Critical weight loss is a major prognostic indicator for disease-specific survival in patients with head and neck cancer receiving radiotherapy

Investigating adherence to Australian nutritional care guidelines in patients with head and neck cancer

BACKGROUND

Significant weight loss and malnutrition are common in patients with head and neck cancer, despite advances in treatment and development of evidenced-based guidelines. The aim of this study was to assess adherence to evidenced-based guidelines and investigate nutrition outcomes during and post radiation treatment in head and neck cancer patients.

METHODS

This was a two-year retrospective cohort study of 209 head and neck cancer patients (85% male) treated with ≥20 fractions of radiation (mean dose = 64.8 Gy delivered over 31.9 fractions) at an Australian tertiary hospital.

RESULTS

Regarding guideline adherences, 80% of patients were seen by a dietitian weekly during treatment and 62% of patients were seen bi-weekly for six-weeks post-treatment. Average weight loss was 6.7% during treatment and 10.3% three-months post treatment. At the end of treatment, oropharyngeal and oral cavity patients had lost the most weight (8.8, 10.9%), with skin cancer and laryngeal patients losing the least weight (4.8, 2.9%). Gastrostomy patients (n = 60) had their tube in-situ for an average of 150 days and lost an average of 7.7 kg (9.4%) during treatment and 11.5 kg (13.5%) from baseline to three-months post treatment. The number of malnourished patients increased from 15% at baseline to 56% at the end of treatment, decreasing to 30% three-months post treatment.

CONCLUSIONS

Despite high adherence to evidenced-based guidelines, large discrepancies in weight loss and nutritional status between tumor sites was seen. This highlights the opportunity for further investigation of the relationship between tumor site, nutritional status and nutrition interventions, which may then influence future evidenced-based guidelines.

Evaluation of classification and regression tree (CART) model in weight loss prediction following head and neck cancer radiation therapy

OBJECTIVE

We explore whether a knowledge-discovery approach building a Classification and Regression Tree (CART) prediction model for weight loss (WL) in head and neck cancer (HNC) patients treated with radiation therapy (RT) is feasible.

METHODS AND MATERIALS

HNC patients from 2007 to 2015 were identified from a prospectively collected database Oncospace. Two prediction models at different time points were developed to predict weight loss ≥5 kg at 3 months post-RT by CART algorithm: (1) during RT planning using patient demographic, delineated dose data, planning target volume-organs at risk shape relationships data and (2) at the end of treatment (EOT) using additional on-treatment toxicities and quality of life data.

RESULTS

Among 391 patients identified, WL predictors during RT planning were International Classification of Diseases diagnosis; dose to masticatory and superior constrictor muscles, larynx, and parotid; and age. At EOT, patient-reported oral intake, diagnosis, N stage, nausea, pain, dose to larynx, parotid, and low-dose planning target volume-larynx distance were significant predictive factors. The area under the curve during RT and EOT was 0.773 and 0.821, respectively.

CONCLUSIONS

We demonstrate the feasibility and potential value of an informatics infrastructure that has facilitated insight into the prediction of WL using the CART algorithm. The prediction accuracy significantly improved with the inclusion of additional treatment-related data and has the potential to be leveraged as a strategy to develop a learning health system.

Preventing Treatment-Related Functional Decline: Strategies to Maximize Resilience

The majority of patients with cancer are older adults. A comprehensive geriatric assessment (CGA) will help the clinical team identify underlying medical and functional status issues that can affect cancer treatment delivery, cancer prognosis, and treatment tolerability. The CGA, as well as more abbreviated assessments and geriatric screening tools, can aid in the treatment decision-making process through improved individualized prediction of mortality, toxicity of cancer therapy, and postoperative complications and can also help clinicians develop an integrated care plan for the older adult with cancer. In this article, we will review the latest evidence with regard to the use of CGA in oncology. In addition, we will describe the benefits of conducting a CGA and the types of interventions that can be taken by the interprofessional team to improve the treatment outcomes and well-being of older adults.

Clinical impact of albumin in advanced head and neck cancer patients with free flap reconstruction-a retrospective study

Background

Poor nutritional status among patients with advanced stage head and neck squamous cell carcinoma (HNSCC) is common. Albumin is a common indicator of nutritional status and has been shown to be a predictor of oncological outcomes and perioperative morbidity. This study aims to determine the prognostic value of the serum albumin level among patients with advanced HNSCC undergoing surgery with simultaneous free flap reconstruction.

Methods

A total of 233 patients with advanced head and neck cancer undergoing tumor resection and immediate microvascular free flap reconstruction in a tertiary referral center were enrolled retrospectively between January 2009 and December 2011. Statistical analyses including Pearson’s chi-squared test were used to determine whether there was a significant difference between each selected clinical factors and postoperative major wound infection. Multiple regression analysis was performed to reveal the relationship between postoperative major wound infection and clinical factors. Kaplan–Meier curves and multivariate Cox regression were applied to analyse survival outcome for overall survival (OS), disease-specific survival (DSS) and disease-free survival (DFS).

Results

Postoperative serum albumin level (p < 0.001) and tumor location were both significantly associated with postoperative major wound infection (p = 0.018) in univariate analysis. Multiple regression analysis showed a higher risk of postoperative major wound infection among patients with postoperative hypoalbuminemia than in their counterparts (odds ratio [OR] 9.811, 95% CI [2.288–42.065], p = 0.002). Patients with a tumor located over the hypopharynx experienced increased risk of postoperative major wound infection (OR 2.591, 95% CI [1.095–6.129], p = 0.030). With respect to oncological outcomes, preoperative serum albumin level is a significant independent prognostic factor for overall survival (OS), disease-specific survival (DSS) and disease-free survival (DFS).

Conclusions

Postoperative hypoalbuminemia is a useful indicator for the development of postoperative complications. In addition, preoperative hypoalbuminemia is a negative prognostic factor for patients who have undergone tumor excision and free flap reconstruction for the advanced stage of HNSCC.

The impact of HPV status on weight loss and feeding tube use in oropharyngeal carcinoma

OBJECTIVES

It has been well established that patients with oropharyngeal carcinoma are at high nutritional risk, with significant weight loss and tube feeding common. Human papillomavirus (HPV)-associated disease has led to a change in the "typical" presentation and nutritional profile of this population. The aim of our study was to determine whether the need for a feeding tube, and weight loss during radiotherapy (RT) in patients with oropharyngeal carcinoma differed with HPV status.

MATERIALS AND METHODS

Patients who received curative RT ± chemotherapy from January 2011 to January 2016 were included (n = 100). We retrospectively evaluated feeding tube use and timing of insertion (prophylactic vs reactive), percentage weight loss during RT and the prevalence of critical weight loss (CWL) ≥5%.

RESULTS

HPV-positive patients had significantly higher weight loss during RT compared to the rest of the cohort (8.4% vs 6.1%, 95%CI 0.8-3.9, p = 0.003). CWL was observed in 86% and in a higher proportion with HPV-positive disease (93%, p = 0.011). Conditional probability modelling analysis revealed, with 74% accuracy, concurrent chemoradiotherapy and HPV-positive status were predictors of CWL when comparing HPV-positive patients to HPV-negative (96%, p = 0.001 and 98%, p = 0.012 respectively). More HPV-positive patients required feeding tubes (n = 43, 63%, p = 0.05), most being reactive (n = 27, 63%). All patients with reactive tubes experienced CWL.

CONCLUSION

The high incidence of CWL in patients with HPV-positive oropharyngeal carcinoma is of concern. Tube feeding continues to be a necessary nutritional intervention in this population and predicting who will require a tube is challenging. Larger, prospective cohort studies are required.

Failure of Further Validation for Survival Nomograms in Oropharyngeal Cancer: Issues and Challenges

PURPOSE

To retrospectively test 2 nomograms recently validated as prognostic tools for patients with oropharyngeal cancer treated with curative radiation-based therapy, in 184 consecutive subjects treated from April 2004 to January 2016.

PATIENT AND METHODS

Complete information regarding disease, survival status, and nomogram covariates was retrieved for 174 patients, with a median follow-up of 51 months. Calibration of the nomograms was obtained by evaluating the ability to accurately predict the absolute risk level; discriminative ability estimated by the Harrell C statistic was tested by assessing the ability of the nomograms to rank the patients from low risk to high risk.

RESULTS

The outcome predicted by the nomograms was worse than observed, especially for progression-free survival. This may be due to several factors: geographic and genetic background, smoking, alcohol use, the different national health system organization, which provides universal and free-of-charge coverage to all individuals, and the setting of treatment in clinical practice, outside of clinical trials.

CONCLUSIONS

Our results show that the usefulness of nomograms to predict outcome of oropharyngeal cancer may not be generalizable to patients of different countries. Further studies are needed to clarify whether sociodemographic, epidemiologic, and cultural scenarios may seriously affect the prognostic ability of newly developed predictive tools.

Nutritional counseling with or without systematic use of oral nutritional supplements in head and neck cancer patients undergoing radiotherapy

BACKGROUND

To evaluate the benefit of oral nutritional supplements (ONS) in addition to nutritional counseling in head and neck cancer (HNC) patients undergoing radiotherapy (RT).

METHODS

In a single-center, randomized, pragmatic, parallel-group controlled trial (ClinicalTrials.gov: NCT02055833; February 2014-August 2016), 159 newly diagnosed HNC patients suitable for to RT regardless of previous surgery and induction chemotherapy were randomly assigned to nutritional counseling in combination with ONS (N = 78) or without ONS (N = 81) from the start of RT and continuing for up to 3 months after its end. Primary endpoint was the change in body weight at the end of RT. Secondary endpoints included changes in protein-calorie intake, muscle strength, phase angle and quality of life and anti-cancer treatment tolerance.

RESULTS

In patients with the primary endpoint assessed (modified intention-to-treat population), counseling plus ONS (N = 67) resulted in smaller loss of body weight than nutritional counseling alone (N = 69; mean difference, 1.6 kg [95%CI, 0.5-2.7]; P = 0.006). Imputation of missing outcomes provided consistent findings. In the ONS-supplemented group, higher protein-calorie intake and improvement in quality of life over time were also observed (P < 0.001 for all). The use of ONS reduced the need for changes in scheduled anti-cancer treatments (i.e. for RT and/or systemic treatment dose reduction or complete suspension, HR=0.40 [95%CI, 0.18-0.91], P = 0.029).

CONCLUSION

In HNC patients undergoing RT or RT plus systemic treatment, and receiving nutritional counseling, the use of ONS resulted in better weight maintenance, increased protein-calorie intake, improved quality of life and was associated with better anti-cancer treatment tolerance.

Ninety Day Mortality After Radical Radiotherapy for Head and Neck Cancer

AIMS

Treatment for head and neck cancers using definitive radiotherapy, with or without chemotherapy, is associated with significant acute toxicity. Our aim was to assess 90 day mortality after radical radiotherapy. A further aim was to identify patient, tumour or treatment factors associated with early death after treatment and whether these could be used to predict outcomes.

MATERIALS AND METHODS

In total, 1116 patients with squamous cell pharyngeal and larynx cancer between January 2011 and December 2015 were included. Patients with T1 larynx cancer were excluded. Patients were treated using radical radiotherapy, with or without chemotherapy. Ninety day mortality was calculated using survival of less than 135 days from the planned start date for radical radiotherapy, to include early deaths during and up to 90 days after treatment.

RESULTS

Overall, 90 day mortality was 4.7%. Among the subgroup of patients treated with concurrent platinum chemotherapy, the 90 day mortality rate was 0.4%. Overall survival at 1, 3 and 5 years was 84%, 62% and 53%, respectively. Factors associated with a higher risk of early death included performance status > 1, haemoglobin <100 g/l, weight < 60 kg, age > 80 years and presence of multiple comorbidities.

CONCLUSION

We report excellent crude overall survival rates among our radically treated cohort of head and neck cancer patients. Several factors were associated with an increased risk of death within 90 days of completion of radical head and neck radiotherapy. Given the potential severe acute effects and the impact on patient quality of life associated with radical head and neck radiotherapy, this information is helpful to inform treatment-related discussions with patients.

A retrospective study of 606 cases of nasopharyngeal carcinoma with or without oropharyngeal candidiasis during radiotherapy

Background

To evaluate the clinical characteristics, treatment-related toxicities and survival in patients with nasopharyngeal carcinoma (NPC) with or without oropharyngealcandidiasis (OPC) during radiotherapy.

Methods

The current study was conducted with NPC patients undergoing radiotherapy at Sun Yat-Sen University Cancer Center between June 2011 and May 2012. A clinical diagnosis of candidiasis was determined on the basis of a positive potassium hydroxide (KOH) test and the presence of pseudomembranous (white) form of candidal overgrowth. The Cox proportional hazard regression model was used to test the association of OPC and related survival rates.

Results

Compared with the non-OPC group, the OPC group had significantly increased occurrence rates of grade 3–4 mucositis (14.5% vs. 7.4%, P = 0.049), anaemia (11.3% vs. 4.4%, P = 0.020), hepatotoxicity (4.8% vs. 1.1%, P = 0.021) and critical weight loss (85.5% vs. 56.6%, P<0.001) during radiotherapy. The OPC group had a significantly lower disease-free survival (DFS) (70.9% vs. 82.6%, P = 0.012), mainly as a result of a reduction in locoregional relapse-free survival (LRFS) (87.0%vs. 94.9%, P = 0.025). After stratification by T stage, the 5-year DFS in T3-4 patients were 82.0% and 68.8% in non-OPC and OPC groups, respectively (P = 0.022). Multivariate analyses indicated that OPC was a prognostic factor for LRFS and DFS.

Conclusions

OPC during radiotherapy may worsen the nutritional status of NPC patients according to weight loss and anaemia, leading to a negative impact on 5-year locoregional relapse-free survival and disease-specific survival. Further investigations are needed to explore whether prevention and treatment of OPC during radiotherapy will be useful.

Clinical predictors for reactive tube feeding in patients with advanced oropharynx cancer receiving radiotherapy ± chemotherapy

Enteral feeding is often required for nutrition support in head and neck cancer patients when oral intake is inadequate. When to initiate the insertion of a feeding tube continues to be a debated issue in our institution. We investigated the use of reactive feeding tubes (RFTs) in patients with advanced stage oropharynx cancer (OPC). Data were retrospectively collected on 131 patients who had radiotherapy (RT) ± chemotherapy from 2005 to 2015. Predictors for RFT insertion were investigated. Weight loss during RT was compared between those with RFT versus prophylactic tubes (PFTs) versus no tube, and survival outcomes evaluated. RFTs were more likely to be needed in patients who had bilateral neck node irradiation (p = 0.001) and concurrent chemoradiotherapy (CRT) (p = 0.038). Patients with RFTs had significantly higher mean percentage weight loss during RT (9.5 ± 3.4%) (p < 0.001) when compared to those with a PFT (5.2 ± 4.7%) and those with no tube (5.4 ± 3.1%). No difference was seen in 5-year survival rates in patients who did not have a feeding tube to those who required a RFT. RFT use is frequent in OPC, although difficult to predict. CRT and bilateral neck node irradiation were found to be associated with the need for the insertion of a feeding tube during RT. These patients also experience significantly higher weight loss, therefore, prophylactic tubes may need to be considered more often in this population.

Assessment and management of radiotherapy induced toxicity in older patients

Radiotherapy is an attractive treatment option for older adults, especially where surgery and chemotherapy pose too great a risk. Radiotherapy toxicity may be divided into acute/early and late effects of treatment. The latter may have limited relevance to an older patient with competing causes of mortality due to significant comorbidity. Altered fractionation regimes have been employed in numerous sites, with no significant toxicity impact. These offer greater convenience in the elderly, especially those with limited social support or in active caregiving roles. As radiotherapy toxicity is site specific, it's important to assess baseline function via Comprehensive Geriatric Assessment (CGA), and any pre-existing comorbidities that may influence toxicity. With modern radiotherapy technology and capabilities, these are less of an issue and radiotherapy is a very suitable treatment option for the older adult. When evaluating the literature on toxicity in older patients, it's important to recognise that older studies do not represent modern day radiotherapy techniques and capabilities. Advanced technology may simultaneously deliver enhanced target coverage and reduced toxicity. More research is required related to the predictive power of CGA in linking radiotherapy toxicity to frailty. What little evidence exists shows that CGA has a role in treatment of older patients with radiotherapy and that, in general, radiotherapy appears to be well tolerated in older adults. The purpose of this review is to provide a broad overview of the mechanisms of normal tissue reactions to radiotherapy and how radiation induced toxicity may affect older patients.

Progressive resistance training in head and neck cancer patients undergoing concomitant chemoradiotherapy

Objectives

Patients with head and neck squamous cell carcinoma undergoing concomitant chemoradiotherapy (CCRT) frequently experience weight loss, especially loss of lean body mass (LBM), and reduced functional performance. This study investigated whether a 12‐week hospital‐based progressive resistance training (PRT) program during CCRT is feasible in the clinical setting before planning initiation of a larger randomized study which is the long‐term goal.

Study design

Prospective pilot study.

Methods

Twelve patients receiving CCRT were planned to attend a 12‐week PRT program. Primary endpoint was feasibility measured as attendance to training sessions. Secondary endpoints included changes in functional performance, muscle strength, and body composition measured by Dual‐energy X‐ray Absorptiometry (DXA) scans. Furthermore, sarcomeric protein content, pentose phosphate pathway (PPP) activity, and glycolysis were determined in muscle biopsies.

Results

Twelve patients with p16 positive oropharyngeal cancer were enrolled. The primary endpoint was met with 9 of the 12 patients completing at least 25 of 36 planned training sessions. The mean attendance rate was 77%. Functional performance was maintained during the treatment period and increased during follow‐up (p < 0.01). Strength was regained after an initial dip during treatment, paralleling responses in LBM and sarcomeric protein content. LBM began to increase immediately after treatment. The PPP was upregulated after the treatment period, whilst glycolysis remained unchanged. No adverse events were related to PRT and in questionnaires, patients emphasized the social and psychological benefits of attendance.

Conclusion

Progressive resistance training is feasible and safe during CCRT for head and neck cancer, and is associated with high patient satisfaction.

Level of Evidence

2C.

Evidence-Based Support for Nutrition Therapy in Head and Neck Cancer

PURPOSE OF REVIEW

Patients diagnosed with head and neck (H&N) cancer often present in a malnourished state for varied reasons; nutritional optimization is therefore critical to the success of treatment for these complex patients. This article aims to review the current nutrition literature pertaining to H&N cancer patients and to present evidence-based strategies for nutritional support specific to this population.

RECENT FINDINGS

Aggressive nutritional intervention is frequently required in the H&N cancer patient population. Rehabilitating nutrition during operative and nonoperative treatment improves compliance with treatment, quality of life, and clinical outcomes. When and whether to establishing alternative enteral access are points of controversy, although recent evidence suggests prophylactic enteral feeding tube placement should not be universally applied. Perioperative nutritional optimization including preoperative carbohydrate loading and provision of arginine-supplemented immunonutrition has been shown to benefit at-risk H&N cancer patients.

SUMMARY

With multidisciplinary collaboration, H&N cancer patients can receive individualized nutritional support to withstand difficult cancer treatment regimens and return to acceptable states of nutritional health.

Nutritional changes in patients with locally advanced head and neck cancer during treatment

OBJECTIVE

The purpose of the study is to evaluate changes in body composition and nutritional status that occur throughout the oncological treatment in head and neck cancer patients.

METHODS

A prospective cohort observational study in patients diagnosed with head and neck squamous cell carcinoma (HNSCC) that underwent treatment with induction chemotherapy (iCT) followed by chemoradiotherapy or bioradiotherapy were invited to participate. All patients had dietetic counseling from the diagnosis and a close monitoring throughout the treatment implementing nutritional support as needed.

RESULTS

From June 2011 until October 2012, 20 patients were included. Nutritional and anthropometric parameters were collected at diagnosis, post iCT, after radiotherapy, 1 and 3months post radiotherapy. According to Patient Generated Subjective Global Assessment, 30% of patients were malnourished at diagnosis. After iCT there was an increase in weight, body mass index (BMI) and fat free mass (FFM) with almost complete improvement in dysphagia and odynophagia. Nevertheless a significant nutritional deterioration (p=0.0022) occurred at the end of radiotherapy with 95% of patients becoming severe or moderate malnourished. Nutritional parameters such as weight, BMI and hand grip strength also decrease significantly during treatment.

CONCLUSIONS

Despite an intensive nutritional support from the diagnosis throughout the oncological treatment in advanced HNSCC cancer patients, nutritional status deteriorates during radiotherapy. Our findings suggest that iCT may help improve nutritional status by ameliorating the symptoms that limit the oral intake. This improvement in the nutritional status could contribute to minimize further deterioration. Further investigations are needed involving novel approaches to avoid nutritional deterioration.

Pretreatment albumin level predicts survival in head and neck squamous cell carcinoma

OBJECTIVES/HYPOTHESIS

Poor nutritional status in patients with head and neck squamous cell carcinoma (HNSCC) is associated with tumor progression and survival. This study examined the prognostic value of nutritional and hematological markers in patients with HNSCC who received definitive treatments.

STUDY DESIGN

A prospective observational cohort study.

METHODS

This study included 338 consecutive patients who underwent surgery and/or radiotherapy/chemoradiotherapy for treatment-naïve HNSCC. Body weight and nutritional and hematological parameters were regularly measured before and after treatment. Univariate and multivariate analyses using Cox proportional hazards models were performed to identify factors associated with disease-free survival (DFS), cancer-specific survival (CSS), and overall survival (OS).

RESULTS

Body weight, serum total protein and albumin levels, and hematological variables significantly decreased after treatment. Univariate analyses illustrated that age, tumor site, T and N classifications, overall stage, pretreatment serum albumin (<3.5 g/dL) and hemoglobin (<12 g/dL) levels, and neutrophil-lymphocyte ratio were significantly associated with DFS, CSS, and OS (all P < .05). Multivariate analyses identified age, tumor site, N classification, and pretreatment albumin levels as independent predictors of DFS, CSS, and OS (all P < .05). Patients with low serum albumin levels prior to treatment experienced approximately sixfold increases in the risks of tumor progression and cancer-specific and overall mortality compared to the findings in their counterparts.

CONCLUSIONS

Our results suggest that pretreatment serum albumin levels predict DFS, CSS, and OS in patients who received definitive treatment for HNSCC. These findings might help to predict treatment outcome and guide nutritional intervention in patients with HNSCC.

LEVEL OF EVIDENCE

2b. Laryngoscope, 127:E437-E442, 2017.

Randomised controlled trial of early prophylactic feeding vs standard care in patients with head and neck cancer

Background:

Weight loss remains significant in patients with head and neck cancer, despite prophylactic gastrostomy and intensive dietary counseling. The aim of this study was to improve outcomes utilising an early nutrition intervention.

Methods:

Patients with head and neck cancer at a tertiary hospital in Australia referred for prophylactic gastrostomy prior to curative intent treatment were eligible for this single centre randomised controlled trial. Exclusions included severe malnutrition or dysphagia. Patients were assigned following computer-generated randomisation sequence with allocation concealment to either intervention or standard care. The intervention group commenced supplementary tube feeding immediately following tube placement. Primary outcome measure was percentage weight loss at three months post treatment.

Results:

Recruitment completed June 2015 with 70 patients randomised to standard care (66 complete cases) and 61 to intervention (56 complete cases). Following intention-to-treat analysis, linear regression found no effect of the intervention on weight loss (10.9±6.6% standard care vs 10.8±5.6% intervention, P=0.930) and this remained non-significant on multivariable analysis (P=0.624). No other differences were found for quality of life or clinical outcomes. No serious adverse events were reported.

Conclusions:

The early intervention did not improve outcomes, but poor adherence to nutrition recommendations impacted on potential outcomes.

Gastric cancer, nutritional status, and outcome

Background

We aim to investigate the prognostic value of several nutrition-based indices, including the prognostic nutritional index (PNI), performance status, body mass index, serum albumin, and preoperative body weight loss in patients with gastric cancer (GC).

Materials and methods

We retrospectively analyzed the records of 1,330 consecutive patients with GC undergoing curative surgery between October 2000 and September 2012. The relationship between nutrition-based indices and overall survival (OS) was examined using Kaplan–Meier analysis and Cox regression model.

Results

Following multivariate analysis, the PNI and preoperative body weight loss were the only nutritional-based indices independently associated with OS (hazard ratio [HR]: 1.356, 95% confidence interval [CI]: 1.051–1.748, P=0.019; HR: 1.152, 95% CI: 1.014–1.310, P=0.030, retrospectively). In stage-stratified analysis, multivariate analysis revealed that preoperative body weight loss was identified as an independent prognostic factor only in patients with stage III GC (HR: 1.223, 95% CI: 1.065–1.405, P=0.004), while the prognostic significance of PNI was not significant (all P>0.05). In patients with stage III GC, preoperative body weight loss stratified 5-year OS from 41.1% to 26.5%. When stratified by adjuvant chemotherapy, the prognostic significance of preoperative body weight loss was maintained in patients treated with surgery plus adjuvant chemotherapy and in patients treated with surgery alone (P<0.001; P=0.003).

Conclusion

Preoperative body weight loss is an independent prognostic factor for OS in patients with GC, especially in stage III disease. Preoperative body weight loss appears to be a superior predictor of outcome compared with other established nutrition-based indices.

Comparison of Nutritional and Clinical Outcomes in Patients with Head and Neck Cancer Undergoing Chemoradiotherapy Utilizing Prophylactic versus Reactive Nutrition Support Approaches

BACKGROUND

The optimal method of tube feeding for patients with head and neck cancer remains unclear. A validated protocol is available that identifies high-nutritional-risk patients who would benefit from prophylactic gastrostomy tube placement. Adherence to this protocol is ultimately determined by clinical team discretion or patient decision.

OBJECTIVE

The study aim was to compare outcomes after adherence and nonadherence to this validated protocol, thus comparing a prophylactic and reactive approach to nutrition support in this patient population.

DESIGN

We conducted a prospective comparative cohort study. Patients were observed during routine clinical practice over 2 years.

PARTICIPANTS/SETTING

Patients with head and neck cancer having curative-intent treatment between August 2012 and July 2014 at a tertiary hospital in Queensland, Australia, were included if assessed as high nutrition risk according to the validated protocol (n=130). Patients were grouped according to protocol adherence as to whether they received prophylactic gastrostomy (PEG) per protocol recommendation (prophylactic PEG group, n=69) or not (no PEG group, n=61).

MAIN OUTCOME MEASURES

Primary outcome was percentage weight change during treatment. Secondary outcomes were feeding tube use and hospital admissions.

STATISTICAL ANALYSIS PERFORMED

Fisher's exact, χ², and two sample t tests were performed to determine differences between the groups. Linear and logistic regression were used to examine weight loss and unplanned admissions, respectively.

RESULTS

Patients were 88% male, median age was 59 years, with predominantly stage IV oropharyngeal cancer receiving definitive chemoradiotherapy. Statistically significantly less weight loss in the prophylactic PEG group (7.0% vs 9.0%; P=0.048) and more unplanned admissions in the no PEG group (82% vs 75%; P=0.029). In the no PEG group, 26 patients (43%) required a feeding tube or had ≥10% weight loss.

CONCLUSIONS

Prophylactic gastrostomy improved nutrition outcomes and reduced unplanned hospital admissions. Additional investigation of characteristics of patients with minimal weight loss or feeding tube use could help refine and improve the protocol.

Benefit of percutaneous endoscopic gastrostomy in patients undergoing definitive chemoradiotherapy for locally advanced nasopharyngeal carcinoma

BACKGROUND AND AIM

To evaluate the impact of percutaneous endoscopic gastrostomy (PEG) tube on nutritional status, treatment-related toxicity, and treatment tolerance in patients with locally advanced nasopharyngeal carcinoma (NPC) who underwent chemoradiotherapy.

PATIENTS AND METHODS

We enrolled 133 consecutive non-metastatic NPC (III/IV stage) patients, who were treated with prophylactic PEG feeding before the initiation of concurrent chemoradiotherapy (CCRT) between June 1, 2010 and June 30, 2014. Meanwhile, another 133 non-PEG patients, who were matched for age, gender, and tumor, node, metastases stage, were selected as historical control cohort. Weight and nutritional status changes from pre-radiotherapy to the end of radiotherapy were evaluated, and treatment tolerance and related acute toxicities were analyzed as well.

RESULTS

We found that significantly more patients (91.73%) in the PEG group could finish two cycles of CCRT, when compared with those in the non-PEG group (57.89%) (P<0.001). We also indicated that more patients (50.38%) in the non-PEG group experienced weight loss of ≥5%, while the phenomenon was only found in 36.09% patients in the PEG group (P=0.019). In addition, the percentage of patients who lost ≥10% of their weight was similar in these two groups. Changes in albumin and prealbumin levels during radiotherapy in the non-PEG group were higher than those obtained for the PEG group with significant differences (P-values of 0.023 and <0.001, respectively). Furthermore, patients in the PEG group had significantly lower incidence of grade III acute mucositis than those in the non-PEG group (22.56% vs 36.84%, P=0.011). Tube-related complications occurred only in 14 (10.53%) patients in the PEG group, including incision infection of various degrees.

CONCLUSION

PEG and intensive nutrition support may help to minimize body weight loss, maintain nutritional status, and offer better treatment tolerance for patients with locally advanced NPC who underwent CCRT.

A Novel Prognostic Score, Based on Preoperative Nutritional Status, Predicts Outcomes of Patients after Curative Resection for Gastric Cancer

PURPOSE: We aimed to determine whether preoperative nutritional status (PNS) was a valuable predictor of outcome in patients with gastric cancer (GC).

METHODS: We retrospectively evaluated 1320 patients with GC undergoing curative resection. The PNS score was constructed based on four objective and easily measurable criteria: prognostic nutritional index (PNI) score 1, serum albumin <35 g/L, body mass index (BMI) <18.5 kg/m², or preoperative weight loss ≥5% of body weight. The PNS score was 2 for patients who met three or four criteria, 1 for those who met one or two criteria, and 0 for those who didn't meet all of these criteria.

RESULTS: The overall survival (OS) rates in patients with PNS scores 0, 1, and 2 were 59.1%, 42.4%, and 23.4%, respectively (P < 0.001). Multivariate analyses revealed the PNS was an independent predictor for OS (HR for PNS 1 and PNS 2: 1.497, 95 % CI: 1.230-1.820 and 2.434, 95 % CI: 1.773-3.340, respectively; p < 0.001). Furthermore, 5-year OS ranged from 92% (stage I) to 37% (stage III), while the combination of TNM and PNS stratified 5-year OS from 95% (TNM I, PNS 0) to 19% (TNM III, PNS 3). Of note, the prognostic significance of PNS was still maintained when stratified by TNM stage, age, sex, tumor size, anemia and adjuvant chemotherapy (All P < 0.05).

CONCLUSIONS: The PNS, a novel nutritional-based prognostic score, is independently associated with OS in GC. Prospective studies are needed to validate its clinical utility.

A Novel Inflammation- and Nutrition-Based Prognostic System for Patients with Laryngeal Squamous Cell Carcinoma: Combination of Red Blood Cell Distribution Width and Body Mass Index (COR-BMI)

Background

Laryngeal squamous cell carcinoma (LSCC) is a head and neck cancer type. In this study, we introduced a novel inflammation- and nutrition-based prognostic system, referred to as COR-BMI (Combination of red blood cell distribution width and body mass index), for LSCC patients.

Methods

A total of 807 LSCC patients (784 male and 23 female, 22–87 y of age) who underwent surgery were enrolled in this retrospective cohort study. The patients were stratified by COR-BMI into three groups: COR-BMI (0) (RDW ≤ 13.1 and BMI ≥ 25); COR-BMI (1) (RDW ≤ 13.1 and BMI < 18.5 or 18.5 ≤ BMI < 25; RDW > 13.1 and 18.5 ≤ BMI < 25 or BMI ≥ 25); or COR-BMI (2) (RDW > 13.1 and BMI < 18.5). Cox regression models were used to investigate the association between COR-BMI and cancer-specific survival (CSS) rate among LSCC patients.

Results

The 5-y, 10-y, and 15-y CSS rates were 71.6%, 60.1%, and 55.4%, respectively. There were significant differences among the COR-BMI groups in age (< 60 versus ≥ 60 y; P = 0.005) and T stage (T1, T2, T3, or T4; P = 0.013). Based on the results, COR-BMI (1 versus 0: HR = 1.76; 95% CI = 0.98–3.15; 2 versus 0: HR = 2.91; 95% CI = 1.53–5.54, P = 0.001) was a significant independent predictor of CSS.

Conclusion

COR-BMI is a novel inflammation- and nutrition-based prognostic system, which could predict long-term survival in LSCC patients who underwent surgery.

Quantitative body mass characterization before and after head and neck cancer radiotherapy: A challenge of height-weight formulae using computed tomography measurement

OBJECTIVES

We undertook a challenge to determine if one or more height-weight formula(e) can be clinically used as a surrogate for direct CT-based imaging assessment of body composition before and after radiotherapy for head and neck cancer (HNC) patients, who are at risk for cancer- and therapy-associated cachexia/sarcopenia.

MATERIALS AND METHODS

This retrospective single-institution study included 215 HNC patients, treated with curative radiotherapy between 2003 and 2013. Height/weight measures were tabulated. Skeletal muscle mass was contoured on pre- and post-treatment CT at the L3 vertebral level. Three common lean body mass (LBM) formulae (Hume, Boer, and James) were calculated, and compared to CT assessment at each time point.

RESULTS

156 patients (73%) had tumors arising in the oropharynx and 130 (61%) received concurrent chemotherapy. Mean pretreatment body mass index (BMI) was 28.5±4.9kg/m(2) in men and 27.8±8kg/m(2) in women. Mean post-treatment BMI were 26.2±4.4kg/m(2) in men, 26±7.5kg/m(2) in women. Mean CT-derived LBM decreased from 55.2±11.8kg pre-therapy to 49.27±9.84kg post-radiation. Methods comparison revealed 95% limit of agreement of ±12.5-13.2kg between CT and height-weight formulae. Post-treatment LBM with the three formulae was significantly different from CT (p<0.0001). In all instances, no height-weight formula was practically equivalent to CT within±5kg.

CONCLUSION

Formulae cannot accurately substitute for direct quantitative imaging LBM measurements. We therefore recommend CT-based LBM assessment as a routine practice of head and neck cancer patient body composition.

Impact of prophylactic percutaneous endoscopic gastrostomy tube placement on treatment tolerance in head and neck cancer patients treated with cetuximab plus radiation

OBJECTIVE

We conducted a retrospective analysis to evaluate the efficacy and safety of cetuximab plus radiation with or without prophylactic percutaneous endoscopic gastrectomy in locally advanced squamous cell carcinoma of the head and neck patients who were not suitable to receive platinum.

PATIENTS AND METHODS

We reviewed the case records of 27 locally advanced squamous cell carcinoma of the head and neck patients treated with cetuximab plus radiation (RT) between January 2013 and July 2014. No patient was able to receive platinum because of renal dysfunction or other contraindications. Patients received an initial dose of cetuximab of 400 mg/m(2), followed by weekly doses of 250 mg/m(2). The total dose of radiotherapy was 66-70 Gy in five daily fractions of 2-2.12 Gy per week.

RESULTS

The incidence of leukopenia was significantly higher in patients without percutaneous endoscopic gastrectomy placement than in those with (67.5% vs. 7%, P = 0.002). The incidence of Grade 3 or 4 mucositis tended to be higher in patients without percutaneous endoscopic gastrectomy placement than in those with (83% vs. 47%, P = 0.058). Five of twelve patients without percutaneous endoscopic gastrectomy placement required interruption of treatment. More patients without percutaneous endoscopic gastrectomy placement had significantly >10% weight loss than patients with (75% vs. 27%, P = 0.013). The overall response rate was 56% in all patients. The 1-year progression-free survival rate was 30.6% in all patients.

CONCLUSIONS

Prophylactic percutaneous endoscopic gastrectomy-feeding tube placement could reduce the incidence of severe toxicities, including mucositis and weight loss, and avoid RT interruption. These results require confirmation in a larger study.

Association of Body Composition With Survival and Locoregional Control of Radiotherapy-Treated Head and Neck Squamous Cell Carcinoma

IMPORTANCE

Major weight loss is common in patients with head and neck squamous cell carcinoma (HNSCC) who undergo radiotherapy (RT). How baseline and posttreatment body composition affects outcome is unknown.

OBJECTIVE

To determine whether lean body mass before and after RT for HNSCC predicts survival and locoregional control.

DESIGN, SETTING, AND PARTICIPANT

Retrospective study of 2840 patients with pathologically proven HNSCC undergoing curative RT at a single academic cancer referral center from October 1, 2003, to August 31, 2013. One hundred ninety patients had computed tomographic (CT) scans available for analysis of skeletal muscle (SM). The effect of pre-RT and post-RT SM depletion (defined as a CT-measured L3 SM index of less than 52.4 cm2/m2 for men and less than 38.5 cm2/m2 for women) on survival and disease control was evaluated. Final follow-up was completed on September 27, 2014, and data were analyzed from October 1, 2014, to November 29, 2015.

MAIN OUTCOMES AND MEASURES

Primary outcomes were overall and disease-specific survival and locoregional control. Secondary analyses included the influence of pre-RT body mass index (BMI) and interscan weight loss on survival and recurrence.

RESULTS

Among the 2840 consecutive patients who underwent screening, 190 had whole-body positron emission tomography-CT or abdominal CT scans before and after RT and were included for analysis. Of these, 160 (84.2%) were men and 30 (15.8%) were women; their mean (SD) age was 57.7 (9.4) years. Median follow up was 68.6 months. Skeletal muscle depletion was detected in 67 patients (35.3%) before RT and an additional 58 patients (30.5%) after RT. Decreased overall survival was predicted by SM depletion before RT (hazard ratio [HR], 1.92; 95% CI, 1.19-3.11; P = .007) and after RT (HR, 2.03; 95% CI, 1.02-4.24; P = .04). Increased BMI was associated with significantly improved survival (HR per 1-U increase in BMI, 0.91; 95% CI, 0.87-0.96; P < .001). Weight loss without SM depletion did not affect outcomes. Post-RT SM depletion was more substantive in competing multivariate models of mortality risk than weight loss-based metrics (Bayesian information criteria difference, 7.9), but pre-RT BMI demonstrated the greatest prognostic value.

CONCLUSIONS AND RELEVANCE

Diminished SM mass assessed by CT imaging or BMI can predict oncologic outcomes for patients with HNSCC, whereas weight loss after RT initiation does not predict SM loss or survival.

Critical weight loss predicts poor prognosis in nasopharyngeal carcinoma

BACKGROUND

The impacts of weight loss on prognosis in nasopharyngeal carcinoma (NPC) remain unclear. The present study was therefore undertaken to investigate the association between critical weight loss and long-term survival in NPC patients.

METHODS

The eligible 2399 NPC patients were reviewed. Weight change was categorized into critical weight loss (CWL) and non-critical weight loss (Non-CWL). The associations of CWL with long-term survival were analyzed by Cox regression in the entire patient and two subsets. Propensity score matching was performed to reduce the effects of confounding factors.

RESULTS

CWL was defined as body weight loss of ≥4.6 %. Compared with patients without CWL, patients with CWL had significantly lower 5-year OS (72.4 vs. 79.3 %, P < 0.001), FFS (71.1 vs. 78.4 %, P <0.001), and LR-FFS (78.1 vs. 84.8 %, P <0.001), respectively. After adjustment for potential confounders, CWL remained an independence prognostic factor for OS (HR = 1.352; 95 % CI 1.160-1.576; P < 0.001), FFS (HR = 3.275; 95 % CI 1.101-9.740; P = 0.033), and LR-FFS (HR = 6.620; 95 % CI 2.990-14.658; P < 0.001), respectively. Furthermore, subgroup analysis in the cohort of patients received concurrent chemoradiotherapy or radiotherapy alone confirmed the results in the entire patient even after the propensity-score matching. In IMRT cohort, CWL was also significantly associated with a lower OS (P = 0.04) and FFS (P = 0.04).

CONCLUSIONS

CWL has a significant and independent impact on long-term survival in nasopharyngeal carcinoma patients.

Spontaneous fractures of the mandible concept & treatment strategy

Background

Spontaneous fractures of the mandible dispose a surgical challenge in comparisons to fractures caused by trauma due to several complicating factors. Additionally: controversies exist concerning the terminology of the field.

Material and Methods

We conducted a retrospective study of all patients with mandibular fractures, with exclusion of fractures of the coronoid process and the alveolar process, treated at the Department of Oral and Maxillofacial Surgery, Aalborg University Hospital, Denmark between February 2003 and February 2013. Data collected from the medical records included sex, age, cause of fracture, site of fracture, and treatment.

Results

We identified 517 patients with 684 mandible fractures. Twenty-five of these were spontaneous fractures and 659 fractures were of traumatic origin. Condylar fractures rarely occur spontaneously, but constitute the majority of the traumatic fractures. Excluding these fractures from the analysis, we found a non-surgical approach in 14 of 24 (58%) of the spontaneous fractures and 110 of 376 (29%) of the traumatic fractures. This was statistically significant.

Conclusions

We found a statistical significant difference in favor of non-surgical approach in spontaneous fractures and we discussed the treatment challenges of these fractures. We addressed the terminological controversies regarding pathological fractures, and suggested the term spontaneous fractures denoting a fracture occurring during normal jaw function being either pathological or non-pathological.

Key words:Mandibular fractures, spontaneous fractures, pathological fractures, traumatic fractures, treatment.

Corilagin Attenuates Radiation-Induced Brain Injury in Mice

Cranial irradiation-induced inflammation plays a critical role in the initiation and progression of radiation-induced brain injury (RIBI). Anti-inflammation treatment may provide therapeutic benefits. Corilagin (beta-1-O-galloyl-3, 6-(R)-hexahydroxydiphenoyl-D-glucose, C₂₇H₂₂O₁₈) was a novel member of the tannin family with anti-inflammatory properties and is isolated from some medicinal plants, such as Phyllanthus amarus and Caesalpinia coriaria. In this study, the effect of Corilagin on RIBI was investigated and the underlying mechanisms were explored. Spatial learning and memory ability of mice were investigated by the Morris water maze test. Evans blue leakage and electron microscopy were used to assess the integrity of blood-brain barrier (BBB). The mRNA and protein expressions of inflammatory cytokines, TNF-α and IL-1β, were measured by using real-time PCR and Western blotting. The activation of microglial cells and expression of TNF-α were examined by immunofluorescence staining. Phosphorylated signal transducers and activators of transcription 3 (p-STAT3) and IκBα, and the translocation of p65 from cytoplasm to nucleus were detected by using Western blotting. Morris water maze test showed that Corilagin ameliorated the neurocognitive deficits in RIBI mice. Evans blue leakage and electron microscopy exhibited that Corilagin partially protected the BBB integrity from cranial irradiation-caused damage; immunofluorescence staining showed that Corilagin could inhibit microglial activation and TNF-α expression. Real-time PCR and Western blotting revealed that Corilagin downregulated the expression of TNF-α and IL-1β and inhibited the irradiation-induced activation of NF-κB pathways by upregulating p-STAT3 expression. In conclusion, Corilagin could attenuate RIBI through inhibiting microglial activation and the expressions of inflammatory cytokines. Corilagin might inhibit the activation of NF-κB pathway in a STAT3-associated manner, thereby downregulating the inflammatory cytokine expressions.

Geriatric assessment for oncologists

The world is experiencing aging of its population. Age-specific incidence rates of cancer are higher and cancer is now recognized as a part of aging. Treating older patients can be challenging. The clinical behavior of some tumors changes with age and the aging process itself brings physiological changes leading to decline in the function of organs. It is essential to identify those patients with longer life expectancy, potentially more likely to benefit from aggressive treatment vs. those that are more vulnerable to adverse outcomes. A primary determination when considering therapy for an older cancer patient is a patient's physiologic, rather than chronologic age. In order to differentiate amongst patients of the same age, it is useful to determine if a patient is fit or frail. Frail older adults have multiple chronic conditions and difficulties maintaining independence. They may be more vulnerable to therapy toxicities, and may not have substantial lasting benefits from therapy. Geriatric assessment (GA) may be used as a tool to determine reversible deficits and devise treatment strategies to mitigate such deficits. GA is also used in treatment decision making by clinicians, helping to risk stratify patients prior to potentially high-risk therapy. An important practical aspect of GA is the feasibility of incorporating it into a busy oncology practice. Key considerations in performing the GA include: available resources, patient population, GA tools to use, and who will be responsible for using the GA results and develop care plans. Challenges in implementing GA in clinical practice will be discussed.

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.

Prediction of critical weight loss during radiation treatment in head and neck cancer patients is dependent on BMI

PURPOSE

The aims of the present study were to explore pre-treatment predictors of weight loss during radiation treatment only in head and neck cancer (HNSCC) patients and investigate the weight loss in patients with or without a feeding tube.

METHODS

Retrospectively, weight change during curative radiotherapy was investigated in 476 consecutive HNSCC patients. Independent predictors were identified using multivariate regression analysis with weight loss below or above 5 % as the primary dependent variable.

RESULTS

Baseline BMI, tumor site, and stage predicted weight loss above 5 %. The odds of weight loss above 5 % in patients with BMI >25 were 3.00 ± 0.64 times higher compared with patients with BMI <25 (p < 0.0001). Patients with pharyngeal, oral cavity, or supraglottic tumors had 3.12 ± 0.80 times higher odds of weight loss above 5 % compared with glottic cancer patients (p < 0.0001), and the odds were 1.68 ± 0.40 times higher in stage III-IV patients compared with stage I-II patients (p = 0.03). Seperate analyses revealed that tumor site and stage only predicted weight loss in patients with BMI >25 but not in patients with BMI <25. Patients receiving a feeding tube weighed less than patients without (73.8 vs 78.3 kg) and feeding tube reduced, but did not prevent, weight loss which averaged 6.7 ± 4.7 kg (7.4 ± 4.7 %) compared with 4.7 ± 5.9 kg (5.5 ± 6.0 %) in patients without a feeding tube (P < 0.0001).

CONCLUSION

Pre-treatment BMI, tumor site and stage predicted weight loss above 5 % in HNSCC patients during radiotherapy. BMI should be considered when analyzing weight loss in HNSCC patients receiving curative radiotherapy.

New radiotherapy techniques do not reduce the need for nutrition intervention in patients with head and neck cancer

BACKGROUND/OBJECTIVES

Since 2007, our institution has used validated guidelines for the insertion of proactive gastrostomy feeding tubes in patients with head and neck cancer. Helical intensity-modulated radiotherapy (H-IMRT) delivered by Tomotherapy, is an advanced radiotherapy technique introduced at our centre in 2010. This form of therapy reduces long-term treatment-related toxicity to normal tissues. The aim of this study is to compare weight change and need for tube feeding following H-IMRT (n=53) with patients that would have previously been treated with three-dimensional conformal radiotherapy (n=134).

SUBJECTS/METHODS

Patients with head and neck cancer assessed as high nutritional risk with recommendation for proactive gastrostomy were identified from cohorts from 2007 to 2008 and 2010 to 2011. Retrospective data were collected on clinical factors, weight change from baseline to completion of treatment, incidence of severe weight loss (⩾ 10%) and tube feeding. Statistical analyses to compare outcomes between the two treatments included χ(2)-test, Fisher's exact and two-sample Wilcoxon tests (P<0.05).

RESULTS

The H-IMRT cohort had higher proportions of patients with definitive chemoradiotherapy (P=0.032) and more advanced N stage (P<0.001). Nutrition outcomes were not significantly different between H-IMRT and conformal radiotherapy, respectively: need for proactive gastrostomy (n=49, 92% versus n=115, 86%, P=0.213), median percentage weight change (-7.2% versus -7.3%, P=0.573) and severe weight loss incidence (28% versus 27%, P=0.843).

CONCLUSIONS

Both groups had median weight loss >5% and high incidences of tube feeding and severe weight loss. Nutrition intervention remains critical in this patient population, despite advances in radiotherapy techniques, and no changes to current management are recommended.

Predictors of Survival in Ampullary, Bile Duct and Duodenal Cancers Following Pancreaticoduodenectomy: a 10-Year Multicentre Analysis

INTRODUCTION

Predictors of survival following pancreaticoduodenectomy (PD) are well described for pancreatic cancers but are less detailed in ampullary (AC), bile duct (BDC) and duodenal cancers (DC). We therefore sought to evaluate the long-term results of PD for AC, BDC and DC, and to determine for each tumour the predictive factors of survival.

METHODS

Medical charts of patients operated on between 2001 and 2011 were retrospectively reviewed. Univariate and multivariate analyses were performed to determine predictors of survival.

RESULTS

One hundred thirty-five patients were identified. Mean follow-up was 47 ± 33 months. Median survival was not reached for DC and was 66 and 24 months for AC and BDC, respectively. Two-year and five-year survival rates were 80 and 51% for DC and 69 and 51% for AC, respectively. BDC had a significantly poorer prognosis, with two-year and five-year survival rates of 51 and 34%, respectively. Predictors of survival were weight loss, N stage and International Union Against Cancer (UICC) stage for AC, T stage and resection margin status for BDC and N stage for DC.

CONCLUSION

AC, BDC and DC display distinctive predictors of survival related to the biological aggressiveness. Preoperative malnutrition worsens the prognosis. The effect of adapted nutritional management on the survival improvement has to be studied.

Evaluation of effect of body mass index and weight loss on survival of patients with nasopharyngeal carcinoma treated with intensity-modulated radiation therapy

BACKGROUND

Previous studies report body-mass index (BMI) and percent weight loss (WL) to have prognostic significance when treating patients with nasopharyngeal carcinoma (NPC). However, most of these investigations studied patients treated using different radiotherapeutic techniques. We evaluated the predictive effect of these two nutrition-related measurements on therapeutic outcome in NPC patients who only received intensity-modulated radiation therapy (IMRT) as part of their total treatment program.

METHODS

We retrospectively studied NPC patients treated with IMRT from January 2006 to February 2012. Cox proportional hazards was used to test the association of pretreatment BMI (<23 kg/m(2) vs. ≥23 kg/m(2)) and percent weight loss (≥5 % vs. <5 %) during therapy and related survival rates while controlling for various potential confounders.

RESULTS

Eighty-one (34 %) of the 238 patients had BMIs ≥23 kg/m(2) at pretreatment and 150 (63 %) had significant (≥5 %) weight loss. Median follow-up time was 41.71 months; median radiotherapy was 7.46 ± 0.77 weeks. Those with BMIs ≥23 kg/m(2) did not have a better 3-year overall survival (p = 0.672), 3-year disease specific survival (p = 0.341), 3-year locoregional free survival (p = 0.281), or 3-year distant metastatic free survival (p = 0.134). Those with significant WL (≥5 %) did not have worse 3-year clinical endpoints, even after stratifying magnitude of weight loss by BMI category. In sensitivity test, the adjusted hazard ratio remained statistically insignificant using different cutoffs for BMIs and percent weight loss.

CONCLUSIONS

This study found no significant relationship between BMI and percent weight loss on survival of NPC patients receiving IMRT based therapy. Further studies might want to consider other nutrition related factors as prognostic indicators when studying the correlate between malnutrition and survival in this population.

Influence of body composition on survival in patients with head and neck cancer

BACKGROUND

Recent evidence has suggested links between obesity and outcomes for various types of cancer. This study investigates the impact that body composition has on survival in patients with head and neck cancer.

METHODS

Data prospectively collected from 578 patients were analyzed using Cox regression models to determine independent associations that pretreatment body mass index (BMI) and 3-month weight change have on observed survival.

RESULTS

Higher BMIs were associated with better survival (p < .001). Five-year rates ranged from 33.8% for underweight to 75.3% for overweight/obese patients. Patients with stable weight had the highest 5-year rate (72.6%; p = .019), whereas patients who gained ≥5% had worse survival (45.8%) than those who lost ≥5% (65.8%). BMI independently predicted survival, whereas weight change was not an independent predictor.

CONCLUSION

This demonstrated association between BMI and survival provides useful information when offering prognoses and investigating optimal treatments © 2015 Wiley Periodicals, Inc. Head Neck 38: E261-E267, 2016.

Pretreatment body mass index and head and neck cancer outcome: A review of the literature

BACKGROUND

The prevalence of overweight and obesity defined as BMI≥25kg/m(2) is increasing, also among head and neck cancer patients. It is unknown whether the presence of high BMI influences disease-related mortality, overall survival and recurrence in these patients.

METHODS

We reviewed available literature using Pubmed and Web of Science. Human observational studies were included if they reported the impact of high BMI on mortality, recurrence or survival for head and neck cancer.

RESULTS

Eleven full articles and two abstracts met the inclusion criteria: six prospective and seven retrospective cohort studies, which comprised 8.306 patients. Patients with higher BMI had increased overall survival and decreased disease-related mortality and recurrence rate compared with underweight and normal weight patients. Most studies were adjusted for potentially confounding variables, such as stage of disease and smoking habits.

CONCLUSION

High BMI is associated with a better outcome in head and neck cancer.

Predictors of 1-Year Mortality in a Prospective Cohort of Elderly Patients With Cancer

BACKGROUND

Mortality prediction is crucial to select the optimal treatment in elderly cancer patients. Our objective was to identify cancer-related factors and Comprehensive Geriatric Assessment (CGA) findings associated with 1-year mortality in elderly inpatients and outpatients with cancer.

METHODS

We prospectively included patients aged ≥70 years who had solid or hematologic malignancies and in whom the CGA was performed by geriatricians in two French teaching hospitals. We identified independent predictors of 1-year mortality after study inclusion, using multivariate Cox models stratified on inpatient/outpatient status. We built three multivariate Cox models, since strong correlations linked activities of daily living (ADL), Eastern Cooperative Oncology Group Performance Status (ECOG-PS), and timed get-up-and-go test (GUG) results; and since physicians' preferences for these three assessments vary. A sensitivity analysis was performed using multiple imputation.

RESULTS

Of the 993 patients (mean age, 80.2 years; 51.2% men), 58.2% were outpatients and 46% had metastatic disease. Colorectal cancer was the most common malignancy (21.4%). Mortality rates after 6 and 12 months were 30.1% and 41.2%, respectively. In all models, tumor site and metastatic status (p < .001), age >80 years (p < .05), higher number of severe comorbidities (p < .05), and malnutrition (p < .001) were associated with death independently from impaired ECOG-PS (p < .001), ADL (p < .001), and GUG (p < .001). The adverse effect of metastatic status differed significantly across tumor sites, being greatest for breast and prostate cancer (p < .001). Multiple imputation produced similar results.

CONCLUSION

The predictors of 1-year mortality identified in our study may help physicians select the optimal cancer-treatment strategy in elderly patients.

Malnutrition and cachexia in patients with head and neck cancer treated with (chemo)radiotherapy

AIM

To highlight the problems associated with nutrition that occur in patients with squamous cell carcinoma of the head and neck (SCCHN).

BACKGROUND

SCCHN is associated with weight loss before, during and after radiotherapy or concurrent chemoradiotherapy. Because of serious consequences of malnutrition and cachexia on treatment outcome, mortality, morbidity, and quality of life, it is important to identify SCCHN patients with increased risk for the development of malnutrition and cachexia.

MATERIALS AND METHODS

Critical review of the literature.

RESULTS

This review describes pathogenesis, diagnosis and treatment of malnutrition and cancer cachexia. Treatment of malnutrition and cancer cachexia includes nutritional interventions and pharmacological therapy. Advantages and disadvantages of different nutritional interventions and their effect on the nutritional status, quality of life and specific oncological treatment are presented.

CONCLUSIONS

Nutritional management is an essential part of care of these patients, including early screening, assessment of nutritional status and appropriate intervention.

Impact of weight loss on survival after chemoradiation for locally advanced head and neck cancer: secondary results of a randomized phase III trial (SAKK 10/94)

Background

To analyze the impact of weight loss before and during chemoradiation on survival outcomes in patients with locally advanced head and neck cancer.

Methods

From 07/1994-07/2000 a total of 224 patients with squamous cell carcinoma of the head and neck were randomized to either hyperfractionated radiation therapy alone or the same radiation therapy combined with two cycles of concomitant cisplatin. The primary endpoint was time to any treatment failure (TTF); secondary endpoints were locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMFS) and overall survival (OS). Patient weight was measured 6 months before treatment, at treatment start and treatment end.

Results

The proportion of patients with >5% weight loss was 32% before, and 51% during treatment, and the proportion of patients with >10% weight loss was 12% before, and 17% during treatment. After a median follow-up of 9.5 years (range, 0.1 – 15.4 years) weight loss before treatment was associated with decreased TTF, LRRFS, DMFS, cancer specific survival and OS in a multivariable analysis. However, weight loss during treatment was not associated with survival outcomes.

Conclusions

Weight loss before and during chemoradiation was commonly observed. Weight loss before but not during treatment was associated with worse survival.

Integrated analysis of serum and intact muscle metabonomics identify metabolic profiles of cancer cachexia in a dynamic mouse model

An integrated analysis of 13 metabolites from the intact muscle gastrocnemius and 43 metabolites from the serum reveals five distinguishable metabolic features of cancer cachexia.

Conventional stents versus stents loaded with (125)iodine seeds for the treatment of unresectable oesophageal cancer: a multicentre, randomised phase 3 trial

BACKGROUND

The combination of stent insertion and single high-dose brachytherapy is a feasible and safe palliative treatment regimen in patients with unresectable oesophageal cancer. We aimed to further assess the efficacy of this treatment strategy compared to a conventional covered stent in patients with dysphagia caused by unresectable oesophageal cancer.

METHODS

In this multicentre, single-blind, randomised, phase 3 trial, we enrolled patients with unresectable oesophageal cancer from 16 hospitals in China. We included adult patients (aged ≥ 20 years) with progressive dysphagia, unresectable tumours due to extensive lesions, metastases, or poor medical condition, and with clear consciousness, cooperation, and an Eastern Cooperative Oncology Group (ECOG) performance status score of 0-3. Eligible patients were randomly assigned (in 1:1 ratio, no stratification) to receive either a stent loaded with (125)iodine radioactive seeds (irradiation group) or a conventional oesophageal stent (control group). The primary endpoint was overall survival. Survival analyses were done in a modified intention-to-treat group. This study is registered with ClinicalTrials.gov, number NCT01054274.

FINDINGS

Between Nov 1, 2009, and Oct 31, 2012, 160 patients were randomly assigned to receive treatment with either an irradiation stent (n=80) or a conventional stent (n=80). During a median follow-up of 138 days (IQR 72-207), 148 stents (73 in the irradiation group and 75 in the control group) were successfully placed into the diseased oesophagus in 148 participants. Median overall survival was 177 days (95% CI 153-201) in the irradiation group versus 147 days (124-170) in the control group (p=0.0046). Major complications and side-effects of the treatment were severe chest pain (17 [23%] of 73 patients in the irradiation group vs 15 [20%] of 75 patents in the control group), fistula formation (six [8%] vs five [7%]), aspiration pneumonia (11 [15%] vs 14 [19%]), haemorrhage (five [7%] vs five [7%]), and recurrent dysphagia (21 [28%] vs 20 [27%]).

INTERPRETATION

In patients with unresectable oesophageal cancer, the insertion of an oesophageal stent loaded with (125)iodine seeds prolonged survival when compared with the insertion of a conventional covered self-expandable metallic stent.