Impact of nutrition on outcome: a prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy

Effects of high-protein supplementation during cancer therapy: a systematic review and meta-analysis

BACKGROUND

Establishing the effectiveness of high-protein supplementation in reducing cancer-related side effects is crucial.

OBJECTIVE

The study aimed to assess the effectiveness and safety of high-protein supplementation on clinical outcomes of patients undergoing cancer therapy.

METHODS

Systematic searches were conducted on Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane Central Register of Controlled Trials, and Scopus from inception until July 2023. Randomized controlled trials administering supplements with ≥10 g protein/serving, given to 20+ adult patients undergoing cancer therapy were included. Random-effects meta-analyses were used to estimate the effects of high-protein supplementation on the primary outcomes of body weight and health-related quality of life (HRQoL). We employed a vote-counting approach based on effect direction for secondary outcomes (that is, body composition, muscle function, hospitalization, response to cancer therapy/toxicity, survival, and systemic inflammation). Risk-of-bias (ROB) was assessed.

RESULTS

Thirty-five studies involving 3701 patients with diverse cancer types were included. Patients who received high-protein supplementation lost less body weight than controls (mean difference = 1.45 kg; 95% CI: 0.42, 2.48 kg; P = 0.006; I2 = 80%). No differences in HRQoL were observed; all studies assessing HRQoL were rated as high ROB. A beneficial effect on muscle mass was found in 11 of 13 studies, although most had a high ROB due to assessment techniques. When considering higher quality studies, evidence of a beneficial effect was found in 5 of 5 studies for muscle strength, and 3 of 4 for hospitalization rate. Effects on other secondary outcomes were inconsistent or limited. No serious adverse effects were reported.

CONCLUSIONS

High-protein supplementation mitigates weight loss, improves muscle strength, and lowers hospitalization rates in patients undergoing cancer therapy. These positive clinical outcomes, along with a favorable safety profile, suggest that high-protein supplementation may be a valuable addition to medical practice. However, given the need for more robust trials and the high ROB observed in the existing studies, these conclusions should be interpreted with caution. This review was prospectively registered with PROSPERO under the registration number CRD42021237372.

Taste and smell are associated with dietary intake, eating behavior, nutritional status, and health-related quality of life in children with cancer

BACKGROUND & AIMS

Smell and taste changes are frequently reported bothersome treatment symptoms during treatment for childhood cancer and assumed to influence outcomes such as food intake. Since nutritional status of children with cancer is already vulnerable, any detrimental effects on food intake should be prevented. Therefore, understanding the exact relationship between chemosensory changes and dietary intake, eating behavior, and other domains such as health-related quality of life (HRQoL), is important for improving outcomes.

METHODS

In this longitudinal study, we followed 87 childhood cancer patients treated for hematological, solid, or brain malignancies. Smell (odor threshold and odor identification) and taste function (total taste score) were objectively investigated using commercial Sniffin' Sticks and Taste Strips respectively, and by self-report. Dietary intake was measured using a 3-day food dairy. For nutritional status, BMI expressed as standard deviation scores was derived from medical records. Eating behavior and HRQoL were assessed by the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) and PedsQL 4.0 Generic Core Scales, respectively. Measurements were taken approximately 6 weeks (T0), 3 months (T1), 6 months after starting chemotherapy (T2), and 3 months after termination of chemotherapy or maintenance phase for children with acute lymphoblastic leukemia (ALL) (T3). Dietary intake, eating behavior, nutritional status, and HRQoL were modelled over time using mixed model analysis. Associations between smell and taste (objective and self-report), as well as patient characteries were studied.

RESULTS

Energy intake significantly increased during the study period, with a higher age, BMI, and total taste scores associated to this increase. Boys had higher energy intake compared to girls. Eating behavior scores significantly declined, indicating less eating problems. Age, pre-diagnosis eating behavior, self-reported smell changes, and tube feeding were associated to eating behavior. BMI significantly increased, with a higher BMI at diagnosis to be related to a higher BMI during the study period. A lower BMI was found in children receiving tube feeding and self-reported taste changes. HRQoL improved during the study period, with lower HRQoL in children receiving tube feeding and self-reported taste changes.

CONCLUSION

Both objective and subjective measures of taste and smell influence dietary intake, eating behavior, nutritional status, and HRQoL. Individual dietary advice and coping strategies are warranted to prevent detrimental effects of chemosensory changes on food intake and clinical outcomes in children with cancer.

A prognostic nomogram for patients with III-IV nasopharyngeal carcinoma based on dynamic changes in the inflammatory and nutrition index

BACKGROUND

The purpose of the study was to explore the value of dynamic changes in inflammatory and nutritional index after comprehensive treatment in patients with stage III-IVA nasopharyngeal carcinoma (NPC). A prognostic model was also established and validated for progression-free survival (PFS) of patients.

METHODS

We retrospectively selected 279 NPC patients with stage III-IVA. Their general clinical data and hematological index were collected and then calculated the changes during treatment. X-tile software was used to determine the optimal cut-off value. COX regression, Lasso method, and Boruta method were used to variable selection and model establishment. Using the bootstrap internal validation method, concordance index (C-index), calibration plot, and Kaplan-Meier curves were used to evaluate the model. To test the prognostic value of the model, we have also evaluated the performance of the nomogram against a conventional tumor metastasis staging system (TNM).

RESULTS

Multivariable COX regression analysis demonstrated that clinical staging, delta lymphocyte, delta monocyte, delta albumin, delta platelet-to-lymphocyte ratio and delta systemic immune inflammation index were related to the PFS of NPC patients. The C-index of the model was 0.712, and the calibration curve indicated that the model had good consistency. The C-index of the TNM staging system was 0.597, which was considerably lower compared to our model (P = 0.015).

CONCLUSION

We demonstrated the predictive value of dynamic changes in inflammatory and nutritional indices for the prognosis of NPC by successfully establishing and validating a prognostic model for predicting 1- and 3-year PFS after comprehensive treatment in patients with stage III-IVA NPC.

The Role of Oral Nutritional Supplements in Head and Neck Cancer Patients Undergoing Chemoradiotherapy

PURPOSE

This study aimed to assess the impact of oral nutritional supplements (ONS) on nutritional intake, body weight, and body composition in head and neck cancer (HNC) patients undergoing chemoradiotherapy. The study evaluated whether ONS could prevent treatment-related nutritional deterioration.

METHODS

This prospective observational pilot study included 30 HNC patients randomized into two groups: ONS (n = 15) and No ONS (n = 15). All participants underwent chemoradiotherapy, with the ONS group receiving 200 mL of a high-calorie, high-protein supplement twice daily. Nutritional status, including body weight, BMI, fat mass, fat-free mass, and bone mass, was assessed at three time points: baseline, mid-treatment, and end of treatment. Data were analyzed using the Mann-Whitney U test, with a p-value of ≤0.05 considered statistically significant.

RESULTS

At baseline, there were no significant differences between the two groups in body weight, BMI, or body composition. By the end of radiotherapy, the No ONS group showed significant reductions in body weight (p < 0.001), BMI (p < 0.001), fat mass (p < 0.001), and fat-free mass (p < 0.001), while the ONS group maintained more stable nutritional parameters. Acute radiotherapy toxicities, including nausea, dysphagia, and oral mucositis, were not significantly different between the two groups.

CONCLUSION

ONS effectively mitigates weight loss and preserves body composition in HNC patients undergoing chemoradiotherapy. While no significant reduction in radiation-induced toxicities was observed, the nutritional benefits of ONS support its use in preventing malnutrition in this patient population. Larger studies are needed to further validate these findings.

Prevention of weight loss in patients with head and neck cancer in ongoing radiation or chemoradiation therapy-A systematic review and meta-analysis

PURPOSE

This systematic review (PROSPERO: CRD4202345740) identified and synthesised existing evidence on nutrition interventions performed by healthcare professionals, and the contents of the interventions that prevented weight loss in patients with HNC undergoing RT/CRT.

METHODS

We included quantitative studies. PubMed, CINAHL, Cochrane Library, and Scopus were searched, and the outcomes of interest were weight change and nutritional status. A narrative synthesis was undertaken to elaborate on the findings across the included studies. Furthermore, a meta-analysis was conducted.

RESULTS

A total of 27 studies were identified. Most focused on the effect of oral nutritional supplements (ONS) and individualised nutrition counselling (INC). A beneficial effect of ONS combined with weekly INC were identified, and compliance, management of adverse effects, involvement of family as well as the knowledge and approach of the healthcare professionals were identified as key elements when supporting the management of nutrition intake in HNC patients during RT/CRT. The meta-analysis showed a non-significant effect of ONS, yet significant when combined with INC, and no overall effect of INC, but significant effect in the RCTs.

CONCLUSION

Our results suggest an optimal effect of ONS combined with weekly INC, requiring a focus on enhancing compliance as well as support from a multidisciplinary team to manage adverse treatment effects. Compliance must be emphasised to provide maximum support to the patient, as well as focus on the knowledge of the health care professionals performing the intervention. Further research on strategies to enhance patient compliance and involvement is needed.

Dietary Counseling Interventions During Radiation Therapy: A Systematic Review of Feasibility, Safety, and Efficacy

Radiotherapy is a common cancer treatment, and concurrent nutritional interventions can maintain nutritional status and improve clinical and supportive care outcomes. However, optimal nutritional interventions during radiotherapy are not firmly established. Herein, we assessed the feasibility, safety, and efficacy of dietary counseling interventions without oral nutrition supplements on health outcomes in adults receiving radiotherapy for cancer in a systematic review. Prospective clinical trials that implemented nutritional counseling interventions during radiotherapy were identified from four databases from inception through December 2023. Feasibility, safety, and efficacy were extracted from 32 articles that described 23 randomized and 4 non-randomized clinical trials. The interventions included individualized nutritional counseling (n = 14 articles), nutritional counseling plus exercise (n = 4), and nutritional counseling focused on increasing or reducing intake of specific nutrients (n = 9). Trials targeted head and neck (n = 12), pelvic cancers (n = 14), and/or breast (n = 5) cancers. Control groups had variable designs and included general nutrition education and intervention as needed. Studies recruited 120 ± 104 participants (range 26-468). Interventions tended to be feasible regarding retention and attendance at sessions, though feasibility metrics varied among different interventions. Most interventions were safe with no studies reporting adverse events attributable to dietary intervention. Individualized dietary counseling interventions tended to lead to between-group differences favoring the intervention group in regard to improved nutritional status, maintenance or attenuation of loss of body mass, improved quality of life, and reduced radiation-induced toxicities. Diets that encouraged/discouraged specific nutrients tended to recruit patients receiving radiation to the pelvic area and resulted in positive or neutral effects on gastrointestinal symptoms. In conclusion, nutritional interventions appear to be feasible, safe, and effective during radiotherapy for various symptom outcomes.

The nutritional impact of metallic taste in head and neck cancer patients: explorations and clinical implications

PURPOSE

Metallic taste (MT) is frequently observed during head and neck cancer treatments, but very little is known about its impact on nutritional status. The aim of this study was to explore the impact of MT on the quality of life and nutritional status in patients with head and neck cancer expressing MT.

METHODS

Questionnaires on quality of life, MT, weight, and food intake were filled out by 44 patients with head and neck cancer before, during, and up to 1 year after their treatment. Patients were divided into two groups based on their reported experience of MT.

RESULTS

MT was commonly observed (n = 12, 27.2%), always during the treatment phase, and mostly linked with radiotherapy or radiochemotherapy. Reported MT intensity was moderate (n = 6, 40%) to high (n = 4, 26.7%). MT had a significant negative impact on quality of life linked to dysgeusia (p = 0.025). The negative impacts of MT on food intake and on weight were not significant, possibly due to a combination of sample size, dropouts, and duration of observation. Further research in this area could provide additional insights into how to better address the issue related to MT and enhance the quality of care provided to this patient population.

CONCLUSION

Metallic taste, experienced by 27.2% of the 44 patients with head and neck cancer, contributes to dysgeusia and results in a significant decline in quality of life associated with dysgeusia.

TRIAL REGISTRATION

ClinicalTrials.gov trial registration number: NCT03558789.

Assessment of the Dietary Intake Changes in Patients with Head and Neck Cancer Treated with Radical Radiotherapy

BACKGROUND

Patients during radiotherapy due to head and neck cancers experience a lot of side effects which may have a considerable impact on the patients' ability to meet individual daily energy demands by means of oral diet.

METHODS

The study included 104 head and neck cancer patients who qualified for radical radiotherapy. Radical treatment takes 6 weeks and every week the patients were assessed for dietary intake. The subjects were covered with the constant care of a dietician, received FSMP (food for special medical purposes), and, if necessary, enteral nutrition.

RESULTS

In the first week of treatment, the patients, from the kitchen diet alone, met 91.5% of the energy demand, while in the last week of treatment, only 40.9%. After introducing the FSMP or enteral nutrition, the patients met 120% of the demand in the first week of therapy and 95% in the last week, respectively. The patients who followed the dietary recommendations were characterized by significantly lower weight loss (3.07 kg) compared to non-adherent patients (5.56 kg).

CONCLUSIONS

The used therapy significantly contributed to decreasing nutritional intake in the subsequent weeks of treatment. On the other hand, incorporating FSMP in the diet and enteral nutrition with industrial diets significantly increased the fulfilled energy demand of patients.

Quality of life endpoints in cancer cachexia clinical trials: Systematic review 3 of the cachexia endpoints series

The use of patient-reported outcomes (PROMs) of quality of life (QOL) is common in cachexia trials. Patients' self-report on health, functioning, wellbeing, and perceptions of care, represent important measures of efficacy. This review describes the frequency, variety, and reporting of QOL endpoints used in cancer cachexia clinical trials. Electronic literature searches were performed in Medline, Embase, and Cochrane (1990-2023). Seven thousand four hundred thirty-five papers were retained for evaluation. Eligibility criteria included QOL as a study endpoint using validated measures, controlled design, adults (>18 years), ≥40 participants randomized, and intervention exceeding 2 weeks. The Covidence software was used for review procedures and data extractions. Four independent authors screened all records for consensus. Papers were screened by titles and abstracts, prior to full-text reading. PRISMA guidance for systematic reviews was followed. The protocol was prospectively registered via PROSPERO (CRD42022276710). Fifty papers focused on QOL. Twenty-four (48%) were double-blind randomized controlled trials. Sample sizes varied considerably (n = 42 to 469). Thirty-nine trials (78%) included multiple cancer types. Twenty-seven trials (54%) featured multimodal interventions with various drugs and dietary supplements, 11 (22%) used nutritional interventions alone and 12 (24%) used a single pharmacological intervention only. The median duration of the interventions was 12 weeks (4-96). The most frequent QOL measure was the EORTC QLQ-C30 (60%), followed by different FACIT questionnaires (34%). QOL was a primary, secondary, or exploratory endpoint in 15, 31 and 4 trials respectively, being the single primary in six. Statistically significant results on one or more QOL items favouring the intervention group were found in 18 trials. Eleven of these used a complete multidimensional measure. Adjustments for multiple testing when using multicomponent QOL measures were not reported. Nine trials (18%) defined a statistically or clinically significant difference for QOL, five with QOL as a primary outcome, and four with QOL as a secondary outcome. Correlation statistics with other study outcomes were rarely performed. PROMs including QOL are important endpoints in cachexia trials. We recommend using well-validated QOL measures, including cachexia-specific items such as weight history, appetite loss, and nutritional intake. Appropriate statistical methods with definitions of clinical significance, adjustment for multiple testing and few co-primary endpoints are encouraged, as is an understanding of how interventions may relate to changes in QOL endpoints. A strategic and scientific-based approach to PROM research in cachexia trials is warranted, to improve the research base in this field and avoid the use of QOL as supplementary measures.

Impact of nutrition counseling on nutrition status in patients with head and neck cancer undergoing radio- or radiochemotherapy: a systematic review

PURPOSE

In this systematic review, we included randomized controlled trials from 2004 to 2021 to determine the effect of individual dietary counseling for patients with head and neck cancer, specifically, nutritional outcome, morbidity, and quality of life (QOL), during and after chemo- and chemoradiotherapy.

METHODS

In October 2023, a systematic search was conducted searching five electronic databases (Embase, Cochrane, PsychInfo, CINAHL, and Medline) to find studies concerning the use and effectiveness of intensive nutritional care on head and neck cancer patients.

RESULTS

From all 2565 search results, 6 studies with 685 head and neck cancer patients were included in this systematic review. The patients were treated with radiotherapy or radiochemotherapy. The therapy concepts include intensive nutritional support from a dietician. Outcomes were nutritional status, body composition, quality of life, and adverse effect. All studies had low quality, high risk of bias, and reported heterogeneous results: some studies reported significant improved nutrition status, body composition and quality of life, while other studies did not find any changes concerning these endpoints.

CONCLUSION

Due to the very heterogeneous results and methodical limitations of the included studies, a clear statement regarding the effectiveness of intensive nutritional therapy of head and neck cancer patients is not possible. Further well-planned studies are needed.

Appetite and dietary intake endpoints in cancer cachexia clinical trials: Systematic Review 2 of the cachexia endpoints series

There is no consensus on the optimal endpoint(s) in cancer cachexia trials. Endpoint variation is an obstacle when comparing interventions and their clinical value. The aim of this systematic review was to summarize and evaluate endpoints used to assess appetite and dietary intake in cancer cachexia clinical trials. A search for studies published from 1 January 1990 until 2 June 2021 was conducted using MEDLINE, Embase and Cochrane Central Register of Controlled Trials. Eligible studies examined cancer cachexia treatment versus a comparator in adults with assessments of appetite and/or dietary intake as study endpoints, a sample size ≥40 and an intervention lasting ≥14 days. Reporting was in line with PRISMA guidance, and a protocol was published in PROSPERO (2022 CRD42022276710). This review is part of a series of systematic reviews examining cachexia endpoints. Of the 5975 articles identified, 116 were eligible for the wider review series and 80 specifically examined endpoints of appetite (65 studies) and/or dietary intake (21 studies). Six trials assessed both appetite and dietary intake. Appetite was the primary outcome in 15 trials and dietary intake in 7 trials. Median sample size was 101 patients (range 40-628). Forty-nine studies included multiple primary tumour sites, while 31 studies involved single primary tumour sites (15 gastrointestinal, 7 lung, 7 head and neck and 2 female reproductive organs). The most frequently reported appetite endpoints were visual analogue scale (VAS) and numerical rating scale (NRS) (40%). The appetite item from the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30/C15 PAL (38%) and the appetite question from North Central Cancer Treatment Group anorexia questionnaire (17%) were also frequently applied. Of the studies that assessed dietary intake, 13 (62%) used food records (prospective registrations) and 10 (48%) used retrospective methods (24-h recall or dietary history). For VAS/NRS, a mean change of 1.3 corresponded to Hedge's g of 0.5 and can be considered a moderate change. For food records, a mean change of 231 kcal/day or 11 g of protein/day corresponded to a moderate change. Choice of endpoint in cachexia trials will depend on factors pertinent to the trial to be conducted. Nevertheless, from trials assessed and available literature, NRS or EORTC QLQ C30/C15 PAL seems suitable for appetite assessments. Appetite and dietary intake endpoints are rarely used as primary outcomes in cancer cachexia. Dietary intake assessments were used mainly to monitor compliance and are not validated in cachexia populations. Given the importance to cachexia studies, dietary intake endpoints must be validated before they are used as endpoints in clinical trials.

[French national standard for the treatment of squamous cell carcinoma of upper aero-digestive tract - General principles of treatment]

OBJECTIVES

The management of upper aerodigestive tract cancers is a complex specialty. It is essential to provide an update to establish optimal care. At the initiative of the INCa and under the auspices of the SFORL, the scientific committee, led by Professor Béatrix Barry, Dr. Gilles Dolivet, and Dr. Dominique De Raucourt, decided to develop a reference framework aimed at defining, in a scientific and consensus-based manner, the general principles of treatment for upper aerodigestive tract cancers applicable to all sub-locations.

METHODOLOGY

To develop this framework, a multidisciplinary team of practitioners was formed. A systematic analysis of the literature was conducted to produce recommendations classified by grades, in accordance with the standards of the French National Authority for Health (HAS).

RESULTS

The grading of recommendations according to HAS standards has allowed the establishment of a reference for patient care based on several criteria. In this framework, patients benefit from differentiated care based on prognostic factors they present (age, comorbidities, TNM status, HPV status, etc.), conditions of implementation, and quality criteria for indicated surgery (operability, resectability, margin quality, mutilation, salvage surgery), as well as quality criteria for radiotherapy (target volume, implementation time, etc.). The role of medical and postoperative treatments was also evaluated based on specific criteria. Finally, supportive care must be organized from the beginning and throughout the patients' care journey.

CONCLUSION

All collected data have led to the development of a comprehensive framework aimed at harmonizing practices nationally, facilitating decision-making in multidisciplinary consultation meetings, promoting equality in practices, and providing a state-of-the-art and reference practices for assessing the quality of care. This new framework is intended to be updated every 5 years to best reflect the latest advances in the field.

Clinical usefulness of the patient-generated subjective global assessment short form© for nutritional screening in patients with head and neck cancer: a multicentric study

Nutritional screening and assessment are considered essential steps in nutritional care for cancer patients, malnutrition remains underreported in clinical practice. The aim of this study was to analyse the clinical usefulness of the Patient-Generated Subjective Global Assessment short form (PG-SGA SF©) for nutritional screening in patients with head and neck cancer (HNC). This is a multicentre, cross-sectional study involving patients with HNC. The final score of the PG-SGA SF© was obtained and the nutritional status was diagnosed using the Patient-Generated Subjective Global Assessment (PG-SGA)®, classifying them as well-nourished or malnourished. Receiver operating characteristic curve, ordinal logistic regression, and C-statistic were used. In total, 353 patients with HNC were enrolled and the prevalence of malnutrition, according to the PG-SGA®, was 64.02% and the median final score of PG-SGA SF© was 11 points. The final score of the PG-SGA SF© had high accuracy (area under the curve = 0.915), and scores ≥9 had the best performance in diagnosing malnutrition. PG-SGA SF© final score ≥9 was associated with malnutrition (odds ratio = 28.32, 95% confidence interval= 15.98-50.17), with excellent discriminatory power (C-statistic = 0.872). In conclusion, the PG-SGA SF© demonstrated excellent performance for nutritional screening in patients with HNC. Given that it is a simple instrument that is faster to administer than the PG-SGA®, we recommend its use in clinical practice among such patients.

Ultrasound Muscle Evaluation for Predicting the Prognosis of Patients with Head and Neck Cancer: A Large-Scale and Multicenter Prospective Study

Head and neck cancer (HNC) is a prevalent and aggressive form of cancer with high mortality rates and significant implications for nutritional status. Accurate assessment of malnutrition in patients with HNC is crucial for optimizing treatment outcomes and improving survival rates. This study aimed to evaluate the use of ultrasound techniques for predicting nutritional status, malnutrition, and cancer outcomes in patients with HNC. A total of 494 patients with HNC were included in this cross-sectional observational study. Various tools and body composition measurements, including muscle mass and adipose tissue ultrasound evaluations, were implemented. Using regression models, we mainly found that high levels of RF-CSA (rectus femoris cross-sectional area) were associated with a decreased risk of malnutrition (as defined with GLIM criteria (OR = 0.81, 95% CI: 0.68-0.98); as defined with PG-SGA (OR = 0.78, 95% CI: 0.62-0.98)) and sarcopenia (OR = 0.64, 95% CI: 0.49-0.82) after being adjusted for age, sex, and BMI. To predict the importance of muscle mass ultrasound variables on the risk of mortality, a nomogram, a random forest, and decision tree models were conducted. RF-CSA was the most important variable under the random forest model. The obtained C-index for the nomogram was 0.704, and the Brier score was 16.8. With an RF-CSA < 2.7 (AUC of 0.653 (0.59-0.77)) as a split, the decision tree model classified up to 68% of patients as possessing a high probability of survival. According to the cut-off value of 2.7 cm2, patients with a low RF-CSA value lower than 2.7 cm2 had worse survival rates (p < 0.001). The findings of this study highlight the importance of implementing ultrasound tools, for accurate diagnoses and monitoring of malnutrition in patients with HNC. Adipose tissue ultrasound measurements were only weakly associated with malnutrition and not with sarcopenia, indicating that muscle mass is a more important indicator of overall health and nutritional status. These results have the potential to improve survival rates and quality of life by enabling early intervention and personalized nutritional management.

Development of machine learning models for the prediction of long-term feeding tube dependence after oral and oropharyngeal cancer surgery

PURPOSE

To predict the necessity of enteral nutrition at 28 days after surgery in patients undergoing major head and neck oncologic procedures for oral and oropharyngeal cancers.

MATERIAL AND METHODS

Data from 193 patients with oral cavity and oropharyngeal squamous cell carcinoma were retrospectively collected at two tertiary referral centers to train (n = 135) and validate (n = 58) six supervised machine learning (ML) models for binary prediction employing 29 clinical variables available pre-operatively.

RESULTS

The accuracy of the six ML models ranged between 0.74 and 0.88, while the measured area under the curve (AUC) between 0.75 and 0.87. The ML algorithms showed high specificity (range 0.87-0.96) and moderate sensitivity (range: 0.31-0.77) in detecting patients with ≥28 days feeding tube dependence. Negative predictive value was higher (range: 0.81-0.93) compared to positive predictive value (range: 0.40-0.71). Finally, the F1 score ranged between 0.35 and 0.74.

CONCLUSIONS

Classification performance of the ML algorithms showed optimistic accuracy in the prediction of enteral nutrition at 28 days after surgery. Prospective studies are mandatory to define the clinical benefit of a ML-based pre-operative prediction of a personalized nutrition protocol.

Interventions to improve quality of life in patients with head and neck cancers receiving radiation therapy: a scoping review

BACKGROUND

Quality of life (QOL) is impaired in patients with head and neck cancers (HNC) due to illness and treatment-associated morbidity. Although there is evidence from the studies on interventions' role in improving QOL receiving radiation therapy, these are not systematically synthesised. In this scoping review, we searched and synthesised the evidence on interventions to improve the QOL and its impact among patients with HNCs.

METHODS

This scoping review was conducted using the framework proposed by Arksey and O'Malley, and the extensions suggested by Levac et al. were incorporated. Two reviewers independently searched four electronic databases using key thesaurus and free-text terms, and the data was extracted, tabulated, synthesised and reported as categories.

RESULTS

Seventy-nine papers reported various interventions of diverse nature such as pharmacological, physical, nutritional, complementary and alternative therapies, psychosocial, oral care related, laser and photobiomodulation therapies, rehabilitative, educational, technology-based, surgical, device-related and nurse lead interventions. Most studies reported clinically meaningful impact of interventions on QOL, although the outcome differences were often statistically insignificant. Few studies reported a combination of interventions to address the multidimensional concerns faced by patients with HNCs. None of the studies examined the impact of interventions on QOL among long-term survivors of HNCs.

CONCLUSION

As QOL concerns in patients with HNCs are multifaceted, more extensive studies with complex multi-component interventions and robust research designs are warranted.

Assessment of Swallowing Function in Patients with Head and Neck Squamous Cell Carcinoma in High vs. Low Dose Cisplatin

Cisplatin-based therapies are standard-of-care for advanced-stage head and neck squamous cell carcinoma (HNSCC). Treatment regimens include 3 weeks of high-dose bolus cisplatin or 6-7 weeks of low-dose weekly cisplatin, both with concurrent radiation. The effects of cisplatin dosage on swallowing function warrant further study. A 237-patient cohort treated for HNSCC at a single center were studied retrospectively. Gastrostomy tube dependence served as the primary endpoint. Secondary endpoints included weight changes, esophageal stricture, and lymphedema. The primary/secondary outcomes were not statistically significant; however, ototoxicity and renal toxicity were significantly higher in the high-dose group. These findings add insight into cisplatin dose-based functional outcomes.

Influence of nutritional counseling on treatment results in patients with head and neck cancers

OBJECTIVES

Nutritional intervention, including nutritional counseling (NC), plays a significant role in the comprehensive management of patients with head and neck cancer (HNC). The aim of this study was to investigate the effects of NC combined with oral nutritional supplements during radical treatment on weight loss and survival outcomes in patients with HNC.

METHODS

The study included 310 patients who received radical treatment for HNC. Among these patients, 119 underwent NC along with oral nutritional supplements (NCONS); 191 were supported with oral nutritional supplements only (ONS). The study aimed to investigate the effects of sex, disease stage, treatment modality, and tumor site on weight loss. Additionally, the Kaplan-Meier method assessed the influence of NC on overall survival and disease-free survival.

RESULTS

The present study suggested that the NC independently prevented weight loss, regardless of sex and disease stage (female: -1.6%, P = 0.001; male: -2.3 %, P = 0.003; T stage (0-2): -1.7%, P = 0.008; T stage (3-4): -2.7%, P = 0.003; N stage (0-1): 2.5%, P = 0,027; N stage (3-4): 2.9%, P < 0.001). The protective effect was most significant in patients with oral cancer and oropharyngeal cancer and in patients treated with chemotherapy (oral: -1.7%, P = 0.03; oropharynx: -3.3%, P < 0.001; radiochemotherapy: -3%, P = 0.028; induction chemotherapy preceded radiochemotherapy: -6%, P < 0.001). Furthermore, the 3-year overall survival rates were 93.4% and 85.4% in the NC along with oral nutritional supplements (NCONS) and oral nutritional supplement (ONS) groups, respectively (P = 0.031).

CONCLUSIONS

Patients with HNC who received NC during radical treatment experienced reduced weight loss. This effect was particularly pronounced in patients with oral cavity or oropharyngeal cancer and those undergoing chemotherapy. Additionally, NC was associated with improved overall survival in this patient cohort. Nevertheless, further studies are required to validate and support these findings.

Factors associated with early discontinuation of anamorelin in patients with cancer-associated cachexia

PURPOSE

Cancer-associated cachexia, a multifactorial syndrome involving loss of muscle mass and anorexia, is an unremitting problem for cancer patients. Anamorelin has become available for cancer-associated cachexia, but early discontinuation is common in clinical practice. This study aimed to explore factors related to the early discontinuation of anamorelin and its relationship to survival.

PATIENTS AND METHODS

This prospective, observational study of multimodal clinical practice involved patients who took anamorelin (100 mg) for cancer-associated cachexia at Aichi Medical University Hospital between 14 May 2021 and 31 March 2022. In July 2022, clinical data were extracted from electronic clinical records. Patients who discontinued anamorelin less than 4 weeks after initiation were defined as the early discontinuation group, and their clinical data and survival time were compared with those of the continuation group. This study was approved by the Ethics Committee of the university (approval no. 2021-124).

RESULTS

Of the 42 patients treated with anamorelin, 40 (median age 72.5 years, median BMI 18.7 kg/m2) were analyzed, including 13 with non-small cell lung cancer, and 12 with pancreatic, 8 with colorectal, and 7 with gastric cancers. On univariate analysis, the early discontinuation group included more patients with worse performance status (PS) (p=0.028), low prognostic nutritional index (PNI) (p=0.001), and no concomitant anticancer drugs (p=0.003). On multivariate analysis, PS and PNI were related to anamorelin continuation. Survival time was significantly shorter in the early discontinuation group (p=0.039).

CONCLUSION

Worse PS and low PNI were associated with early discontinuation of anamorelin. Longer survival time was observed in the continuation group.

Physical function endpoints in cancer cachexia clinical trials: Systematic Review 1 of the cachexia endpoints series

In cancer cachexia trials, measures of physical function are commonly used as endpoints. For drug trials to obtain regulatory approval, efficacy in physical function endpoints may be needed alongside other measures. However, it is not clear which physical function endpoints should be used. The aim of this systematic review was to assess the frequency and diversity of physical function endpoints in cancer cachexia trials. Following a comprehensive electronic literature search of MEDLINE, Embase and Cochrane (1990-2021), records were retrieved. Eligible trials met the following criteria: adults (≥18 years), controlled design, more than 40 participants, use of a cachexia intervention for more than 14 days and use of a physical function endpoint. Physical function measures were classified as an objective measure (hand grip strength [HGS], stair climb power [SCP], timed up and go [TUG] test, 6-min walking test [6MWT] and short physical performance battery [SPPB]), clinician assessment of function (Karnofsky Performance Status [KPS] or Eastern Cooperative Oncology Group-Performance Status [ECOG-PS]) or patient-reported outcomes (physical function subscale of the European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaires [EORTC QLQ-C30 or C15]). Data extraction was performed using Covidence and followed PRISMA guidance (PROSPERO registration: CRD42022276710). A total of 5975 potential studies were examined and 71 were eligible. Pharmacological interventions were assessed in 38 trials (54%). Of these, 11 (29%, n = 1184) examined megestrol and 5 (13%, n = 1928) examined anamorelin; nutritional interventions were assessed in 21 trials (30%); and exercise-based interventions were assessed in 6 trials (8%). The remaining six trials (8%) assessed multimodal interventions. Among the objective measures of physical function (assessed as primary or secondary endpoints), HGS was most commonly examined (33 trials, n = 5081) and demonstrated a statistically significant finding in 12 (36%) trials (n = 2091). The 6MWT was assessed in 12 trials (n = 1074) and was statistically significant in 4 (33%) trials (n = 403), whereas SCP, TUG and SPPB were each assessed in 3 trials. KPS was more commonly assessed than the newer ECOG-PS (16 vs. 9 trials), and patient-reported EORTC QLQ-C30 physical function was reported in 25 trials. HGS is the most commonly used physical function endpoint in cancer cachexia clinical trials. However, heterogeneity in study design, populations, intervention and endpoint selection make it difficult to comment on the optimal endpoint and how to measure this. We offer several recommendations/considerations to improve the design of future clinical trials in cancer cachexia.

Effects of food-based interventions in the management of chemoradiotherapy-induced nausea and vomiting: a systematic review

BACKGROUND

Cancer treatment-related nausea and vomiting continue to be common and distressing symptoms for patients, despite improvements in antiemetics. Dietary modifications could potentially improve this symptom experience. Clinicians frequently provide dietary advice to patients, although the evidence base of such suggestions or recommendations is not clear.

PURPOSE

This systematic review aimed to examine the current literature on food interventions associated with improvements in cancer treatment-related nausea and vomiting.

METHODS

Eight electronic databases were searched with a specific search term strategy covering trials without time or language limitations. Eligible studies focused on a food substance, defined as any nutritious substance that people eat or drink to maintain life and well-being. Trials in children and adults during chemotherapy or radiotherapy were included. Cochrane risk of bias tool was used to assess trial quality and GRADE was used to assess the certainty in the effect of each outcome.

RESULTS

Seventeen trials were included, 3 focusing on children and 14 on adults. Two trials included patients receiving radiation. Ten out of 17 trials (59%) had a high risk of bias. Strongest evidence with highest certainty was found for dietary counseling to meet macronutrient requirements in reducing incidence of radiotherapy-related nausea and vomiting in adults (n=2 studies; n=124 participants; GRADE level: moderate). There was also moderate certainty in the beneficial effect of protein supplementation on nausea and vomiting incidence in adults during radiotherapy (n=2 studies; n=124 participants; GRADE level: moderate). A significant positive effect on CINV incidence and/or severity in adults was also found for dietary counseling to meet macronutrient requirements during chemotherapy, a peppermint drink, scaly wood mushroom, chamomile, protein with ginger, and a colorless odorless diet (GRADE level: low to very low).

CONCLUSIONS

The review identified food-based approaches that could improve the nausea and vomiting experience in patients with cancer and provide guidance to clinicians. However, confidence in these findings was low and studies were heterogeneous and mostly of low quality, requiring further investigation before stronger recommendations can be made. Future research is needed to confirm efficacy and safety.

TRIAL REGISTRATION

PROSPERO CRD42022341154.

The Impact of NUTRItional Status at First Medical Oncology Visit on Clinical Outcomes: The NUTRIONCO Study

Malnutrition affects up to 75% of cancer patients and results from a combination of anorexia and metabolic dysregulation. Metabolic and nutritional abnormalities in cancer patients can lead to cachexia, a multifactorial syndrome characterized by involuntary loss of skeletal muscle mass, systemic inflammation and increased protein catabolism. Cancer cachexia negatively affects patients' outcomes, response to anticancer treatments, quality of life, and survival. However, risk of malnutrition, and cachexia are still under-recognized in cancer patients. The Prevalence of Malnutrition in Oncology (PreMiO) study revealed that 51% of patients already had nutritional deficiencies at their first medical oncology visit. Here, we report the results of the subsequent retrospective, observational NUTRItional status at first medical oncology visit ON Clinical Outcomes (NUTRIONCO) study, aimed at assessing the impact of baseline nutritional and non-nutritional variables collected in the PreMiO study on the clinical outcomes of the same patients followed up from August 2019 to October 2021. We have highlighted a statistically significant association between baseline variables and patient death, rehospitalization, treatment toxicity, and disease progression at follow-up. We found a higher overall survival probability in the well-nourished general study population vs. malnourished patients (p < 0.001). Of major interest is the fact that patient stratification revealed that malnutrition decreased survival probability in non-metastatic patients but not in metastatic patients (p < 0.001). Multivariate analysis confirmed that baseline malnutrition (p = 0.004) and VAS score for appetite loss (p = 0.0104), in addition to albumin < 35 g/L (p < 0.0001) and neutrophil/lymphocyte ratio > 3 (p = 0.0007), were independently associated with the death of non-metastatic patients at follow-up. These findings highlight the importance of proactive, early management of malnutrition and cachexia in cancer patients, and in particular, in non-metastatic patients, from the perspective of a substantial improvement of their clinical outcomes.

Nutrition as prevention for improved cancer health outcomes: a systematic literature review

BACKGROUND

Among adults with cancer, malnutrition is associated with decreased treatment completion, more treatment harms and use of health care, and worse short-term survival. To inform the National Institutes of Health Pathways to Prevention workshop, "Nutrition as Prevention for Improved Cancer Health Outcomes," this systematic review examined the evidence for the effectiveness of providing nutrition interventions before or during cancer therapy to improve outcomes of cancer treatment.

METHODS

We identified randomized controlled trials enrolling at least 50 participants published from 2000 through July 2022. We provide a detailed evidence map for included studies and grouped studies by broad intervention and cancer types. We conducted risk of bias (RoB) and qualitative descriptions of outcomes for intervention and cancer types with a larger volume of literature.

RESULTS

From 9798 unique references, 206 randomized controlled trials from 219 publications met the inclusion criteria. Studies primarily focused on nonvitamin or mineral dietary supplements, nutrition support, and route or timing of inpatient nutrition interventions for gastrointestinal or head and neck cancers. Most studies evaluated changes in body weight or composition, adverse events from cancer treatment, length of hospital stay, or quality of life. Few studies were conducted within the United States. Among intervention and cancer types with a high volume of literature (n = 114), 49% (n = 56) were assessed as high RoB. Higher-quality studies (low or medium RoB) reported mixed results on the effect of nutrition interventions across cancer and treatment-related outcomes.

CONCLUSIONS

Methodological limitations of nutrition intervention studies surrounding cancer treatment impair translation of findings into clinical practice or guidelines.

Expert Consensus Statement: Management of Dysphagia in Head and Neck Cancer Patients

OBJECTIVE

To develop an expert consensus statement (ECS) on the management of dysphagia in head and neck cancer (HNC) patients to address controversies and offer opportunities for quality improvement. Dysphagia in HNC was defined as swallowing impairment in patients with cancers of the nasal cavity, paranasal sinuses, nasopharynx, oral cavity, oropharynx, larynx, or hypopharynx.

METHODS

Development group members with expertise in dysphagia followed established guidelines for developing ECS. A professional search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements targeted at providers managing dysphagia in adult HNC populations. The development group prioritized topics where there was significant practice variation and topics that would improve the quality of HNC patient care if consensus were possible.

RESULTS

The development group identified 60 candidate consensus statements, based on 75 initial proposed topics and questions, that focused on addressing the following high yield topics: (1) risk factors, (2) screening, (3) evaluation, (4) prevention, (5) interventions, and (6) surveillance. After 2 iterations of the Delphi survey and the removal of duplicative statements, 48 statements met the standardized definition for consensus; 12 statements were designated as no consensus.

CONCLUSION

Expert consensus was achieved for 48 statements pertaining to risk factors, screening, evaluation, prevention, intervention, and surveillance for dysphagia in HNC patients. Clinicians can use these statements to improve quality of care, inform policy and protocols, and appreciate areas where there is no consensus. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to dysphagia in HNC patients.

Protocol for the SEHNeCa randomised clinical trial assesing Supervised Exercise for Head and Neck Cancer patients

OBJECTIVES

To evaluate the effectiveness of an innovative supervised exercise programme to mitigate the loss of lean body mass, functional capacity and quality of life in people with head and neck cancer, as well as to identify the optimal moment to apply it, before or after radiotherapy treatment, compared with the prescription of a physical activity plan carried out autonomously.

METHODS

Patients with squamous cell carcinoma of the head and neck (n = 144), treated with radiotherapy, will be randomly assigned to one of 3 comparison groups: pre-radiotherapy supervised exercise, post-radiotherapy supervised exercise and autonomous exercise, stratifying by human papillomavirus infection and previous surgery. The exercise programme will be carried out in 36 sessions over 12 weeks, combining moderate and high intensity strength and aerobic exercises. The main outcome variable is the change in lean body mass at 6 months measured by bioimpedance, while secondary variables are functional capacity, symptoms, quality of life and adverse effects. Longitudinal generalised mixed models will be used for the analyses of the repeated measurements at 3, 6, and 12 months after baseline.

CONCLUSIONS

The pilot study supports the feasibility and safety of the project. However, as the programme progressed, attendance at the sessions decreased. Strategies will be necessary for increasing attendance, as well as involving the patient in their recovery and other incentives. Follow-up after treatment to assess acute/late toxicity will enable us to know the response to both the exercise programme and its adherence.

TRIAL REGISTRATION

NCT04658706 Date and version identifier: March 1, 2023. Version 1.1.

Barriers and Facilitators to Adherence to a Mediterranean Diet Intervention during Chemotherapy Treatment: A Qualitative Analysis

Patients undergoing chemotherapy are at risk for malnutrition and a high symptom burden, and nutritional interventions can address clinical and supportive care outcomes. Herein, we identified barriers and facilitators to adhering to a Mediterranean Diet (MedDiet) intervention during chemotherapy. Patients with cancer (any type) who were undergoing chemotherapy were enrolled into a clinical trial testing the effects of an 8-week MedDiet intervention on cancer-related fatigue. Participants were randomized 2:1, MedDiet:control. The intervention entailed food provision, education, a cookbook, a session with a nutritionist, and weekly check-ins. Post-intervention, all participants completed semi-structured exit interviews. The interviews were transcribed and open coding was conducted to describe the facilitators and barriers to MedDiet adherence. Participants (n = 29, n = 21 in the intervention group) were 51.0 ± 15.1 years old and 93.1% had breast cancer. Educational materials and convenient food delivery were the highest reported facilitators. Many patients offered that changing their diet gave a sense of control and empowerment. Barriers to adherence were that the frozen food was unappetizing, participants' (or their spouse/children's) food preferences did not align with the MedDiet, and chemotherapy-induced side effects that prevented food consumption (eg, mouth sores, lack of appetite). This project helps understand the patient experience within nutritional interventions to optimize dietary programs during chemotherapy treatment.

Prophylactic versus reactive feeding approach in patients undergoing adjuvant radiation therapy for oral cavity squamous cell carcinoma: A propensity score matched-pair analysis

BACKGROUND

To assess the efficacy of prophylactic versus reactive feeding strategy in oral cavity squamous cell carcinoma (OCSCC) patients receiving adjuvant radiation therapy (RT).

METHODS

This was a post hoc analysis of patients of OCSCC enrolled in a randomized trial comparing three adjuvant strategies. In this trial, till 2010, a prophylactic feeding approach was followed for all patients. Since January 2011, a reactive feeding approach was followed.

RESULTS

Two hundred and sixty-eight in each cohort (total n = 526) were eligible for analysis after propensity score matching. At 6 weeks post-RT completion, the median weight loss in the prophylactic versus reactive cohort was 5 versus 3 kg, p = 0.002. At all other time points until 1 year, the median weight loss was lesser in reactive than in the prophylactic cohort.

CONCLUSIONS

A reactive feeding tube approach should be preferred for OCSCC receiving adjuvant RT.

Using coword analysis and chord diagrams to examine the effect of nutritional counseling and support (DCNS) on patients with oral and oropharyngeal cancer

BACKGROUND

Dietary counseling and nutritional support (DCNS) are generally accepted as being necessary for patients with oral cancer and oropharyngeal cancer (OC). However, there is no evidence that dietary counseling plays a significant role in weight loss. In this study, we examined the DCNS based on persistent weight loss during and after treatment in oral cancer and OC patients, as well as the effect of body mass index (BMI) on survival in both groups.

METHODS

A retrospective chart review was conducted on 2622 patients diagnosed with cancer between 2007 and 2020, including 1836 oral and 786 oropharyngeal patients. In comparison with the sample of patients treated by DCNS, differences in proportional counts for key factors associated with survival were compared between oral cancer and OC patients using the forest plot. An analysis of cowords was conducted to determine CNS associated with weight loss and overall survival. The Sankey diagram was used to display DCNS effectiveness. The log-rank test was used to evaluate the chi-squared goodness of fit test on the null assumption model of equal survival distributions between the groups.

RESULTS

Almost 41% of the patients (=1064/2262) received DCNS, with a frequency ranging from 1 to 44. Counts for 4 DCNS categories were 566, 392, 92, and 14, respectively, against BMI increases or decreases from much to less with counts of 3, 44, 795, 219, and 3, respectively. In the first year following treatment, DCNS decreased sharply to 50%. One year after hospital discharge, the overall weight loss increased from 3 to 9% (mean = -4%, standard deviation = 14%). Patients with a BMI above average had a significantly longer survival time (P < .001). Statistically, OC patients have a significantly higher survival rate than oral cancer patients.

CONCLUSION

Despite receiving frequent DCNS, patients continued to lose body weight during and 1 year after treatment. The survival time of an individual with a BMI above average appears to be increased. Future studies should preferably use randomized trials to compare standard DCNS with more intensive DCNS, which includes earlier and/or prolonged treatment.

Systematic Review of Nutrition Interventions to Improve Short Term Outcomes in Head and Neck Cancer Patients

Head and neck cancer (HNC) is associated with high rates of malnutrition. We conducted a systematic review and descriptive analysis to determine the effects of nutrition interventions on the nutrition status, quality of life (QOL), and treatment tolerance of HNC patients. PubMed, Web of Science, and Embase were searched to include all potentially relevant studies published between 2006-2022. Meta-analysis was not conducted due to heterogeneity of study designs and outcomes reported. Studies were categorized as nutrition interventions: (1) with oral nutrition supplements (ONS) and medical nutrition therapy (MNT) delivered by an RD; (2) with enteral nutrition (EN) support and MNT delivered by an RD; (3) with motivational interviewing and no ONS or EN; and (4) with ONS and no RD. Seven articles met inclusion criteria. Studies measured outcomes from immediately following treatment to 12 months post-treatment. Interventions resulted in benefits to lean mass/weight maintenance (three studies), QOL (two studies), nutrient intake adequacy (one study) and treatment tolerance (two studies). Nutrition counseling by a registered dietitian leads to improved nutrition status and QOL. Further research is needed to determine best practices related to timing of initiation, duration of nutrition intervention, as well as frequency of dietitian follow-up.

Prognostic Utility of Nutritional Risk Index in Patients with Head and Neck Soft Tissue Sarcoma

BACKGROUND

The nutritional risk index (NRI) is an excellent indicator of nutritional status and a significant prognostic factor in several malignancies, but the relationship between NRI and the prognosis of head and neck soft tissue sarcoma (HNSTS) patients remains unclear. The aim of this study was to investigate the role of NRI in patients with HNSTS.

METHODS

We retrospectively reviewed patients with HNSTS between 1990 and 2021. In order to determine the optimal cut-off value of NRI, the Maximally selected log-rank statistic was performed. We evaluated the effect of NRI on overall survival (OS) and progression-free survival (PFS) by using the Kaplan-Meier method and Cox regression analysis. Then, OS and PFS nomograms based on NRI were constructed.

RESULTS

In total, 436 HNSTS patients were included in this study. The optimal cut-off value of NRI was 99.34. Patients with low-NRI showed significantly worse OS and PFS than patients with high-NRI, respectively (5-year OS rate of 43.0 vs. 70.8%, 5-year PFS rate of 29.0 vs. 45.0%, all p < 0.05). In the multivariate analysis, distant metastasis, deep tumor depth, tumor grade, and NRI were prognostic factors for both PFS and OS, and treatment modality was associated with OS but not PFS. The concordance indexes (C-indexes) of OS and PFS nomograms were 0.794 (95% CI, 0.759-0.829) and 0.663 (95% CI, 0.626-0.700), respectively, which also performed well in the validation set.

CONCLUSIONS

NRI is an independent predictor of OS and PFS in HNSTS patients. The validated nomograms based on NRI provide useful predictions of OS and PFS for patients with HNSTS.

Oncology-Led Early Identification of Nutritional Risk: A Pragmatic, Evidence-Based Protocol (PRONTO)

Nutritional issues, including malnutrition, low muscle mass, sarcopenia (i.e., low muscle mass and strength), and cachexia (i.e., weight loss characterized by a continuous decline in skeletal muscle mass, with or without fat loss), are commonly experienced by patients with cancer at all stages of disease. Cancer cachexia may be associated with poor nutritional status and can compromise a patient's ability to tolerate antineoplastic therapy, increase the likelihood of post-surgical complications, and impact long-term outcomes including survival, quality of life, and function. One of the primary nutritional problems these patients experience is malnutrition, of which muscle depletion represents a clinically relevant feature. There have been recent calls for nutritional screening, assessment, treatment, and monitoring as a consistent component of care for all patients diagnosed with cancer. To achieve this, there is a need for a standardized approach to enable oncologists to identify patients commencing and undergoing antineoplastic therapy who are or who may be at risk of malnutrition and/or muscle depletion. This approach should not replace existing tools used in the dietitian's role, but rather give the oncologist a simple nutritional protocol for optimization of the patient care pathway where this is needed. Given the considerable time constraints in day-to-day oncology practice, any such approach must be simple and quick to implement so that oncologists can flag individual patients for further evaluation and follow-up with appropriate members of the multidisciplinary care team. To enable the rapid and routine identification of patients with or at risk of malnutrition and/or muscle depletion, an expert panel of nutrition specialists and practicing oncologists developed the PROtocol for NuTritional risk in Oncology (PRONTO). The protocol enables the rapid identification of patients with or at risk of malnutrition and/or muscle depletion and provides guidance on next steps. The protocol is adaptable to multiple settings and countries, which makes implementation feasible by oncologists and may optimize patient outcomes. We advise the use of this protocol in countries/clinical scenarios where a specialized approach to nutrition assessment and care is not available.

Pilot randomized, controlled, preoperative intervention for nutrition trial in head and neck cancer

BACKGROUND

Several prospective studies report improved outcomes with pretreatment nutrition interventions prior to radiation therapy for head and neck cancer (HNC), but none have assessed similar interventions before surgery for HNC.

METHODS

POINT, a pilot randomized controlled trial, was conducted to evaluate a multimodal nutrition intervention. Patients undergoing primary surgery with free flap reconstruction for HNC were randomly assigned to the control arm or a preoperative multimodal nutrition intervention.

RESULTS

POINT included 49 patients. Nutrition risk scores did not change significantly for either the intervention or control group. Control patients had a significant decrease in body weight in the preoperative period (p < 0.001). Conversely, weight among intervention patients did not significantly decrease (p = 0.680). The intervention mitigated weight loss in patients with dysphagia (p = 0.001).

CONCLUSIONS

Preoperative nutrition optimization shows potential to reduce weight loss normally experienced by patients with head and neck cancer prior to surgical extirpation, especially among those with subjective dysphagia.

Dysgeusia in Patients with Breast Cancer Treated with Chemotherapy-A Narrative Review

Breast cancer (BC) is the most common cancer worldwide. Chemotherapy (CT) is essential for the treatment of BC, but is often accompanied by several side effects, including taste alterations, due to different mechanisms. Although dysgeusia is usually underestimated by clinicians, it is considered very worrying and disturbing by cancer patients undergoing CT, because it induces changes in dietary choices and social habits, affecting their physical and psychological health, with a profound impact on their quality of life. Several strategies and therapies have been proposed to prevent or alleviate CT-induced dysgeusia. This review aimed to evaluate the available evidence on prevalence, pathophysiological mechanisms, clinical consequences, and strategies for managing dysgeusia in BC patients receiving CT. We queried the National Library of Medicine, the Cochrane Library, Excerpta Medica dataBASE, and the Cumulative Index to Nursing and Allied Health Literature database, performing a search strategy using database-specific keywords. We found that the literature on this topic is scarce, methodologically limited, and highly heterogeneous in terms of study design and criteria for patient inclusion, making it difficult to obtain definitive results and make recommendations for clinical practice.

The Effects of Nutrition Intervention on Postoperative Patients with Tongue Cancer and Floor of Mouth Cancer

The aim of this study is to evaluate the effect of intensive nutrition support on patients with tongue cancer and floor of mouth cancer after surgery at K Hospital, Tan Trieu campus. Study the clinical intervention with a control group. We conducted the intensive nutrition intervention for our patients by giving counseling materials, sample menu and nutritional supplements, while the control group had only advice about dietary regimens. We evaluated a group before and after the intervention, at the same time compare the two groups before and after the intervention. After 1 mo, the intervention group increased 0.51±1.43 kg in comparison with their weight at the beginning; the weight of the control group lost -0.59±2.33 kg; the difference had statistical significance (p=0.025). After 1 and 2 mo of intervention, the rates of the participants without risk of malnutrition in the intervention group increased significantly in comparison with that in the control group; the difference has statistical significance with p=0.001 and p=0.003. In terms of quality of life, patients' problems related to areas including health status, functioning, symptoms of the intervention group improved more greatly than those of the control group. Especially, anorexia symptoms and financial impact were improved well in the intervention group (p=0.033, p=0.018). Nutrition intervention in patients with tongue cancer and floor of mouth cancer has shown a beneficial effect of nutrition counseling and intervention to improve patients' status in terms of nutrition and their quality of life.

Perioperative Blood Transfusion Is Dose-Dependently Associated with Cancer Recurrence and Mortality after Head and Neck Cancer Surgery

BACKGROUND

The association between perioperative blood transfusion and cancer prognosis in patients with head and neck cancer (HNC) receiving surgery remains controversial.

METHODS

We designed a retrospective observational study of patients with HNC undergoing tumor resection surgery from 2014 to 2017 and followed them up until June 2020. An inverse probability of treatment weighting (IPTW) was applied to balance baseline patient characteristics in the exposed and unexposed groups. COX regression was used for the evaluation of tumor recurrence and overall survival.

RESULTS

A total of 683 patients were included; 192 of them (28.1%) received perioperative packed RBC transfusion. Perioperative blood transfusion was significantly associated with HNC recurrence (IPTW adjusted HR: 1.37, 95% CI: 1.1-1.7, p = 0.006) and all-cause mortality (IPTW adjusted HR: 1.37, 95% CI: 1.07-1.74, p = 0.011). Otherwise, there was an increased association with cancer recurrence in a dose-dependent manner.

CONCLUSION

Perioperative transfusion was associated with cancer recurrence and mortality after HNC tumor surgery.

The role of nutritional support in treatment of head and neck tumors: clinical case

The article presents a clinical observation of treatment of locally advanced squamous cell oropharyngeal carcinoma. The problems of nutritional support of patients during primary chemoradiation treatment are considered. The presented clinical case shows that use of sip feeds can significantly improve nutritional condition in patients with head and neck tumors and improve tolerability and results of antitumor treatment.

Malnutrition, nutrition support and dietary intervention: the role of the dietitian supporting patients with head and neck cancer

Malnutrition is prevalent in patients with head and neck cancer (HNC) at diagnosis but can occur at any stage of the treatment pathway. The impact of disease burden and treatment side effects can lead to altered anatomy, compromised quality and quantity of saliva and impaired swallowing function, which can result in deleterious effects on nutritional status. Optimising nutrition status is critical, as malnutrition is adversely associated with treatment tolerance and outcomes, wound healing, morbidity, mortality, quality of life and survival. Dietitians are integral members of the HNC multidisciplinary team and are uniquely qualified in the assessment, management and optimisation of nutritional status across the care pathway. This includes providing informational counselling to patients and carers on the short- and long-term nutritional impact of planned treatments alongside multidisciplinary members. Dietitians lead on the recommendation, provision and monitoring of nutrition support, which can be via the oral, enteral or parenteral route. Oral nutrition support includes dietary counselling, nourishing dietary, food fortification advice and high energy/protein oral nutritional supplements. Enteral nutrition support, or tube feeding, can be required on a short- and/or long-term basis and dietitians support appropriate decision-making for the type of tube and timing of placement across the care pathway.

Supplemental parenteral nutrition in cancer care: why, who, when

Malnutrition is an often-overlooked challenge for patients with cancer. It is associated with muscle mass reduction, poor compliance and response to cancer treatments, decreased quality of life, and reduced survival time. The nutritional assessment and intervention should be a vital part of any comprehensive cancer treatment plan. However, data on artificial nutrition supplied based on caloric needs during cancer care are scarce. In this review, we discuss the recommendations of the European and American societies for clinical nutrition on the use of nutritional interventions in malnourished patients with cancer in the context of current clinical practice. In particular, when enteral nutrition (oral or tube feeding) is not feasible or fails to meet the complete nutritional needs, supplemental parenteral nutrition (SPN) can bridge the gap. We report the available evidence on SPN in cancer patients and identify the perceived barriers to the wider application of this intervention. Finally, we suggest a ‘permissive’ role of SPN in cancer care but highlight the need for rigorous clinical studies to further evaluate the use of SPN in different populations of cancer patients.

THE MULTIDISCIPLINARY TEAM (MDT) IN THE TREATMENT OF HEAD AND NECK CANCER - A SINGLE-INSTITUTION EXPERIENCE

Head and neck cancers are associated with significant morbidity and mortality despite advancements in treatment in recent decades. A multidisciplinary approach to the treatment of these diseases is thus of essential importance and is becoming the gold standard. Head and neck tumors also endanger relevant structures of the upper aerodigestive tracts, including bodily functions such as voice, speech, swallowing, and breathing. Damage to these functions can significantly influence quality of life. Thus, our study examined not only the roles of head and neck surgeons, oncologists and radiotherapists, but also the importance of the participation of different scientific professions such as anesthesiologists, psychologists, nutritionists, stomatologists, and speech therapists in the work of a multidisciplinary team (MDT). Their participation results in a significant improvement of patient quality of life. We also present our experiences in the organization and work of the MDT as part of the Center for Head and Neck Tumors of the Zagreb Clinical Hospital Center.

Subjective Global Assessment of Nutritional Status in Head and Neck Cancer Patients Treated with Radiotherapy - A Prospective Observational Study from North East India

Head and neck cancer (HNC) patients undergoing curative radiotherapy (RT) are at risk of malnutrition due to disease process as well as effects of therapy. Identifying the nutritional status of these patients at the earliest, helps to introduce adequate and timely interventions that can improve compliance and outcomes of treatment. Various tools for nutritional assessment in cancer patients have been proposed. In this prospective observational study we used the Subjective Global Assessment (SGA) questionnaire in a cohort of HNC patients receiving definitive RT at a regional cancer center of North East India. Recording of data was done at baseline, at two weekly intervals during treatment, at end of radiotherapy (EORT) and at follow-up upto 6 months. We observed that despite proper nutrition counseling, our patients suffered from malnutrition throughout their course of RT, which was at its peak by EORT but gradually improved over six months of follow-up. Pain on eating and swallowing were the most debilitating symptoms which caused significant decline of nutrient intake, body fat and muscle mass among patients together with deteriorating SGA ratings. Our results will hopefully help us design better strategies for nutrition management while delivering curative (chemo)radiotherapy for HNC patients of this region- which has one of the highest incidences of HNC in the world.

The Effects of a Mediterranean Diet Intervention on Cancer-Related Fatigue for Patients Undergoing Chemotherapy: A Pilot Randomized Controlled Trial

Cancer-related fatigue is a common, burdensome symptom of cancer and a side-effect of chemotherapy. While a Mediterranean Diet (MedDiet) promotes energy metabolism and overall health, its effects on cancer-related fatigue remain unknown. In a randomized controlled trial, we evaluated a rigorous MedDiet intervention for feasibility and safety as well as preliminary effects on cancer-related fatigue and metabolism compared to usual care. Participants had stage I−III cancer and at least six weeks of chemotherapy scheduled. After baseline assessments, randomization occurred 2:1, MedDiet:usual care. Measures were collected at baseline, week 4, and week 8 including MedDiet adherence (score 0−14), dietary intake, and blood-based metabolic measures. Mitochondrial respiration from freshly isolated T cells was measured at baseline and four weeks. Participants (n = 33) were 51.0 ± 14.6 years old, 94% were female, and 91% were being treated for breast cancer. The study was feasible, with 100% completing the study and >70% increasing their MedDiet adherence at four and eight weeks compared to baseline. Overall, the MedDiet intervention vs. usual care had a small-moderate effect on change in fatigue at weeks 4 and 8 (ES = 0.31, 0.25, respectively). For those with a baseline MedDiet score <5 (n = 21), the MedDiet intervention had a moderate-large effect of 0.67 and 0.48 at weeks 4 and 8, respectively. The MedDiet did not affect blood-based lipids, though it had a beneficial effect on fructosamine (ES = −0.55). Fatigue was associated with mitochondrial dysfunction including lower basal respiration, maximal respiration, and spare capacity (p < 0.05 for FACIT-F fatigue subscale and BFI, usual fatigue). In conclusion, the MedDiet was feasible and attenuated cancer-related fatigue among patients undergoing chemotherapy, especially those with lower MedDiet scores at baseline.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients

Delivering care that meets patients' preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients' preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient's specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients

Delivering care that meets patients' preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients' preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient's specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients

Delivering care that meets patients’ preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients’ preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient’s specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

Pretreatment Glasgow Prognostic Score Correlated with Serum Histidine Level and Three-Year Mortality of Patients with Locally Advanced Head and Neck Squamous Cell Carcinoma and Optimal Performance Status

Few prospective cohort trials have investigted the effect of pretreatment nutritional and inflammatory status on the clinical outcome of patients with cancer and optimal performance status and assessed the interplay between nutrition, inflammation, body composition, and circulating metabolites before treatment. Here, 50 patients with locally advanced head and neck squamous cell carcinoma (LAHNSCC) and Eastern Cooperative Oncology Group performance status (ECOG PS) ≤ 2 were prospectively recruited along with 43 healthy participants. Before concurrent chemoradiotherapy, compared with healthy controls, the cancer group showed lower levels of histidine, leucine, and phenylalanine and had low values in anthropometric and body composition measurements; however, the group displayed higher ornithine levels, more malnutrition, and severe inflammation. Pretreatment advanced Glasgow prognostic score (1 and 2) status was the sole prognostic factor for 3-year mortality rate and was associated with age and serum histidine levels in patients with cancer. Thus, even at the same tumor stage and ECOG PS, patients with LAHNSCC, poor nutrition, and high inflammation severity at baseline may have inferior survival outcomes than those with adequate nutrition and low inflammation severity. Assessment of pretreatment nutritional and inflammatory status should be included in the enrollment criteria in future studies.

A prospective randomized comparative trial evaluating postoperative nutritional intervention in patients with oral cancer

Extensive surgical treatment of oral cancer results in significant deterioration of nutritional status with concomitant increased nutrient requirements. The consequences are an elevated risk of postoperative complaints as well as morbidity and mortality. The aim of this study was to investigate an additional postoperative nutritional intervention through professional nutritional advice and nutritional supplementation in patients with oral cancer for at least six months. 62 patients with oral cancer in the department of oral and maxillofacial surgery were randomized into two groups. The intervention group received nutritional supplements, protein-rich, high-fiber diet and care by a professional nutritionist in addition to the standard treatment. The control group received only the standard treatment. Statistical analysis includes the evaluation of means and standard deviations as well as the calculation of p values with a significance level of 0.05. A deficiency of protein, albumin, vitamin D, zinc and iron was noticed in both groups immediately after surgery. Patients in the intervention group recorded significantly less weight loss (pT2 = 0.0031, pT4 = 0.0424), a more stable BMI (pT2 = 0.0496), better values for albumin (pT2 = 0.0265), vitamin A (pT3 = 0.0248, pT4 = 0.0007) and calcium (pT3 = 0.0362) during the follow-ups. The patients in the intervention group showed significantly fewer digestive problems (p = 0.0062) and muscular complaints (p = 0.0448). They showed better eating habits (p = 0.0348) and were capable of more physical activity (p = 0.0045) than patients in the control group. Patients with oral cancer can have a benefit from postoperative nutritional intervention. Early screening, appropriate care by a nutritionist and supplementation with vitamin D, zinc, calcium and protein-rich food are recommended.

Nutritional prehabilitation in head and neck cancer: a systematic review

PURPOSE

Prehabilitation affords an opportunity to support the management of malnutrition that is strongly associated with head and neck cancer. The purpose of this systematic review was to identify the components of nutritional prehabilitation interventions and their effects on nutritional and health outcomes in head and neck cancer patients.

METHODS

A comprehensive search was completed within Medline (including PubMed), CINHAL, Cochrane database, EMBASE, PRoQUEST, clinical trials registries, and grey literature to identify studies involving a nutritional intervention pre-treatment in head and neck cancer patients receiving any form of curative therapy. Nutritional intervention was defined as a specified period pre-treatment and outcome measures had to include assessment of nutritional status or body composition. Quality of included studies was assessed using Cochrane risk of bias 2.

RESULTS

From 557 identified studies, two met the inclusion criteria. Due to the low number of studies, a meta-analysis was not indicated. Both studies conducted a nutritional intervention using an "enriched formula" in malnourished patients prior to surgery. Neither study reported the intervention was effective for reducing weight loss, physical function, surgical complications, or length of stay versus the comparison.

CONCLUSION

There is limited nutritional prehabilitation research within head and neck cancer. An "enriched formula" provided in the prehabilitation period appears no more advantageous than routine standard nutritional formula in mitigating against the weight loss experienced in malnourished head and neck patient. Due to the malnutrition risks on diagnosis and the negative impact of poor nutritional status on clinical and functional outcomes, robust nutritional prehabilitation research is required to inform clinical practice.