatment for head and neck cancer through symptom management and tobacco cessation to improve quality of life and patient-reported outcomes. Nurses and interdisciplinary teams in the United States and Europe report successful, novel nurse-led care models that optimize influence on management.

SUMMARY

Current research suggests that nurses can influence head and neck cancer treatment through emphasis on symptom management, tobacco and alcohol cessation, and on patient and family education and care coordination. Nonetheless, evidence for practice remains scant. Only continued research, employing qualitative and quantitative approaches, conducted by nurse and interdisciplinary investigator teams will advance head and neck cancer management and optimize influence of nursing within it. Novel models for nursing care that are well fit into the organizations and society in which care is delivered may further improve care and patient outcomes. Evaluation of such models is further required to document improvements.

Pretreatment health behaviors predict survival among patients with head and neck squamous cell carcinoma

PURPOSE

Our prior work has shown that the health behaviors of head and neck cancer patients are interrelated and are associated with quality of life; however, other than smoking, the relationship between health behaviors and survival is unclear.

PATIENTS AND METHODS

A prospective cohort study was conducted to determine the relationship between five pretreatment health behaviors (smoking, alcohol, diet, physical activity, and sleep) and all-cause survival among 504 head and neck cancer patients.

RESULTS

Smoking status was the strongest predictor of survival, with both current smokers (hazard ratio [HR] = 2.4; 95% CI, 1.3 to 4.4) and former smokers (HR = 2.0; 95% CI, 1.2 to 3.5) showing significant associations with poor survival. Problem drinking was associated with survival in the univariate analysis (HR = 1.4; 95% CI, 1.0 to 2.0) but lost significance when controlling for other factors. Low fruit intake was negatively associated with survival in the univariate analysis only (HR = 1.6; 95% CI, 1.1 to 2.1), whereas vegetable intake was not significant in either univariate or multivariate analyses. Although physical activity was associated with survival in the univariate analysis (HR = 0.95; 95% CI, 0.93 to 0.97), it was not significant in the multivariate model. Sleep was not significantly associated with survival in either univariate or multivariate analysis. Control variables that were also independently associated with survival in the multivariate analysis were age, education, tumor site, cancer stage, and surgical treatment.

CONCLUSION

Variation in selected pretreatment health behaviors (eg, smoking, fruit intake, and physical activity) in this population is associated with variation in survival.

Comparison of animal models for head and neck cancer cachexia

OBJECTIVES/HYPOTHESIS

Despite its negative impact on cancer patients, there are few animal models of cancer cachexia. Our hypothesis was that different human cell lines would variably induce cachexia.

STUDY DESIGN

Prospective animal study.

METHODS

We established two xenograft models in athymic mice and compared these with a cachexigenic cell line, the murine adenocarcinoma 16 (MAC16) cell line. Eight-week-old female, athymic mice were injected with human head and neck cell lines (JHU022, JHU012) and the MAC16 cell line. Body weight, food intake, body composition, leg weights, serum cytokines, and lipid mobilizing factor (LMF) were compared.

RESULTS

Mean food intake for all groups was equivalent. Mean percent change in body weight after 18 days was 18%, 19%, 12%, and 3% for control, JHU012, JHU022, and MAC16 experimental groups, respectively. Both JHU022- and MAC16-injected mice showed wasting even when tumor burden was low. In contrast, mice injected with JHU012 developed larger tumors yet lacked evidence of cachexia. These mice demonstrated loss of lean body mass but not fat mass. Serum cytokine levels for interleukin (IL)-1 alpha and IL-1 beta were elevated in JHU022-bearing mice, whereas IL-1 alpha, IL-6, interferon (IFN)-gamma, and tumor necrosis factor alpha (TNF)-alpha were elevated in MAC16-bearing mice. LMF was present in both the JHU022 and JHU012 cell lines.

CONCLUSIONS

The JHU022 cell line caused more severe cachexia than the JHU012 cells, suggesting these cell lines may be used to further study cancer cachexia. IL-1 alpha and IL-1 beta in the JHU022 model may be mediators of cachexia, whereas TNF-alpha, IFN-gamma, and IL-6 may be mediators in MAC16-induced cachexia.

Immunocompetent murine model of cancer cachexia for head and neck squamous cell carcinoma

BACKGROUND

Muscle wasting and weight loss were observed when carcinomas were induced in a murine model of head and neck squamous cell carcinomas. Our hypothesis was C3H/HeN mice would develop evidence of cachexia when injected with tumor cells

METHODS

Age- and weight-matched female mice were injected with SCCF/VII cells. Daily food intake and weights were measured. Body composition and analysis of circulating cytokines was performed. At the completion of experiments, hind legs were weighed. Muscle atrophy was detected using analysis for muscle ring finger 1 (MuRF1). The tumor-derived lipid mobilizing factor (LMF) was measured.

RESULTS

Despite increased food intake, tumor-bearing mice lost weight and experienced reduced hind leg weights. Interleukin-1beta (IL-1beta) was increased and MuRF1 was present in tumor-bearing mice but not controls. LMF was present in SCCF/VII cells.

CONCLUSION

In this immunocompetent murine model, we demonstrated the development of cancer cachexia in mice inoculated with SCCF cells, which express LMF. There was increased serum IL-1beta, weight loss, and muscle wasting and atrophy in tumor-bearing mice.

Defining cancer cachexia in head and neck squamous cell carcinoma

PURPOSE

Cancer cachexia is a devastating and understudied illness in patients with head and neck squamous cell carcinoma (HNSCC). The primary objective was to identify clinical characteristics and serum levels of cytokines and cachexia-related factors in patients with HNSCC. The secondary objective was to detect the occurrence of cytokine and cachexia-related factor gene expression in HNSCC tumors.

EXPERIMENTAL DESIGN

For the primary objective, cross-sectional data were obtained from prospectively recruited patients identified as cachexia cases and matching cachexia-free controls. For the secondary objective, a retrospective cohort design with matched controls was used.

RESULTS

Clinical characteristics associated with cancer cachexia in HNSCC were T(4) status (P = 0.01), increased C-reactive protein (P = 0.01), and decreased hemoglobin (P < 0.01). Exploratory multiplex analysis of serum cytokine levels found increased interleukin (IL)-6 (P = 0.04). A highly sensitive ELISA confirmed the multiplex result for increased IL-6 in cachectic patients (P = 0.02). Quality of life was substantially reduced in patients with cachexia compared with noncachectic patients (P < 0.01). All tumors of HNSCC patients both with and without cachexia expressed RNA for each cytokine tested and the cachexia factor lipid-mobilizing factor. There were no statistically significant differences between the cytokine and cachexia factor RNA expression of cachectic and noncachectic patients (each P > 0.05). No tumors expressed the cachexia factor proteolysis-inducing factor.

CONCLUSION

We have identified clinical characteristics and pathophysiologic mechanisms associated with cancer cachexia in a carefully defined population of patients with HNSCC. The data suggest that the acute-phase response and elevated IL-6 are associated with this complex disease state. We therefore hypothesize that IL-6 may represent an important therapeutic target for HNSCC patients with cancer cachexia.