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Senesse P, Briant J, Boisselier P, Bensadoun RJ, Vinches M, Faravel K. Head and neck cancer patients treated with concomitant chemoradiotherapy involving the oral cavity and oropharynx: is another choice possible than prophylactic gastrostomy? Curr Opin Oncol 2024; 36:128-135. [PMID: 38573201 DOI: 10.1097/cco.0000000000001031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
PURPOSE OF REVIEW Recent recommendations on cachexia highlight, in head and neck cancers, the heterogeneity of studies, focusing on weight loss and sequelae including swallowing disorders. The current national guidelines emphasize that, in cases of concurrent chemoradiotherapy (cCRT) involving the oral cavity and oropharynx, prophylactic gastrostomy placement should be carried out systematically. We review why this technique is particularly relevant in this specific location for the feasibility of cCRT. RECENT FINDINGS A randomized trial is underway on swallowing disorders and the quality of life of patients after prophylactic vs. reactive gastrostomy in advanced oropharyngeal cancer patients treated with CRT. Concurrently, recent literature reviews emphasize the importance of the cumulative dose of chemotherapy for local control and survival. In cases of cCRT involving the oral cavity or the oropharynx, nutritional support could have a beneficial or detrimental impact on chemotherapy. SUMMARY Specifically for patients treated with cCRT involving the oral cavity and oropharynx, prophylactic gastrostomy would be able to fulfill the three objectives of local control, survival, and quality of life, minimizing complications related to nutritional support. Studies need to be more homogeneous. In clinical practice, nutrition should primarily assist in carrying out cancer treatment when survival is the main goal.
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Affiliation(s)
- Pierre Senesse
- Institut du Cancer Montpellier, (ICM), Supportive Care Department, University of Montpellier, France
| | - Jeanne Briant
- Institut du Cancer Montpellier, (ICM), Supportive Care Department, University of Montpellier, France
| | - Pierre Boisselier
- Institut du Cancer Montpellier (ICM), Radiotherapy Department, University of Montpellier, France
| | | | - Marie Vinches
- Institut du Cancer Montpellier (ICM), Medical Oncology Department, University of Montpellier, France
| | - Kerstin Faravel
- Institut du Cancer Montpellier, (ICM), Supportive Care Department, University of Montpellier, France
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2
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Haldeman PB, Ghani MA, Rubio P, Pineda M, Califano J, Sacco AG, Minocha J, Berman ZT. Interdisciplinary Approach to Expedited Outpatient Gastrostomy Tube Placement in Head and Neck Cancer Patients: A Single Center Retrospective Study. Acad Radiol 2024:S1076-6332(24)00149-1. [PMID: 38521613 DOI: 10.1016/j.acra.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/18/2024] [Accepted: 03/04/2024] [Indexed: 03/25/2024]
Abstract
RATIONALE AND OBJECTIVE Treatment for head and neck cancer (HNC) can lead to decreased oral intake which often requires gastrostomy tube (g-tube) placement to provide nutritional support. A multidisciplinary team (MDT) consisting of interventional radiology (IR), HNC oncology and surgery, nutrition, and speech language pathology departments implemented an expedited outpatient g-tube placement pathway to reduce hospital stays and associated costs, initiate feeds sooner, and improve communication between care teams. This single center study investigates differences in complications, time to procedure and costs savings with implementing this pathway. METHODS 142 patients with HNC who underwent elective image guided g-tube placement by IR from 2015 to 2022 were identified retrospectively. 52 patients underwent the traditional pathway, and 90 patients underwent the expedited pathway. Patient demographics, procedure characteristics, periprocedural costs and 90-day complication rates were collected and compared statistically. RESULTS The 90-day complication rate was comparable between groups (traditional=32.7%; expedited=22.2%; p-value=0.17). The expedited pathway decreased the time from consult to procedure by 11.1 days (95% CI 7.6 - 14.6; p < 0.001) and decreased charge per procedure by $2940 (95% CI $989-$4891; p < 0.001). CONCLUSION A MDT for the treatment of patients with HNC successfully provided enteral nutrition support faster, with fewer associated costs, and in a more patient centered approach than previously done at this institution.
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Affiliation(s)
- Pearce B Haldeman
- Department of Interventional Radiology, UC San Diego, La Jolla, California, USA
| | - Mansur A Ghani
- Department of Interventional Radiology, UC San Diego, La Jolla, California, USA
| | - Patricia Rubio
- Moores Cancer Center, UC San Diego, La Jolla, California, USA
| | - Minette Pineda
- Department of Interventional Radiology, UC San Diego, La Jolla, California, USA
| | - Joseph Califano
- Moores Cancer Center, UC San Diego, La Jolla, California, USA; Department of Otolaryngology, UC San Diego, La Jolla, California, USA
| | | | - Jeet Minocha
- Department of Interventional Radiology, UC San Diego, La Jolla, California, USA; Moores Cancer Center, UC San Diego, La Jolla, California, USA
| | - Zachary T Berman
- Department of Interventional Radiology, UC San Diego, La Jolla, California, USA; Moores Cancer Center, UC San Diego, La Jolla, California, USA.
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3
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Neves MT, Ferreira A, Branco V, Abreu M, Alves FR, Baptista C, Graça J, Ferreira F, Malheiro M, Martins A. Utility of Prophylactic Percutaneous Gastrostomy in Patients With Head and Neck Cancer Receiving Concurrent Chemoradiotherapy: A Multicenter Analysis. Cureus 2023; 15:e44637. [PMID: 37671078 PMCID: PMC10476146 DOI: 10.7759/cureus.44637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2023] [Indexed: 09/07/2023] Open
Abstract
INTRODUCTION Patients with head and neck cancer (HNC) have an elevated incidence of cachexia and malnutrition due to the tumor's location interfering with oral feeding. Concurrent chemoradiation (CCRT) can have an emetic effect and cause dysphagia and oral mucositis. Adequate nutrition improves immunity, raises the response to therapy, reduces adverse effects, and improves survival. Numerous studies have suggested the utility of nutritional support from percutaneous endoscopic gastrostomy (PEG) in HNC patients. Although PEG is usually considered a safe procedure, it has a mortality rate of 0-2.2% and a risk of other procedure-related complications of 17-40%. Our work intends to evaluate the utility of PEG in patients with locally advanced HNC who underwent CCRT. METHODS We performed a cohort study at three institutions. We included patients with HNC who underwent definitive CCRT treatment from January 2013 to December 2022. The study consisted of an observational, descriptive, retrospective analysis of prespecified clinical data. Descriptive statistics were used to compare the data between the PEG group and the non-PEG group. Analysis of covariance (ANCOVA) was used for covariance analysis. Fisher's exact test was used to compare proportional data and Student's t-test was used to assess the differences in continuous data. Survival analysis was performed using the Kaplan-Meier estimator. P-values of <0.05 were considered to be indicative of statistical significance. The SPSS Statistics version 28.0 (Armonk, NY: IBM Corp.) was used to perform all statistical evaluations. RESULTS We identified 90 eligible patients diagnosed with local advanced HNC who had received definitive CCRT with three weekly cycles of cisplatin as follows: 44 with a prophylactic PEG tube and 46 without a prophylactic PEG tube. Most patients were male (84.4%) and 50% of patients were diagnosed with stage IVa HNC at the time of diagnosis. There wasn't an effect of PEG placement on BMI at the end of CCRT after controlling for the effect of baseline BMI (F {1.84}=0.065 {p=0.799}). In the study population, BMI was significantly lower after CCRT (21.30 kg/m2 vs. 23.97 kg/m2), t (86)=12.389, p<0.001. In the subgroup with baseline BMI <18.5 kg/m2 (15 patients), 90% of patients with prophylactic PEG were able to complete the three planned cycles of chemotherapy vs. 66.7% in the non-PEG group. Ten patients in the PEG group (22.7%) referred feeding tube dependency. Patients with dysphagia were 3.2 times more likely to have placed prophylactic PEG (p=0.007). The difference in overall survival and progression-free survival between the two groups was not statistically significant (p=0.57 and p=0.497, respectively). CONCLUSION In this study using real-world data, we found a potentially protective effect of PEG in underweight patients with locally advanced HNC performing CCRT in order to complete three cycles of treatment.
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Affiliation(s)
- Maria Teresa Neves
- Medical Oncology, Hospital São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental (CHLO), Lisbon, PRT
| | - André Ferreira
- Medical Oncology, Hospital São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental (CHLO), Lisbon, PRT
| | - Vanessa Branco
- Medical Oncology, Hospital São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental (CHLO), Lisbon, PRT
| | - Maria Abreu
- Medical Oncology, Hospital São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental (CHLO), Lisbon, PRT
| | - Fátima R Alves
- Medical Oncology, Hospital São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental (CHLO), Lisbon, PRT
| | | | - Joana Graça
- Medical Oncology, Hospital de Vila Franca de Xira, Vila Franca de Xira, PRT
| | - Filipa Ferreira
- Medical Oncology, Hospital São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental (CHLO), Lisbon, PRT
| | - Mariana Malheiro
- Medical Oncology, Hospital CUF Tejo, Lisbon, PRT
- Medical Oncology, Hospital São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental (CHLO), Lisbon, PRT
| | - Ana Martins
- Medical Oncology, Hospital São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental (CHLO), Lisbon, PRT
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4
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Faravel K, Jarlier M, Senesse P, Huteau ME, Janiszewski C, Stoebner A, Boisselier P. Trismus Occurrence and Link With Radiotherapy Doses in Head and Neck Cancer Patients Treated With Chemoradiotherapy. Integr Cancer Ther 2023; 22:15347354221147283. [PMID: 36625502 PMCID: PMC9834786 DOI: 10.1177/15347354221147283] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Chemoradiotherapy (CRT) for head and neck cancer (HNC) induces side-effects, including trismus, which impairs quality of life by causing difficulty to eat, speak, and maintain good oral hygiene, and by altering social life. Given the wide variation of reported trismus prevalence and as a first mandatory step for the preventive physiotherapy OPEN program (NCT03979924) this study evaluated trismus occurrence and its link with radiation doses. METHODS Study population was non-larynx HNC patients with epidermoid carcinoma treated with CRT, with or without surgery. A physiotherapist measured maximal interincisal distance before, during and after CRT, at 10 weeks and 6 months. The proportion of patients with trismus (with a 95% confidence interval) was estimated. Irradiation doses were analyzed between patients with and without trismus using non-parametric Kruskal-Wallis test. RESULTS We included 45 patients (77.8% male), median age 61 years (range 41-77). The proportion of trismus at baseline was 24.4%, 26.8% at 10 weeks and 37.1% at 6 months. During radiotherapy, it was 27.9% at week 3 and increased to 41.9% at week 6. Trismus occurrence at 10 weeks was higher when the radiation dose to the ipsilateral lateral pterygoid muscle was above the median value, that is, 36.8 grays. CONCLUSION Trismus occurrence differed according to radiation dose and cancer location. These findings highlight the necessity of early preventive physiotherapy programs to reduce trismus occurrence. The second step, of the interventional multicenter OPEN program, is currently evaluating the impact of preventive physiotherapy and patient education on trismus in a sample of 175 patients.
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Affiliation(s)
- Kerstin Faravel
- University of Montpellier, Montpellier,
France,Kerstin Faravel, Department of Supportive
Care, Physiotherapy Unit, Institut du Cancer de Montpellier (ICM), 208 Avenue
des Apothicaires, Montpellier 34298, France.
| | | | - Pierre Senesse
- University of Montpellier, Montpellier,
France,University of Montpellier INSERM, IRCM,
IDESP, UMR 1302, Montpellier, France
| | | | | | - Anne Stoebner
- University of Montpellier, Montpellier,
France,University of Montpellier INSERM, IRCM,
IDESP, UMR 1302, Montpellier, France
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Copeland-Halperin LR, Divakar P, Stewart T, Demsas F, Levy JJ, Nigriny JF, Paydarfar JA. Predictors of Gastrostomy Tube Placement in Head and Neck Cancer Patients at a Rural Tertiary Care Hospital. JOURNAL OF RECONSTRUCTIVE MICROSURGERY OPEN 2023. [DOI: 10.1055/s-0043-1760757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Abstract
Background Head and neck cancer is a leading cause of cancer. Treatment often requires surgical resection, free-flap reconstruction, radiation, and/or chemotherapy. Tumor burden and pain may limit swallowing and impair nutrition, increasing complications and mortality. Patients commonly require gastrostomy tubes (G-tube), but predicting which patients are in need remains elusive. This study identifies predictors of G-tube among head and neck cancer patients undergoing immediate free-flap reconstruction.
Methods Institutional Review Board approval was obtained. Retrospective database review was performed of patients at 18 years of age or older with head and neck cancer who underwent resection with immediate free-flap reconstruction from 2011 to 2019. Patients who underwent nonfree-flap or delayed reconstruction or with mortality within 7 days postoperatively were excluded. Patient demographics and comorbidities, tumor/treatment characteristics, and need for G-tube were analyzed to identify univariate and multivariate predictors.
Results In total, 107 patients were included and 72 required G-tube placement. On multivariate analysis, tracheostomy (odds ratio [OR]: 81.78; confidence interval [CI]: 7.43–1,399.92; p < 0.01), anterolateral thigh flap reconstruction (OR: 16.18; CI: 1.14–429.66; p = 0.04), and age 65 years or younger (OR: 9.35; CI: 1.47–89.11; p = 0.02) were predictors of G-tube placement.
Conclusion Head and neck cancer treatment commonly involves extensive resection, reconstruction, and/or chemoradiation. These patients are at high risk for malnutrition and need G-tube. Determining who requires a pre- or postoperative G-tube remains a challenge. In this study, the need for tracheostomy or ALT flap reconstruction and age 65 years or younger were predictive of postoperative G-tube placement. Future research will guide a multidisciplinary perioperative pathway to facilitate the optimization of nutrition management.
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Affiliation(s)
| | - Prashanthi Divakar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Talia Stewart
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Falen Demsas
- Department of Surgery, The Massachusetts General Hospital, Boston, Massachusetts
| | - Joshua J. Levy
- Department of Biomedical Sciences, Geisel School of Medicine, Hanover, New Hampshire
| | - John F. Nigriny
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Joseph A. Paydarfar
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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6
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Dechaphunkul T, Soonthornrak P, Geater SL, Dechaphunkul A. Utility of prophylactic percutaneous endoscopic gastrostomy tube in head and neck cancer patients undergoing concurrent chemoradiation: A prospective observational cohort. Am J Otolaryngol 2022; 43:103512. [PMID: 35636089 DOI: 10.1016/j.amjoto.2022.103512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/16/2022] [Accepted: 05/16/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE The necessity of prophylactic percutaneous endoscopic gastrostomy (PPEG) before concurrent chemoradiation (CCRT) in head and neck cancer (HNC) patients remains uncertain. We evaluated the utilization rate of PPEG tube. Weight changes and tube dependence were also assessed. MATERIALS AND METHODS This prospective cohort study evaluated the utilization rate of PPEG tube in patients with newly diagnosed HNC undergoing CCRT. Baseline characteristics, nutrition status, and weight loss data were collected and compared between use and non-use groups. RESULTS 110 patients (94.8%) used PPEG tube (70 fully-used and 40 partially-used groups). Non-users had a tendency to lose weight more than partially and fully-used groups; 9.13%, 3.42%, and 1.95%, respectively (p = 0.085). Fully-used group had significantly longer time of tube dependence than partially-used group, 7.0 months versus 4.9 months (p = 0.012). The type of PPEG tube use (full use or partial use) and presence of dysphagia were significantly related to tube dependence. The time ratio of tube dependence for partially-used patients versus fully-used patients was 0.82 (95% CI: 0.68-0.99) (p = 0.039). The time ratio for patients with symptoms of dysphagia was 1.29 (95% CI: 1.02-1.63) (p = 0.032). At the end of CCRT, 96.6% of patients agreed that PPEG tube was necessary. CONCLUSION We recommend PPEG for patients undergoing CCRT. Partial use of PPEG with continuous oral intake as tolerated is strongly encouraged to maintain weight, and to reduce risk of tube dependence. Future study to evaluate effective swallowing exercise is warranted.
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7
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Effect of prophylactic gastrostomy on nutritional and clinical outcomes in patients with head and neck cancer. Eur J Clin Nutr 2022; 76:1536-1541. [PMID: 35534701 DOI: 10.1038/s41430-022-01154-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 04/20/2022] [Accepted: 04/26/2022] [Indexed: 11/08/2022]
Abstract
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.
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8
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Benefits of prophylactic percutaneous gastrostomy in patients with nasopharyngeal cancer receiving concurrent chemoradiotherapy: A multicenter analysis. Am J Otolaryngol 2022; 43:103356. [PMID: 34972008 DOI: 10.1016/j.amjoto.2021.103356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/15/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE Prophylactic percutaneous endoscopic gastrostomy (PPEG) is widely used for patients with head and neck cancer undergoing concurrent chemoradiation (CCRT). Nevertheless, the necessity of its use in patients with nasopharyngeal cancer (NPC) is uncertain. This study aimed to evaluate the benefits of PPEG on prevention of weight loss and treatment tolerance in patients with NPC receiving CCRT. MATERIALS AND METHODS A retrospective multicenter chart review of 904 patients, 378 in the PPEG group and 526 in the non-PPEG group, was conducted. Baseline characteristics, weight loss, and treatment tolerance were analyzed and compared between the two groups. RESULTS There was no significant difference in the mean baseline body mass index (BMI) between the groups. At the end of CCRT, no difference in weight loss was found between the 2 groups (non-PPEG group, 6.6%; PPEG group, 5.9%). Nonetheless, the subgroup analysis demonstrated that a baseline BMI < 18.5 kg/m2 (underweight) and non-intensity-modulated radiation therapy (IMRT) technique were independent factors associated with prevention of weight loss by PPEG. More patients in the PPEG group were able to complete planned cycles of chemotherapy (73.3% vs. 49.0%, P < .0001). CONCLUSION Although the benefits of PPEG on prevention of weight loss were not observed for the entire cohort, we found a potentially protective effect of PPEG in some subgroups of patients. Additionally, PPEG significantly enhanced chemotherapy tolerance. Therefore, PPEG tube insertion should be strongly considered for patients with NPC receiving CCRT, particularly for underweight patients and those undergoing a non-IMRT technique.
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9
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Vujasinovic M, Marsk E, Tsolakis AV, Hynning B, Nordberg M, Lindblad M, Lindqvist C, Nordenvall LH, Bark R, Elbe P. Complications of Gastrostomy Tubes in Patients With Head and Neck Cancer. Laryngoscope 2022; 132:1778-1784. [PMID: 35041225 DOI: 10.1002/lary.30017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 12/03/2021] [Accepted: 12/28/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Head and neck cancers (HNCs) include various malignant tumors of the upper aerodigestive tract. Due to their anatomical location, HNCs can cause obstruction, odynophagia, or trismus, leading to dysphagia. In addition, this patient group may be vulnerable to treatment side effects both by surgery and oncological treatment, exposing the patients to an even higher risk of malnutrition. The risk of malnourishment is often resolved by applying a feeding gastrostomy tube. The present study aims to identify complication rates after percutaneous endoscopic gastrostomy (PEG) and open gastrostomy (OG) in patients treated for HNC in a high-volume center. STUDY DESIGN Retrospective cohort study. METHODS A retrospective cohort study of all patients treated for a new diagnosis of HNC at the Department of Otorhinolaryngology and Head and Neck Surgery at Karolinska University Hospital between January 1, 2000 and December 31, 2018 in whom gastrostomy was performed. RESULTS Regarding tumor location, 165 (56.7%) were in the pharynx, 68 (23.4%) in the oral cavity, 57 (19.6%) in the larynx, and 1 (0.3%) in the nasal cavity. PEG was performed in 240 (82.5%) and OG in 51 (17.5%) patients. The overall complication rate was 28.2%: 64 (26.7%) among PEG patients and 18 (35.3%) among OG patients. The incidence of major complications was 3.1%. CONCLUSIONS Our study confirms that enteral feeding via gastrostomy is a safe method, regardless of the technique used (PEG or OG), with a low rate of major complications and no mortality linked to the procedure. LEVEL OF EVIDENCE 3 Laryngoscope, 2022.
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Affiliation(s)
- Miroslav Vujasinovic
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Elin Marsk
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Apostolos V Tsolakis
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Boel Hynning
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Martin Nordberg
- Department of Surgery, Södersjukhuset, Stockholm, Sweden.,Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Mats Lindblad
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Catarina Lindqvist
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.,Medical Unit Clinical Nutrition, Karolinska University Hospital, Stockholm, Sweden
| | - Lalle H Nordenvall
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Rusana Bark
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Peter Elbe
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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10
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Predictors of the need for prophylactic percutaneous endoscopic gastrostomy in head and neck cancer patients treated with concurrent chemoradiotherapy. Int J Clin Oncol 2021; 26:1179-1187. [PMID: 34086112 DOI: 10.1007/s10147-021-01889-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 02/11/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND We investigated whether prophylactic percutaneous endoscopic gastrostomy (PEG) is used effectively for patients treated with definitive concurrent chemoradiotherapy (CCRT) and the predictors of the need for PEG. METHODS 326 patients with laryngeal, oropharyngeal or hypopharyngeal cancers were retrospectively reviewed. RESULTS The PEG tube use group had more favorable results than the total parenteral nutrition and nasogastric tube groups in terms of rate of serum albumin loss, incidence of severe fever and aspiration pneumonia, CCRT completion rate and hospitalization period. However, it was inferior to oral intake. Analysis of the relative risk of requiring enteral or parenteral nutrition revealed that performance status (PS) 2, primary site (supraglottis, oropharynx, or hypopharynx), N3 disease, and cisplatin were predictors of the need for nutritional support. CONCLUSIONS Prophylactic PEG is effective for patients treated with definitive CCRT and is especially required for patients with PS2 or oropharyngeal cancer.
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11
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Boisselier P, Thézénas S, Flori N, Vinches M, Bourhis J, Senesse P. Reply to Caccialanza et al. Am J Clin Nutr 2021; 113:1054-1055. [PMID: 33822866 DOI: 10.1093/ajcn/nqaa425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Pierre Boisselier
- From the Radiotherapy Department, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - Simon Thézénas
- Biometrics Unit, Montpellier Cancer Institute (ICM), University of Montpellier, France
| | - Nicolas Flori
- Clinical Nutrition and Gastroenterology Department, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - Marie Vinches
- Oncology Department, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - Jean Bourhis
- Department of Radiotherapy, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Pierre Senesse
- Clinical Nutrition and Gastroenterology Department, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France.,IRCM, University of Montpellier, INSERM, ICM, Montpellier, France
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12
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Nutritional Support in Head and Neck Radiotherapy Patients Considering HPV Status. Nutrients 2020; 13:nu13010057. [PMID: 33375430 PMCID: PMC7823874 DOI: 10.3390/nu13010057] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 12/21/2020] [Accepted: 12/23/2020] [Indexed: 02/07/2023] Open
Abstract
Malnutrition is a common problem in patients with head and neck cancer (HNC), including oropharyngeal cancer (OPC). It is caused by insufficient food intake due to dysphagia, odynophagia, and a lack of appetite caused by the tumor. It is also secondary to the oncological treatment of the basic disease, such as radiotherapy (RT) and chemoradiotherapy (CRT), as a consequence of mucositis with the dry mouth, loss of taste, and dysphagia. The severe dysphagia leads to a definitive total impossibility of eating through the mouth in 20–30% of patients. These patients usually require enteral nutritional support. Feeding tubes are a commonly used nutritional intervention during radiotherapy, most frequently percutaneous gastrostomy tube. Recently, a novel HPV-related type of OPC has been described. Patients with HPV-associated OPC are different from the HPV− ones. Typical HPV− OPC is associated with smoking and alcohol abuse. Patients with HPV+ OPC are younger and healthy (without comorbidities) at diagnosis compared to HPV− ones. Patients with OPC are at high nutritional risk, and therefore, they require nutritional support in order to improve the treatment results and quality of life. Some authors noted the high incidence of critical weight loss (CWL) in patients with HPV-related OPC. Other authors have observed the increased acute toxicities during oncological treatment in HPV+ OPC patients compared to HPV− ones. The aim of this paper is to review and discuss the indications for nutritional support and the kinds of nutrition, including immunonutrition (IN), in HNC, particularly OPC patients, undergoing RT/CRT, considering HPV status.
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Boisselier P, Kaminsky MC, Thézenas S, Gallocher O, Lavau-Denes S, Garcia-Ramirez M, Alfonsi M, Cupissol D, de Forges H, Janiszewski C, Geoffrois L, Sire C, Senesse P. A double-blind phase III trial of immunomodulating nutritional formula during adjuvant chemoradiotherapy in head and neck cancer patients: IMPATOX. Am J Clin Nutr 2020; 112:1523-1531. [PMID: 32936874 DOI: 10.1093/ajcn/nqaa227] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 07/22/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND In a previous phase II study an immunonutrient supplement was found to reduce severe acute toxicities for head and neck squamous cell cancer (HNSCC) patients treated with concomitant cisplatin and radiotherapy. OBJECTIVES The primary objective of the present study was to evaluate efficacy of the same immunonutrient supplement on severe mucositis. Secondary objectives included tolerance, compliance to oral supplementation, chemotherapy interruptions and delays, quality of life, and progression-free survival (PFS) and overall survival (OS) at 1, 2, and 3 y. METHODS Between November 2009 and June 2013, 180 HNSCC patients eligible for adjuvant chemotherapy after surgery with curative intent were included in our double-blind phase III multicenter trial. They were assigned to receive oral supplementation (3 sachets/d) of either a formula enriched with l-arginine and omega-3 (n-3) fatty and ribonucleic acids (experimental arm), or an isocaloric isonitrogenous control (control arm), for 5 d before each of 3 cycles of cisplatin. Intention-to-treat (ITT) and per-protocol (PP) analyses were undertaken, along with subgroup analyses of ≥75% compliant patients, to compare the incidence of acute mucositis (Radiation Therapy Oncology Group and WHO scales) and 36-mo survival. RESULTS At 1 mo after terminating chemoradiotherapy (CRT), no differences were observed in the incidence of grade 3-4 mucositis between treatment groups, in the ITT, PP (172 patients), and subgroup (≥75% compliance, n = 112) analyses. The immunomodulating supplement did not significantly improve survival in the ITT and PP analyses at 3 y after CRT. Among ≥75% compliant patients, however, OS at 3 y was significantly improved in the immunomodulating formula group (81%; 95% CI: 67%, 89%) compared with controls (61%; 95% CI: 46%, 73%; P = 0.034), as well as PFS (73%; 95% CI: 58%, 83% compared with 50%; 95% CI: 36%, 63%; P = 0.012). CONCLUSIONS Although this immunomodulating formula failed to reduce severe mucositis during CRT, the findings suggest that the long-term survival of compliant HNSCC patients was improved.This trial was registered at clinicaltrials.gov as NCT01149642.
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Affiliation(s)
- Pierre Boisselier
- Radiotherapy Department, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | | | - Simon Thézenas
- Biometrics Unit, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | | | | | | | - Marc Alfonsi
- Radiotherapy Department, Sainte Catherine Institute, Avignon, France
| | - Didier Cupissol
- Oncology Department, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - Hélène de Forges
- Clinical Research and Innovation Department, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - Chloé Janiszewski
- Clinical Research and Innovation Department, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - Lionnel Geoffrois
- Radiotherapy Department, Lorraine Cancer Institute, Vandœuvre-Lès-Nancy, France
| | - Christian Sire
- Radiotherapy Department, Bretagne Sud Hospital, Lorient, France
| | - Pierre Senesse
- Clinical Nutrition and Gastroenterology Department, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France.,IRCM, University of Montpellier, Inserm, and ICM, Montpellier, France
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Jensen AD, Langer C. [Late toxicity following primary conservative treatment : Dysphagia and xerostomia]. HNO 2020; 69:263-277. [PMID: 33180145 DOI: 10.1007/s00106-020-00961-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2020] [Indexed: 11/28/2022]
Abstract
Dysphagia and xerostomia are still among the most important acute and late side effects of radiotherapy. Technical developments over the past two decades have led to improved diagnostics and recognition as well as understanding of the causes of these side effects. Based on these findings and advances in both treatment planning and irradiation techniques, the incidence and severity of treatment-associated radiogenic late sequelae could be clearly reduced by the use of intensity-modulated radiotherapy (IMRT), which could contribute to marked long-term improvements in the quality of life in patients with head and neck cancer. Highly conformal techniques, such as proton therapy have the potential to further reduce treatment-associated side effects in head and neck oncology and are currently being prospectively tested within clinical trial protocols at several centers.
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Affiliation(s)
- A D Jensen
- Klinik für Strahlentherapie, Universitätsklinikum Gießen und Marburg, Klinikstr. 33, 35392, Gießen, Deutschland. .,FB 20 (Medizin), Philipps-Universität Marburg, Marburg, Deutschland.
| | - C Langer
- Klinik für HNO-Heilkunde, Kopf‑/Halschirurgie, Plastische Operationen, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen, Deutschland.,Justus-Liebig Universität Gießen, Gießen, Deutschland
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Lacroix C, Georges G, Thézenas S, Flori N, Francioni L, Janiszewski C, Courraud J, Lecornu H, de Forges H, Senesse P. [The role of the specialist nurse in parenteral nutrition : An observational study of complications with home parenteral nutrition in adult cancer patients]. Rech Soins Infirm 2020; 140:107-116. [PMID: 32524798 DOI: 10.3917/rsi.140.0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Background : In France, home parenteral nutrition (HPN) is managed by two parallel healthcare systems : in approved specialist centers (HPN > 12 weeks), and outside of these approved specialist centers (HPN<12 weeks).
Objective : To prospectively evaluate infectious and vascular complications in adult cancer patients undergoing HPN administered via a central venous line, outside of approved specialist HPN centers.
Methods : Our observational prospective study included adult patients with cancer, hospitalized for 48 hours or more, and under HPN. They had a WHO performance status of ≤ 2 and had had a nutritional consultation before discharge.
Results : 25 patients were included in the study, with a median age of 63 years [19–74]. Weight loss of ≥ 5% was reported in 79% of patients. The Ingesta score was < 7 in 96% of cases. 87% of patients presented chill or body temperature variation episodes, with a median of 2 episodes [1–6] per patient. The median delay between end of hospitalization and the first chill episode was 11 days [1–85]. A vascular complication (obstruction without thrombosis) was reported in one patient.
Discussion : This high number of infectious episodes requires improvement of patient care when it comes to strictly adhering to the recommendations. Getting the approved specialist HPN centers to work together and share care protocols could be the first important step.
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Muscaritoli M, Arends J, Aapro M. From guidelines to clinical practice: a roadmap for oncologists for nutrition therapy for cancer patients. Ther Adv Med Oncol 2019; 11:1758835919880084. [PMID: 31762796 PMCID: PMC6854759 DOI: 10.1177/1758835919880084] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 08/30/2019] [Indexed: 02/06/2023] Open
Abstract
Tackling malnutrition in cancer patients remains one of the most challenging tasks in clinical practice. Even though robust evidence exists stressing the role of nutritional status in relation to treatment outcome, its appropriate consideration in clinical practice is often lacking. In this review, we discuss the significance of nutritional status and of malnutrition for the cancer patient. Drawn from experience and from current recommendations of the European Society for Clinical Nutrition and Metabolism (ESPEN), we propose concrete and manageable steps to routinely incorporate nutritional aspects in today’s oncological clinical practice.
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Affiliation(s)
- Maurizio Muscaritoli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell'Università, 37, Rome 00185, Italy
| | - Jann Arends
- Department of Medicine I, University of Freiburg, Freiburg, Germany
| | - Matti Aapro
- Cancer Center, Clinique de Genolier, Genolier, Switzerland
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Li X, Zhou J, Chu C, You Q, Zhong R, Rao Z, Hu W. Home enteral nutrition may prevent myelosuppression of patients with nasopharyngeal carcinoma treated by concurrent chemoradiotherapy. Head Neck 2019; 41:3525-3534. [PMID: 31301097 DOI: 10.1002/hed.25861] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 05/16/2019] [Accepted: 06/18/2019] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Xuemei Li
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, China
| | - Jidan Zhou
- Department of Radiotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Ci Chu
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, China
| | - Qian You
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, China
| | - Renming Zhong
- Department of Radiotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Zhiyong Rao
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, China
| | - Wen Hu
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, China
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Yanni A, Dequanter D, Lechien JR, Loeb I, Rodriguez A, Javadian R, Van Gossum M. Malnutrition in head and neck cancer patients: Impacts and indications of a prophylactic percutaneous endoscopic gastrostomy. Eur Ann Otorhinolaryngol Head Neck Dis 2019; 136:S27-S33. [PMID: 30846293 DOI: 10.1016/j.anorl.2019.01.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 11/12/2018] [Accepted: 01/11/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Head and neck cancer (HNC) patients often experience malnutrition before and during treatment. Prophylactic gastrostomy has emerged as an efficient tool for ensuring adequate nutrition. However, there is no suitable algorithm able to identify patients at high risk of malnutrition. The aim of this study was to describe the nutritional management, to assess the impact of prophylactic gastrostomy, and to identify predictors of malnutrition. METHODS This retrospective study included 152 patients treated with surgery, radiotherapy, or chemotherapy for HNC. The patients were classified according to their gastrostomy status (prophylactic or non-prophylactic). Nutritional, tumoral and treatment characteristics were reported. Clinical and nutritional outcomes were measured 6 weeks after the beginning of treatment. In order to describe the nutritional management and the impact of prophylactic gastrostomy on patients, univariate analysis was generated using chi-square test and Mann-Whitney test or Student's t-test. Logistic regression was performed to identify factors associated with malnutrition. RESULTS Forty-one patients received prophylactic gastrostomy whereas 111 patients had no nutritional support. Prophylactic gastrostomy placement was associated with a lower initial body mass index, with severe malnutrition, and with initial oral intake disorder. Patients who did not experienced prophylactic gastrostomy had much worse outcomes such as hospital readmissions (P=0.042), relative weight loss at 6 weeks (P<0.0001), dysphagia, severe malnutrition, and poor state of health (P=0.001). Our complication rates (4.9%) were lower than the usual range (5.9-9.3%) and no life-threatening complication was reported. Positive N status, oral intake disorder, concomitant radiochemotherapy, nasopharyngeal, and hypopharyngeal tumor site were significant predictive factors for malnutrition. CONCLUSIONS Prophylactic percutaneous endoscopic gastrostomy showed advantages in terms of hospital readmissions, relative weight loss at 6 weeks, dysphagia, severe malnutrition, and poor state of health. Tumoral, nutritional and treatment characteristics seem to be predictors for malnutrition. Hence, physicians should integrate these factors in their nutrition algorithm approach.
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Affiliation(s)
- A Yanni
- Department of Stomatology and maxillofacial surgery, School of Medicine, Université Libre de Bruxelles, CHU Saint-Pierre, Brussels, Belgium
| | - D Dequanter
- Department of Stomatology and maxillofacial surgery, School of Medicine, Université Libre de Bruxelles, CHU Saint-Pierre, Brussels, Belgium; Department of Otorhinolaryngology and Head and Neck Surgery, School of Medicine, Université Libre de Bruxelles, CHU Saint-Pierre, Brussels, Belgium
| | - J R Lechien
- Department of Otorhinolaryngology and Head and Neck Surgery, School of Medicine, Université Libre de Bruxelles, CHU Saint-Pierre, Brussels, Belgium; Laboratory of Anatomy and Cell Biology, Department of Anatomy and Experimental Oncology, Faculty of Medicine, Mons School of Medicine, University of Mons (UMons), UMONS Research Institute for Health Sciences and Technology, Avenue du Champ-de-Mars, 6, 7000 Mons, Belgium.
| | - I Loeb
- Department of Stomatology and maxillofacial surgery, School of Medicine, Université Libre de Bruxelles, CHU Saint-Pierre, Brussels, Belgium
| | - A Rodriguez
- Department of Otorhinolaryngology and Head and Neck Surgery, School of Medicine, Université Libre de Bruxelles, CHU Saint-Pierre, Brussels, Belgium
| | - R Javadian
- Department of Stomatology and maxillofacial surgery, School of Medicine, Université Libre de Bruxelles, CHU Saint-Pierre, Brussels, Belgium
| | - M Van Gossum
- Department of gastroenterology, School of Medicine, université Libre de Bruxelles, CHU Saint-Pierre, Brussels, Belgium
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McCullough R. Merit-based Claim Adjudication for Cancer Treatment Toxicities - Policy Trends that Lower Downstream Costs. J Insur Med 2019; 47:236-248. [PMID: 30779603 DOI: 10.17849/insm-47-4-1-13.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND -Due largely to the lack of effective therapeutic options, between 1973-2013, chemoradiation toxic mucositis (CRTM) has remained an uncapped expenditure for 40 years, with incremental costs of $17,000-$40,000 per patient per episode. Costs in patient morbidity and mortality have continued as well. A recent therapeutic option associated with complete prevention and/or rapid sustained elimination (high potency polymerized cross-linked sucralfate, HPPCLS) delivers value by eliminating downstream costs CRTM experienced in the first 12 months. While many insurers carry the therapy as a specialty pharmacy support drug, few are familiar with the associated health economic benefits and the statutory requirements driving its coverage. PURPOSE -To present the rationale behind early policy trends that frame CRTM as an emergent/urgent medical condition mandated coverage as an essential health benefit. Rather than problematic for costs, this coverage trend appears to be value-based. METHODS -Discuss early adverse claim experience of HPPCLS. Present the costs, tenets and statutes driving policy trend toward obligatory coverage of CRTM. Review the ethical (fiduciary) and statutory requirements for CRTM coverage. RESULTS -CRTM coverage is ethically responsible since it is a direct consequence of authorized cancer treatment. The symptom/signs complex of CRTM meets the 'prudent layperson' statutory definition of emergency medical condition. All previously uncapped downstream costs of CRTM can be reduced to the cost of therapy, saving $15-$30K per patient per CRTM episode. CONCLUSIONS -Policy trend of CRTM coverage as an emergent/urgent medical condition is a value-based approach of toxicity management, conserving resources, cutting costs and eliminating patient morbidity and mortality.
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Affiliation(s)
- Ricky McCullough
- Translational Medicine Clinic & Research Center, 1768 Storrs Road, Storrs Connecticut 06268; ph: 860-477-0961;
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Senesse P, Isambert A, Janiszewski C, Fiore S, Flori N, Poujol S, Arroyo E, Courraud J, Guillaumon V, Mathieu-Daudé H, Colasse S, Baracos V, de Forges H, Thezenas S. Management of Cancer Cachexia and Guidelines Implementation in a Comprehensive Cancer Center: A Physician-Led Cancer Nutrition Program Adapted to the Practices of a Country. J Pain Symptom Manage 2017; 54:387-393.e3. [PMID: 28778558 DOI: 10.1016/j.jpainsymman.2017.01.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 01/09/2017] [Accepted: 01/10/2017] [Indexed: 01/13/2023]
Abstract
CONTEXT Cancer-associated cachexia is correlated with survival, side-effects, and alteration of the patients' well-being. OBJECTIVES We implemented an institution-wide multidisciplinary supportive care team, a Cancer Nutrition Program (CNP), to screen and manage cachexia in accordance with the guidelines and evaluated the impact of this new organization on nutritional care and funding. METHODS We estimated the workload associated with nutrition assessment and cachexia-related interventions and audited our clinical practice. We then planned, implemented, and evaluated the CNP, focusing on cachexia. RESULTS The audit showed a 70% prevalence of unscreened cachexia. Parenteral nutrition was prescribed to patients who did not meet the guideline criteria in 65% cases. From January 2009 to December 2011, the CNP team screened 3078 inpatients. The screened/total inpatient visits ratio was 87%, 80%, and 77% in 2009, 2010, and 2011, respectively. Cachexia was reported in 74.5% (n = 2253) patients, of which 94.4% (n = 1891) required dietary counseling. Over three years, the number of patients with artificial nutrition significantly decreased by 57.3% (P < 0.001), and the qualitative inpatients enteral/parenteral ratio significantly increased: 0.41 in 2009, 0.74 in 2010, and 1.52 in 2011. Between 2009 and 2011, the CNP costs decreased significantly for inpatients nutritional care from 528,895€ to 242,272€, thus financing the nutritional team (182,520€ per year). CONCLUSION Our results highlight the great benefits of implementing nutritional guidelines through a physician-led multidisciplinary team in charge of nutritional care in a comprehensive cancer center.
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Affiliation(s)
- Pierre Senesse
- Department of Clinical Nutrition and Gastroenterology, Institut régional du Cancer de Montpellier (ICM), Montpellier, France; Epsylon, EA 4556 Dynamics of Human Abilities and Health Behaviors, University of Montpellier, Montpellier, France.
| | - Agnès Isambert
- Epsylon, EA 4556 Dynamics of Human Abilities and Health Behaviors, University of Montpellier, Montpellier, France
| | - Chloé Janiszewski
- Clinical Research Department, Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Stéphanie Fiore
- Department of Clinical Nutrition and Gastroenterology, Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Nicolas Flori
- Department of Clinical Nutrition and Gastroenterology, Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Sylvain Poujol
- Department of Pharmacy, Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Eric Arroyo
- Computer Information Organisation, Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Julie Courraud
- Clinical Research Department, Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Vanessa Guillaumon
- SIRIC Montpellier Cancer, Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Hélène Mathieu-Daudé
- Medical Information Department, Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Sophie Colasse
- Financial Affairs, Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Vickie Baracos
- Department of Oncology, University of Alberta, Edmonton, Canada
| | - Hélène de Forges
- Clinical Research Department, Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Simon Thezenas
- Biometrics Unit, Institut régional du Cancer de Montpellier (ICM), Montpellier, France
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Nesemeier R, Dunlap N, McClave SA, Tennant P. Evidence-Based Support for Nutrition Therapy in Head and Neck Cancer. CURRENT SURGERY REPORTS 2017; 5:18. [PMID: 32288971 PMCID: PMC7102400 DOI: 10.1007/s40137-017-0179-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Patients diagnosed with head and neck (H&N) cancer often present in a malnourished state for varied reasons; nutritional optimization is therefore critical to the success of treatment for these complex patients. This article aims to review the current nutrition literature pertaining to H&N cancer patients and to present evidence-based strategies for nutritional support specific to this population. RECENT FINDINGS Aggressive nutritional intervention is frequently required in the H&N cancer patient population. Rehabilitating nutrition during operative and nonoperative treatment improves compliance with treatment, quality of life, and clinical outcomes. When and whether to establishing alternative enteral access are points of controversy, although recent evidence suggests prophylactic enteral feeding tube placement should not be universally applied. Perioperative nutritional optimization including preoperative carbohydrate loading and provision of arginine-supplemented immunonutrition has been shown to benefit at-risk H&N cancer patients. SUMMARY With multidisciplinary collaboration, H&N cancer patients can receive individualized nutritional support to withstand difficult cancer treatment regimens and return to acceptable states of nutritional health.
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Affiliation(s)
- Ryan Nesemeier
- Department of Otolaryngology-Head and Neck Surgery, University of Louisville, 529 S Jackson St., 3rd Floor, Louisville, KY 40202 USA
| | - Neal Dunlap
- Department of Radiation Oncology, University of Louisville, Louisville, KY USA
| | - Stephen A. McClave
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, University of Louisville, Louisville, KY USA
| | - Paul Tennant
- Department of Otolaryngology-Head and Neck Surgery, University of Louisville, 529 S Jackson St., 3rd Floor, Louisville, KY 40202 USA
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Axelsson L, Silander E, Nyman J, Bove M, Johansson L, Hammerlid E. Effect of prophylactic percutaneous endoscopic gastrostomy tube on swallowing in advanced head and neck cancer: A randomized controlled study. Head Neck 2017; 39:908-915. [PMID: 28152219 DOI: 10.1002/hed.24707] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 11/16/2016] [Accepted: 12/09/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Dysphagia is common in head and neck cancer. A percutaneous endoscopic gastrostomy (PEG) tube is used to facilitate nutrition; however, some retrospective studies have indicated that the PEG tube causes dysphagia. METHODS A randomized study of patients with head and neck cancer was conducted with up to 10 years of follow-up. Patients were randomized to either the prophylactic PEG tube group (study group) or the common clinical nutritional support group (control group). At each follow-up, a dietician assessed the oral intake, noted the patients' weight, and if the patients used a PEG tube. Dysphagia was also assessed by the quality of life questionnaire, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 Head and Neck 35-questions (EORTC-QLQ-H&N35). RESULTS One hundred thirty-four patients were included in this study. There was no significant difference in swallowing function between the groups after 12 months, 24 months, and 8 years based on the EORTC-QLQ-H&N35, the oral intake scale, tube dependence, esophageal intervention, weight, body mass index (BMI), and overall survival. CONCLUSION A prophylactic PEG tube can be used without an increased risk of long-term dysphagia in patients with head and neck cancer. © 2017 Wiley Periodicals, Inc. Head Neck 39: 908-915, 2017.
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Affiliation(s)
- Lars Axelsson
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Ewa Silander
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Jan Nyman
- Department of Oncology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Mogens Bove
- Department of Otorhinolaryngology, NU Hospital Group, Trollhättan, Sweden
| | - Leif Johansson
- Department of Otorhinolaryngology, Central Hospital, Skövde, Sweden
| | - Eva Hammerlid
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
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Fonseca J, Santos CA, Brito J. Malnutrition and Clinical Outcome of 234 Head and Neck Cancer Patients who Underwent Percutaneous Endoscopic Gastrostomy. Nutr Cancer 2016; 68:589-97. [PMID: 27144413 DOI: 10.1080/01635581.2016.1158297] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Head and neck cancer (HNC) patients who underwent percutaneous endoscopic gastrostomy (PEG) present malnutrition risk and speech impairments. Their assessment relies on objective anthropometric/laboratory data. Focusing on HNC PEG patients, our aims were to evaluate: 1) outcome; 2) nutritional status when the patients underwent PEG; and 3) association of nutritional status/outcome, creating a survival predictive model. We evaluated the outcome based on NRS 2002, dietary assessment, body mass index (BMI), mid-upper arm circumference (MUAC), triceps skinfold thickness (TSF), mid-arm muscle circumference (MAMC), albumin, transferrin, and cholesterol on the day of gastrostomy. Using BMI, TSF, MAMC, and laboratory data, a survival predictive model was created. Of the 234 patients (cancer stages III-IV), 149 died, 33 were still PEG-fed, and 36 resumed oral intake (NRS-2002≥3, caloric needs <50% in all). BMI was 12.7-43. 189, 197, and 168 patients displayed, respectively, low MUAC, TSF, and MAMC. 91, 155, and 119 patients displayed low albumin, transferrin, and cholesterol. Albumin, cholesterol, and transferrin were strongly associated with the outcome. A predictive model was created, discriminating between short-term survivors (<4 months) and long-term survivors. HNC patients were malnourished. Using anthropometric/laboratory parameters, a predictive model provides discrimination between patients surviving PEG for <4 months and long-term survivors. Teams taking care of PEG patients may provide special support to potential short-term survivors.
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Affiliation(s)
- Jorge Fonseca
- a GENE - Hospital Garcia de Orta , Almada , Portugal.,b CiiEM - Center for Interdisciplinary Research Egas Moniz , Monte de Caparica , Portugal
| | | | - José Brito
- b CiiEM - Center for Interdisciplinary Research Egas Moniz , Monte de Caparica , Portugal
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Pramyothin P, Manyanont S, Trakarnsanga A, Petsuksiri J, Ithimakin S. A prospective study comparing prophylactic gastrostomy to nutritional counselling with a therapeutic feeding tube if required in head and neck cancer patients undergoing chemoradiotherapy in Thai real-world practice. J Hum Nutr Diet 2016; 29:768-776. [DOI: 10.1111/jhn.12377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- P. Pramyothin
- Division of Nutrition; Department of Medicine; Siriraj Hospital; Mahidol University; Bangkok Thailand
| | - S. Manyanont
- Division of Medical Oncology; Department of Internal Medicine; Siriraj Hospital; Mahidol University; Bangkok Thailand
| | - A. Trakarnsanga
- Division of General Surgery; Department of Surgery; Siriraj Hospital; Mahidol University; Bangkok Thailand
| | - J. Petsuksiri
- Division of Radiation Oncology; Department of Radiology; Siriraj Hospital; Mahidol University; Bangkok Thailand
| | - S. Ithimakin
- Division of Medical Oncology; Department of Internal Medicine; Siriraj Hospital; Mahidol University; Bangkok Thailand
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Predictive Factors for Prophylactic Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement and Use in Head and Neck Patients Following Intensity-Modulated Radiation Therapy (IMRT) Treatment: Concordance, Discrepancies, and the Role of Gabapentin. Dysphagia 2016; 31:206-13. [PMID: 26753929 DOI: 10.1007/s00455-015-9679-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 12/09/2015] [Indexed: 10/22/2022]
Abstract
The prophylactic placement of a percutaneous endoscopic gastrostomy (PEG) tube in the head and neck cancer (HNC) patient is controversial. We sought to identify factors associated with prophylactic PEG placement and actual PEG use. Since 2010, data regarding PEG placement and use were prospectively recorded in a departmental database from January 2010 to December 2012. HNC patients treated with intensity-modulated radiation therapy (IMRT) were retrospectively evaluated from 2010 to 2012. Variables potentially associated with patient post-radiation dysphagia from previous literature, and our experience was evaluated. We performed multivariate logistic regression on these variables with PEG placement and PEG use, respectively, to compare the difference of association between the two arms. We identified 192 HNC patients treated with IMRT. Prophylactic PEG placement occurred in 121 (63.0 %) patients, with PEG use in 97 (80.2 %) patients. PEG placement was associated with male gender (p < .01), N stage ≥ N2 (p < .05), pretreatment swallowing difficulties (p < .01), concurrent chemotherapy (p < .01), pretreatment KPS ≥80 (p = .01), and previous surgery (p = .02). Concurrent chemotherapy (p = .03) was positively associated with the use of PEG feeding by the patient, whereas pretreatment KPS ≥80 (p = .03) and prophylactic gabapentin use (p < .01) were negatively associated with PEG use. The analysis suggests there were discrepancies between prophylactic PEG tube placement and actual use. Favorable pretreatment KPS, no pretreatment dysphagia, no concurrent chemotherapy, and the use of gabapentin were significantly associated with reduced PEG use. This analysis may help refine the indications for prophylactic PEG placement.
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Bishop S, Reed WM. The provision of enteral nutritional support during definitive chemoradiotherapy in head and neck cancer patients. J Med Radiat Sci 2015; 62:267-76. [PMID: 27512573 PMCID: PMC4968562 DOI: 10.1002/jmrs.132] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 07/15/2015] [Accepted: 07/28/2015] [Indexed: 02/05/2023] Open
Abstract
Combination chemoradiation is the gold standard of management for locally advanced squamous cell carcinomas of the head and neck. One of the most significant advantages of this approach to treatment is organ preservation which may not be possible with radical surgery. Unfortunately, few treatments are without side-effects and the toxicity associated with combined modality treatment causes meaningful morbidity. Patients with head and neck cancer (HNC) may have difficulties meeting their nutritional requirements as a consequence of tumour location or size or because of the acute toxicity associated with treatment. In particular, severe mucositis, xerostomia, dysgeusia and nausea and vomiting limit intake. In addition to this, dysphagia is often present at diagnosis, with many patients experiencing silent aspiration. As such, many patients will require enteral nutrition in order to complete chemoradiotherapy (CRT). Feeding occurs via catheters placed transnasally (nasogastric tubes) or directly into the stomach through the anterior abdominal wall (percutaneous gastrostomy tubes). In the absence of clear evidence concerning the superiority of one method over another, the choice of feeding tube tends to be dependent on clinician and patient preference. This review examines key issues associated with the provision of enteral nutritional support during definitive CRT in HNC patients, including feeding methods, patient outcomes and timing of tube insertion and use.
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Affiliation(s)
- Sarah Bishop
- Illawarra Cancer Care CentreDepartment of Radiation Oncology, Wollongong HospitalWollongongNew South WalesAustralia
- Radiation Oncology DepartmentNelune Comprehensive Cancer CentrePrince of Wales HospitalRandwickNew South WalesAustralia
| | - Warren Michael Reed
- Medical Image Optimisation and Perception GroupDiscipline of Medical Radiation SciencesFaculty of Health SciencesThe University of SydneyLidcombeNew South WalesAustralia
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Predictive Factors for Preoperative Percutaneous Endoscopic Gastrostomy Placement: Novel Screening Tools for Head and Neck Reconstruction. J Craniofac Surg 2015; 26:2124-7. [PMID: 26468795 DOI: 10.1097/scs.0000000000002132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The treatment of head and neck cancer has varying impact on postoperative recovery and return of swallowing function. The authors aim to establish screening tools to assist in preoperatively determining the need for gastrostomy tube placement. METHODS The authors prospectively assessed all patients undergoing complex head and neck reconstructive surgery during a 1-year study period. Only patients tolerating an oral diet, without preoperative gastrostomies, were enrolled for study. Eight parameters were assessed including: body mass index (BMI), prealbumin, albumin, smoking history, comorbidities [including coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM)], age, use of microvascular reconstruction, and type of defect. Two specific screening tools were assessed. In the first, a multivariate logistic regression model was employed to determine factor(s) that predict postoperative gastrostomy tube. In a second screening tool, the 8 parameters were scored between 0 to 1 points. The total score obtained for each patient was correlated with postoperative gastrostomy placement. RESULTS Out of the 60 study patients enrolled in the study, 24 patients (40%) received a postoperative gastrostomy. In the logistic regression model, albumin level was the only factor that was significantly associated with need for postoperative gastrostomy (P < 0.0023). A score of 4 or greater was determined to have a sensitivity of 83% and specificity of 61% for postoperative gastrostomy. CONCLUSIONS Patients with a score of 4 or more with this screening scoring system or those patients with an albumin level <3.5 g/dL were at high risk for postoperative feeding tube placement.
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Exploration of risk factors for weight loss in head and neck cancer patients. JOURNAL OF RADIOTHERAPY IN PRACTICE 2015. [DOI: 10.1017/s146039691500031x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractIntroductionHead and neck cancer patients receiving radiotherapy can experience a number of toxicities, including weight loss and malnutrition, which can impact upon the quality of treatment. The purpose of this retrospective cohort study is to evaluate weight loss and identify predictive factors for this patient group.Materials and methodsA total of 40 patients treated with radiotherapy since 2012 at the study centre were selected for analysis. Data were collected from patient records. The association between potential risk factors and weight loss was investigated.ResultsMean weight loss was 5 kg (6%). In all, 24 patients lost >5% starting body weight. Age, T-stage, N-stage, chemotherapy and starting body weight were individually associated with significant differences in weight loss. On multiple linear regression analysis age and nodal status were predictive.ConclusionYounger patients and those with nodal disease were most at risk of weight loss. Other studies have identified the same risk factors along with several other variables. The relative significance of each along with a number of other potential factors is yet to be fully understood. Further research is required to help identify patients most at risk of weight loss; and assess interventions aimed at preventing weight loss and malnutrition.
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Ohba S, Yokoyama J, Kojima M, Fujimaki M, Anzai T, Komatsu H, Ikeda K. Significant preservation of swallowing function in chemoradiotherapy for advanced head and neck cancer by prophylactic swallowing exercise. Head Neck 2015; 38:517-21. [PMID: 25351675 DOI: 10.1002/hed.23913] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2014] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Dysphagia is a serious complication of chemoradiotherapy (CRT) in patients with head and neck cancer. Approximately 20% to 30% of patients who have dysphagia require feeding tubes. The purpose of this study was to evaluate the impact of prophylactic swallowing exercises on swallowing function. METHODS Fifty-one patients with advanced oropharyngeal, hypopharyngeal, and laryngeal cancers were included in this study. Twenty-one patients performed the Shaker exercise and 30 practiced traditional Mendelsohn maneuvers (control group). Before and after treatment, videofluoroscopy and swallowing motion were analyzed to establish movement of the hyoid bone, larynx, and aspiration scores. RESULTS Average movement of the hyoid bone, thyrohyoid shortening, and upper esophageal sphincter opening were significantly better maintained in the Shaker group. Aspiration score of the Shaker exercise was significantly lower than control group. Feeding tube rates for the Shaker and control groups were 14% and 40% (p < .05). CONCLUSION Shaker exercises as a prophylactic exercise contributed to preservation of swallowing function in patients with head and neck cancer.
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Affiliation(s)
- Shinichi Ohba
- Department of Otorhinolaryngology-Head and Neck Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Junkichi Yokoyama
- Department of Otorhinolaryngology-Head and Neck Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Masataka Kojima
- Department of Otorhinolaryngology-Head and Neck Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Mitsuhisa Fujimaki
- Department of Otorhinolaryngology-Head and Neck Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Takashi Anzai
- Department of Otorhinolaryngology-Head and Neck Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Hiroaki Komatsu
- Department of Otorhinolaryngology-Head and Neck Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Katsuhisa Ikeda
- Department of Otorhinolaryngology-Head and Neck Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan
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Bachmann P, Bensadoun RJ, Besnard I, Bourdel-Marchasson I, Bouteloup C, Crenn P, Goldwasser F, Guérin O, Latino-Martel P, Meuric J, May-Lévin F, Michallet M, Vasson MP, Hébuterne X. Clinical nutrition guidelines of the French Speaking Society of Clinical Nutrition and Metabolism (SFNEP): Summary of recommendations for adults undergoing non-surgical anticancer treatment. Dig Liver Dis 2014; 46:667-74. [PMID: 24794790 DOI: 10.1016/j.dld.2014.01.160] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 01/28/2014] [Indexed: 12/11/2022]
Abstract
Up to 50% of patients with cancer suffer from weight loss and undernutrition (as called cachexia) even though it is rarely screened or properly handled. Patients' prognosis and quality of life could be greatly improved by simple and inexpensive means encompassing nutritional status assessment and effective nutritional care. These guidelines aim to give health professionals and patients practical and up-to-date advice to manage nutrition in the principal situations encountered during the cancer course according to the type of tumour and treatment (i.e. radio and/or chemotherapy). Specific suggestions are made for palliative and elderly patients because of specific risks of undernutrition and related comorbidities in this subset. Levels of evidence and grades of recommendations are detailed as stated by current literature and consensus opinion of clinical experts in each field.
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Raynard B, Antoun S. Peut-on améliorer la qualité de vie par une prise en charge nutritionnelle en cancérologie ? NUTR CLIN METAB 2014. [DOI: 10.1016/j.nupar.2013.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Via MA, Mechanick JI. Malnutrition, Dehydration, and Ancillary Feeding Options in Dysphagia Patients. Otolaryngol Clin North Am 2013; 46:1059-71. [DOI: 10.1016/j.otc.2013.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Lescut N, Personeni E, Desmarets M, Puyraveau M, Hamlaoui R, Servagi-Vernat S, Bosset JF, Nguyen F. Évaluation d’un score prédictif de dénutrition chez les patients pris en charge par irradiation pour un cancer des voies aérodigestives supérieures : étude rétrospective chez 127 patients. Cancer Radiother 2013; 17:649-55. [DOI: 10.1016/j.canrad.2013.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 02/18/2013] [Accepted: 03/27/2013] [Indexed: 12/31/2022]
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Flori N, Chrostek H, Bianchi L, Assenat É, Fallières A, Vaille A, Bouteloup C, Senesse P. Prise en charge d’un patient atteint d’un cancer des voies aéro-digestives supérieures. NUTR CLIN METAB 2013. [DOI: 10.1016/j.nupar.2013.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Peerawong T, Phungrassami T, Pruegsanusak K, Sangthong R. Comparison of treatment compliance and nutritional outcomes among patients with nasopharyngeal carcinoma with and without percutaneous endoscopic gastrostomy during chemoradiation. Asian Pac J Cancer Prev 2013; 13:5805-9. [PMID: 23317260 DOI: 10.7314/apjcp.2012.13.11.5805] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Thanarpan Peerawong
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
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Ottosson S, Zackrisson B, Kjellén E, Nilsson P, Laurell G. Weight loss in patients with head and neck cancer during and after conventional and accelerated radiotherapy. Acta Oncol 2013; 52:711-8. [PMID: 23106176 PMCID: PMC3622234 DOI: 10.3109/0284186x.2012.731524] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background Weight loss is common among patients with squamous cell carcinoma of the head and neck (SCCHN) and is mainly due to tumor and treatment related factors. The aim of the present study was to evaluate weight loss in patients with SCCHN undergoing two different radiotherapy (RT) schedules. Material and methods Nutritional data were analyzed from the ARTSCAN study, a controlled randomized prospective Swedish multicenter study conducted with the aim of comparing conventional fractionation (2.0 Gy per day, total 68 Gy during 7 weeks) and accelerated fractionation (1.1 + 2.0 Gy per day, total 68 Gy during 4.5 weeks). Seven hundred and fifty patients were randomized and 712 patients were followed from the start of RT in the present nutritional study. Results The patients had a weight loss of 11.3% (± 8.6%) during the acute phase (start of RT up to five months after the termination of RT). No difference in weight loss was seen between the two RT fractionation schedules (p = 0.839). Three factors were significantly predictive for weight loss during the acute phase, i.e. tumor site, overweight/obesity or lack of tube feeding at the start of RT. Moreover, the nadir point of weight loss occurred at five months after the termination of RT. Conclusion The results of the present study showed no difference in weight loss between the two RT fractionation schedules and also highlight that weight loss in SCCHN is a multifactorial problem. Moreover, the nadir of weight loss occurred at five months after the termination of treatment which calls for more intense nutritional interventions during the period after treatment.
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Affiliation(s)
- Sandra Ottosson
- Department of Clinical Sciences, Otorhinolaryngology, Umeå University, Umeå, Sweden.
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Systemic treatment and medical management of metastatic squamous cell carcinoma of the head and neck: review of the literature and proposal for management changes. Oral Oncol 2013; 49:482-91. [PMID: 23415727 DOI: 10.1016/j.oraloncology.2013.01.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 01/10/2013] [Accepted: 01/16/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Worldwide, head and neck carcinomas account for 5% of all malignancies. Two-thirds of patients relapse after initial multimodal therapy. Until early 2000, the median overall survival (OS) of metastatic patients was about 6 months. Recently, new drugs have been incorporated in patient management, thus enabling an increase in OS. This review aims to define the comprehensive medical management of patients with relapsing head and neck carcinoma. METHODS A comprehensive review of the literature was made targeting four topics: first- and second-line treatment, supportive care, and management of elderly patients. RESULTS The choice of first- or second-line treatments is mainly based on performance status. In the elderly, geriatric assessment could be helpful. For PS 0.1 patients, the standard first-line treatment is 6 cycles of cisplatin-5FU-cetuximab. In the event of response, cetuximab alone is prolonged until progression or unacceptable toxicity. For second-line treatment, several options are currently available: enrolment in clinical trials, single-agent therapy (methotrexate, taxane, cetuximab), and best supportive care (BSC). Supportive care has to be initiated very early in the course of the disease to prevent pain, dysphagia and malnutrition. In elderly patients, the therapeutic options are: first-line treatment with the EXTREME regimen replacing cisplatin by carboplatin for patients in good general condition or methotrexate alone for other patients. BSC continues to be given to all patients (i.e. poor general conditions). CONCLUSION In spite of numerous pending issues requiring further investigation, these recommendations seem to be routinely applicable.
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Bhayani MK, Hutcheson KA, Barringer DA, Lisec A, Alvarez CP, Roberts DB, Lai SY, Lewin JS. Gastrostomy tube placement in patients with oropharyngeal carcinoma treated with radiotherapy or chemoradiotherapy: factors affecting placement and dependence. Head Neck 2013; 35:1634-40. [PMID: 23322563 DOI: 10.1002/hed.23200] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2012] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Although many patients require nutritional support during radiotherapy or chemoradiotherapy for oropharyngeal cancer, little is known regarding the risk factors that predispose to gastrostomy tube (g-tube) placement and prolonged dependence, or the therapeutic interventions that may abrogate these effects. METHODS We performed a retrospective medical chart review of patients who were treated for primary oropharyngeal cancer at a tertiary care center from 2003 to 2008. Patients who had a complete response at the primary site at 1-year posttreatment were included. G-tube placement and dependence ≥6 months were evaluated in relationship to site and stage of primary tumor, baseline characteristics, treatment type, smoking status, and swallowing intervention. RESULTS We evaluated 474 patients (79%) with oropharyngeal cancer; 215 patients (40%) had concurrent chemotherapy, 73 patients (15%) had induction chemotherapy, and 69 patients (15%) had induction chemotherapy followed by concurrent chemotherapy. Two hundred ninety-three patients (62%) received g-tubes, of which 238 (81%) received the g-tube during radiation. At 1-year follow-up, 41 patients (9%) remained dependent on enteral feedings. Placement of g-tubes and prolonged g-tube dependence were significantly more likely in patients with T3 to 4 tumors (p < .001), baseline self-reported dysphagia (p < .001), odynophagia (p < .001), >10% baseline weight loss (p < .001), and in those treated with concurrent chemoradiotherapy. Patients who reported adherence to exercises had significantly lower rates of g-tube placement (p < .001), and duration of dependence was significantly shorter in those who reported adherence to swallowing exercises (p < .001). CONCLUSION Almost 40% of patients with oropharyngeal cancer treated with nonsurgical organ preservation modalities may avoid feeding tube placement. Factors that predispose to g-tube placement and prolonged dependence include T3 to T4 tumors, concurrent chemotherapy, current smoking status, and baseline swallowing dysfunction or weight loss. Adherence to an aggressive swallowing regimen may reduce long-term dependence on enteral nutrition and limit the rate of g-tube placement overall.
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Affiliation(s)
- Mihir K Bhayani
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
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The role of dietary counseling and nutrition support in head and neck cancer patients. Curr Opin Support Palliat Care 2012; 6:438-45. [DOI: 10.1097/spc.0b013e32835999d5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Crenn P, Bouteloup C, Michallet M, Senesse P. Nutrition chez le patient adulte atteint de cancer : place de la nutrition artificielle dans la prise en charge des patients atteints de cancer. NUTR CLIN METAB 2012. [DOI: 10.1016/j.nupar.2012.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Keung EZ, Liu X, Nuzhad A, Rabinowits G, Patel V. In-hospital and long-term outcomes after percutaneous endoscopic gastrostomy in patients with malignancy. J Am Coll Surg 2012; 215:777-86. [PMID: 22999329 DOI: 10.1016/j.jamcollsurg.2012.08.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 08/15/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although percutaneous endoscopic gastrostomy (PEG) is widely performed for nutrition or palliation, PEG-associated outcomes in cancer patients remain poorly described. We examined the safety and benefits of PEG placement in this population at our institution. STUDY DESIGN A 5-year retrospective review of patients with malignancy (excluding head/neck and thoracic malignancy) who underwent PEG at our institution was performed. RESULTS One hundred and eighty-nine patients with malignancy underwent PEG; 33.9% had hematologic malignancy, 66.1% had nonhematologic malignancy, and 44.4% had metastatic disease. Indications for PEG were enteral access (73%) and gastric decompression/management of obstructive symptoms (27%). Few patients achieved independence from total parenteral nutrition (22%) or diet advancement (24.6%). Overall rates of major complications (eg, aspiration, tube dislodgement/leakage, bleeding, visceral injury, respiratory failure after procedure, and cardiac arrest) and minor complications (eg, superficial infection and ileus) were 10.2% and 11.3%, respectively. All-cause in-hospital mortality was high (19.6%) and was associated with ICU admission (p = 0.018), earlier bone marrow transplantation (p = 0.022), steroid treatment (p = 0.024), and lower preoperative albumin (p = 0.003). Code status was changed after PEG in 44 patients from full code to DNR/do no intubate or comfort measures only. CONCLUSIONS Percutaneous endoscopic gastrostomy placement in this study population was associated with major procedure-related complications. The majority of patients failed to achieve total parenteral nutrition independence or advancement of diet. Nearly 25% of patients declined aggressive resuscitation strategies after undergoing surgery for PEG. This study cautions to carefully weigh the risks and benefits of PEG placement in this patient population. Prospective studies are needed to uncover factors affecting the decision process and patient selection.
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Affiliation(s)
- Emily Z Keung
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Machon C, Thezenas S, Dupuy AM, Assenat E, Michel F, Mas E, Senesse P, Cristol JP. Immunonutrition before and during radiochemotherapy: improvement of inflammatory parameters in head and neck cancer patients. Support Care Cancer 2012; 20:3129-35. [DOI: 10.1007/s00520-012-1444-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 03/12/2012] [Indexed: 01/09/2023]
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