Nutrition outcomes following implementation of validated swallowing and nutrition guidelines for patients with head and neck cancer

Nutrition outcomes and treatment toxicities in patients with head and neck cancer receiving helical intensity-modulated radiotherapy

BACKGROUND

Helical intensity-modulated radiotherapy (H-IMRT) provides excellent limitation of dose to tissues not requiring treatment, although acute toxicity still occurs. The present study aimed to determine how treatment-related acute toxicities affect nutrition outcomes in patients with head and neck cancer.

METHODS

A prospective observational study was conducted in 194 patients undergoing curative intent H-IMRT with or without other treatment modalities. Weight outcomes (kg) and acute toxicity and dysphagia data were collected during treatment using Common Toxicity Criteria for Adverse Effects (CTCAE), version 4.0.

RESULTS

Significant weight loss (> 10%) was observed in 30% of high nutritional risk patients and 7% of low nutritional risk patients. Nausea, adjusted for baseline dysphagia, in high nutritional risk patients and nausea, dysphagia and pharyngeal mucositis in low nutritional risk patients were significant factors in explaining the percentage loss in baseline weight to treatment completion.

CONCLUSIONS

Significant weight loss remains an issue during treatment, despite improvements in radiotherapy technology and high-level multidisciplinary care.

Sample size calculations for continuous outcomes in clinical nutrition

In nutrition research, sample size calculations for continuous outcomes are important for the planning phase of many randomized trials and could also be relevant for some observational studies such as cohort and cross-sectional studies. However, only little literature dedicated to this topic exists within nutritional science. This article reviews the most common methods for sample size calculations in nutrition research. Approximate formulas are used for explaining concepts and requirements and for working through examples from the literature. Sample size calculations for the various study designs, which are covered, may all be seen as extensions of the sample size calculation for the basic two-group comparison through the application of suitable scaling factors and, possibly, modification of the significance level. The latter is needed for sample size calculations for multi-group designs and designs involving multiple primary outcomes. Like cluster-randomized designs, these types of study designs may be more challenging than standard sample size calculations. In such non-standard scenarios, there may be a need for consulting a biostatistician. Finally, it should be stressed that there may be many ways to plan a study. The final sample size calculation provided for a grant applicant, study protocol, or publication will often not only depend on considerations and input information as described in this article but will also involve restrictions in terms of logistics and/or resources.

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.

Validation of the efficacy of the NUTRISCORE for the nutritional screening of cancer patients in China

Background

Malnutrition is common in cancer patients. The NUTRISCORE is a newly developed cancer-specific nutritional screening tool and was validated by comparison with the Patient-Generated Subjective Global Assessment (PG-SGA) and Malnutrition Screening Tool (MST) in Spain. We aimed to evaluate the performance of the NUTRISCORE, MST, and PG-SGA in estimating the risk of malnutrition in Chinese cancer patients.

Methods

Data from an open parallel and multicenter cross-sectional study in 29 clinical teaching hospitals in 14 Chinese cities were used. Cancer patients were assessed for malnutrition using the PG-SGA, NUTRISCORE, and MST. The sensitivity, specificity, and areas under the receiver operating characteristic curve were estimated for the NUTRISCORE and MST using the PG-SGA as a reference.

Results

A total of 1000 cancer patients were included. The mean age was 55.9 (19 to 92 years), and 47.5% were male. Of these patients, 450 (45.0%) had PG-SGA B and C, 29 (2.9%) had a NUTRISCORE ≥5, and 367 (36.7%) had an MST ≥ 2. Using the PG-SGA as a reference, the sensitivity, specificity, and area under the curve values of the NUTRISCORE were found to be 6.2, 99.8%, and 0.53, respectively. The sensitivity, specificity, and area under the curve values of the MST were 50.9, 74.9%, and 0.63, respectively. The kappa index between the NUTRISCORE and PG-SGA was 0.066, and that between the MST and PG-SGA was 0.262 (P < 0.05).

Conclusions

The NUTRISCORE had an extremely low sensitivity in cancer patients in China compared with the MST when the PG-SGA was used as a reference.

Nutritional assessment in a maxillectomy patient from the preoperative period to definitive obturator insertion: A case report

PATIENT

A 69-year-old Japanese male with squamous cell carcinoma of the right maxilla (T4M0N0) was referred to our department for a preoperative examination. An immediate surgical obturator was fabricated before surgery. He underwent surgical treatment, which included right subtotal maxillectomy and reconstruction with a split skin graft. One week postoperatively, the immediate surgical obturator was modified to expand the nasal cavity for obturator prosthesis. Oral intake was started 12 days postoperatively with an immediate surgical obturator in situ. The definitive obturator was fabricated after the wound surface had healed 8 months postoperatively. Assessment of the nutritional status included body mass index, serum albumin level, resting energy expenditure (REE) measured using indirect calorimetry, and predicted REE using the Harris-Benedict equation. These assessments were performed several times, from the time of admission until the definitive obturator was applied.

DISCUSSION

Malnutrition occurs frequently in patients with head and neck cancer because this region is vital for swallowing and mastication. Maxillectomy patients require a maxillofacial prosthesis to improve their nutritional status from the preoperative period to recovery. This case report describes maxillofacial prosthetic treatment from the perspective of nutrition. The patient wore the immediate surgical obturator postoperatively, which was followed by marked weight loss after restoration, and then weight gain returned to the normal range when wearing the definitive obturator.

CONCLUSION

Maxillofacial prosthetic treatments should make efforts to maintain nutritional status and achieve optimal function and quality of life in patients with head and neck cancers.

Nutritional Deficiencies in Radiotherapy-Treated Head and Neck Cancer Patients

Nutritional deficiencies (malnutrition, cachexia, sarcopenia, and unfavorable changes in the body composition) developing as a side effect of radiotherapy (RT) currently represents a significant but still inaccurately studied clinical problem in cancer patients. The incidence of malnutrition observed in head and neck cancer (HNC) patients in oncological radiology departments can reach 80%. The presence of malnutrition, sarcopenia, and cachexia is associated with an unfavorable prognosis of the disease, higher mortality, and deterioration of the quality of life. Therefore, it is necessary to identify patients with a high risk of both metabolic syndromes. However, the number of studies investigating potential predictive markers for the mentioned purposes is still significantly limited. This literature review summarizes the incidence of nutritional deficiencies in HNC patients prior to therapy and after the commencement of RT, and presents recent perspectives for the prediction of unfavorable nutritional changes developing as a result of applied RT.

Oral Nutritional Supplementation Affects the Dietary Intake and Body Weight of Head and Neck Cancer Patients during (Chemo) Radiotherapy

Considering the symptoms of (chemo) radiotherapy and the reduction in food intake in head and neck cancer (HNC) patients, this study aimed to investigate the association between treatment time points and oral nutritional supplementation (ONS) on dietary intake to estimate the frequency of energy and nutrient inadequacy, and also to evaluate body weight changes (BWC). Dietary intake data of 65 patients were obtained from 24-h dietary recalls and prevalence of inadequacy was calculated before or at the beginning (T0), in the middle (T1), and at the end of treatment (T2). BWC were calculated as the weight difference considering the previous weight reported and/or measured. Energy and macronutrient intake decreased in T1 and then improved in T2 (p < 0.001 for both). Micronutrient intake increased during treatment due to ONS use, but still presented a high probability of inadequate intake. In particular, calcium, magnesium, and vitamin B6 showed almost 100% of probability of inadequacy for those who did not use ONS. Finally, overweight patients suffered a higher weight accumulated deficit with a delta of −15 kg compared to other BMI (body mass index) categories. Therefore, we strongly recommend initiating nutritional counseling in conjunction with prophylactic ONS prescription from diagnosis to adjust nutrient intake and minimize weight loss.

Yusop NB, Ibrahim Z, Abdul Rahman Z, Jamhuri N. Changes in Nutrition Impact Symptoms, Nutritional and Functional Status during Head and Neck Cancer Treatment

Background: The purpose of this study is to evaluate changes in nutrition impact symptoms (NIS) and nutritional and functional status that occur throughout radiotherapy in head and neck cancer (HNC) patients. Methods: A prospective observational study of HNC inpatients who underwent radiotherapy with or without chemotherapy were recruited to participate. Fifty patients were followed for the periods before, in the middle and at the end of radiotherapy. Nutritional parameters were collected throughout radiotherapy. Results: According to Patient-Generated Subjective Global Assessment (PG-SGA), there was an increase from a baseline of 56% malnourished HNC patients to 100% malnourished with mean weight loss of 4.53 ± 0.41kg (7.39%) at the end of radiotherapy. Nutritional parameters such as muscle mass, fat mass, body mass index, dietary energy and protein intake decrease significantly (p < 0.0001) while NIS score, energy and protein intake from oral nutritional supplements (ONS) increased significantly (p < 0.0001). Hand grip strength did not differ significantly. All HNC patients experienced taste changes and dry mouth that required ONS at the end of treatment. ONS compliance affected the percentage of weight loss (p = 0.013). Conclusions: The intensive nutritional care time point was the middle of RT. The PG-SGA and NIS checklist are useful for monitoring nutrition for HNC patients.

Competing Morbidities In Advanced Head And Neck Squamous Cell Carcinoma Concurrent Chemoradiotherapy: A Strong Implication Of A Multidisciplinary Team Approach

Concurrent chemoradiotherapy (CCRT) is the standard approach for the treatment of locally advanced head and neck squamous cell carcinoma. Despite its undisputed advantages, CCRT is associated with acute and late toxicities, leading to unfavorable implications (eg, unplanned interruptions and noncancer-related mortality). The former prolongs the overall treatment time leading to a detrimental effect on tumor control. The latter consists of several noncancer morbidities arising from treatment-related toxicities, identifying a new pathway in cancer fate. This pathway has been termed noncancer mortality or competing mortality and consists of a series of treatment-competing morbidities, which nullify all therapeutic efforts aimed at curing these patients. The management of patients with head and neck squamous cell carcinoma who experience treatment-related toxicities is complex and requires expertise in oncological treatment as well as supportive care. The optimal management of these patients should start with knowledge regarding the most important competing morbidities developing during all phases of the disease (ie, from diagnosis to follow-up) to minimize treatment interruptions, ensure appropriate psychological support, and achieve the best oncological result. The purpose of the present review is to analyze the most important competing morbidities due to patient’s condition at baseline and CCRT, which could result in noncancer mortality. A multidisciplinary team approach is strongly required in the management of this disease.

Gastrostomy versus nasogastric tube feeding for chemoradiation patients with head and neck cancer: the TUBE pilot RCT

BACKGROUND

Approximately 9000 new cases of head and neck squamous cell cancers (HNSCCs) are treated by the NHS each year. Chemoradiation therapy (CRT) is a commonly used treatment for advanced HNSCC. Approximately 90% of patients undergoing CRT require nutritional support via gastrostomy or nasogastric tube feeding. Long-term dysphagia following CRT is a primary concern for patients. The effect of enteral feeding routes on swallowing function is not well understood, and the two feeding methods have, to date (at the time of writing), not been compared. The aim of this pilot randomised controlled trial (RCT) was to compare these two options.

METHODS

This was a mixed-methods multicentre study to establish the feasibility of a RCT comparing oral feeding plus pre-treatment gastrostomy with oral feeding plus as-required nasogastric tube feeding in patients with HNSCC. Patients were recruited from four tertiary centres treating cancer and randomised to the two arms of the study (using a 1 : 1 ratio). The eligibility criteria were patients with advanced-staged HNSCC who were suitable for primary CRT with curative intent and who presented with no swallowing problems.

MAIN OUTCOME MEASURES

The primary outcome was the willingness to be randomised. A qualitative process evaluation was conducted alongside an economic modelling exercise. The criteria for progression to a Phase III trial were based on a hypothesised recruitment rate of at least 50%, collection of outcome measures in at least 80% of those recruited and an economic value-of-information analysis for cost-effectiveness.

RESULTS

Of the 75 patients approached about the trial, only 17 consented to be randomised [0.23, 95% confidence interval (CI) 0.13 to 0.32]. Among those who were randomised, the compliance rate was high (0.94, 95% CI 0.83 to 1.05). Retention rates were high at completion of treatment (0.94, 95% CI 0.83 to 1.05), at the 3-month follow-up (0.88, 95% CI 0.73 to 1.04) and at the 6-month follow-up (0.88, 95% CI 0.73 to 1.04). No serious adverse events were recorded in relation to the trial. The qualitative substudy identified several factors that had an impact on recruitment, many of which are amenable to change. These included organisational factors, changing cancer treatments and patient and clinician preferences. A key reason for the differential recruitment between sites was the degree to which the multidisciplinary team gave a consistent demonstration of equipoise at all patient interactions at which supplementary feeding was discussed. An exploratory economic model generated from published evidence and expert opinion suggests that, over the 6-month model time horizon, pre-treatment gastrostomy tube feeding is not a cost-effective option, although this should be interpreted with caution and we recommend that this should not form the basis for policy. The economic value-of-information analysis indicates that additional research to eliminate uncertainty around model parameters is highly likely to be cost-effective.

STUDY LIMITATIONS

The recruitment issues identified for this cohort may not be applicable to other populations undergoing CRT. There remains substantial uncertainty in the economic evaluation.

CONCLUSIONS

The trial did not meet one of the three criteria for progression, as the recruitment rate was lower than hypothesised. Once patients were recruited to the trial, compliance and retention in the trial were both high. The implementation of organisational and operational measures can increase the numbers recruited. The economic analysis suggests that further research in this area is likely to be cost-effective.

FUTURE WORK

The implementation of organisational and operational measures can increase recruitment. The appropriate research question and design of a future study needs to be identified. More work is needed to understand the experiences of nasogastric tube feeding in patients undergoing CRT.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN48569216.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 16. See the NIHR Journals Library website for further project information.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Effect of Evidence-Based Nutrition Clinical Care Pathways on Nutrition Outcomes in Adult Patients Receiving Non-Surgical Cancer Treatment: A Systematic Review

Nutritional decline associated with non-surgical cancer treatment has been well documented. The implementation of an evidence-based nutrition care pathway is one approach suggested to improve the nutrition outcomes of this group of patients. We aimed to systematically review published original research to determine whether evidence-based nutrition clinical care pathways, as compared with usual care, improve outcomes for patients receiving non-surgical cancer treatment. The review was registered with PROSPERO (CRD42017048816) and followed PRISMA guidelines. The search strategy was conducted in four databases, and supplemented by an internet search, from inception to October 2016. Study quality was assessed using the Quality Criteria Checklist for Primary Research. Results were synthesized descriptively. Six reports of five studies formed the final library with a range of interventions and control practices investigated across several diagnostic groups. Nutrition outcomes were reported using multiple approaches with either no effect, or in favor of the clinical pathway intervention. Risk of bias was low in two studies with some risk in the remaining three studies. It was not possible to determine whether the effect on nutritional outcomes was attributable to care pathway implementation. The need to extend the evidence base through high-quality clinical trials was evident.

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

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

Tube feeding during treatment for head and neck cancer - Adherence and patient reported barriers

OBJECTIVES

The main aim was to investigate the incidence of patient adherence to nutritional tube feeding recommendations in patients with head and neck cancer and to determine patient barriers to meeting tube feeding prescription.

MATERIALS AND METHODS

This was an observational study from a randomised controlled trial in patients with head and neck cancer deemed at high nutritional risk with prophylactic gastrostomy (n=125). Patients were randomised to receive early tube feeding prior to treatment (intervention group) or standard care. All patients in the intervention and standard care groups then commenced clinical tube feeding as required during treatment. Patients maintained a daily record of gastrostomy intake, main nutrition impact symptom necessitating gastrostomy use, and reasons for not meeting nutrition prescription. Adherence was defined as meeting ≥75% of total prescribed intake.

RESULTS

Patients were predominantly male (89%), median age 60, with oropharyngeal tumours (78%), stage IV disease (87%) treated with chemoradiotherapy (87%). Primary reasons for gastrostomy use were poor appetite/dysgeusia (week 2-3) and odynophagia/mucositis (week 4-7). Early tube feeding adherence was 51%. Clinical tube feeding adherence was significantly higher in the intervention group (58% vs 38%, p=0.037). Key barriers to both phases of tube feeding were; nausea, early satiety and treatment factors (related to hospital healthcare processes).

CONCLUSIONS

Early tube feeding can improve patient adherence to clinically indicated tube feeding during treatment. Low adherence overall is a likely explanation for clinically significant weight loss despite intensive nutrition interventions. Optimising symptom management and strategies to overcome other barriers are key to improving adherence.

CLINICAL TRIAL REGISTRATION

This trial has been registered in the Australian New Zealand Clinical Trials registry as ACTRN12612000579897.

Nutritional management in head and neck cancer: United Kingdom National Multidisciplinary Guidelines

Nutritional support and intervention is an integral component of head and neck cancer management. Patients can be malnourished at presentation, and the majority of patients undergoing treatment for head and neck cancer will need nutritional support. This paper summarises aspects of nutritional considerations for this patient group and provides recommendations for the practising clinician.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PARTICIPANTS/SETTING

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

MAIN OUTCOME MEASURES

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

STATISTICAL ANALYSIS PERFORMED

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

RESULTS

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

CONCLUSIONS

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

Weight loss after head and neck cancer: A dynamic relationship with depressive symptoms

BACKGROUND

Weight loss and depressive symptoms are critical head and neck cancer outcomes, yet their relation over the illness course is unclear.

METHODS

Associations between self-reported depressive symptoms and objective weight loss across the year after head and neck cancer diagnosis were examined using growth curve modeling techniques (n = 564).

RESULTS

A reciprocal covariation pattern emerged-changes in depressive symptoms over time were associated with same-month changes in weight loss (t [1148] = 2.05; p = .041), and changes in weight loss were associated with same-month changes in depressive symptoms (t [556] = 2.43; p = .015). To the extent that depressive symptoms increased, patients lost incrementally more weight than was lost due to the passage of time and vice versa. Results also suggested that pain and eating-related quality of life might explain the reciprocal association between depressive symptoms and weight loss.

CONCLUSION

In head and neck cancer, a transactional interplay between depressive symptoms and weight loss unfolds over time. © 2016 Wiley Periodicals, Inc. Head Neck 39: 370-379, 2017.

A conceptual approach to practitioners’ health information literacy

Purpose

The purpose of this paper is to examine healthcare professionals’ own health literacy through the lenses of information behavior and evidence-based practice. These practitioners’ health information literacy is critical to client care.

Design/methodology/approach

This conceptual paper applies general and professional-specific models of information behavior and issues of bias to methods in which healthcare practitioners seek, evaluate and use research information within professional practice.

Findings

Case examples from library, medical and the broader healthcare literature are used to explore ways in which care professionals’ information behaviors align with or deviate from information behavior models and the role of different types of bias in their information behavior. Adaption of evidence-based practice precepts, already familiar to healthcare professionals, is proposed as a method to improve practitioners’ health information literacy.

Originality/value

Explorations of “health literacy” have primarily focused on healthcare consumers’ interactions with basic health information and services. The health literacy (and health information literacy) of care practitioners has received much less attention. By gaining a greater understanding of how information behaviors intersect with healthcare practitioners’ own health literacy, the librarians and educators who serve future and current care professionals can offer more informed information literacy instruction, enabling practitioners to provide improved patient care.

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

BACKGROUND/OBJECTIVES

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

SUBJECTS/METHODS

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

RESULTS

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

CONCLUSIONS

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

Squamous cell carcinoma of the lip: depth of invasion, local recurrence and regional metastases. Experience of a rural multidisciplinary head and neck unit

BACKGROUND

The internationally recognised American Joint Committee on Cancer (tumour-node-metastasis) staging system utilises tumour size to determine stage. Other factors (i.e. tumour depth) may provide additional prognostic information.

METHOD

A thorough retrospective analysis was performed of 68 patients with primary lip squamous cell carcinoma operated on or discussed by the Darling Downs Health Service between 2005 and 2013.

RESULTS

Twelve patients developed lymphatic spread. There was a statistically significant increased risk of nodal metastasis in: patients with tumours of increased thickness (U = 103.50; degrees of freedom = 68; p < 0.001), those with a larger overall tumour size (U = 163.50; degrees of freedom = 68; p = 0.005) and patients living further from the treatment centre (U = 199.00; degrees of freedom = 68; p = 0.018).

CONCLUSION

It may be reasonable that other factors are considered for staging of lip squamous cell carcinomas, in combination with tumour-node-metastasis staging. Depth of invasion may have utility in prognosis and treatment; however, larger prospective analysis needs to be performed. Patients living in a more rural setting presented with more advanced disease, suggesting an ongoing rural-metropolitan gap in healthcare.

Protocol for a randomized controlled trial of early prophylactic feeding via gastrostomy versus standard care in high risk patients with head and neck cancer

Background

Patients with head and neck cancer are at high risk of malnutrition and dysphagia. Enteral tube feeding via a gastrostomy or nasogastric tube is often required in response to dysphagia, odynophagia or side effects of treatment that lead to dehydration and/or weight-loss. A recent systematic review concluded that the optimal method of tube feeding remains unclear; however prophylactic gastrostomy, placed in anticipation of its use during and after treatment, is common practice, following a number of demonstrated benefits. However the majority of these studies have been undertaken in patients receiving radiotherapy alone. More recent studies in patient populations receiving concurrent chemoradiotherapy are showing that despite prophylactic gastrostomy placement significant weight loss still occurs, placing the patient at risk of the consequences of malnutrition. Therefore we set out to investigate innovative prophylactic nutrition support via the gastrostomy to optimise the nutritional outcomes of patients with head and neck cancer.

Methods/Design

Patients with head and neck cancer will be eligible for this single centre randomised controlled trial if they are identified for referral for a prophylactic gastrostomy using local guidelines. Patients will be excluded if they are: under the age of eighteen; pregnant; unable to give informed consent; or severely malnourished or moderately malnourished with significant dysphagia requiring a liquid or puree diet. All eligible patients who consent for the study will be allocated randomly to either the intervention or control group (usual care). The intervention group will commence prophylactic supplementary nutrition support via the gastrostomy immediately following placement compared to usual care where nutrition support is commenced via the gastrostomy when clinically indicated during treatment. Key outcome measures will be percentage weight loss, body composition, nutritional status and quality of life, measured at baseline and three months post treatment.

Discussion

To our knowledge this is the first study to evaluate the effectiveness of early prophylactic tube feeding compared to commencement of feeding during treatment, as per current standard practice, in patients undergoing prophylactic gastrostomy prior to treatment for head and neck cancer.

Trial registration

This trial has been registered in the Australian New Zealand Clinical Trials registry as ACTRN12612000579897.