Impact of pretreatment body mass index on patients with head-and-neck cancer treated with radiation

Obesity paradox: is a high body mass index positively influencing survival outcomes in gynecological cancers? A systematic review and meta-analysis

OBJECTIVE

Obesity represents an exponentially growing preventable disease leading to different health complications, particularly when associated with cancer. In recent years, however, an 'obesity paradox' has been hypothesized where obese individuals affected by cancer counterintuitively show better survival rates. The aim of this systematic review and meta-analysis is to assess whether the prognosis in gynecological malignancies is positively influenced by obesity.

METHODS

This study adheres to PRISMA guidelines and is registered with PROSPERO. Studies reporting the impact of a body mass index (BMI) of >30 kg/m2 compared with <30 kg/m2 in patients with gynecological cancers listed in PubMed, Google Scholar and ClinicalTrials.gov were included in the analysis. The Quality Assessment of Diagnostic Accuracy Studies 2 tool (QUADAS-2) was used for quality assessment of the selected articles.

RESULTS

Twenty-one studies were identified for the meta-analysis, including 14 108 patients with cervical, ovarian, or endometrial cancer. There was no benefit in 5-year overall survival for obese patients compared with non-obese patients (OR 1.2, 95% CI 1.00 to 1.44, p=0.05; I2=71%). When pooling for cancer sub-groups, there were no statistically significant differences in 5-year overall survival in patients with cervical cancer and 5-year overall survival and progression-free survival in patients with ovarian cancer. For obese women diagnosed with endometrial cancer, a significant decrease of 44% in 5-year overall survival (p=0.01) was found, with no significant difference in 5-year disease-free survival (p=0.78).

CONCLUSION

According to the results of the present meta-analysis, a BMI of ≥30 kg/m2 does not have a positive prognostic effect on survival compared with a BMI of <30 kg/m2 in women diagnosed with gynecological cancers. The existence of the 'obesity paradox' in other fields, however, suggests the importance of further investigations with prospective studies.

Impact of pretreatment body mass index on the survival of head and neck cancer patients

BACKGROUND

Differences in pretreatment body mass index (BMI) have been associated with survival in squamous cell carcinoma of head and neck (SCCHN). We examined effects of BMI on survival in SCCHN patients after stratifying patients by tumor human papillomavirus (HPV) status and subsite.

METHODS

Totally 2204 SCCHN patients in a prospective study were included in this secondary analysis. Multivariable Cox models were used to evaluate associations between pretreatment BMI and overall survival, disease-specific survival, and disease-free survival.

RESULTS

BMI was significantly higher among patients with HPV-positive tumors than HPV-negative tumors. BMI >25 kg/m2 was associated with improved survival, while BMI <18.5 kg/m2 was associated with reduced survival, particularly in patients with HPV-positive oropharyngeal cancer tumors.

CONCLUSIONS

This exploratory analysis suggests that pretreatment BMI could be an independent prognostic factor of survival outcomes in SCCHN patients, particularly in patients with HPV-positive oropharyngeal cancer tumors. Further prospective investigations are warranted.

Baseline weight recovery and mortality risk in head and neck cancer

BACKGROUND

As a surrogate of malnutrition, degree of weight loss and recovery from head and neck cancer (HNC) treatment is understudied. The influence of modifiable factors that affect weight, including speech/language pathology (SLP) and nutrition counseling, is also poorly defined. We characterize weight loss trends, baseline weight recovery (BWR), and the impact of interdisciplinary care on oncologic outcomes.

METHODS

Retrospective cohort study assessing 266 newly diagnosed patients with HNC who completed curative-intent radiation (definitive or adjuvant) between January 2016 to January 2022. Relevant treatment factors were analyzed using multivariable Cox regression models.

RESULTS

Altogether, 266 patients completed full-course radiation therapy (RT), encompassing definitive chemoRT (53.0%), surgery with chemoRT (18.4%), surgery with RT (17.7%), and RT alone (10.9%). Patient weight reached a nadir at median 3.0 months (IQR 3.0-11.3) after radiation, with a median weight loss of 12.6% (IQR 7.9-18.7). Notably, only 47.4% exhibited BWR. For those who recovered, median time to BWR was 10.5 months (IQR 3.0-24.0). On multivariable analysis, BWR by 6 months was significantly associated with overall survival (HR 0.28 [95% CI 0.10-0.76], p = 0.013), as was SLP consultation (HR 0.40 [95% CI 0.17-0.92], p = 0.031) and nutrition consultation (HR 0.34 [95% CI 0.13-0.89], p = 0.028).

CONCLUSION

A high proportion of patients with HNC fail to recover baseline weight after treatment; those that do can take longer than expected to return. Failure to recover baseline weight is associated with a notable decrease in survival. Similarly, SLP and nutrition consultation are independent, modifiable determinants correlated with outcomes, supporting the emphasis on multidisciplinary management. Measures to promote BWR may reduce mortality.

Oral Health in Patients with History of Head and Neck Cancer: Complexity and Benefits of a Targeted Oral Healthcare Pathway

PURPOSE OF REVIEW

This work consists in a literature review on the current state of knowledge regarding the oral management of patients with a history of head and neck cancer (HNC), corroborated by clinical cases and illustrated by clear infographic summaries. It aims to provide healthcare professionals with a comprehensive overview of the oral health status of HCN patients.

RECENT FINDINGS

Head and neck cancers (HNCs) represent the seventh most common type of cancer worldwide, with over 660,000 annual new cases. Despite the significant negative impact of HNCs on oral health, patients often receive no or inappropriate oral care while the significant impact of oral pathologies on cancer prognosis is commonly underestimated. This work (i) describes the oral cavity during and after HNC through the prism of care complexity and (ii) highlights several potential key factors that could worsen long-time patients' prognosis and quality of life. By investigating the biological, microbiological, functional, and psychological dimensions of the interrelationships between HNCs and oral health, the authors explored the barriers and benefits of a targeted oral healthcare pathway. This article emphasizes the importance of multidisciplinary care and highlights the need for further research elucidating the intricate relationships between oral health and HNCs, particularly through the microbiota.

Predictive Factors for Critical Weight Loss in Saudi Head and Neck Cancer Patients Undergoing (Chemo)Radiotherapy

Weight loss is a significant health problem among patients with head and neck cancer (HNC) that is attributable primarily to the tumor or tumor therapy. Critical weight loss (CWL) is defined as the unintentional loss of ≥5% of weight. Therefore, this study's goal was to investigate and determine the possible factors influencing CWL among patients with HNC who have received radiotherapy or concurrent chemoradiotherapy (CCRT). We conducted a retrospective analysis of 175 patients who received radiotherapy or CCRT as either their primary, adjuvant, or combined treatment at the Oncology Center in King Abdullah Medical City. All patients were ≥18 years of age and diagnosed with HNC with no metastasis. The study results showed that 107 patients (61%) had CWL, while 68 (39%) did not. The following factors were significantly predictive of CWL with a multivariate regression analysis: pretreatment BMI (AOR = 1.1, 95% CI = 1.02-1.17), oral cavity cancer (AOR = 10.36, 95% CI = 1.13-94.55), and male sex (AOR = 3.15, 95% CI = 1.39-7.11). In conclusion, weight loss is highly prevalent among HNC patients during treatment. Accordingly, pretreatment BMI, cancer in the oral cavity, and being male can be considered predictive factors for CWL.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association of Body Mass Index With Outcomes Among Patients With Head and Neck Cancer Treated With Chemoradiotherapy

Importance

Combined modality therapy, such as chemoradiotherapy, often results in significant morbidity among patients with head and neck cancer. Although the role of body mass index (BMI) varies based on cancer subtypes, its association with treatment response, tumor recurrence, and survival outcomes among patients with head and neck cancer remains unclear.

Objective

To evaluate the role of BMI in treatment response, tumor recurrence, and survival outcomes among patients with head and neck cancer undergoing chemoradiotherapy.

Design, Setting, and Participants

This retrospective, observational, single-institution cohort study conducted at a comprehensive cancer center included 445 patients with nonmetastatic head and neck cancer who underwent chemoradiotherapy from January 1, 2005, to January 31, 2021.

Exposure

Normal vs overweight or obese BMI.

Main Outcomes and Measures

Metabolic response after chemoradiotherapy, locoregional failure (LRF), distant failure (DF), overall survival (OS), and progression-free survival (PFS), with Bonferroni correction used to adjust for multiple comparisons and P < .025 being considered statistically significant.

Results

A total of 445 patients (373 men [83.8%]; median age, 61 years [IQR, 55-66 years]; 107 [24.0%] with normal BMI, 179 [40.2%] with overweight BMI, and 159 [35.7%] with obese BMI) were included for analysis. Median follow-up was 48.1 months (IQR, 24.7-74.9 months). On Cox proportional hazards regression multivariable analysis, only overweight BMI was associated with improved OS (5-year OS, 71.5% vs 58.4%; adjusted hazard ratio [AHR], 0.59 [95% CI, 0.39-0.91]; P = .02) and PFS (5-year PFS, 68.3% vs 50.8%; AHR, 0.51 [95% CI, 0.34-0.75]; P < .001). On logistic multivariable analysis, overweight BMI (91.6% vs 73.8%; adjusted odds ratio [AOR], 0.86 [95% CI, 0.80-0.93]; P < .001) and obese BMI (90.6% vs 73.8%; AOR, 0.89 [95% CI, 0.81-0.96]; P = .005) were associated with complete metabolic response on follow-up positron emission tomography-computed tomography after treatments. On Fine-Gray multivariable analysis, overweight BMI was associated with reduction in LRF (5-year LRF, 7.0% vs 25.9%; AHR, 0.30 [95% CI, 0.12-0.71]; P = .01), but not DF (5-year DF, 17.4% vs 21.5%; AHR, 0.92 [95% CI, 0.47-1.77]; P = .79). Obese BMI was not associated with LRF (5-year LRF, 10.4% vs 25.9%; AHR, 0.63 [95% CI, 0.29-1.37]; P = .24) or DF (5-year DF, 15.0% vs 21.5%; AHR, 0.70 [95% CI, 0.35-1.38]; P = .30).

Conclusion

In this cohort study of patients with head and neck cancer, when compared with normal BMI, overweight BMI was an independent factor favorably associated with complete response after treatments, OS, PFS, and LRF. Further investigations are warranted to improve understanding on the role of BMI among patients with head and neck cancer.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Predicting Nomogram for Severe Oral Mucositis in Patients with Nasopharyngeal Carcinoma during Intensity-Modulated Radiation Therapy: A Retrospective Cohort Study

BACKGROUND

Oral mucositis is an acute adverse reaction with high incidence during radiotherapy. Severe oral mucositis can seriously affect patients' quality of life and compliance with radiotherapy. The aim of this study was to identify the risk factors for severe oral mucositis and to develop a nomogram for predicting severe oral mucositis in patients with nasopharyngeal carcinoma.

METHODS

One hundred and ninety patients with nasopharyngeal carcinoma were retrospectively screened in this study. Least absolute shrinkage and selection operator regression and multivariate logistic regression analyses were performed to identify the best predictors of severe oral mucositis. A nomogram was constructed based on the factors. Finally, the discriminative ability of the nomogram was evaluated.

RESULTS

Four independent factors predicting severe oral mucositis were identified: age, N stage, the cycle of induction chemotherapy, and dose-volumetric parameter V40 (%) of oral cavity. The area under the receiver of operating characteristic curve of the nomogram was 0.759 (95% confidence interval: 0.691-0.827).

CONCLUSIONS

A predictive nomogram for severe oral mucositis was established and validated in this study. The nomogram provides a reliable and practical model for clinically predicting the probability of severe oral mucositis in patients with nasopharyngeal carcinoma before intensity-modulated radiation therapy.

Association between body composition and survival in head and neck cancer patients undergoing radiotherapy

BACKGROUND

Body composition may influence the prognosis of head and neck cancer (HNC) patients. To find out the most crucial factors in this relationship, we explored the association between body composition and survival.

METHODS

In this prospective longitudinal study, HNC patients who underwent radiotherapy (RT) from March 2017 to December 2018 were recruited. The association between body composition and survival was analyzed using Cox proportional hazard regression.

RESULTS

Final analysis included 316 patients, with a median follow-up of 34.4 months. Multivariable analysis revealed that weight loss 6 months before RT and body composition changes during RT did not affect the survival outcome. However, patients with low appendicular skeletal muscle mass index (ASMI) before RT exhibited poor overall survival (OS). ASMI before RT was an independent prognostic factor for OS.

CONCLUSIONS

Body composition loss was common during RT, and ASMI before RT independently influenced the survival outcomes of HNC patients.

The Body Mass Index Paradox in Head and Neck Cancer: A Systematic Review and Meta-Analysis

The body mass index (BMI) paradox describes that among patients with certain cancers, higher pretreatment BMI may be associated with improved survival. We examine the impact of BMI on overall survival (OS) in head and neck squamous cell carcinoma (HNSCC) patients. A literature search was performed, and articles using hazard ratios to describe the prognostic impact of BMI on OS in HNSCC were included. Random-effects DerSimonian and Laird methods were employed for meta-analysis. Meta-analysis of OS indicated a lower hazards of death in the overweight (BMI: 25 kg/m2-30 kg/m2) compared to the normal weight (BMI: 18.5 kg/m2-25 kg/m2). This protective relationship loses significance when BMI exceeds 30 kg/m². Underweight patients (BMI < 18.5 kg/m2) demonstrate higher hazards of death compared to normal weight patients. Compared to HNSCC patients with normal weight, being overweight up to a BMI of 30 kg/m² is a positive predictor of OS, while being underweight confers a prognostic disadvantage. Further studies are needed to determine the mechanisms by which increased body mass influences survival outcomes in HNSCC.

Nutritional Factors during and after Cancer: Impacts on Survival and Quality of Life

The French National Cancer Institute conducted a collective expertise study with researchers and clinical experts from the French Network for Nutrition And Cancer Research (NACRe Network). The objective was to update the state of knowledge on the impacts of nutritional factors on clinical endpoints during or after cancer. Data from 150 meta-analyses, pooled analyses or intervention trials and 93 cohort studies were examined; they concerned 8 nutritional factors, 6 clinical events and 20 cancer locations. This report shows that some nutritional factors have impacts on mortality and on the risks of recurrence or second primary cancer in cancer patients. Therefore, high-risk nutritional conditions can be encountered for certain cancer sites: from the diagnosis and throughout the health care pathways, weight loss (lung and esophageal cancers), malnutrition (lung, esophageal, colorectal, pancreatic, gastric and liver cancers), weight gain (colorectal, breast and kidney cancers) and alcohol consumption (upper aerodigestive cancers) should be monitored; and after cancer treatments, excess weight should be detected (colorectal, breast and kidney cancers). These situations require nutritional assessments, and even support or management by health care professionals, in the context of tertiary prevention. This report also highlights some limitations regarding the existing literature and some needs for future research.

Impact of photobiomodulation for oral mucositis on body weight and BMI of patients with head and neck cancer

PURPOSE

To evaluate the impact of photobiomodulation for oral mucositis on body weight and body mass index (BMI) in head and neck cancer patients.

METHODS

Patients were separated into two groups: photobiomodulation (PBM) (n = 17) and SHAM (n = 19). Participants assigned to the PBM group received the photobiomodulation therapy on alternate days at 33 different sites of the oral mucosa (1 J for 10 s per application point) using a low-power aluminum gallium arsenide (AsGaAl) laser device with a maximum output power of 86.7 mW and a wavelength of 660 nm (red). The same protocol was performed in patients allocated in the SHAM group but with the device turned off. At the first and twenty-fourth radiotherapy sessions, participants from both groups underwent an intraoral examination to assess the presence or absence of mucositis using the WHO scale, and measurements of weight and height for BMI calculation were undertaken.

RESULTS

All patients had significant differences in weight and BMI throughout the study period. Patients in the PBM group lost less weight (p < 0.01) and had a reduced BMI loss (p < 0.01) in comparison to patients in the SHAM group. Although PBM did not prevent oral mucositis, it decreased its severity (p < 0.01).

CONCLUSION

Photobiomodulation for oral mucositis reduced weight loss and prevented a reduction in BMI in patients who underwent chemoradiotherapy for head and neck cancer. Retrospectively registered at https://data.mendeley.com//datasets/4kd7s49wk4/1 .

Long-term monitoring and predictive factors of critical weight loss among patients with nasopharyngeal carcinoma in a curative treatment setting

PURPOSE

We aimed to determine weight change over time and identify risk factors of critical weight loss among patients with nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

In this retrospective study, we investigated weight change over time in 445 patients with NPC who underwent curative treatment. Logistic regression analysis was used to identify possible predictors of critical weight loss.

RESULTS

The incidence of critical weight loss was 67.87%. The long-term monitoring demonstrated a rapid weight loss, especially in the first 2 months of treatment, which continued up to 5 months. Patients with critical weight loss did not regain weight until 3 years. Univariate analysis showed that the following factors were significantly associated with critical weight loss: lower pretreatment body mass index (BMI), tumor stage, subjective global assessment score, Eastern Cooperative Oncology Group (ECOG) score, and enteral tube feeding. Multivariate analysis showed four factors that were associated with a lower critical weight loss: pretreatment BMI < 18.5 kg/m² (p < 0.001, 95% confidence interval [CI] = 0.25 [0.12-0.52]), early tumor stage (p = 0.004, 95% CI = 0.46 [0.27-0.79]), ECOG grade II (p = 0.006, 95% CI = 0.15 [0.04-0.51]), and early prophylactic percutaneous gastrostomy (PEG) tube feeding (p = 0.001, 95% CI = 0.26 [0.12-0.59]).

CONCLUSION

Patients having NPC with critical weight loss showed a significantly rapid decline in their weight in the first 2 months; the weight was persistently less than the baseline value during a 36-month follow-up period. Patients with lower BMI, early-stage cancer, and early prophylactic PEG tube feeding had a significantly lower critical weight loss than those without the abovementioned characteristics.

Prognostic Relevance of Change in Body Mass Index in Patients With Nasopharyngeal Carcinoma Undergoing Volumetric Modulated Arc Therapy: A Retrospective Study

Objective

To assess the effect of pretreatment body mass index (BMI) and the extent of change in BMI (ΔBMI) during the treatment course on the treatment outcomes in patients with nasopharyngeal carcinoma (NPC) receiving volumetric modulated arc therapy (VMAT).

Methods

Data pertaining to 498 consecutive NPC patients with stage I–IVA disease who received VMAT between January 2010 and November 2011 at a single center were retrospectively analyzed. Univariate Kaplan-Meier and multivariate Cox regression analyses were used to evaluate the prognostic significance of pretreatment BMI and ΔBMI. Receiver operating characteristic (ROC) curve analysis was used to determine the optimal cut-off point of ΔBMI.

Results

The 5-year loco-regional failure-free (L-FFR), distant failure-free survival (D-FFR), disease-free survival (DFS), and overall survival (OS) rates were 90.6%, 83.7%, 71.5% and 79.3%, respectively. The 5-year L-FFR, D-FFR, DFS, OS rates for NPC patients with ΔBMI ≤1 kg/m² vs ΔBMI >1 kg/m² were 92.3% vs 89.3% (P = .137), 90.9% vs 78.5% (P < .001), 80.4% vs 65.1% (P < .001), and 88.0% vs 73.0% (P < .001), respectively. ΔBMI >1 kg/m² was an independent predictor of D-FFR (P = .002), DFS (P = .002), and OS (P = .001).

Conclusions

ΔBMI during treatment course may have a significant impact on the prognosis of NPC patients receiving VMAT.

The Spectrum of Malnutrition/Cachexia/Sarcopenia in Oncology According to Different Cancer Types and Settings: A Narrative Review

Nutritional status in oncological patients may differ according to several modifiable and non-modifiable factors. Knowledge of the epidemiology of malnutrition/cachexia/sarcopenia may help to manage these complications early in the course of treatment, potentially impacting patient quality of life, treatment intensity, and disease outcome. Therefore, this narrative review aimed to critically evaluate the current evidence on the combined impact of tumor- and treatment-related factors on nutritional status and to draw some practical conclusions to support the multidisciplinary management of malnutrition in cancer patients. A comprehensive literature search was performed from January 2010 to December 2020 using different combinations of pertinent keywords and a critical evaluation of retrieved literature papers was conducted. The results show that the prevalence of weight loss and associated symptoms is quite heterogeneous and needs to be assessed with recognized criteria, thus allowing a clear classification and standardization of therapeutic interventions. There is a large range of variability influenced by age and social factors, comorbidities, and setting of cures (community-dwelling versus hospitalized patients). Tumor subsite is one of the major determinants of malnutrition, with pancreatic, esophageal, and other gastroenteric cancers, head and neck, and lung cancers having the highest prevalence. The advanced stage is also linked to a higher risk of developing malnutrition, as an expression of the relationship between tumor burden, inflammatory status, reduced caloric intake, and malabsorption. Finally, treatment type influences the risk of nutritional issues, both for locoregional approaches (surgery and radiotherapy) and for systemic treatment. Interestingly, personalized approaches based on the selection of the most predictive malnutrition definitions for postoperative complications according to cancer type and knowledge of specific nutritional problems associated with some new agents may positively impact disease course. Sharing common knowledge between oncologists and nutritionists may help to better address and treat malnutrition in this population.

Matched pair analysis to evaluate weight loss during radiation therapy for head and neck cancer as a prognostic factor for survival

Background

One frequent consequence of radiation therapy (RT) for head and neck cancer (HNC) is weight loss (WL). HNC patients reportedly lose about 9% of their weight during treatment, regardless of pre-treatment WL and nutritional support. We investigated whether high WL during RT has an association with overall (OS) and cancer-specific survival (CSS).

Methods

We retrospectively reviewed weight during RT in HNC patients treated at Roswell Park Comprehensive Cancer Center between 2003 and 2017. High WL was defined as greater than or equal to the median WL. Logistic regression analysis was performed to identify predictors for WL during RT. Multivariate Cox regression and Kaplan-Meier analyses were used to estimate survival outcomes. Propensity score matching was performed to obtain balanced matched-pairs and compare survival outcomes.

Results

A total of 843 patients received either definitive (71%) or post-operative (29%) RT. Median follow-up was 53.6 months [interquartile range (IQR) 35.7–88.9]. Median WL was 5.8% (IQR 0.24–10.6) from baseline weight. Patients with high WL had better OS [hazard ratio (HR) 0.75, 95% confidence interval (CI), 0.61–0.93, P=0.01] and CSS (HR 0.71, 95% CI, 0.55–0.93, P=0.01). 258 matched-pairs were analyzed. Median follow-up was 54.8 months (IQR 35.8–90.4). Median OS was 39.2 months (IQR 21.4–75.7) for high WL versus 36.7 months (IQR 14.6–61.7) for low WL cohorts (P=0.047).

Conclusions

Different from previous reports, this study shows that patients with less WL have worse OS. WL during RT may not be a reliable marker for worse prognosis. A better way to evaluate malnutrition in patients undergoing RT is warranted.

[Impact of nutritional factors during and after cancer]

Nutritional factors (diet, weight, alcohol, physical activity) are identified as factors having an impact on the onset of several cancer sites. Less abundant scientific data also underline their impact on the tumor progression. A review of the scientific literature was carried out by a group of experts established by the French National Cancer Institute (INCa) to better document the influence of nutritional factors during and after cancer on outcomes such as overall mortality, cancer specific mortality, recurrence, second primary cancers and quality of life. This analysis of the literature completes messages of reduction of alcohol consumption, prevention of undernutrition or excess weight and adherence to dietary recommendations, avoiding the use of dietary supplements, fasting or restrictive diets and strengthens messages promoting the practice of physical activity and the fight against sedentary lifestyle.

Body mass index and self-care behaviors related to oral health-related quality of life in patients with oral squamous cell carcinoma within three months posttreatment

PURPOSE

Oral dysfunction is a common adverse event of treatment and may affect oral health-related quality of life (OHRQoL). This study aimed to identify factors associated with OHRQoL in patients with oral squamous cell carcinoma (OSCC) within the first three months posttreatment.

METHODS

This cross-sectional study examined OSCC patients who received treatment from the outpatient radiation department of a single cancer center in northern Taiwan. Demographic and clinical characteristics were recorded, and patients were assessed using the Self-Care Behaviors Scale (SCB), Oral Health Impact Profile (OHIP), and Karnofsky Performance Status (KPS) questionnaires.

RESULTS

Among 148 OSCC patients, 11.5% reported being underweight and 70.3% reported normal weight. The most common self-care factors associated with adverse effects were decreased appetite and fatigue. Psychological disability, functional limitation, and physical pain were the most negative OHRQoL factors. Poor OHRQoL was associated with more severe adverse effects after self-care behaviors, using feeding tubes during treatment, and having BMI less than 25, which together explained 33.5% of the variance in OHRQoL.

CONCLUSIONS

The severity of adverse effects after self-care behaviors and using feeding tubes during treatment strongly influenced overall OHRQoL and seven specific dimensions of OHRQoL.

Evaluation of Prognosis in Nasopharyngeal Cancer Using Machine Learning

BACKGROUND AND AIM

Although the prognosis of nasopharyngeal cancer largely depends on a classification based on the tumor-lymph node metastasis staging system, patients at the same stage may have different clinical outcomes. This study aimed to evaluate the survival prognosis of nasopharyngeal cancer using machine learning.

SETTINGS AND DESIGN

Original, retrospective.

MATERIALS AND METHODS

A total of 72 patients with a diagnosis of nasopharyngeal cancer who received radiotherapy ± chemotherapy were included in the study. The contribution of patient, tumor, and treatment characteristics to the survival prognosis was evaluated by machine learning using the following techniques: logistic regression, artificial neural network, XGBoost, support-vector clustering, random forest, and Gaussian Naive Bayes.

RESULTS

In the analysis of the data set, correlation analysis, and binary logistic regression analyses were applied. Of the 18 independent variables, 10 were found to be effective in predicting nasopharyngeal cancer-related mortality: age, weight loss, initial neutrophil/lymphocyte ratio, initial lactate dehydrogenase, initial hemoglobin, radiotherapy duration, tumor diameter, number of concurrent chemotherapy cycles, and T and N stages. Gaussian Naive Bayes was determined as the best algorithm to evaluate the prognosis of machine learning techniques (accuracy rate: 88%, area under the curve score: 0.91, confidence interval: 0.68-1, sensitivity: 75%, specificity: 100%).

CONCLUSION

Many factors affect prognosis in cancer, and machine learning algorithms can be used to determine which factors have a greater effect on survival prognosis, which then allows further research into these factors. In the current study, Gaussian Naive Bayes was identified as the best algorithm for the evaluation of prognosis of nasopharyngeal cancer.

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.

The utility of nutritional supportive care with an eicosapentaenoic acid (EPA)-enriched nutrition agent during pre-operative chemoradiotherapy for pancreatic cancer: Prospective randomized control study

BACKGROUND & AIMS

Neoadjuvant chemoradiotherapy (NACRT) for pancreatic cancer (PC) is potentially associated with various toxicities, which can lead to impaired nutritional status. Eicosapentaenoic acid (EPA) can reduce proinflammatory cytokines and positively influence cancer cachexia syndrome. The aim of this study is to clarify the utility of EPA enriched nutrition support during NACRT for PC.

METHODS

We randomly assigned 62 patients with PC that received NACRT to either a nutrition intervention (NI) or a normal diet (ND). Patients in the NI group received 2 bottles/day (550 kcal/day) of an EPA-enriched nutrition supplement during NACRT. The primary endpoints were the before-to-after NACRT ratios (post/pre ratios) of skeletal muscle mass and psoas major muscle area (PMA). The secondary endpoints were the post/pre ratios of other nutritional parameters and treatment-related toxicities.

RESULTS

Only 14 patients (45.2%) in the NI group consumed more than 50% of the EPA-enriched supplement provided. The post/pre ratio of skeletal muscle mass in the NI group (0.99 ± 0.060) was not significantly different from that of the ND group (0.96 ± 0.079, p = 0.102). However, patients that consumed ≥50% of the EPA-enriched supplement (the good intake group) had significantly higher skeletal muscle mass ratios than patients in the ND group (p = 0.042). The PMA ratio was significantly higher in the NI group (0.96 ± 0.081) than in the ND group (0.89 ± 0.072, p = 0.001). The NI and ND groups were not significantly different in other nutritional parameters or in NACRT-related toxicity.

CONCLUSIONS

We found that EPA-enriched intake could potentially improve the nutritional status of patients with PC that received NACRT, but it was difficult for many patients to drink, due to its disagreeable taste. University Hospital Medical Information Network (http://www.umin.ac.jp), registration number UMIN000033589, https://upload.umin.ac.jp/cgi-bin/ctr_e/ctr_view.cgi?recptno=R000038300.

Prevalence and prognostic significance of malnutrition in patients with cancers of the head and neck

BACKGROUND & AIMS

Head and neck cancer (HNC) are at high nutritional risk; however the prevalence and severity of malnutrition in contemporary patients with HNC are unclear. Diagnostic criteria for cancer-associated weight loss grading (WLG) (Grades 0 to 4) [1] have been validated and are recommended in oncology nutrition clinical practice guidelines [2-3]. The aim was to determine the prevalence using WLG in HNC patients and determine the extent to which reduced dietary intake (DI) explained variation of WLG.

METHODS

A population-based cohort of HNC patients (N = 1756) in northern Alberta, Canada included consecutive new patients, 2004-2016. At referral to the regional cancer center weight history and DI categories were collected. Multinomial logistic regression (MLR) identified predictors of weight loss (WL) severity. Overall survival (OS) in relation to WL Grade and DI was determined by multivariable Cox proportional hazard.

RESULTS

WL was absent in 42.9% and the remainder had Grade 1 (18%), Grade 2 (14.7%), Grade 3 (15.9%) and Grade 4 (8.5%) WL. Independent predictors of WLG in adjusted MLR model, included stage (P < 0.000), performance status (PS) (P < 0.000) and DI categories (P < 0.000); sex, age and disease site were not significant. Compared to "normal food in normal amount" adjusted Odds Ratio for WL Grade 4 was 4.0 (2.1-7.5) "normal food, but less than normal amount"; 25.2 (10.7-59.1) "little solid food"; 51.8 (10.5-255.3) "very little of anything"; 42.4 (11.0-163.0) "only liquids"; 25.9 (7.1-94.3) "only nutritional supplements". In the Cox model controlled for age, sex, cancer stage and site and PS, both WLG ((P < 0.000) and DI categories (P = 0.003) independently predicted OS.

CONCLUSION

Data from this population cohort provide a benchmark for prevalence of cancer associated WL severity at diagnosis. Patient reported DI categories are strong predictors of WL and prognostic for OS.

Prognostic significance of body mass index in patients with localized renal cell carcinoma

OBJECTIVE

To investigate the relationship between the pretreatment body mass index (BMI) and the clinical outcomes in patients with localized stage I - III renal cell carcinoma (RCC) surgically treated.

MATERIALS AND METHODS

From January 2000 to December 2012, 798 patients with stage I - III RCC were recruited from First Affiliated Hospital and Cancer Center of Sun Yat - Sen University. Patients were divided into two groups of BMI < 25 kg / m2 or BMI ≥ 25 kg / m2 according to the World Health Organization classifications for Asian populations. The differences in the long-term survival of these two BMI groups were analyzed.

RESULTS

The 5 - year failure - free survival rates for BMI < 25 kg / m2 and BMI ≥ 25 kg / m2 groups were 81.3% and 93.3%, respectively (P = 0.002), and the 5 - year overall survival rates were 82.5% and 93.8%, respectively (P = 0.003). BMI was a favored prognostic factor of overall survival and failure - free survival in a Cox regression model.

CONCLUSIONS

Pretreatment body mass index was an independent prognostic factor for Chinese patients surgically treated, localized stage I - III RCC.

Relationship between body mass index and outcomes for patients with oral squamous cell carcinoma

OBJECTIVE

The purpose of our study was to investigate body mass index (BMI) as a prognostic factor and to examine the relationship between pretreatment BMI and oral squamous cell carcinoma (OSCC) outcomes in northern Chinese patients.

METHODS

This retrospective study enrolled 633 patients with OSCC who underwent surgery between 2004 and 2014.

RESULTS

Most baseline characteristics (gender, sites, smoking history, comorbidity, hypertension, T stage, clinical features, perineural invasion, flap reconstruction) were differentiated by BMI groups. Overall, the Kaplan-Meier curves indicated no significant relationship between BMI and disease-free survival (DFS) or disease-specific survival (DSS). Interestingly, obese patients exhibited higher risks of recurrence and death than normal-weight patients (DFS: HR: 1.86, 95% CI: 1.16-2.96; DSS: HR: 2.04, 95% CI: 1.08-3.86). However, postoperative complications occurred more frequently in underweight patients than in normal-weight patients.

CONCLUSIONS

Obesity may contribute to a higher recurrence rate and a worse prognosis in OSCC patients than in normal-weight patients in northern China. However, underweight patients have a higher risk of postoperative complications.

Prognostic significance of combined pretreatment lymphocyte counts and body mass index in patients with head and neck cancer treated with radiation therapy

We aimed to investigate the prognostic significance of combined pretreatment lymphocyte counts (LCs) and body mass index (BMI) in patients with head and neck cancer (HNC) treated with radiation therapy (RT). Nine hundred and twelve patients with HNC who were treated with RT were retrospectively reviewed. Survival was analyzed by stratifying the patients according to pretreatment LCs and BMI. Patients with low pretreatment LCs and BMI were characterized by a more advanced T stage, fewer nasopharyngeal subsites, less smoking and drinking, and fewer comorbidities. Patients with low pretreatment LCs and BMI had a significantly poorer overall and distant metastasis-free survival than those with high pretreatment LCs and BMI. No significant differences were observed in terms of local or regional recurrence-free survival. Combined pretreatment LCs and BMI may be more effective at predicting overall and distant metastasis-free survival in patients with HNC treated with RT.

Pharmacological modulation of radiation-induced oral mucosal complications

Radiation-induced mucositis is a common toxicity, especially in patients with head and neck cancers. Despite recent technological advances in radiation therapy, such as intensity-modulated radiotherapy, radiation-induced mucositis is still causing treatment disruptions, negatively affecting patients' long and short term quality of life, and impacting medical resources use with economic consequences. The objective of this article was to review the latest updates in the management of radiation-induced mucositis, with a focus on pharmaceutical strategies for the prevention or treatment of mucositis. Although numerous studies analysing the prevention and management of oral radiation-induced mucositis have been conducted, there are still few reliable data to guide daily clinical practice. Furthermore, most of the tested drugs have shown no (anti-inflammatory cytokine, growth factors) or limited (palifermin) effect. Therapies for acute oral mucositis are predominantly focused on improving oral hygiene and providing symptoms control. Although low-level laser therapy proved efficient in preventing radiation-induced oral mucositis in patients with head and neck cancer, this intervention requires equipment and trained medical staff, and is therefore insufficiently developed in clinical routine. New effective pharmacological agents able to prevent or reverse radio-induced mucositis are required.

Pretreatment subcutaneous adipose tissue predicts the outcomes of patients with head and neck cancer receiving definitive radiation and chemoradiation in Taiwan

We aimed to determine whether body composition assessment before treatment can predict outcomes in patients with head and neck cancer (HNC). All 881 patients with locoregional head and neck cancer treated with curative intent radiotherapy (RT) between 2005 and 2012 were retrospectively investigated. Body composition was analyzed via pre-RT planning computed tomography (CT) images. Subcutaneous adipose tissue (SAT) and skeletal muscle (SM) indices were measured cross-sectionally at the level of the third thoracic vertebra. Overall survival (OS), locoregional control (LRC), and distant metastasis-free survival (MFS) were analyzed by body composition index and body mass index (BMI). Survivors were followed up for a median of 4.68 years. The SAT indices in female patients were significantly higher than those in males (P < 0.001). The median SAT and muscle indices were 18.6 and 34.3 cm² /m² for women and 6.19 and 51.74 cm² /m² for men, respectively. The 5- and 10-year MFS, LRC, and OS rates were 83% and 82.1%, 73.4% and 71.4%, and 66.4 and 57.6%, respectively. Higher pretreatment SAT index was associated with MFS (hazard ratio [HR]: 0.65; P = 0.015), LRC (HR: 0.758; P = 0.047), and OS (HR: 0.604; P < 0.001). Higher pretreatment BMI was associated with MFS (HR: 0.642; P = 0.031) and OS (HR: 0.615; P < 0.001). The pretreatment SM index had no significant effect on MFS, LRC, and OS. Multivariate analysis revealed that T-stage, N-stage, lesion sites, age, and RT treatment days are independent factors associated with OS; T-stage, N-stage, and lesion sites are independent factors associated with MFS; and N-stage, smoking history, and betel quid chewing history are independent factors associated with LRC. A higher CT-assessed SAT index predicts superior MSF, LCR, and OS in patients with curative HNC, whereas SM does not predict survival or locoregional control.

Clinical Value of Nutritional Status in Cancer: What is its Impact and how it Affects Disease Progression and Prognosis?

Malnutrition is a common finding in cancer patients, which can affect disease progression and survival. This review aims to critically summarize the prognostic role of nutritional status, from Body Mass Index (BMI) and weight loss to nutrition screening tools and biochemical indices, in cancer patients. According to the currently available data, Prognostic Nutritional Index (PNI) was a significant prognostic factor of patients' survival, both in univariate and multivariate analyses. Pre-operative albumin was also correlated with worse outcomes, being an independent prognostic factor of survival in several studies. BMI was also well-studied, with contradictory results. Although, lower BMI was found to be an independent prognostic factor of shorter survival in some studies, in others it did not have an impact on survival. In this aspect, this review highlights the significant prognostic role of nutritional status in the disease progression and survival of cancer patients. Further, good-quality prospective studies are needed in order to draw precise conclusions on the prognostic role of specific nutritional assessment tools, and biochemical indices associated with the nutritional status in more cancer types, such as liver, breast and prostate cancer, and hematological malignancies.

Long-term results of a phase II study of gemcitabine and cisplatin chemotherapy combined with intensity-modulated radiotherapy in locoregionally advanced nasopharyngeal carcinoma

Objectives

To evaluate long-term results of a phase II study of induction and adjuvant gemcitabine and cisplatin (GP) chemotherapy with intensity-modulated radiotherapy (IMRT) in locoregionally advanced nasopharyngeal carcinoma (NPC).

Materials and methods

One hundred and twelve patients (Stage III: 65, IVA-B: 47) with locoregionally advanced NPC were enrolled in this study. All patients received induction chemotherapy consisting of 1000 mg/m2 gemcitabine on day 1 and 8, and cisplatin 25 mg/m2 on day 1–3, every 3 weeks for 2 cycles. Adjuvant chemotherapy for 2 cycles of the same regime was given 28 days after the end of IMRT. The IMRT technique was utilized for all patients.

Results

In total, 97.3% patients completed 2 cycles of induction chemotherapy. The overall response rate (RR) of cervical lymph nodes was 89.0%. Acute toxicities were mainly grade 1–2 myleosuppression and vomiting. And 83.9% patients completed 2 cycles of adjuvant chemotherapy. All patients finished IMRT with RR at the end of IMRT for nasopharynx, lymph nodes of neck and retropharyngeal area being 99.1%, 97.9% and 97.7%, respectively. The 5-year local control, regional control, distant metastasis-free and overall survival rates were 93.2%, 92.3%, 89.0% and 82.1%, respectively. The 5-year overall survival of stage III and IVA-B were 87.0%, and 75.5%, respectively. The incidence of grade 3–4 acute radiotherapy-related mucositis was 28.6%. Severe late toxicities were uncommon.

Conclusion

IMRT combined with GP for locoregionally advanced NPC is well tolerated, effective, and convenient, and warrants further studies.

Association of Body Mass Index With Infectious Complications in Free Tissue Transfer for Head and Neck Reconstructive Surgery

Importance

Elevated body mass index (BMI) has been proposed as a risk factor for morbidity and mortality among patients undergoing surgery. Conversely, an elevated BMI may confer a protective effect on perioperative morbidity.

Objective

To examine whether an elevated BMI is an independent risk factor for perioperative and postoperative infectious complications after free tissue transfer in head and neck reconstructive surgery.

Design, Setting, and Participants

This cohort study included patients undergoing major head and neck surgery requiring free tissue transfer at a tertiary care center. Data were collected for 415 patients treated from January 1, 2007, through December 31, 2014.

Main Outcomes and Measures

The outcome of interest was postoperative infection and complications after head and neck surgery using free flaps. Covariates considered for adjustment in the statistical model included alcohol consumption (defined as >5 drinks per day [eg, 360 mL of beer, 150 mL of wine, or 45 mL of 80-proof spirits]), type 2 diabetes, prior radiotherapy, anesthesia time, hypothyroidism, smoking, American Society of Anesthesiologists classification, antibiotic regimen received (defined as a standard regimen of a first- or second-generation cephalosporin with or without metronidazole hydrochloride vs an alternative antibiotic regimen for patients allergic to penicillin), and primary surgeon. A multiple logistic regression model was developed for the incidence of the infection end point as a function of elevated BMI (>30.0).

Results

Among the 415 patients included in this study (277 men [66.7%] and 138 women [33.2%]; mean [SD] age, 61.5 [13.9] years), type 2 diabetes and use of an alternative antibiotic regimen were found to be independently associated with increased infectious complications after free flap surgery of the head and neck, with estimated odds ratios of 2.78 (95% CI, 1.27-6.09) and 2.67 (95% CI, 1.14-6.25), respectively, in the multiple logistic regression model. However, a high BMI was not found to be statistically significant as an independent risk factor for postoperative infectious complication (estimated odds ratio, 1.19; 95% CI, 0.48-2.92).

Conclusions and Relevance

Elevated BMI does not seem to play a role as an independent risk factor in postoperative complications in free tissue transfer in head and neck surgery.

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

OBJECTIVES/HYPOTHESIS

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

STUDY DESIGN

A prospective observational cohort study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Body mass index and prognosis in patients with head and neck cancer

BACKGROUND

Body mass index (BMI) has been associated variably with head and neck cancer outcomes. We evaluated the association between BMI at either diagnosis or at early adulthood head and neck cancer outcomes.

METHODS

Patients with invasive head and neck squamous cell cancer at Princess Margaret Cancer Centre in Toronto, Canada, were surveyed on tobacco and alcohol exposure, performance status, comorbidities, and BMI at diagnosis. A subset also had data collected for BMI at early adulthood.

RESULTS

With a median follow-up of 2.5 years, in 1279 analyzed patients, being overweight (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.4-0.8; p = .001) at diagnosis was associated with improved survival when compared with individuals with normal weight. In contrast, underweight patients at diagnosis were associated with a worse outcome (HR, 1.89; 95% CI, 1.2-3.1; p < .01).

CONCLUSION

Being underweight at diagnosis was an independent, adverse prognostic factor, whereas being overweight conferred better prognosis. BMI in early adulthood was not associated strongly with head and neck cancer outcomes. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1226-1233, 2017.

Does Quitting Smoking Make a Difference Among Newly Diagnosed Head and Neck Cancer Patients?

INTRODUCTION

To determine if smoking after a cancer diagnosis makes a difference in mortality among newly diagnosed head and neck cancer patients.

METHODS

Longitudinal data were collected from newly diagnosed head and neck cancer patients with a median follow-up time of 1627 days (N = 590). Mortality was censored at 8 years or September 1, 2011, whichever came first. Based on smoking status, all patients were categorized into four groups: continuing smokers, quitters, former smokers, or never-smokers. A broad range of covariates were included in the analyses. Kaplan-Meier curves, bivariate and multivariate Cox proportional hazards models were constructed.

RESULTS

Eight-year overall mortality and cancer-specific mortality were 40.5% (239/590) and 25.4% (150/590), respectively. Smoking status after a cancer diagnosis predicted overall mortality and cancer-specific mortality. Compared to never-smokers, continuing smokers had the highest hazard ratio (HR) of dying from all causes (HR = 2.71, 95% confidence interval [CI] = 1.48-4.98). Those who smoked at diagnosis, but quit and did not relapse-quitters-had an improved hazard ratio of dying (HR = 2.38, 95% CI = 1.29-4.36) and former smokers at diagnosis with no relapse after diagnosis-former smokers-had the lowest hazard ratio of dying from all causes (HR = 1.68, 95% CI = 1.12-2.56). Similarly, quitters had a slightly higher hazard ratio of dying from cancer-specific reasons (HR = 2.38, 95% CI = 1.13-5.01) than never-smokers, which was similar to current smokers (HR = 2.07, 95% CI = 0.96-4.47), followed by former smokers (HR = 1.70, 95% CI = 1.00-2.89).

CONCLUSIONS

Compared to never-smokers, continuing smokers have the highest HR of overall mortality followed by quitters and former smokers, which indicates that smoking cessation, even after a cancer diagnosis, may improve overall mortality among newly diagnosed head and neck cancer patients. Health care providers should consider incorporating smoking cessation interventions into standard cancer treatment to improve survival among this population.

IMPLICATIONS

Using prospective observational longitudinal data from 590 head and neck cancer patients, this study showed that continuing smokers have the highest overall mortality relative to never-smokers, which indicates that smoking cessation, even after a cancer diagnosis, may have beneficial effects on long-term overall mortality. Health care providers should consider incorporating smoking cessation interventions into standard cancer treatment to improve survival among this population.

Association of pretreatment body mass index and survival in human papillomavirus positive oropharyngeal squamous cell carcinoma

BACKGROUND

Pretreatment body mass index (BMI) >25kg/m(2) is a positive prognostic factor in patients with head and neck cancer. Previous studies have not been adequately stratified by human papilloma virus (HPV) status or subsite. Our objective is to determine prognostic significance of pretreatment BMI on overall survival in HPV+ oropharyngeal squamous cell carcinoma (OPSCC).

METHODS

This is a retrospective review of patients with HPV+ OPSCC treated between 8/1/2006 and 8/31/2014. Patients were stratified by BMI status (>/<25kg/m(2)). Univariate and multivariate analyses of survival were performed.

RESULTS

300 patients met our inclusion/exclusion criteria. Patients with a BMI >25kg/m(2) had a longer overall survival (HR=0.49, P=0.01) as well as a longer disease-specific survival (HR=0.43, P=0.02). Overall survival remained significantly associated with high BMI on multivariate analysis (HR=0.54, P=0.04).

CONCLUSIONS

Pre-treatment normal or underweight BMI status is associated with worse overall survival in HPV+ OPSCC.

Systemic Immune-inflammation Index, Based on Platelet Counts and Neutrophil-Lymphocyte Ratio, Is Useful for Predicting Prognosis in Small Cell Lung Cancer

Small cell lung cancer (SCLC) is an aggressive disease characterized by rapid growth and metastases. It has been recognized that the inflammation of the microenvironment plays a critical role in the development of malignancies. However, little is known about the role of multiple inflammatory and hematological markers in the prognosis of SCLC. The aim of this study was to determine the clinical significance of pre-treatment inflammation-based scores and characteristics as prognostic indicators for the survival of SCLC patients. A retrospective analysis of 919 SCLC cases was performed. Patients' characteristics and hematologic tests data at initial diagnosis were collected. The univariate analysis of all SCLC patients indicated that favorable prognostic factors were age ˂ 70 years, non-smokers, good performance status, limited disease and response to treatment. Moreover, univariate analysis of inflammation-based scores and other blood parameters showed that neutrophil-lymphocyte ratio ≥ 5, platelet-lymphocyte ratio ≥ 250, systemic immune-inflammation index (SII) ≥ 1,600 × 10(9)/L, prognostic nutritional index (albumin + 5 × lymphocyte) < 45, and elevated serum lactate dehydrogenase (LDH) predicted poor prognosis in SCLC patients. SII represents the score that is calculated as follows: platelet count × neutrophil count/lymphocyte count. In the multivariate analysis, SII, together with serum LDH, stage and response to therapy, were associated with overall survival (OS). This study demonstrated that the combination of platelet count and neutrophil-lymphocyte ratio could help to predict poor prognosis in SCLC. Our findings will facilitate the understanding of survival differences in SCLC patients in clinical practice.

Socioeconomic and Other Demographic Disparities Predicting Survival among Head and Neck Cancer Patients

BACKGROUND

The Institute of Medicine (IOM) report, "Unequal Treatment," which defines disparities as racially based, indicates that disparities in cancer diagnosis and treatment are less clear. While a number of studies have acknowledged cancer disparities, they have limitations of retrospective nature, small sample sizes, inability to control for covariates, and measurement errors.

OBJECTIVE

The purpose of this study was to examine disparities as predictors of survival among newly diagnosed head and neck cancer patients recruited from 3 hospitals in Michigan, USA, while controlling for a number of covariates (health behaviors, medical comorbidities, and treatment modality).

METHODS

Longitudinal data were collected from newly diagnosed head and neck cancer patients (N = 634). The independent variables were median household income, education, race, age, sex, and marital status. The outcome variables were overall, cancer-specific, and disease-free survival censored at 5 years. Kaplan-Meier curves and univariate and multivariate Cox proportional hazards models were performed to examine demographic disparities in relation to survival.

RESULTS

Five-year overall, cancer-specific, and disease-free survival were 65.4% (407/622), 76.4% (487/622), and 67.0% (427/622), respectively. Lower income (HR, 1.5; 95% CI, 1.1-2.0 for overall survival; HR, 1.4; 95% CI, 1.0-1.9 for cancer-specific survival), high school education or less (HR, 1.4; 95% CI, 1.1-1.9 for overall survival; HR, 1.4; 95% CI, 1.1-1.9 for cancer-specific survival), and older age in decades (HR, 1.4; 95% CI, 1.2-1.7 for overall survival; HR, 1.2; 95% CI, 1.1-1.4 for cancer-specific survival) decreased both overall and disease-free survival rates. A high school education or less (HR, 1.4; 95% CI, 1.0-2.1) and advanced age (HR, 1.3; 95% CI, 1.1-1.6) were significant independent predictors of poor cancer-specific survival.

CONCLUSION

Low income, low education, and advanced age predicted poor survival while controlling for a number of covariates (health behaviors, medical comorbidities, and treatment modality). Recommendations from the Institute of Medicine's Report to reduce disparities need to be implemented in treating head and neck cancer patients.

Critical weight loss predicts poor prognosis in nasopharyngeal carcinoma

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Definitive Surgical Therapy after Open Neck Biopsy for HPV-Related Oropharyngeal Cancer

OBJECTIVE

To determine the impact of prior open neck biopsy on the prognosis of patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) who are subsequently treated with a definitive surgical paradigm, including adjuvant therapy when indicated.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary care university hospital.

SUBJECTS AND METHODS

Patients with open neck biopsies who were treated with definitive surgery, with or without adjuvant therapy, for HPV-related OPSCC between 1998 and 2012 were compared with a matched control group who did not undergo open neck biopsy. Outcomes were disease-free survival, overall survival, disease-specific survival, incidence of tumor deposit in dermal scar, patterns of recurrence, and neck dissection complications.

RESULTS

Forty-five patients who underwent open neck biopsy were compared with 90 matched controls. Tumor deposits in dermal scars from the prior open neck biopsy were found in 3 patients (7%) during completion neck dissection. Overall complications of the neck dissection were not significantly increased in the open biopsy group over matched controls (20% vs 12%, respectively; P > .05). Five-year Kaplan-Meier estimates for disease-free survival, overall survival, and disease-specific survival were not significantly different between the open biopsy and control groups (93% vs 91%, 98% vs 97%, 98% vs 99%, respectively; all P > .05). Recurrence rates were also not significantly different between groups.

CONCLUSIONS

Patients with HPV-related OPSCC who have undergone a prior open neck biopsy can be successfully treated with a definitive surgical paradigm. Although needle biopsy is preferable to establish a diagnosis, previous open neck biopsy does not affect prognosis in these patients.

Overweight and obesity predict better overall survival rates in cancer patients with distant metastases

Recent studies conducted in patients with chronic diseases have reported an inverse association between body mass index (BMI) and mortality. However, the question as to whether BMI may predict prognosis in patients with metastatic cancer remains open. We therefore designed the current retrospective study to investigate the potential association between BMI and overall survival (OS) in patients with distant metastases (DM) and a favorable performance status. Between 2000 and 2012, a total of 4010 cancer patients with DM who required radiotherapy (RT) and had their BMI measured at the initiation of RT were identified. The relation between BMI and OS was examined by univariate and multivariable analysis. The median OS time was 3.23 months (range: 0.1–122.17) for underweight patients, 6.08 months (range: 0.03–149.46) for normal‐weight patients, 7.99 months (range: 0.07–158.01) for overweight patients, and 12.49 months (range, 0.2–164.1) for obese patients (log‐rank: P < 0.001). Compared with normal‐weight patients, both obese (HR = 0.676; 95% P < 0.001) and overweight individuals (HR = 0.84; P < 0.001) had a reduced risk of all‐cause mortality in multivariable analysis. Conversely, underweight patients had a significantly higher risk of death from all causes (HR = 1.41; P < 0.001). Overweight and obesity are independent predictors of better OS in metastatic patients with a good performance status. Increased BMI may play a role to identify metastatic patients with superior survival outcome and exhibit a potential to encourage aggressive management in those patients even with metastases.

Prognostic value of nutritional and hematologic markers in head and neck squamous cell carcinoma treated by chemoradiotherapy

PURPOSE

Malnutrition and systemic lymphopenia are common in many cancers and are associated with tumor progression. The purpose of this study was to investigate the prognostic values of nutritional and hematologic markers in patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

This prospective study included 153 patients with treatment-naïve HNSCC who underwent definitive chemoradiotherapy. Body weight, serologic and hematologic parameters were measured at baseline and after 2 months of treatment. Univariate and multivariate analyses using Cox proportional hazards model were used to identify predictors of progression-free survival (PFS), cancer-specific survival (CSS), and overall survival (OS).

RESULTS

Body weight, body mass index (BMI), serum albumin, total serum proteins, hemoglobin, and circulating neutrophil, lymphocyte, monocyte, and platelet counts significantly decreased, but neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) significantly increased after 2 months of treatment (P<0.05 each). Multivariate analyses showed that pretreatment hypoalbuminemia and high NLR were independent predictors of PFS (P<0.01 each). ECOG performance status, BMI<18.5 kg/m(2) and NLR were independent predictors of CSS and OS (P<0.01 each).

CONCLUSIONS

Our data support the evidence that several nutritional and hematologic markers are associated with the prognosis of HNSCC.

Dietary counselling and nutritional support in oropharyngeal cancer patients treated with radiotherapy: persistent weight loss during 1-year follow-ups

BACKGROUND/OBJECTIVES

The need for dietary counselling and nutritional support in oropharyngeal cancer patients is generally accepted. However, evidence for the effectiveness is sparse. The aim of this study was to describe dietary counselling, nutritional support, body weight and toxicity during and after treatment, and investigate the effect of pre-treatment body mass index (BMI) on survival in oropharyngeal cancer patients.

SUBJECTS/METHODS

A retrospective chart review was made in 276 oropharyngeal cancer patients treated with radiotherapy (RT). End points were dietary consultations, weight loss, toxicity, overall survival and disease-free survival.

RESULTS

Almost all oropharyngeal cancer patients received dietary counselling (94%) and nutritional support (99%). Dietary counselling decreased sharply shortly after treatment to 38% at 1 year after treatment. Overall weight loss increased during the first year of follow-up and ranged from 3% at start of RT, until 11% at 1 year after RT. Overall survival was significantly longer for patients with a BMI above average (P=0.01). Acute dysphagia (P=0.001), mucositis (P=0.000) and toxicity grade 3 (P=0.002) were significantly more prevalent in patients who had lost 10% or more of their body weight.

CONCLUSIONS

This study showed that patients continue to lose body weight during and until 1 year after treatment, despite nutrition support and frequent dietetic consultation. A BMI above average appears to increase survival time. Future studies, preferably randomized trials, are needed to compare standard dietary counselling with more intensive dietary counselling that consists of earlier and/or prolonged treatment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effective Biomarkers and Radiation Treatment in Head and Neck Cancer

CONTEXT

Radiation is a key arm in the multidisciplinary treatment of patients with head and neck squamous cell carcinoma. During the past 2 decades, significant changes in the way radiation therapy is planned and delivered have improved efficacy and decreased toxicity. Refined approaches in the application of radiation and chemoradiation have led to organ-sparing treatment regimens for laryngeal and pharyngeal cancers and have improved local and regional control rates in the postoperative, adjuvant setting. The molecular and genetic determinants of tumor cell response to radiation have been studied, and several potential biomarkers are emerging that could further improve application and efficacy of radiation treatment in head and neck squamous cell carcinoma.

OBJECTIVE

To discuss the current understanding of potential biomarkers related to radiation response in head and neck squamous cell carcinoma.

DATA SOURCES

Existing published literature.

CONCLUSIONS

Several potential biomarkers are actively being studied as predictors and targets to improve the use and efficacy of radiation therapy to treat head and neck squamous cell carcinoma. Several promising candidates have been defined, and new markers are on the horizon.