Prophylactic PEG placement in head and neck cancer: How many feeding tubes are unused (and unnecessary)?

Comparison of treatment compliance and nutritional outcomes among patients with nasopharyngeal carcinoma with and without percutaneous endoscopic gastrostomy during chemoradiation

AIMS

The study aimed to compare treatment compliance and nutritional outcomes in nasopharyngeal carcinoma (NPC) patients during chemoradiation.

METHODS

Clinical information of patients with NPC that underwent chemoradiation during 2004-2009 were retrieved from the hospital database and retrospectively reviewed. Patients were categorised into a prophylactic percutaneous endoscopic gastrostomy (PPEG) group and a non-PPEG group. Clinical information including treatment compliance, weight, haematological and renal toxicity was compared.

RESULTS

A total of 219 patients were reviewed and categorised into PPEG (n=77) and non-PPEG (n=142). Significant differences in absolute percentage weight loss between groups were found from the 3rd cycle of chemotherapy. There were 24.2, 20.3 and 24.8% in the third, the fourth and the fifth cycles of chemotherapy, respectively. Migration of grade 2 to grade 3 weight loss was obviously seen in the 3rd cycle as well. A significant difference of grade 3 or more hypokalemia was found with values of 14.3% and 50% in the PPEG and non-PPEG groups, respectively. Other toxicity parameters and treatment compliance were not different between the groups.

CONCLUSIONS

Use of PPEG resulted in decreased severe weight loss, reduced migration from grade 2 to grade 3 weight loss and reduced hypokalaemia. However, benefits in treatment compliance could not be detected. So consideration of PPEG in NPC patients requires care.

Gastrostomy tube placement in patients with oropharyngeal carcinoma treated with radiotherapy or chemoradiotherapy: factors affecting placement and dependence

BACKGROUND

Although many patients require nutritional support during radiotherapy or chemoradiotherapy for oropharyngeal cancer, little is known regarding the risk factors that predispose to gastrostomy tube (g-tube) placement and prolonged dependence, or the therapeutic interventions that may abrogate these effects.

METHODS

We performed a retrospective medical chart review of patients who were treated for primary oropharyngeal cancer at a tertiary care center from 2003 to 2008. Patients who had a complete response at the primary site at 1-year posttreatment were included. G-tube placement and dependence ≥6 months were evaluated in relationship to site and stage of primary tumor, baseline characteristics, treatment type, smoking status, and swallowing intervention.

RESULTS

We evaluated 474 patients (79%) with oropharyngeal cancer; 215 patients (40%) had concurrent chemotherapy, 73 patients (15%) had induction chemotherapy, and 69 patients (15%) had induction chemotherapy followed by concurrent chemotherapy. Two hundred ninety-three patients (62%) received g-tubes, of which 238 (81%) received the g-tube during radiation. At 1-year follow-up, 41 patients (9%) remained dependent on enteral feedings. Placement of g-tubes and prolonged g-tube dependence were significantly more likely in patients with T3 to 4 tumors (p < .001), baseline self-reported dysphagia (p < .001), odynophagia (p < .001), >10% baseline weight loss (p < .001), and in those treated with concurrent chemoradiotherapy. Patients who reported adherence to exercises had significantly lower rates of g-tube placement (p < .001), and duration of dependence was significantly shorter in those who reported adherence to swallowing exercises (p < .001).

CONCLUSION

Almost 40% of patients with oropharyngeal cancer treated with nonsurgical organ preservation modalities may avoid feeding tube placement. Factors that predispose to g-tube placement and prolonged dependence include T3 to T4 tumors, concurrent chemotherapy, current smoking status, and baseline swallowing dysfunction or weight loss. Adherence to an aggressive swallowing regimen may reduce long-term dependence on enteral nutrition and limit the rate of g-tube placement overall.

Gastrostomy tube placement in patients with hypopharyngeal cancer treated with radiotherapy or chemoradiotherapy: factors affecting placement and dependence

BACKGROUND

Placement of gastrostomy tubes (g-tubes) in patients with hypopharyngeal cancers undergoing radiation and chemotherapy is generally empirically determined. We examined our experience to identify predictive factors for g-tube placement and length of dependence.

METHODS

We performed a retrospective review of all patients with primary hypopharyngeal cancer treated with nonsurgical modalities at a tertiary care center between 2002 and 2008. Rates of g-tube placement and length of dependence on enteral feedings were analyzed in relationship to multiple risk factors.

RESULTS

Forty-three patients with hypopharyngeal primary tumors (77%) who had a complete response at the primary site after treatment were included. Thirteen patients (30%) never required g-tube placement. At 1-year follow-up, 11 patients (28%) maintained a g-tube. No clinical variables were significantly associated with g-tube placement. Duration of g-tube dependence was significantly longer in patients with a posterior hypopharyngeal wall primary tumors (p = .026), current smokers (p = .001), and patients with >40 pack-years (p = .010). The duration of g-tube dependence was significantly shorter in those who maintained oral intake at the end of treatment (p = .05), and those who reported adherence to dysphagia exercise regimens (p = .048).

CONCLUSION

Approximately one third of patients with hypopharyngeal tumors treated on organ preservation regimens may be able to avoid g-tube placement, but further research is needed to identify clinical factors that predict g-tube placement in this population. A posterior hypopharyngeal wall primary and smoking history correlated with longer gastrostomy tube dependence. Adherence to aggressive targeted swallowing exercise regimens may help to prevent long-term dependence on feeding tubes.

Initial staging for squamous cell carcinoma of the mouth, larynx and pharynx (except nasopharynx). Part 3: general assessment. 2012 SFORL recommendations

OBJECTIVES

The French Society of Otorhinolaryngology (SFORL) set up a work group to draw up guidelines for initial staging of head and neck squamous cell carcinoma. Locoregional and remote extension assessment are dealt with in two separate reports. The present part 3 deals with the assessment of frequent associated symptoms and pathologies, requiring early treatment and the collection of data on a certain number of clinical and paraclinical parameters for therapeutic decision-making in the multidisciplinary team meeting.

MATERIALS AND METHODS

A multidisciplinary critical analysis of the literature was conducted. General assessment here covers screening, assessment and initial management of the following: usual risk factors (smoking, alcohol, HPV), the most frequent medical comorbidities, nutritional status, social and psychological status, dental status, pain and possible anemia. As oncologic management frequently associates surgery, radiation therapy and chemotherapy, the underlying examinations should be early, as part of initial staging. The levels of evidence for the examinations were estimated so as to grade guidelines, failing which expert consensuses were established.

RESULTS

The high rates of pain, malnutrition and anemia call for systematic screening and early management, especially as rapidly effective treatments exist. Assessing comorbidity and social and psychological status enables general health status to be assessed, along with possible contraindications to the usual treatments. Tracheal intubation problems may require intubation under flexible endoscopy or jet-ventilation by inter-cricothyroid catheterization from the diagnostic endoscopy stage. Assessment and adapted dental care should be conducted if radiation therapy is likely or certain.

CONCLUSION

Early management of symptoms and comorbidity and anticipation of subsequent treatment are intended to shorten initial staging time and to collate the data needed for therapeutic decision-making. This assessment should be performed at the same time as the locoregional and remote extension assessment, and is obviously to be adapted according to tumoral extension stage and the possible treatment options.

Nutrition support and therapy in patients with head and neck squamous cell carcinomas

Head and neck squamous cell carcinomas (HNSCC) present a unique set of challenges in both the treatment of the disease and in support of the patient afflicted with the cancer. A major challenge is the nutritional support of these patients. Often, patients with HNSCC are malnourished at baseline due to an underlying dysphagia. Many others develop dysphagia as a result of their surgical resection and external beam radiation therapy. This dysphagia further exacerbates the chronic dehydration and malnutrition. This article will review strategies to provide nutritional support to HNSCC patients and also to review nutritional strategies that may decrease the morbidity and mortality associated with HNSCC treatment.

[Inappropriate and insufficient nutrition in ENT tumors]

Tumours of the upper aerodigestive tract cause malnutrition in the majority of ENT cancer patients. This situation is complicated by multimodal treatment regimens (including surgery and/or irradiation). The resulting malnutrition is a disease entity in its own right and requires special treatment concepts. Effective screening tools (NRS 2002) need to be introduced and data such as body mass index and bioimpedance analysis need to be gathered. The nutrition plan for individual ENT patients differs according to the grade of malnutrition and dysphagia. Oral nutrition should always form the basis of any nutrition programme, such that logopedic therapy is required in all cases of dysphagia. Artifical, oral high-energy nutrition is a pharmacological procedure as well as enteral feeding via PEG or PEJ. Partial or total parenteral nutrition (central venous access) should be restricted to crisis interventions or fast-track regimens.