Prophylactic Gastrostomy before Chemoradiation in Advanced Head and Neck Cancer: a Multiprofessional Web-based Survey to Identify Current Practice and to Analyse Decision Making

A review of unplanned admissions in head and neck cancer patients undergoing oncological treatment

AIM

Non-surgical treatment for head and neck cancer (HNC) often results in severe toxicities, which are detrimental to a patient's health and quality of life. There is limited published UK data on unplanned hospital admissions and reasons associated with admission. We aim to identify frequencies and reasons for unplanned hospital admissions, highlighting those patient groups who are most vulnerable.

METHODS

A retrospective study of unplanned hospital admissions of HNC patients receiving non-surgical treatment was completed. An inpatient admission was defined as ≥ 1 night spent in the hospital. To test potential demographic and treatment predictors of inpatient admission, a multiple regression model was constructed using the endpoint measure (unplanned admission), as the dependent variable.

RESULTS

A cohort of 216 patients was identified over a 7-month period, and 38 of these patients (17%) required an unplanned admission. Treatment type was the only statistically significant predictor of in-patient admission. The majority of admissions were patients receiving chemoradiotherapy (CRT) (58%) with predominant reasons for admission being nausea and vomiting (25.5%) and decreased oral intake/dehydration (30%). Of the patients admitted, 12 had a prophylactic PEG placed pre-treatment, and 18 of 26 admitted without prophylactic PEG required nasogastric tube feeding during their admission.

DISCUSSION

Almost one-fifth of HNC patients over this time period required hospital admission; the majority of which can be attributed to treatment toxicities when receiving CRT. This is concurrent with other studies which review the impact of radiotherapy versus CRT. Increased support and monitoring, particularly focused on nutrition, are required for patients with HNC who receive CRT.

KEY MESSAGE

This article describes a retrospective review of a patient undergoing non-surgical treatment for head and neck cancer. These patients frequently require unplanned hospital admission. The results indicate that patients undergoing (chemo)radiotherapy are most vulnerable to deterioration and additional support focused on nutrition for these patients is indicated.

Enteral nutrition support and treatment toxicities in patients with head and neck cancer receiving definitive or adjuvant helical intensity-modulated radiotherapy with concurrent chemotherapy

BACKGROUND

Enteral nutrition (EN) is often required in patients with head and neck cancer (HNSCC); however, initiation criteria is limited or inconsistent. This study aimed to describe the relationship of treatment toxicities and requirement for EN and investigate toxicity and baseline characteristics association with EN duration.

METHODS

Acute toxicities and baseline characteristics were collected from patients with HNSCC (n = 110) undergoing H-IMRT. Percentage EN contributing to estimated requirements and EN duration were measured.

RESULTS

The threshold for patients needing ≥50% of estimated requirements via EN increased from week 3 to 4 for grade ≥2 oral/pharyngeal mucositis, dysgeusia, thick saliva and nausea, and for grade 3 dysphagia. Patients with grade 2-3 dysphagia had a reduced risk of ceasing EN compared to those with grade 0-1 dysphagia.

CONCLUSIONS

Using acute toxicities in clinical practice may be a useful tool to inform prompt initiation of EN prior to decline in nutritional status and anticipate EN duration.

Patient-reported outcomes in terms of swallowing and quality of life after prophylactic versus reactive percutaneous endoscopic gastrostomy tube placement in advanced oropharyngeal cancer patients treated with definitive chemo-radiotherapy: Swall PEG study

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is often used to provide nutritional support in locally advanced head and neck cancer patients undergoing multimodality treatment. However, there is little published data on the impact of prophylactic versus reactive PEG. PEG placement may affect swallowing-related physiology, function, and quality of life. The Swall PEG study is a randomized controlled phase III trial testing the impact of prophylactic versus reactive PEG on patient-reported outcomes in terms of swallowing and quality of life in oropharyngeal cancer patients.

METHODS

Patients with locally advanced oropharyngeal cancer receiving chemo-radiotherapy will be randomized to either the prophylactic or reactive PEG tube group. Randomization will be stratified by human papillomavirus (HPV) status and unilateral versus bilateral positive neck lymph nodes. The primary objective of the study is the patient's reported outcome in terms of swallowing (MD Anderson Dysphagia Inventory (MDADI)) at 6 months. Secondary objectives include health-related quality of life, dosimetric parameters associated with patient-reported outcomes, chemo-radiation toxicities, PEG tube placement complications, the impact of nutritional status on survival and toxicity outcomes, loco-regional control, overall survival, the impact of HPV and tobacco smoking on survival outcomes and toxicities, and the cost-effectiveness of each treatment strategy.

DISCUSSION

Findings from this study will enhance clinical evidence regarding nutritional management in oropharyngeal cancer patients treated by concurrent chemo-radiation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04019548, study protocol version 2.0_08/08/2019. Registered on 15 July 2019.

Effect of prophylactic gastrostomy on nutritional and clinical outcomes in patients with head and neck cancer

BACKGROUND

We aimed to identify which enteral feeding method was most beneficial for patients and compare clinical outcomes, quality of life, and complication rates by assessing patients who underwent prophylactic percutaneous endoscopic gastrostomy (pPEG) tube, reactive percutaneous endoscopic gastrostomy (rPEG) tube or reactive nasogastric tube (rNGT) insertion.

METHODS

Patients with head and neck cancers (HNCs) were enrolled between April 1, 2013 and April 17, 2019 (n = 335; 296 males, 39 females). Data concerning patient characteristics and treatment modalities were extracted from the medical records. Comparisons between enteral feeding methods were made by univariate and multivariate analysis. Overall survival (OS) outcomes were analyzed by the log rank test using the Kaplan-Meier method.

RESULTS

A total of 335 patients were included. The median follow-up time was 29.5 months. There were forty-six patients in the pPEG tube group, 23 patients in the rPEG tube group, and 266 patients in the rNGT group. pPEG, increased body-mass index (BMI), and N0-1 category were significantly associated with less weight loss in the multivariate analysis (all P < 0.05). pPEG decreased the rate of radiotherapy delay compared with that of reactive interventions (23.1% vs. 47.1%, P = 0.007). In terms of quality of life, global health status, role functioning, emotional functioning, cognitive functioning, pain, and dyspnea were significantly improved in the pPEG tube group (all P < 0.05). BMI and weight loss were independent prognostic factors for clinical survival outcomes (all P < 0.05).

CONCLUSIONS

pPEG could improve nutrition outcomes, reduce treatment delay, and maintain quality of life.

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.

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.

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.

The changing landscape of oropharyngeal cancer management

Background:

Oropharyngeal cancer is increasing in prevalence in the UK and this is thought to be due to the emergence of disease related to human papilloma virus.

Method:

A literature review was conducted on the diagnosis and latest management of oropharyngeal cancer.

Results:

In non-smokers, human papilloma virus related disease is thought to have better outcomes, but this casts doubt on previous research which did not stratify patients according to human papilloma virus status. However, this theory provides a route for researchers to risk stratify and de-escalate treatments, and hence reduce treatment burden. In addition, the emergence of minimally invasive transoral techniques allows surgeons to remove large tumours without many of the side effects associated with radical (chemo)radiotherapy.

Conclusion:

The emergence of human papilloma virus related disease and minimally invasive techniques have led the clinical and academic community to reconsider how oropharyngeal cancer is managed. Comparative and risk-stratification trials are urgently required and ongoing.

A feasibility study incorporating a pilot randomised controlled trial of oral feeding plus pre-treatment gastrostomy tube versus oral feeding plus as-needed nasogastric tube feeding in patients undergoing chemoradiation for head and neck cancer (TUBE trial): study protocol

BACKGROUND

There are 7000 new cases of head and neck squamous cell cancers (HNSCC) treated by the NHS each year. Stage III and IV HNSCC can be treated non-surgically by radio therapy (RT) or chemoradiation therapy (CRT). CRT can affect eating and drinking through a range of side effects with 90 % of patients undergoing this treatment requiring nutritional support via gastrostomy (G) or nasogastric (NG) 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, not been compared to assess which leads to a better patient outcome. The purpose of this study is to explore the feasibility of conducting a randomised controlled trial (RCT) comparing these two options with particular emphasis on patient willingness to be randomised and clinician willingness to approach eligible patients.

METHODS/DESIGN

This is a mixed methods multicentre study to establish the feasibility of a randomised controlled trial comparing oral feeding plus pre-treatment gastrostomy versus oral feeding plus as required nasogastric tube feeding in patients with HNSCC. A total of 60 participants will be randomised to the two arms of the study (1:1 ratio). The primary outcome of feasibility is a composite of recruitment (willingness to randomise and be randomised) and retention. A qualitative process evaluation investigating patient, family and friends and staff experiences of trial participation will also be conducted alongside an economic modelling exercise to synthesise available evidence and provide estimates of cost-effectiveness and value of information. Participants will be assessed at baseline (pre-randomisation), during CRT weekly, 3 months and 6 months.

DISCUSSION

Clinicians are in equipoise over the enteral feeding options for patients being treated with CRT. Swallowing outcomes have been identified as a top priority for patients following treatment and this trial would inform a future larger scale RCT in this area to inform best practice.

TRIAL REGISTRATION

ISRCTN48569216.

Gastrostomy in head and neck cancer: current literature, controversies and research

PURPOSE OF REVIEW

This article explores the literature on the role of gastrostomy tube feeding use in the management of head and neck cancer, with special attention to its indications, timing of insertion, advantages, complications and quality of life issues.

RECENT FINDINGS

The current guidelines in place across different countries and two ongoing randomized controlled trials are discussed in detail, and placed in the context of current evidence.

SUMMARY

There remains a lack of consensus about when and which enteral feeding routes (gastrostomy or nasogastric tube) should be used and controversy about the long-term effects on swallowing function as well as quality of life for patients. Local guidelines should be used or generated to guide practice or patients enrolled into existing trials until higher level evidence is generated.

Swallowing performance and tube feeding status in patients treated with parotid-sparing intensity-modulated radiotherapy for head and neck cancer

BACKGROUND

The purpose of this prospective study was to evaluate the swallowing performance of patients with head and neck cancer treated with parotid-sparing intensity-modulated radiotherapy (IMRT).

METHODS

Sixty-two patients were recruited. Data were collected before and up to 12 months after treatment. Measures included the Performance Status Scale for head and neck cancer (PSS-HN Normalcy of Diet and Eating in Public subscales), tube feeding status, and 100 mL water swallow test (WST) volume and capacity scores.

RESULTS

There was a significant reduction in PSS-HN and WST scores from baseline to 3 months (p < .001). Significant improvements were observed up to 12 months on the PSS-HN. Swallowing volume and capacity scores recovered but did not reach statistical significance. Tube feeding was not required in 47% of the patients.

CONCLUSION

IMRT significantly impacts on swallowing performance, although there is a trend for improvement up to 12 months after treatment. Our data support a case-by-case approach to tube feeding. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1436-E1444, 2016.

Impact of feeding tubes on prospective functional outcomes in patients with locally advanced head and neck cancer undergoing radiation therapy

PURPOSE

The optimal timing of enteral feeding tube (FT) insertion during radiation therapy for head and neck cancer remains controversial. This study compares prospectively collected functional outcomes for prophylactic versus reactive insertion.

METHODS AND MATERIALS

Patients undergoing primary radiation therapy for stage III-IV head and neck cancer between 2004 and 2009 underwent functional outcome assessment at baseline and 3, 6, 12, 24, and 36 months posttreatment. Instruments included the Royal Brisbane Hospital Outcome Measure for Swallowing, Performance Status Scale for Head and Neck Cancer Patients, and modified Edmonton Symptom Assessment Scale. Multivariable regression analysis was conducted to determine the impact of FT use on functional outcomes.

RESULTS

A total of 178 patients were assessed with a median follow-up of 36.4 months. Use of an FT was prophylactic in 92 and reactive in 24; no tube was used in 62 patients. Compared with prophylactic placement, reactive FT use was not associated with worse function for Performance Status Scale for Head and Neck Cancer Patients Normalcy of Diet for soft foods (adjusted odds ratio [AOR] 1.16, P = .85) or Eating in Public (AOR 1.87, P = .31). Similarly, there were no differences in the Royal Brisbane Hospital Outcome Measure for Swallowing for modified diet (AOR 1.27, P = .7) or FT dependence (AOR 3.01, P = .2).

CONCLUSIONS

There were no significant differences in long-term swallowing function between patients who received a prophylactic versus reactive FT.

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.

Factors affecting duration of gastrostomy tube retention in survivors following treatment for head and neck cancer

Background:

Many patients treated for head and neck cancer require nutritional support, which is often delivered using a gastrostomy tube. It is difficult to predict which patients will retain their gastrostomy tube in the long term. This study aimed to identify the factors which affect the duration of gastrostomy tube retention.

Method:

In this retrospective study, 151 consecutive patients from one centre were audited. All patients had a mucosal tumour of the head and neck, and underwent gastrostomy tube insertion between 2003 and 2007.

Results:

There were near-complete data sets for 132 patients. The gastrostomy tube was retained in survivors (n = 66) for a mean of 21.3 months and in non-survivors (n = 66) for 11.9 months. Univariate analysis showed that co-morbidity was the only factor which significantly increased duration of gastrostomy tube retention in survivors (p = 0.041).

Conclusion:

Co-morbidity alone was associated with a significant increase in gastrostomy tube retention. It is suggested that co-morbidity be included as a variable in future relevant research. Co-morbidity should also be considered when counselling patients about their long-term function following cancer treatment. Gastrostomy tube retention is likely to be affected by many factors, with few single variables having importance independently.

Laryngeal cancer management in a small, rural, multidisciplinary team setting: 15-year review

Background:

The Cumberland Infirmary, Carlisle, serves a largely remote, rural population of 330 000. The aim of this study was to report the treatment and survival figures for patients treated for laryngeal cancer at this centre.

Methods:

The study included 209 consecutive patients with squamous cell carcinoma of the larynx diagnosed between 1996 and 2010 at the Cumberland Infirmary.

Results:

Disease-specific survival was 100 per cent for stage one, 76 per cent for stage two, 87 per cent for stage three and 46 per cent for stage four. In total, 76 patients (36 per cent) had a laryngectomy, either as primary treatment or as a salvage procedure.

Conclusion:

Our tumour-specific survival rate was very high, and this success may be due in part to high rates of surgical intervention. Survival data compared favourably with other centres, despite less radical radiotherapy regimes. Laryngeal cancer can be managed effectively in a small, relatively remote, multidisciplinary team setting.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Validated swallowing and nutrition guidelines for patients with head and neck cancer: identification of high-risk patients for proactive gastrostomy

BACKGROUND

The "Swallowing and Nutrition Guidelines for Patients with Head and Neck Cancer" were developed to guide early identification and management of dysphagia and nutritional risk before, during, and after cancer treatment. The purpose of this study was to validate these guidelines.

METHODS

Patients attending a Combined Head and Neck Clinic at a major tertiary hospital in 2007 to 2008 were assessed using the guidelines, with high-risk category patients recommended for proactive gastrostomy. Data were collected on guideline adherence, gastrostomy tube insertion, and weight. Sensitivity, specificity, and positive predictive value were calculated for validation.

RESULTS

Proactive gastrostomy tubes were inserted in 173 of 501 patients (25%). Overall guideline adherence was 87%. High-risk category adherence was 75%. Validation outcomes were sensitivity 54%, specificity 93%, and positive predictive value 82%.

CONCLUSION

The risk categories in the guidelines are valid to assist early identification of swallowing and nutritional risk and guide decision-making on proactive gastrostomy tube insertion.

Consensus-based nutritional recommendations for patients with head-and-neck cancer

Patients with head-and-neck cancer constitute one of the diagnostic groups that most commonly experi-ence deterioration of nutrition status.[...]

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.