Effect of oral nutritional supplementation on weight loss and percutaneous endoscopic gastrostomy tube rates in patients treated with radiotherapy for oropharyngeal carcinoma

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.

Effects of induction chemotherapy on nutrition status in locally advanced nasopharyngeal carcinoma: a multicentre prospective study

BACKGROUND

Induction chemotherapy (IC) and concurrent chemoradiotherapy (CCRT) is the standard of care for locoregionally advanced nasopharyngeal carcinoma (LA-NPC). This intensive treatment regimen increases acute toxicities, which could negatively impact patients' nutritional status. We conducted this prospective, multicentre trial to investigate the effects of IC and CCRT on nutritional status in LA-NPC patients, so as to provide evidence for further study of nutritional intervention, which was registered in ClinicalTrials.gov (NCT02575547).

METHODS

Patients with biopsy-proven NPC and planned for IC + CCRT were recruited. IC entailed two cycles of 3-weekly docetaxel 75 mg/m² and cisplatin 75 mg/m² ; CCRT entailed two to three cycles of 3-weekly cisplatin 100 mg/m² depending on the duration of radiotherapy. Nutritional status and quality of life (QoL) were assessed pre-IC, post-cycles one and two of IC, W4 and W7 of CCRT. Primary endpoint was the cumulative proportion of ≥ 5.0% weight loss (WL_5.0 ) by the end of treatment (W7-CCRT). Secondary endpoints included body mass index, NRS2002 and PG-SGA scores, QoL, hypoalbuminaemia, treatment compliance, acute and late toxicities and survivals. The associations between primary and secondary endpoints were also evaluated.

RESULTS

One hundred and seventy-one patients were enrolled. Median follow-up was 67.4 (IQR: 64.1-71.2) months. 97.7% (167/171) patients completed two cycles of IC, and 87.7% (150/171) completed at least two cycles of concurrent chemotherapy; all, except one patient (0.6%), completed IMRT. WL was minimal during IC (median of 0.0%), but increased sharply at W4-CCRT (median of 4.0% [IQR: 0.0-7.0%]) and peaked at W7-CCRT (median of 8.5% [IQR: 4.1-11.7%]). 71.9% (123/171) of patients recorded a WL_5.0 by W7-CCRT, which was associated with a higher malnutrition risk (NRS2002 ≥ 3 points: 87.7% [WL ≥ 5.0%] vs 58.7% [WL < 5.0%], P < 0.001) and requirement of nutritional intervention (PG-SGA ≥ 9 points: 82.0% [WL ≥ 5.0%] vs 66.7% [WL < 5.0%], P = 0.038). The median %WL at W7-CCRT was higher in patients who suffered from ≥ G2 mucositis (9.0% vs 6.6%, P = 0.025) and xerostomia (9.1% vs 6.3%, P = 0.003). Besides, patients with cumulative WL_5.0 also reported a higher detriment on QoL at W7-CCRT compared with patients without, with a difference of -8.3 points (95% CI [-15.1, -1.4], P = 0.019).

CONCLUSIONS

We observed a high prevalence of WL among LA-NPC patients who were treated with IC + CCRT, which peaked during CCRT, and had a detriment on patients' QoL. Our data support the need to monitor patient's nutritional status during the later phase of treatment with IC + CCRT and inform on nutritional intervention strategies.

Are We Ready for a New Approach to Comparing Coverage and Reimbursement Policies for Medical Nutrition in Key Markets: An ISPOR Special Interest Group Report

OBJECTIVES

Healthcare policy makers should ensure optimal patient access to medical nutrition (MN) as part of the management of nutrition-related disorders and conditions. Questions remain whether current healthcare policies reflect the clinical and economic benefits of MN. The objective of this article is to characterize coverage and reimbursement of MN, defined as food for special medical purposes/medical food for a diverse set of countries, including Australia, Belgium, Brazil, Canada, China, France, Germany, Hong Kong, Italy, Japan, The Netherlands, Singapore, Spain, United Kingdom, and United States.

METHODS

Data sources included published literature and online sources. ISPOR's Nutrition Economics Special Interest Group developed a data collection form to guide data extraction that included reimbursement coverage, years that reimbursement policies were established, and presence of a formal health technology assessment (HTA) for MN technologies.

RESULTS

Reimbursement coverage of MN technologies varied across the countries that were reviewed. All but 3 countries limited coverage to specific formulations of products, regardless of demonstrated clinical benefit. The year that reimbursement policies were established varied across countries (ranging from 1984 to 2017), and only 4 countries regularly update policies. France and Brazil are the only countries with a formal HTA process for MN technologies.

CONCLUSIONS

Most countries have limited MN reimbursement, have not updated reimbursement policies, and lack HTA for MN technologies. These limitations may lead to suboptimal access to MN technologies where they are indicated to manage nutrition-related disorders and conditions, with the potential of negatively affecting patient and healthcare system outcomes.

A National Evaluation of Food Insecurity in a Head and Neck Cancer Population

OBJECTIVES/HYPOTHESIS

To determine the food security status of patients with a history of head and neck cancer and compare to other types of cancer.

STUDY DEIGN

A retrospective analysis using the National Health Interview Series.

METHODS

The National Health Interview Series (NHIS) for the calendar years 2014 to 18 was used to elicit food security status (secure, marginally secure/not secure) among adult patients with a history of throat/pharynx head and neck cancer (pHNC), thyroid cancer, and colon cancer. The relationship between food security and the primary site was compared and subanalyses were performed according to sex, race, and ethnicity.

RESULTS

The study population included 199.0 thousand patients with pHNC, with 17.7% (95% confidence interval, 10.5%-28.1%) of pHNC patients reporting their food security status as marginally secure or not secure. Food insecurity was significantly higher among pHNC patients when compared to thyroid cancer (insecurity 10.7%, [7.7%-14.7%]) and colon cancer patients (10.1%, [7.8%-13.2%]). Among pHNC patients, there was no significant difference in rates of food insecurity when stratified by gender, race, or ethnicity. However, black individuals were more likely to have food insecurity with a history of thyroid or colon cancer (P < .042) and Hispanics were more likely to have food insecurity with a history of thyroid cancer (P = .005).

CONCLUSIONS

Food insecurity disproportionally affects patients with a history of pHNC, though there is less demographic variability when compared to other cancer primary sites. Food security assessments should be part of the tailored approach to survivorship management in head and neck cancer.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1539-E1542, 2021.

Reliability and validity of the mandarin version of the supportive care needs survey short-form (SCNS-SF34) and the head and neck cancer-specific supportive care needs (SCNS-HNC) module

Background

This study aimed to translate the English version of the supportive care needs scale of head and neck cancer patients (SCNS-HNC) questionnaire into Mandarin and to test the reliability and validity of the SCNS-SF34 and SCNS-HNC module in head and neck cancer patients.

Methods

The Mandarin version of the Supportive Care Needs Survey Short-Form (SCNS-SF34) and SCNS-HNC scales were used to assess 206 patients with head and neck cancer in Chengdu, China. Among them, 51 patients were re-tested 2 or 3 days after the first survey. The internal consistency of the scale was evaluated by Cronbach’s alpha coefficient, the retest reliability of the scale was evaluated by retest correlation coefficient r, the structural validity of the scale was evaluated by exploratory factor analysis, and the ceiling and floor effects of the scale were evaluated.

Results

The Mandarin version of the SCNS-HNC had Cronbach’s alpha coefficients greater than 0.700 (0.737 ≤ 0.962) for all of the domains. Except for the psychological demand dimension (r = 0.674) of the SCNS-SF34 scale, the retest reliability of the other domains was greater than 0.8. Three common factors were extracted by exploratory factor analysis, and the cumulative variance contribution rate was 64.39%.

Conclusions

The Mandarin version of the SCNS-SF34 and SCNS-HNC demonstrated satisfactory reliability and validity and is able to measure the supportive care needs of Chinese patients with head and neck cancer.

Trial registration

ChiCTR, ChiCTR1900026635. Registered 16 October 2019- Retrospectively registered.

Biomechanical modeling of radiation dose-induced volumetric changes of the parotid glands for deformable image registration

PURPOSE

Early animal studies suggest that parotid gland (PG) toxicity prediction could be improved by an accurate estimation of the radiation dose to sub-regions of the PG. Translation to clinical investigation requires voxel-level dose accumulation in this organ that responds volumetrically throughout treatment. To date, deformable image registration (DIR) has been evaluated for the PG using only surface alignment. We sought to develop and evaluate an advanced DIR technique capable of modeling these complex PG volume changes over the course of radiation therapy.

MATERIALS AND METHODS

Planning and mid-treatment magnetic resonance images from 19 patients and computed tomography images from nine patients who underwent radiation therapy for head and neck cancer were retrospectively evaluated. A finite element model (FEM)-based DIR algorithm was applied between the corresponding pairs of images, based on boundary conditions on the PG surfaces only (Morfeus-spatial). To investigate an anticipated improvement in accuracy, we added a population model-based thermal expansion coefficient to simulate the dose distribution effect on the volume change inside the glands (Morfeus-spatialDose). The model accuracy was quantified using target registration error for magnetic resonance images, where corresponding anatomical landmarks could be identified. The potential clinical impact was evaluated using differences in mean dose, median dose, D98, and D50 of the PGs.

RESULTS

In the magnetic resonance images, the mean (±standard deviation) target registration error significantly reduced by 0.25 ± 0.38 mm (p = 0.01) when using Morfeus-spatialDose instead of Morfeus-spatial. In the computed tomography images, differences in the mean dose, median dose, D98, and D50 of the PGs reached 2.9 ± 0.8, 3.8, 4.1, and 3.8 Gy, respectively, between Morfeus-spatial and Morfeus-spatialDose.

CONCLUSION

Differences between Morfeus-spatial and Morfeus-spatialDose may be impactful when considering high-dose gradients of radiation in the PGs. The proposed DIR model can allow more accurate PG alignment than the standard model and improve dose estimation and toxicity prediction modeling.

Impact of choice of feeding tubes on long-term swallow function following chemoradiotherapy for oropharyngeal carcinoma

Background: Prior reports have raised concerns that a prophylactic gastrostomy may be detrimental to long-term swallow function. This study evaluates patient-reported swallow function following chemoradiotherapy for oropharyngeal carcinoma in relation to the use of a prophylactic gastrostomy or nasogastric (NG) tube as required. Material and methods: The MD Anderson Dysphagia Inventory (MDADI) was posted to 204 disease-free patients at least 2 years following chemoradiotherapy for oropharyngeal carcinoma between 2010 and 2014. Results: Overall, 181/204 (89%) patients returned questionnaire at a median of 34 months post-treatment. 97/181 (54%) and 84/181 (46%) were managed with an approach of a prophylactic gastrostomy or NG tube as required, respectively. A prophylactic gastrostomy was associated with higher rates of enteral feeding (92% vs. 58%, p < .001), lower median percentage weight loss (7.0% vs. 9.4%, p < .001), increased duration of enteral feed (median 3.3 vs. 1.1 months, p < .001). There was no significant difference in patient-reported swallow function measured by MDADI summary scores and subscales for patients managed with an approach of prophylactic gastrostomy or NG as required. Duration of enteral feed correlated negatively with composite MDADI scores. A subgroup of 116/181 (64%) patients were documented as having been offered a choice of enteral feeding approach and therefore can be considered to represent clinical equipoise; there were no significant differences in MDADI scores according to route. Conclusions: Despite concern regarding the use of a prophylactic gastrostomy in prior studies, the approaches of using a prophylactic gastrostomy or an NG tube as required to support patients during/after chemoradiotherapy for oropharyngeal carcinoma were associated with similar long-term swallow outcomes.

Home enteral nutrition may prevent myelosuppression of patients with nasopharyngeal carcinoma treated by concurrent chemoradiotherapy

BACKGROUND

The aim of this study is to assess the effect of home enteral nutrition (HEN) on the myelosuppression of patients with nasopharyngeal cancer (NPC) during the course of concurrent chemoradiotherapy (CCRT).

METHODS

A total of 18 outpatients with NPC administered oral nutritional supplementation intervention at home during the course of CCRT were designated as the HEN group, whereas 36 patients with NPC who had previously completed CCRT were retrospectively included as the control group. Patient Generated Subjective Global Assessment, body mass index (BMI), and blood test were evaluated prior to CCRT. During the course of CCRT, blood test was assessed every 2 weeks.

RESULTS

In male patients, hemoglobin (HB) and red blood cell were decreased (P < .05) in both HEN and control group after CCRT, whereas white blood cell (WBC) started to decrease since week 2 of CCRT in the control group but maintained in the HEN group which was significantly higher than the control (5.05 ± 1.29 vs 3.77 ± 1.5, P < .05). In female patients, HB and WBC were reduced in control group during CCRT, whereas these indicators also maintained in the HEN group. Surprisingly, all patients with lower BMI (<24 kg/m² ) had a significant increase in platelet (PLT) after CCRT (200.78 ± 58.03 vs 253.00 ± 69.82, P < .05), while had steady HB and WBC values in the HEN group. At the end of CCRT, WBC and PLT of the HEN group were both higher than those in the control group (5.21 ± 1.07 vs 3.37 ± 1.52), (253.00 ± 69.82 vs 165.57 ± 59.56) (P < .05 for both). Our findings suggest that HEN is effective in preventing myelosuppression during CCRT for patients with NPC.

CONCLUSION

Our findings suggest that HEN is effective in preventing myelosuppression during CCRT for patients with NPC.

Nutritional parameters associated with hospital admissions in patients being treated for head and neck cancer

PURPOSE

This study analysed nutritional parameters (baseline body mass index (BMI), weight changes and enteral nutrition (EN) use, and their association with hospital admissions during radiotherapy in patients with head and neck cancer (HNC)).

METHODS

A retrospective review of patients diagnosed with HNC and treated with radiotherapy between October 2012 and April 2014 was conducted. Data on each subject's diagnosis, age, sex, chemotherapy, previous surgery, EN use, weight changes, and BMI were examined for their association with hospital admissions during treatment.

RESULTS

Eighty-three patients were included, mean age (±standard deviation) = 61 (± 11 years). Thirty-four percent had self-reported weight loss at diagnosis, and mean BMI was 26.2 ± 5.3 kg/m². Mean weight change during treatment was - 5.1 ± 6.2%. Ten patients used EN, with mean weight stabilisation during EN use (0.3 ± 5.1%). Higher presenting BMI, younger age, and definitive radiotherapy ± chemotherapy predicted greater weight loss (p < 0.05). Critical weight loss ≥ 5% was associated with a higher number of hospital admissions for nutrition reasons (n = 10) (p = 0.011) compared with those without critical weight loss (n = 2). EN use was associated with a higher number of nutrition-related admissions; however, it did not predict length of stay among those admitted.

CONCLUSION

Critical weight loss during radiotherapy was associated with unplanned nutrition-related hospital admissions. Higher BMI was associated with greater weight loss during radiotherapy, whilst EN use assisted in weight preservation. Further research around patient selection for nutritional interventions aimed at preventing critical weight loss and unplanned hospital admissions is needed.

Impact of prophylactic gastrostomy or reactive NG tube upon patient-reported long term swallow function following chemoradiotherapy for oropharyngeal carcinoma: A matched pair analysis

OBJECTIVES

The purpose of this matched pair analysis is to assess patient-reported long term swallow function following chemoradiotherapy for locally advanced oropharyngeal cancer in relation to the use of a prophylactic gastrostomy or reactive nasogastric (NG) tube.

MATERIALS AND METHODS

The MD Anderson Dysphagia Inventory (MDADI) was posted to 68 consecutive patients with stage III/IV oropharyngeal squamous cell carcinoma who had completed parotid sparing intensity modulated radiotherapy with concurrent chemotherapy between 2010 and 2012, had not required therapeutic enteral feeding prior to treatment, minimum 2years follow up post treatment, and who were disease free. 59/68 replies were received, and a matched pair analysis (matching for T and N stage) was performed for 52 patients, 26 managed with a prophylactic gastrostomy and 26 with an approach of an NG tube as needed.

RESULTS

There were no significant differences in patient demographics, pre-treatment diet and treatment factors between the two groups. Patient-reported swallowing function measured using the MDADI was superior for patients managed with an NG tube as required compared with a prophylactic gastrostomy: overall composite score 68.1 versus 59.4 (p=0.04), global score 67.7 versus 60 (p=0.04), emotional subscale 73.5 versus 60.4 (p<0.01), functional subscale 75.4 versus 61.7 (p<0.01), and physical subscale 59.6 versus 57.1 (p=0.38).

CONCLUSIONS

Compared with an approach of an NG tube as required, the use of a prophylactic gastrostomy was associated with inferior long term patient-reported long term swallow outcomes.

Nutrition management for head and neck cancer patients improves clinical outcome and survival

Up to 80% of patients with head and neck cancers are malnourished because of their lifestyle and the risk factors associated with this disease. Unfortunately, nutrition management systems are not implemented in most head and neck cancer clinics. Even worse, many head and neck surgeons as well as hospital management authorities disregard the importance of nutrition management in head and neck cancer patients. In addition, the often extensive resection and reconstruction required for tumors in the upper aerodigestive tract pose special challenges for swallowing and sufficient food intake, placing special demands on nutrition management. This article presents the basics of perioperative metabolism and nutrition management of head and neck cancer patients and makes recommendations for clinical practice. Implementing a nutrition management system in head and neck cancer clinics will improve the clinical outcome and the survival of the patients.

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.

Vicious circle of acute radiation toxicities and weight loss predicts poor prognosis for nasopharyngeal carcinoma patients receiving intensity modulated radiotherapy

Background: Weight loss during radiotherapy has been known as a negative prognostic factor for nasopharyngeal carcinoma (NPC) patients, but the factors related to weight loss during radiotherapy were not fully understood.

Methods: A total of 322 newly diagnosed NPC patients receiving intensity modulated radiotherapy (IMRT) in Sun Yat-sen University Cancer Center between June 2002 and August 2006 were enrolled. Kaplan-Meier methods and log-rank test were applied for survival analysis; a multiple regression was used to identify the factors related to weight loss during radiotherapy.

Results: The mean and median values of weight loss (%) during radiotherapy were 6.85% and 6.70%. NPC patients with critical weight loss (> 5.4%) have poorer overall survival (OS) and distant metastasis-free survival (DMFS) than the patients without critical weight loss (p = 0.002 and 0.021, respectively). Pre-radiotherapy weight, acute mucosal toxicity, acute pharynx and esophagus toxicity, and acute upper gastrointestinal toxicity were related to the weight loss during radiotherapy independently (p = 0.01, p < 0.001, p < 0.001, and p = 0.009, respectively).

Conclusions: Acute radiation toxicities had significant and independent impact on weight loss during radiotherapy. The vicious circle of acute radiation toxicities and weight loss had bad effect on prognosis of NPC patients.

Computed tomography-guided percutaneous gastrostomy: initial experience at a cancer center

Gastrostomy is indicated for patients with conditions that do not allow adequate oral nutrition. To reduce the morbidity and costs associated with the procedure, there is a trend toward the use of percutaneous gastrostomy, guided by endoscopy, fluoroscopy, or, most recently, computed tomography. The purpose of this paper was to review the computed tomography-guided gastrostomy procedure, as well as the indications for its use and the potential complications.

[What nutritional management in patients with head and neck cancers undergoing radiotherapy? An overview]

Radiotherapy is an effective treatment for head and neck cancers but patients often experience side effects, which lead to malnutrition. Morbidity related to weight loss during treatment may include dehydration, hospitalization, compromised treatment efficacy, and reduced quality of life and may impact survival hence the importance of early nutritional management prior to radiotherapy. Multiple interventions have been implemented to help ameliorate the impact of treatment on weight loss and nutritional status, including the use of percutaneous endoscopic gastrostomy tubes. The goal of this overview is to search the predictive factors of malnutrition and an overview of the different types of nutritional interventions and their impact on the local control of the disease, mortality and quality of life of patients treated with radiotherapy or concomitant chemoradiotherapy.

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.

The effect of prophylactic percutaneous endoscopic gastrostomy (PEG) tube placement on swallowing and swallow-related outcomes in patients undergoing radiotherapy for head and neck cancer: a systematic review

Patients undergoing radiotherapy for head and neck cancer (HNC) often experience malnutrition and dehydration during treatment. As a result, some centres place PEG tubes prophylactically (pPEG) to prevent these negative consequences. However, recent research has suggested that pPEG use may negatively affect swallowing physiology, function and/or quality of life, especially in the long term. The purpose of this study was to systematically review the literature on pPEG use in HNC patients undergoing radiotherapy and to determine its impact on swallowing-related outcomes. The following electronic databases were searched for all relevant primary research published through February 24, 2014: AMED, CINAHL, the Cochrane Library, Embase, Healthstar, Medline, and PsycINFO. Main search terms included HNC, radiotherapy, deglutition disorders, feeding tube(s), and prophylactic or elective. References for all accepted papers were hand searched to identify additional relevant research. Methodological quality was assessed using Cochrane's Risk of Bias. At all levels, two blinded raters provided judgments. Discrepancies were resolved by consensus. The search retrieved 181 unique citations. Twenty studies met our inclusion criteria. Quality assessment revealed that all studies were at risk for bias due to non-randomized sampling and unreported or inadequate blinding. Ten studies demonstrated selection bias with significant baseline differences between pPEG patients and controls. Results regarding the frequency and severity of dysphagia and swallowing-related outcomes were varied and inconclusive. The impact of pPEG use on swallowing and swallowing-related outcomes remains unclear. Well-controlled, randomized trials are needed to determine if pPEG places patients at greater risk for developing long-term dysphagia.

Nutri-jelly may improve quality of life and decrease tube feeding demand in head and neck cancer patients

Purpose

Eating difficulty is a critical and common problem in head and neck cancer patients undergoing radiotherapy (RT). It leads to poor quality of life and extensive tube feeding use. Nutri-jelly, a food gel with semisolid texture, water-releasing ability, and ready-to-eat by spoon, was recently developed to alleviate the trouble. However, its efficacy was unknown. This study investigated the potential effect of Nutri-jelly on health-related quality of life (HRQOL) and nasogastric tube feeding use.

Methods

A prospective quasi-randomized patients-preference controlled trial was conducted in 74 head and neck cancer patients. Subjects in study and control groups (37 each) had similar baseline HRQOL and body mass index and undergone definitive radiotherapy (25–35 RT fractions, 5,000–7,000 cGy). Only study group received a 200-ml box of Nutri-jelly as daily supplement throughout radiotherapy. HRQOL was scored by validated questionnaires. The use of tube feeding was collected from medical records.

Results

From 11 to 35 RT fractions, the study group maintained higher overall HRQOL score than that of control group (p < 0.0001). Multiple physiologic and psychological aspects of HRQOL especially swallowing difficulty and overall eating problems were significantly improved in study as compared to control group. Promisingly, the percentage of tube feeding use in study group (13.5 %) was dramatically lower than control group (48.6 %).

Conclusions

Continuous supplementation of Nutri-jelly throughout radiotherapy may improve HRQOL and reduce tube feeding demand in head and neck cancer patients who preferred to take them. Nutri-jelly could be an alternative for head and neck cancer patients who have eating difficulty during radiotherapy.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-014-2488-5) contains supplementary material, which is available to authorized users.

Gastrostomy dependence in head and neck carcinoma patient receiving post-operative therapy

OBJECTIVE

Post-operative concurrent chemoradiotherapy significantly improves the rates of locoregional control and disease-free survival in high-risk patients but has significant adverse effects. Percutaneous endoscopic gastrostomy and opioid-based pain control increase treatment completion rates but can result in dysphagia.

METHODS

The rate and duration of use of prophylactically placed percutaneous endoscopic gastrostomies were evaluated in 43 patients who underwent post-operative radiotherapy or chemoradiotherapy from April 2007 through March 2010. All patients completed treatment and received 60 Gy or more of radiotherapy.

RESULTS

Thirty four of 43 patients (79.1%) used percutaneous endoscopic gastrostomies, which could later be removed in 25 of 34 patients. The median period of use was 108 days. Only one disease-free patient was permanently dependent on percutaneous endoscopic gastrostomy feeding. The frequency of percutaneous endoscopic gastrostomy use among patients with oral, oropharyngeal and hypopharyngeal cancer was 91.7, 100 and 54.5%, respectively.

CONCLUSIONS

Prolonged percutaneous endoscopic gastrostomy use is not required in patients receiving post-operative chemoradiotherapy and will not lead to dysphagia.

Clinical nutrition guidelines of the French Speaking Society of Clinical Nutrition and Metabolism (SFNEP): Summary of recommendations for adults undergoing non-surgical anticancer treatment

Up to 50% of patients with cancer suffer from weight loss and undernutrition (as called cachexia) even though it is rarely screened or properly handled. Patients' prognosis and quality of life could be greatly improved by simple and inexpensive means encompassing nutritional status assessment and effective nutritional care. These guidelines aim to give health professionals and patients practical and up-to-date advice to manage nutrition in the principal situations encountered during the cancer course according to the type of tumour and treatment (i.e. radio and/or chemotherapy). Specific suggestions are made for palliative and elderly patients because of specific risks of undernutrition and related comorbidities in this subset. Levels of evidence and grades of recommendations are detailed as stated by current literature and consensus opinion of clinical experts in each field.

Prediction of posttreament significant body weight loss and its correlation with disease-free survival in patients with oral squamous cell carcinomas

Significant loss of body weight (SLW) by patients treated for squamous cell carcinomas of the oral cavity and oropharynx (OSCC) may affect treatment completion and results. We assessed factors predicting SLW and its correlation with disease-free survival (DFS) in these patients. We evaluated 226 consecutive patients with previously untreated, operable OSCC whose body weight was recorded before, during, and for up to 1 year after treatment. SLW was defined as ≥10% reduction in pretreatment body weight. Clinicopathologic parameters were compared in patients with and without SLW. Of the 226 patients, 94 (41.6%) experienced SLW and 132 (58.4%) did not. Univariate analyses showed that factors significantly associated with SLW included T3-4, N+, stage III-IV, and oropharyngeal tumors, nonsurgical (radiotherapy or chemotherapy) vs. surgical treatment, posttreatment recurrence, histologic differentiation, involved resection margin, and number of metastatic lymph nodes (pLNs) ≥ 3 (P < 0.05). Multivariate analyses showed that radiotherapy, recurrence, and number of pLNs were significant independent predictors of SLW (P < 0.005). DFS rate was significantly higher in patients without than with SLW (P < 0.01). OSCC patients with multiple pLNs, those undergoing radiotherapy, and those with posttreatment recurrences may require close nutritional monitoring and support.

An exploration of factors predicting malnutrition in patients with advanced head and neck cancer

OBJECTIVES/HYPOTHESIS

Malnutrition is common among head and neck cancer patients and negatively impacts on survival and quality of life. This study aimed to identify predictors of malnutrition at time of diagnosis in order to identify patients at risk and enable early nutritional support and prevent malnutrition.

MATERIALS AND METHOD

A total of 134 patients with advanced oral and pharyngeal cancer were included in the study. Weight, body mass index (BMI), fat free mass (FFM), dysphagia, and quality of life were measured at diagnosis and after 6 months. Two definitions for malnutrition were applied: >10% weight loss and BMI <20 after 6 months.

RESULTS

Six months after diagnosis, 66% of the patients were malnourished as per the >10% weight loss definition, and 26% of the patients were malnourished as per the BMI < 20 weight loss definition. In multivariate analysis, low BMI followed by low FFM and dysphagia were the strongest predictors for malnutrition using BMI <20. Chemotherapy and high BMI at diagnosis were the strongest predictors of malnutrition using the 10% weight loss definition. For patients treated with chemotherapy, the risk for malnutrition was very high both for patients with normal BMI (67%) and for patients with BMI 30 (89%).

CONCLUSION

Unintended weight loss more than 10% seems to be the most reasonable definition of malnutrition for identifying predictors of this in head and neck cancer patients. The weight loss correlated significantly to a loss of FFM. Treatment with chemotherapy was a strong predictor, as was a high BMI at time of diagnosis. This is an important finding since overweight patients might not be considered at high risk for developing malnutrition, and consequently nutritional support for them might be delayed.

Expertise regarding dental management of oral cancer patients receiving radiation therapy among Western Australian dentists

OBJECTIVES

Dental care forms an important part of the multidisciplinary management of oral cancer patients. The aim of this study was to examine actual and self-perceived knowledge and clinical expertise regarding dental management of oral cancer patients receiving radiation therapy among Western Australian general dentists.

MATERIALS AND METHODS

An invitation to participate in a web-based questionnaire was emailed to 1095 dentists registered with the Australian Dental Association (ADA), WA branch. To assess dentists' knowledge and expertise, actual and perceived knowledge was investigated. Information regarding type of practice, practice location, year of graduation and number of oral cancer patients treated in the preceding 12 months was also obtained.

RESULTS

One hundred and ninety one dentists responded to the survey. General dentists who took part in the study appeared to possess some knowledge regarding dental management of oral cancer patients treated with radiation therapy. The majority of responders however identified deficiencies in their knowledge and willingness to participate in continuing education programs.

CONCLUSION

In view of the rising incidence of oral cancer in Western Australia, efforts should be made to provide more clinically relevant training to dentists in this area.

Head and neck cancer patients' experiences of percutaneous endoscopic gastrostomy feeding: a Q-methodology study

Head and neck cancer patients are at high risk of malnutrition and its complications and therefore often undergo non-oral nasogastric or percutaneous endoscopic gastrostomy (PEG) nutrition support. However, there is little evidence that either approach is effective in this group. While one possible explanation for these findings relates to the relationship between artificial tube feeding and poor quality of life, there is little research that examines the patient's subjective experience of nutrition support. This study investigated the experiences of PEG tube feeding in head and neck cancer patients undergoing radical treatment. Conventional Q-methodology was used with 15 head and neck cancer patients, who rank-ordered 36 statements according to the extent to which these reflected their experiences of PEG tube feeding. The sorted statements were factor-analysed case-wise to provide clusters of similar experiences. Three perspectives emerged. Factor 1, labelled 'Constructive cognitive appraisal', focused around positive adaptation to, and acceptance of, PEG feeding. Factor 2, labelled 'Cognitive-affective dissonance', reflected ambivalence between cognitive acceptance and affective rejection of the PEG tube. Factor 3, labelled 'Emotion-focused appraisal', was characterised by tube-focused anxiety and fear. The findings broadly confirm Levanthal et al.'s Self-Regulatory Model of coping and support the need for genuine and individualised patient-centred nutritional care.

A clinical audit of the nutritional status and need for nutrition support amongst head and neck cancer patients treated with radiotherapy

BACKGROUND

Radiotherapy is an effective treatment for head and neck cancers but patients often experience side effects which lead to weight loss. Nutrition intervention in the form of counselling or oral nutrition support (ONS) is frequently needed for these patients. For some patients, tube feeding is required to minimise weight loss during treatment.

METHOD

Data was collected on 48 patients who received radiotherapy to the head and neck region over a nine-month period (June 2009-March 2010). Retrospective data collection was commenced in July 2010. Each patient's Diet Therapy Department record was reviewed. Main outcome measures were: 1) type of nutrition support; 2) percentage weight change during treatment; and 3) Patient-Generated Subjective Global Assessment Global (PG-SGA) rating.

RESULTS

On initial assessment 28 (77.8%) patients were classified as well nourished using the PG-SGA. Mean weight loss during radiotherapy was 5.74%. Risk factors for the need for ONS and enteral nutrition support (ENS) were older age, presence of nutrition impact symptoms, high-risk tumour sites, advanced disease and chemotherapy. No significant difference was shown in weight loss between ONS and ENS groups.

CONCLUSION

This study identified the need for early dietetic intervention for high nutritional risk groups of head and neck cancer patients to prevent significant weight loss. Pre-treatment nutritional status did not influence weight loss during treatment. ONS alone cannot prevent significant weight loss in patients with multiple nutrition impact symptoms. Early enteral feeding should be considered in this group of patients.

Prophylactic percutaneous endoscopic gastrostomy tube placement in treatment of head and neck cancer: a comprehensive review and call for evidence-based medicine

BACKGROUND

Patients with head and neck cancers (HNCs) are at increased risk of experiencing malnutrition, which is associated with poor outcomes. Advances in the treatment of HNCs have resulted in improved outcomes that are associated with severe toxic oral side effects, placing patients at an even greater risk of malnutrition. Prophylactic placement of percutaneous endoscopic gastrostomy (PEG) tubes before treatment may be beneficial in patients with HNC, especially those undergoing more intense treatment regimens. PEG tube placement, however, is not without risks.

METHODS

A comprehensive review of the literature was conducted.

RESULTS

Systematic evidence assessing both the benefits and harm associated with prophylactic PEG tube placement in patients undergoing treatment for HNC is weak, and benefits and harm have not been established.

CONCLUSIONS

More research is necessary to inform physician behavior on whether prophylactic PEG tube placement is warranted in the treatment of HNC.

Swallowing, nutrition and patient-rated functional outcomes at 6 months following two non-surgical treatments for T1-T3 oropharyngeal cancer

PURPOSE

Altered fractionation radiotherapy with concomitant boost (AFRT-CB) may be considered an alternative treatment for patients not appropriate for chemoradiation (CRT). As functional outcomes following AFRT-CB have been minimally reported, this exploratory paper describes the outcomes of patients managed with AFRT-CB or CRT at 6 months post-treatment.

METHODS

Using a cross-sectional analysis design, functional outcomes of 14 AFRT-CB and 17 CRT patients with T1-T3 oropharyngeal cancers were explored at 6 months post-treatment. Clinical and instrumental swallow assessments, weight and nutritional status, and the functional impact of treatment were examined.

RESULTS

Inferior outcomes were observed for the CRT patients on the RBHOMS (p = 0.03) which was reflected in diet and fluid restrictions with 18% of the CRT group requiring modified fluids and diets. Although a trend (p = 0.07) was noted for increased lingual deficits and aspiration risk for fluids in the CRT group, no other significant differences were observed. Both groups experienced an average of 10 kg weight loss and reported reduced general and swallowing-related function.

CONCLUSIONS

These preliminary data suggest functional outcomes following AFRT-CB and CRT were largely comparable at 6 months post-treatment. Treatment intensification in any form may contribute to impaired function which requires multidimensional intervention. Larger cohort investigations with systematic methodology are needed to further examine these initial findings.

A specific approach for elderly patients with head and neck cancer

Approximately 10% of head and neck (HN) tumors occur in patients aged more than or equal to 80 years. In this population, the main challenge for physicians is to deal with the benefit/risk ratio of treatments and tumor-related symptoms. As elderly patients are generally excluded from clinical trials, there is a lack of evidence-based data with regard to the most appropriate multidisciplinary management. The prevalence of frailty and the pattern of comorbidities in this specific population are still unknown. The management of these tumors in a geriatric context is complex due to the high risk of toxicity of locoregional treatments. Thus, physicians often have to adapt to the treatment schedule to decrease potential adverse effects even with a risk of undertreatment. A retrospective series reported that the treatment delivered to elderly patients presenting with HN tumor complies with an institution's policy in less than 50% of cases, emphasizing the need to assess the outcome of personalized/adapted treatment in geriatric patients. The major issue is to determine which adaptation could be carried out, and then, what could be the respective individual benefit/risk ratio of each adaptation. In this review, we will focus on the locoregional management of elderly patients, and develop the issue of adapted local treatment. We will discuss the feasibility of adapted surgery and radiotherapy and provide current evidence-based data that may allow physicians involved in locoregional treatment of elderly patients with HN cancers to be acquainted with practical guidelines. Then, we will highlight the importance of nutritional support in this population in which the prevalence of malnutrition is high.

Nutritional surveillance and weight loss in head and neck cancer patients

PURPOSE

This retrospective single-institution cohort study aims to evaluate if therapeutic approach, tumour site, tumour stage, BMI, gender, age and civil status predict body weight loss and to establish the association between weight loss on postoperative infections and mortality.

METHODS

Consecutive patients with head and neck cancer were seen for nutritional control at a nurse-led outpatient clinic and followed-up for 2 years after radiotherapy. Demographic, disease-specific and nutrition data were collected from case records. The primary outcome measure was maximum body weight loss during the whole study period.

RESULTS

The nadir of body weight loss was observed 6 months after radiotherapy. In total, 92 patients of 157 (59%) with no evidence of residual tumour after treatment received enteral nutrition. The mean maximum weight loss for patients receiving enteral nutrition and per oral feeding was 13% and 6%, respectively (p < 0.001). Using multivariate analysis, tumour stage (p < 0.001) was the only independent factor of maximum weight loss. Weight loss was not significantly related to risk for postoperative infection.

CONCLUSIONS

Weight loss is frequently noted among head and neck cancer patients during and after treatment. Weight loss was not found to be associated with postoperative infections and mortality. Nutritional surveillance is important in all patients, but special attention should be given to those on enteral nutrition and those with more advanced disease.

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

AIM: To determine the rate of use and non-use of prophylactic percutaneous endoscopic gastrostomy (PEG) tubes among patients with head and neck cancer (HNC) patients.

METHODS: All patients with HNC undergoing PEG between January 1, 2004 and June 30, 2006 were identified. Patients (or their next-of-kin) were surveyed by phone and all available medical records and cancer registry data were reviewed. Prophylactic PEG was defined as placement in the absence of dysphagia and prior to radiation or chemoradiation. Each patient with a prophylactic PEG was assessed for cancer diagnosis, type of therapy, PEG use, and complications related to PEG.

RESULTS: One hundred and three patients had PEG tubes placed for HNC. Thirty four patients (33%) could not be contacted for follow-up. Of the 23 (22.3%) patients with prophylactic PEG tubes, 11/23 (47.8%) either never used the PEG or used it for less than 2 wk. No association with PEG use vs non-use was observed for cancer diagnosis, stage, or specific cancer treatment. Non-use or limited use was observed in 3/6 (50%) treated with radiation alone vs 8/17 (47.1%) treated with chemoradiation (P = 1.0), and 3 of 10 (30%) treated with surgery vs 8 of 13 (62%) not treated with surgery (P = 0.21). Minor complications were reported in 5/23 (21.7%). One (4.3%) major complication was reported.

CONCLUSION: There is a high rate of unnecessary PEG placement when done prophylactically in patients with head and neck cancer.

A prospective investigation of swallowing, nutrition, and patient-rated functional impact following altered fractionation radiotherapy with concomitant boost for oropharyngeal cancer

Altered fractionation radiotherapy for head and neck cancer has been associated with improved locoregional control, overall survival, and heightened toxicity compared with conventional treatment. Swallowing, nutrition, and patient-perceived function for altered fractionation radiotherapy with concomitant boost (AFRT-CB) for T1-T3 oropharyngeal squamous cell carcinoma (SCC) have not been previously reported. Fourteen consecutive patients treated with AFRT-CB for oropharyngeal SCC were recruited from November 2006 to August 2009 in a tertiary hospital in Brisbane, Australia. Swallowing, nutrition, and patient-perceived functional impact assessments were conducted pretreatment, at 4-6 weeks post-treatment, and at 6 months post-treatment. Deterioration from pretreatment to 4-6 weeks post-treatment in swallowing, nutrition, and functional impact was evident, likely due to the heightened toxicity associated with AFRT-CB. There was significant improvement at 6 months post-treatment in functional swallowing, nutritional status, patient-perceived swallowing, and overall function, consistent with recovery from acute toxicity. However, weight and patient perception of physical function and side effects remained significantly worse than pretreatment scores. The ongoing deficits related to weight and patient-perceived outcomes at 6 months revealed that this treatment has a long-term impact on function possibly related to the chronic effects of AFRT-CB.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Use of gastrostomy in head and neck cancer: a systematic review to identify areas for future research

OBJECTIVES

To perform a systematic review of studies, which investigate the role of gastrostomy tube feeding in head and neck squamous cell cancer.

DESIGN

A systematic review of the English literature, identifying areas of clinical equipoise and recommendations for future studies.

MAIN OUTCOME MEASURES

Varying practices in G-tube use in HNSCC, the benefits and disadvantages of G-tubes, the effect of G-tube placement on multidimensional outcomes in patients with head and neck cancer, including quality of life and health economics and to draw themes that may lend themselves to future research.

RESULTS

The search identified 216 articles of which 59 were considered relevant. During treatment, a significant number of patients need enteral nutritional supplementation through nasogastric or G-tubes. Gastrostomy tubes have a good safety profile. Most clinicians agree that the use should be restricted to advanced tumours. Studies on prophylactic insertion of G-tubes do not show a consistent advantage to the nutritional status compared with NG tubes. At 1 year, G-tube retention rates vary between 10% and 30%. The presence of a feeding tube has a negative impact on quality of life. Placing G-tubes may have an adverse effect on swallowing after chemoradiation.

CONCLUSIONS

There is a lack of consensus among clinicians about indications for placing G-tubes. There is sufficient equipoise in this area for further investigation of the effect of varying feeding practices on functional outcomes, quality of life and health economics.

Effects of chemoradiotherapy on voice and swallowing

PURPOSE OF REVIEW

Chemotherapy has been found to result in comparable survival rates to surgery for head and neck cancer. However, toxicity can often be worse after chemoradiotherapy, with impairment in voice, swallowing, nutrition, and quality of life. Investigators are attempting to modify radiotherapy treatment regimens to spare organs that have an impact on swallowing. This review will highlight voice and swallowing impairment seen after chemoradiotherapy, as well as treatment for voice and swallowing disorders in this population. Results of newer radiotherapy regimens will also be highlighted.

RECENT FINDINGS

Specific oropharyngeal swallowing motility disorders after chemoradiotherapy have been identified. Damage to specific structures has been correlated with specific pharyngeal phase swallow impairment. Swallowing function and quality of life have been examined over time, with improvement seen in both. Preventive/prophylactic swallow exercise programs have been encouraging. Chemoradiotherapy effects on voice have been identified in terms of acoustic, aerodynamic, and patient and clinician-rated perception of function. Improvement in voice has also been observed over time after chemoradiotherapy. Voice therapy has been found to have a positive impact on voice and perceptual measures in this population.

SUMMARY

Current studies show some improvement in swallow function after swallow and voice therapy in patients treated with chemoradiotherapy. Further, there is a suggestion of improved swallow function with sparing of organs with specific radiotherapy protocols. Future research needs to focus on specific voice and swallow treatment regimens in the head and neck cancer patient treated with chemoradiotherapy, specifically, timing, frequency, duration, and specific treatment types.

Advances in quality of life and symptom management for head and neck cancer patients

PURPOSE OF REVIEW

Head and neck cancer and its therapy are associated with marked symptom burden, functional impairment and decreased quality of life. This review will encompass the recent studies addressing supportive care issues facing head and neck cancer patients.

RECENT FINDINGS

Although it has long been recognized that head and neck cancer therapy results in significant acute toxicity, it is now becoming recognized that the late effects of therapy are equally problematic. In addition, it is clear that many acute and late effects of therapy, including oral health issues, nutritional deficiencies and the role of physical therapy and rehabilitation, are under recognized and under studied. Although supporting data are scant, allied health professions play a critical role in managing acute and late effects of therapy.

SUMMARY

Healthcare providers must take an active role in the evaluation and management of the acute and late effects of therapy. Referral for appropriate supportive care and rehabilitative services is critical in order to minimize the acute and late effects of therapy and to maximize long-term function.