Swedish Translation and Cultural Adaptation of the Head and Neck Patient Symptom Checklist: An Instrument to Screen for Nutrition Impact Symptoms in Clinical Practice and Research

BACKGROUND

The Head and Neck Patient Symptom Checklist (HNSC) is a validated 2-part instrument used to ask patients with head and neck cancer about the nutrition impact symptoms they experience (part 1) and how these interfere with their eating (part 2).

PURPOSE

The purpose of this work was to translate and culturally adapt the HNSC into Swedish in accordance with the guidelines of the International Society for Health Economics and Outcomes Research (ISPOR).

METHODS

The ISPOR guidelines include 10 steps, and these were thoroughly followed. In step 7, 9 health care professionals from the field of head and neck cancer assessed the perceived relevance (content validity) of each item in the HNSC, as well as the full HNSC. A total of 522 participants with head and neck cancer were included and followed up on 7 occasions using the HNSC to assess internal consistency.

RESULTS

The HNSC was translated from English into Swedish, ensuring accuracy through forward and backward translation and harmonization in the research team. Content validity for each part of the HNSC was rated excellent (scale content validity index 0.96). Internal consistency demonstrated a good Cronbach's alpha score (>0.8) across the 7 follow-up time points (from baseline [before the start of treatment] and up to 24 months posttreatment).

CONCLUSIONS

The HNSC has been successfully translated and culturally adapted into Swedish. The HNSC can be used in both clinical practice and research to screen for nutrition impact symptoms and symptoms that interfere with eating in patients with head and neck cancer.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03343236 (date of registration: November 17, 2017).

How did the COVID-19 pandemic change patient experience during radiation therapy for head and neck cancer: A single centre survey

INTRODUCTION/BACKGROUND

Patients receiving treatment for head and neck cancer (HNC) with curative intent, will potentially undergo primary or adjuvant radiation therapy (RT). These patients require supportive management from an extended multi-disciplinary team, to manage the severe toxicities and distress that a course of treatment can bring. A survey was designed to determine if there were changes in the experience of HNC patients attending for radical RT, from the beginning to the end of their treatment course. During the conduct of the survey the COVID-19 pandemic began. As a result cancer services were adapted to keep patients receiving treatment protected from the virus, while continuing to treat their malignant disease. This enabled a comparison of HNC patient experiences pre-pandemic (PP) and during the pandemic (DP). The study aimed to assess the impact of changes in treatment logistics, implemented as a result of the COVID-19 pandemic, on the patient experience, analysing and comparing how well patients understood the information provided to them, their level of distress and anxiety during treatment, and their overall satisfaction with the experience.

METHODS

Eligible patients were receiving radical RT for HNC of any sub-site or histological type. Identical, anonymous surveys were distributed to patients at week 1 and the final week of RT. The initial PP questionnaire (distributed December 2019 to 11th March 2020) contained 22 questions with space for free text. The questionnaire was amended DP to include 6 additional COVID-19 related questions (distributed June to November 2020).

RESULTS

One hundred and eighty two surveys were returned; 95 (52%) PP and 87 (48%) DP. Patients were moderately distressed from wearing the immobilisation mask towards the end of treatment DP with a statistically significant difference in the final week, median (IQR) values of 1 (0-4) PP and 2 (1-6) DP, p=0.024. Patients reported increased distress by attending daily for treatment by the final week of RT DP, with a PP and DP median of 1 (0-3) and 2 (1-4) respectively, p=0.039. Patients reporting increased levels of distress about attending for RT also reported high levels of anxiety about COVID-19 (r=0.40, p=0.005). COVID-19 anxiety score displayed a weak inverse association with overall treatment satisfaction score (r=-0.28, p=0.008).

CONCLUSION

Despite the adapted COVID-19 working practices implemented and the challenges a course of head and neck RT entails, patients reported a positive experience attending for treatment, both PP and DP.

Postradiation trismus in head and neck cancer survivors: a qualitative study of effects on life, rehabilitation, used coping strategies and support from the healthcare system

PURPOSE

This study aimed to explore the experiences of head and neck cancer (HNC) survivors with postradiation trismus, specifically how oncological treatment affected their lives, rehabilitation, use of coping strategies, and healthcare experiences.

METHODS

A qualitative descriptive approach was used and semi-structured interviews of 10 HNC survivors with postradiation trismus were conducted 6-30 months after completing oncological treatment. The interviews were transcribed verbatim and analyzed by qualitative content analysis.

RESULTS

The analysis of interviews yielded four main categories: Bodily symptoms, Effects on life, Support from the healthcare system, and Strategies to handle life and symptoms. Participants reported ongoing problems with xerostomia, dysgeusia, eating, and limited physical fitness. Pain related to trismus was not a major issue in this cohort. Participants expressed limitations in their social lives due to their eating difficulties, yet a sense of thankfulness for life and overall satisfaction with the healthcare they received. Psychological and practical coping strategies developed by the participants were also revealed.

CONCLUSION

The results highlight areas of unmet need among HNC survivors that healthcare providers can target by establishing multi-professional teams dedicated to individualizing post-cancer rehabilitation care.

Effect of individualized nutritional intervention on head and neck cancer patients receiving radiotherapy

OBJECTIVE

To explore the effect of individualized nutritional interventions on head and neck cancer (HNC) patients receiving radiotherapy and provide a basis for improving the quality of life for those patients.

METHODS

A convenience sampling method was adopted to select HNC patients as the study objects. The Nutritional Risk Screening 2002 scale (NRS2002) was used to screen the nutritional risk in 108 HNC patients receiving radiotherapy, and the patients were randomly divided into control group and observation group. Routine dietary guidance was conducted in the control group, and individualized nutritional intervention was applied in the observation group.

RESULTS

Six months after the intervention, the albumin levels (37.40 ± 4.03 g/L), hemoglobin levels (128.70 ± 15.22 g/L), and body mass index scores (BMI) (23.96 ± 3.23 kg/m2) of the observation group were all better than to those of control group (t = 2.370, 2.216, and 3.135, respectively, and P < 0.05 in all). Six months after the intervention, the anxiety and depression scores in observation group (27.6 ± 7.2 points, 27.3 ± 2.2 points) were lower than those in control group (38.6 ± 9.6 points, 37.9 ± 3.3 points). The quality-of-life score in the observation group was higher than that in control group. The nursing satisfaction in the observation group (96.43%) was higher than that in the control group (75.00%).

CONCLUSION

The implementation of individualized nutritional intervention has promoted the improvement of laboratory indicators, weight, and BMI of head and neck cancer patients, reduced the risk of malnutrition of head and neck cancer patients, improved their quality of life, reduced the occurrence of adverse reactions during radiotherapy, and promoted long-term efficacy.

Nutrition and Dietary Intervention in Cancer: Gaps, Challenges, and Future Perspectives

The term "cancer" refers to the state in which cells in the body develop mutations and lose control over their replication. Malignant cancerous cells invade in various other tissue sites of the body. Chemotherapy, radiation, and surgery are the first-line modalities for the majority of solid cancers. These treatments work by mitigating the DNA damage of cancerous cells, but they can also cause harm to healthy cells. These side effects might be immediate or delayed, and they can cause a high rate of morbidity and mortality. Dietary interventions have a profound impact on whole-body metabolism, including immunometabolism and oncometabolism which have been shown to reduce cancer growth, progression, and metastasis in many different solid tumor models with promising outcomes in early phase clinical studies. Dietary interventions can improve oncologic or quality-of-life outcomes for patients that are undergoing chemotherapy or radiotherapy. In this chapter, we will focus on the impact of nutritional deficiencies, several dietary interventions and their proposed mechanisms which are used as a novel therapy in controlling and managing cancers.

Mapping the impact of malnutrition as defined by the Global Leadership Initiative on Malnutrition and nutrition impact symptoms on the possibility of returning to work after treatment for head and neck cancer

PURPOSE

This study aimed to investigate whether malnutrition or nutrition impact symptoms (NIS) affect the possibility of returning to work after treatment for head and neck cancer.

METHODS

Patients of working age with head and neck cancer were followed up from treatment initiation to 3 months (n = 238), 1 year (n = 182), and 2 years (n = 130) after treatment completion. The observed decrease in the number of patients over time was due to retirement, lack of follow-up, or death. Returning to work was dichotomised as yes or no. Malnutrition was diagnosed 7 weeks after treatment initiation using the Global Leadership Initiative on Malnutrition (GLIM) criteria. This time-point corresponds to the end of chemoradiotherapy or radiotherapy (with or without prior surgery), except for patients who underwent exclusive surgery. NIS were scored on a Likert scale (1-5) at each follow-up using the Head and Neck Patient Symptom Checklist© (HNSC©). Nonparametric tests were used to analyse the ability of patients with/without malnutrition and high/low NIS scores to return to work.

RESULTS

At 3 months, 1 year, and 2 years after treatment completion, 135/238 (56.7%), 49/182 (26.9%), and 23/130 (17.7%) patients had not returned to work. Patients with malnutrition at 7 weeks after treatment initiation were more likely to not return to work at 3 months than those without malnutrition, 70.5% compared to 47.1% (p < 0.001). At all three follow-up time-points, patients reporting high scores for a number of NIS had more often not returned to work, with this pattern being most distinct at 2 years.

CONCLUSION

Malnutrition according to the GLIM criteria at 7 weeks after treatment initiation and NIS assessed by the HNSC© at subsequent follow-ups were predictors of the return-to-work process after treatment for up to 2 years.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT03343236 (date of registration 17/11/2017).

Managing eating problems after cancer

Cancer treatment can cause food-limiting eating problems that persist or arise months or years after treatment, with negative consequences for the survivor's nutritional status, physical and social function, and quality of life. Hence, post-treatment follow-up and cancer rehabilitation services should aim to support the survivor in managing treatment-related eating problems. This narrative review summarizes the evidence on and provides an overview of interventions to manage eating problems after cancer. Interventions are grouped into four: 1) food-based interventions, including alternating food/fluids and experimenting through the trial-and-error strategy to find tolerated foods; 2) eating behavioral interventions, including instructions on swallowing techniques, posture, and utensils; 3) psychosocial support interventions, including group-based interventions and interventions including relatives; and 4) physical interventions, including exercises to improve dysphagia or trismus. While physical interventions are supported by evidence from several intervention studies, few studies evaluating the effect of other types of interventions in survivors were identified. Instead, qualitative and observational data providing insights on experiences of and coping strategies applied by survivors with eating problems underpin the need for the other types of interventions. Since existing research primarily focuses on survivors of head and neck cancer, future studies on the organization and effects of interventions aimed at managing eating problems among different groups of survivors are relevant.

Perceptions of life and experiences of health care support among individuals one year after head and neck cancer treatment - An interview study

PURPOSE

To examine how individuals treated for head and neck cancer perceive life one year after the end of treatment and how they experience supportive efforts from health care.

METHODS

A semi-structured interview study of 21 patients was performed one year after the end of treatment. The patients gave their views concerning physical, psychological, and return-to-work issues, and their experiences concerning rehabilitative efforts from health care and particularly the contact nurse were captured. A thematic analysis was conducted.

RESULTS

One year after treatment the patients were still suffering from side effects and from fear of recurrence, but they strived to live as they did before the cancer diagnosis, such as having returned to work and resuming leisure activities. Moreover, the rehabilitative efforts from health care had ended. Having access to a contact nurse, also known as a clinical nurse specialist, was positive, however, the participants lacked regular long-term follow-ups with the contact nurse regarding rehabilitation needs. Improvement possibilities were seen in clarifying the role of the contact nurse and that the contact nurse should show engagement and make the initial contact with the patients.

CONCLUSION

Despite the sequelae from treatment, the patients strived to live as before their diagnosis. By regular, engaged, and long-term follow-ups by the contact nurse, remaining needs may be uncovered, and appropriate individualized support and rehabilitation can be offered.

[Weight, nutrition, quality of life-Perspective of oncological patients]

Nutrition is associated with pleasure and quality of life. The majority of oncological patients experience tumor-associated and treatment-associated nutrition-related symptoms and malnutrition. Consequently, the perception of nutrition during the course of the disease is increasingly more characterized by negative associations, which may persist for years after the end of treatment. This leads to a decreased quality of life, social isolation and a burden for relatives. In contrast, weight loss is initially positively perceived, especially by patients who previously perceived themselves as being overweight, until malnutrition becomes evident and leads to a decreased quality of life. Nutritional counseling can prevent weight loss, relieve adverse side effects, improve the quality of life and reduce mortality. Patients are not aware of this and the German healthcare system lacks structured and firmly established access pathways to nutritional counseling. Therefore, oncological patients need to be informed about the consequences of weight loss at an early stage and low-threshold access to nutritional counseling needs to be comprehensively implemented. Thus, malnutrition can be recognized and treated at an early stage and nutrition can contribute to a higher quality of life as a positively perceived daily activity.

Nutrition care is an integral part of patient-centred medical care: a European consensus

While healthcare is becoming more patient-centred, evidence-based nutrition interventions are still not accessible to all patients with cancer. As nutrition interventions directly improve clinical and socioeconomic outcomes, patient-centred care is not complete without nutrition care. While awareness of the negative impact of malnutrition on clinical outcomes, quality of life, and functional and emotional wellbeing in cancer is growing, there is relatively poor awareness amongst patients, clinicians, policymakers, and payers that nutrition interventions -particularly those begun in the early stages of the disease course- are an effective method for improving such outcomes. The European Beating Cancer Plan recognises the need for a holistic approach to cancer but lacks actionable recommendations to implement integrated nutrition cancer care at member state level. When considering nutrition care as a human right, the impact on quality of life and functional status must be prioritized, as these may be equally as important to patients, especially in advanced cancer where improvements in clinical outcomes such as survival or tumour burden may not be attainable. We formulate actions needed at the regional and the European level to ensure integrated nutrition care for all patients with cancer. The 4 main Take Home Messages are as follows: 1. The goals of Europe's Beating Cancer Plan cannot be achieved without integrating nutrition across the cancer care continuum. 2. Malnutrition negatively impacts clinical outcomes and has socioeconomic consequences for patients and healthcare systems. 3. Championing integrating nutrition care into cancer care is therefore the duty and ethical responsibility of clinicians (Hippocratic Oath-primum non nocere) and 4. Nutrition care is a cost effective, evidence-based therapy.

Factors that affect quality of life for older people with head and neck cancer: A systematic review

PURPOSE

Quality of life is a critical aspect in the management of older head and neck cancer patients. It needs to be considered alongside survival benefit, treatment burden, and longer-term outcomes. The purpose was to undertake a systematic review of empirical peer-reviewed studies with a primary focus on factors impacting quality of life for older head and neck cancer patients.

METHODS

A systematic review, searching 5 electronic databases (PsychoINFO, MEDLINE, CINHAL, Embase, and Scopus) using PRISMA methodology was conducted. Data was appraised using the Newcastle-Ottawa scale and a narrative synthesis performed.

RESULTS

Only 10 papers fulfilled the inclusion criteria. Two main themes emerged: 1) Impact of head and neck cancer on quality of life domains and 2) quality of life in treatment decision-making.

CONCLUSIONS

In an era of progressive personalised care, there is an evident need for more qualitative and quantitative studies focusing on quality of life for older head and neck cancer patients. However, older head and neck cancer patients experience notable differences, especially with poorer physical functioning and greater eating and drinking challenges. Quality of life impacts older patients decision-making, treatment planning and intensifies post-treatment support.

Internet-based support for informal caregivers to individuals with head and neck cancer (Carer eSupport): a study protocol for the development and feasibility testing of a complex online intervention

INTRODUCTION

It is strongly recommended that randomised controlled trials are preceded with an exploration of the needs of the target population and feasibility testing of the intervention. The present study protocol is set out to describe these steps in the development of a complex intervention.The past decades' transition of care from inpatient to outpatient settings has increased the complexity of caregivers' responsibilities, which they may not be prepared for. There is a need to support informal caregivers (ICs) to prepare them for caregiving and decrease the caregiver burden. The main aim of this study is to describe the development of an internet-based intervention (Carer eSupport) to improve ICs' ability to support individuals with head and neck cancer and to describe the testing of the feasibility and acceptability of Carer eSupport.

METHODS AND ANALYSIS

This is a multicentre study involving the ear, nose and throat clinics and the oncology and radiotherapy clinics at three university hospitals. The study protocol comprises two phases, development and feasibility testing, using the Medical Research Council framework for developing a complex intervention. Carer eSupport will be based on the results from focus group discussions with ICs and healthcare professionals (planned for n=6-8 in respective groups) and scientific evidence, the Social Cognitive Theory and the Theory of Acceptance and Use of Technology. The feasibility testing will include 30 ICs who will have access to Carer eSupport for 1 month. The feasibility testing will be evaluated with a mixed-method design.

ETHICS AND DISSEMINATION

All procedures have been approved by the Ethics Committee at Uppsala University (Dnr: 2020-04650). Informed consent will be obtained before enrolment of patients, their ICs and healthcare staff. The feasibility testing is registered at Clinicaltrials.gov (Identifier: NCT05028452). Findings will be disseminated in peer-reviewed journal publications.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov (Identifier: NCT05028452).

Addressing symptoms that affect patients' eating according to the Head and Neck Patient Symptom Checklist©

PURPOSE

The purpose of this prospective study was to assess which nutritional impact symptoms (NIS) interfere with oral intake in patients with head and neck cancer (HNC) and how the symptoms interfere with body weight loss, up to 1 year after treatment.

METHODS

This was a prospective study of 197 patients with HNC planned for treatment with curative intention. Body weight was measured before the start of treatment, at 7 weeks after the start of treatment, and at 6 and 12 months after completion of treatment. NIS and NIS interfering with oral intake at each follow-up were examined with the Head and Neck Patient Symptom Checklist^© (HNSC^©).

RESULTS

At 7 weeks of follow-up, patients experienced the greatest symptom and interference burden, and 12 months after treatment the NIS scorings had not returned to baseline. One year after treatment, the highest scored NIS to interfere with oral intake was swallowing problems, chewing difficulties, and loss of appetite. At all 3 follow-ups, the total cumulative NIS and NIS interfering with oral intake were associated with body weight loss. Factors increasing the risk for a body weight loss of ≥ 10% at 12 months after treatment were pain, loss of appetite, feeling full, sore mouth, difficulty swallowing, taste changes, and dry mouth. Women scored higher than men in NIS and NIS interfering with oral intake. Furthermore, during the study period about half of the population had a body weight loss > 5%.

CONCLUSION

Because both nutritional and clinical factors may affect body weight, this study highlights the importance of a holistic approach when addressing the patients' nutritional issues.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03343236, date of registration: November 17, 2017.

Culinary Solitude in the Diet of People with Functional Diversity

This qualitative ethnographic study identifies how problems in the feeding process of a group of people with functional diversity influence different eating situations. The study, which was carried out in the Autonomous Community of Castilla La Mancha, Spain, is based on interviews conducted at the headquarters of the different participating associations for functionally diverse people, at the participants’ homes, and in public spaces. The study included 27 subjects aged between 18–75 years. Their functional diversity had caused significant changes in their sociability, particularly in contexts associated with food consumption. The analysis identified three main themes: social ghettoisation and culinary loneliness; stigma, shame, feeling like a burden, and loneliness; and exclusion or self-exclusion at the dining table. Our participants’ narratives underscored the importance of acknowledging the significance of changes in eating-related sociability due to functional diversity. For the study subjects, grief, loneliness, and shame contributed to disassociating food consumption from social celebrations, withdrawing from restaurant meals, or conversations while eating to avoid other people’s stares.

Experiences and perceptions of social eating for patients living with and beyond head and neck cancer: a qualitative study

Purpose

Patients with head and neck cancer (HNC) describe eating as more than a physical activity for nutrition and calories. After treatment for HNC, patients report a changed social experience around food, with eating and drinking in front of family and friends depicted as a challenge. However, there is limited research exploring how patients with HNC adapt and cope with social eating difficulties. This study aims to explore patients’ experiences and perceptions of social eating and drinking following treatment for HNC.

Methods

A qualitative research design using semi-structured interviews was employed to understand the experiences of social eating of patients living with and beyond HNC. Reflexive thematic analysis was used to inductively develop key themes from the data.

Results

Fourteen interviews were conducted with patients, and two key themes were identified: (1) “Social eating became a conscious process” and (2) “Strategies to maximise social eating participation”. To maximise social eating enjoyment, patients attempted to minimise the attention on their eating function and the fuss created around food. Patients with HNC established psychological and cognitive adaptations to manage expectations and promote positive participation in social eating.

Conclusion

This paper identifies key barriers limiting or diminishing social eating for patients with HNC; including being self-conscious, lack of understanding from others and functional issues with eating and drinking. This research highlights the need to raise awareness of social eating challenges and for the social dimensions of eating to be addressed through family-centred, supportive holistic interventions implemented early in the patient’s cancer journey.

Eating experiences and quality of life in patients with larynx cancer in Spain. A qualitative study

Purpose

This paper aims at describing the eating experience of people diagnosed with and treated for laryngeal cancer. Going beyond the mere conceptualization of “after-effect” or the quantification of the disease’s impact on the basis of standardized questionnaires, we present a qualitative analysis of the narratives of such experiences.

Methods

Ethnographic study. Data is obtained from conversations, semi-structured interviews, participant observation, and written documents. A discourse analysis of the narrative information was conducted, with process coding and using the constant comparative method, inductive content analysis, category analysis, units of meaning associated with each other, and triangulation.

Results

The impact of cancer on eating processes is not limited to nutrition, but also affects the social and cultural value of food, which is put into question. The symbolic and social values which accompany the traditional way of eating are modified, which is connected with impaired quality of life.

Conclusions

The impact on the eating process and its relationship with quality-of-life impairment are clear and connect with the importance of eating ways in culture and social organization. Greater attention should be paid to these contexts in clinical practice, which can affect even more than the impact on communicative processes.

Nutrition Impact Symptom Clusters in Patients With Head and Neck Cancer Receiving Concurrent Chemoradiotherapy

OBJECTIVES

The objective of this study was to identify the nutrition impact symptom (NIS) clusters in patients with head and neck cancer (HNC) receiving concurrent chemoradiotherapy (CCRT) and explore their relationships with the weight loss rate (WLR).

METHODS

This longitudinal study included 169 patients. At baseline (T₁), the demographics, clinical information, and weight before radiotherapy (RT) were recorded. At the third week (T₂) and the end of RT (T₃), we assessed the weight, prevalence, severity, and interference of the NIS with the Head and Neck Patient Symptom Checklist. The mean scores of the severity of NIS at T₂ and T₃ were used as a whole to perform the exploratory factor analysis and identify the symptom clusters. Cronbach's α coefficient was used to evaluate the internal consistency of the symptom clusters. Generalized estimating equations were used to analyze the relationships between clusters and the WLR.

RESULTS

We extracted three clusters from 14 NISs: the RT-specific symptom cluster including pain, difficulty swallowing, oral mucositis, thick saliva, difficulty chewing, and dry mouth (Cronbach's α = 0.820); the gastrointestinal symptom cluster including nausea, loss of appetite, feeling full, vomiting, and taste change (Cronbach's α = 0.592); the psychological status cluster including depressed, anxious, and lack of energy (Cronbach's α = 0.710). The multivariable model showed that participants with more serious RT-specific symptom cluster (β = 1.020, 95% CI: 0.570-1.471, P < 0.001) had higher WLR.

CONCLUSIONS

The NIS had close internal connections with each other, so the strategies applied by healthcare professionals should focus on multiple related symptoms, especially to manage the RT-specific symptom cluster.

Does Etiology Matter? Comparative Analysis of a Singing-Enhanced Swallowing Protocol for Patients with Neurological Impairment versus Head and Neck Cancer

Swallowing difficulties are a common complaint among patients with a variety of diseases. To address these concerns, a singing-enhanced swallowing protocol was constructed, and its differential benefits for two patient populations were investigated. Two patients with Parkinson’s disease (PD) and two patients with head and neck cancer (HNC) participated in this study. Each patient participated in 30-min individual sessions of a singing-enhanced swallowing protocol two times per week for 12 weeks. Following the intervention, laryngeal diadochokinesis and quality-of-life measurements were found to be higher in all four patients. However, the Videofluoroscopic Dysphagia Scale showed this improvement was associated with different swallowing tasks for each patient group. In addition, the maximum phonation time decreased for patients with HNC, while it increased for patients with PD. The findings support the use of a singing-enhanced swallowing protocol for patients whose swallowing difficulties are due to neurological or structural impairment. In addition, the study results suggest that different intervention components should be considered depending on the etiology of the patient’s swallowing difficulties.

Mapping Health-Related Quality of Life, Anxiety, and Depression in Patients with Head and Neck Cancer Diagnosed with Malnutrition Defined by GLIM

Patients with cancer deal with problems related to physical, psychological, social, and emotional functions. The aim was to investigate malnutrition defined by the Global Leadership Initiative on Malnutrition (GLIM) criteria in relation to health-related quality of life, anxiety, and depression in patients with head and neck cancer. This was a prospective observational research study with 273 patients followed at the start of treatment, seven weeks, and one year. Data collection included nutritional status and support, and the questionnaires: European Organization for Research and Treatment of Cancer Head and neck cancer module (EORTC QLQ-H&N35) and the Hospital Anxiety and Depression Scale (HADS). Malnutrition was defined using the GLIM criteria. The study showed that patients with malnutrition had significantly greater deterioration in their health-related quality of life at seven weeks. On a group level, health-related quality of life was most severe at this time point and some scores still implied problems at one year. Significantly, more patients reported anxiety at the start of treatment whereas significantly more patients reported depression at seven weeks. Over the trajectory of care, the need for support often varies. Psychosocial support is imperative and at the end of treatment extra focus should be put on nutritional interventions and managing treatment-related symptoms to improve nutritional status and health-related quality of life. In the long-term, head and neck cancer survivors need help to find strategies to cope with the remaining sequel.

Patients with head and neck cancer treated with radiotherapy: Their experiences after 6 months of prophylactic tooth extractions and temporary removable dentures

OBJECTIVES

The impact of dental occlusion on the experiences of head and neck cancer patients and their oral, social and psychological functioning has been sparsely investigated. There is a lack of knowledge regarding the experience of tooth loss and dentures among patients treated for head and neck cancer. The aim of this study was to describe the experiences of head and neck cancer patients of prophylactic tooth extractions and temporary removable dentures, 6 months after radiotherapy treatment.

MATERIAL AND METHODS

An individual interview with 25 patients 6 months after radiotherapy was subjected to a qualitative content analysis.

RESULTS

Two categories, Impaired oral function and Belief in the future, and seven subcategories described the patients' experiences of temporary removable dentures during the first 6 months after prophylactic tooth extractions. The temporary removable dentures affected the patients' ability to chew, swallow and speak, caused pain, and were experienced as an enemy. Despite that, the patients were hopeful and had a wish for recovery, which gave them the energy to live.

CONCLUSION

Prophylactic tooth extractions and temporary removable dentures 6 months after radiotherapy treatment affect head and neck cancer patients' recovery and everyday life. However, they have the will to take on these challenges, pertaining not only to themselves, but also to relatives and health professionals. At the individual level, the patient needs individualized professional support to get through the arduous procedure, from the acute situation until the end of the rehabilitation phase.

A qualitative systematic review of the social eating and drinking experiences of patients following treatment for head and neck cancer

PURPOSE

Patients living with and beyond head and neck cancer (HNC) often have long-term, functional challenges as a result of treatment. A key functional challenge relates to eating and drinking; often associated with physical, emotional, and social difficulties. Eating and drinking with family members and friends can become a struggle, increasing the risk of social isolation and loneliness. This systematic review aims to identify and synthesise the literature on the experiences of social eating and drinking for patients following treatment for HNC.

METHODS

Six electronic databases (Pubmed, Web of Science, CINAHL, EMBASE, PsychINFO, and Scopus) were systematically searched using subject headings and free-text word searches in February 2020. Citation chaining and Google Scholar were used to identify grey literature. PRISMA procedures were followed.

RESULTS

Of 6910 records identified, 24 studies met the inclusion criteria. Synthesis of the research findings results in two major themes: (1) the experience of loss associated with social eating and drinking, and (2) adjusting and support to promote social eating and drinking.

CONCLUSION

Losses associated with social eating affect a patient's psychological and emotional well-being and impact on close relationships. To promote positive participation in social eating, patients were more likely to seek and receive support from someone within their close social network, rather than a healthcare professional. Family and friends are an essential source of support and are integral in facilitating engagement with social eating following treatment for HNC. Future interventions should promote family orientated resources, incorporating self-management strategies.

Health-related quality of life became worse in short-term during treatment in head and neck cancer patients: a prospective study

BACKGROUND

Quality of life (QoL) is influenced in head and neck cancer (HNC) patients by a set of factors related to diagnosis, treatment and tumor impacts. The aim of this study was to evaluate the Quality of Life (QoL) changes in Head and Neck cancer (HNC) patients during treatment (radiotherapy and/or chemoradiotherapy).

METHODS

QoL was evaluated prospectively in 63 HNC patients during radiotherapy and/or chemoradiotherapy at three moments: before or at beginning (T0), in the middle (T1 ~ four weeks) and immediately at the end (T2 ~ eight weeks) of treatment. The differences between the scores at different time points was verified using Friedman's non-parametric test. Negative changes between time points were evaluated, with differences (delta) of ±10 points being considered to be clinically significant.

RESULTS

The total mean age was 59.1 ± 9.5y, and 82.5% were male. The oral cavity and larynx were more frequent tumors. The functional score for 'role' was decreased at time points T1 and T2 as compared to T0, while an improvement in scores was observed for cognitive function. Several physical symptoms also worsened over time, such as: fatigue, nausea and vomiting, dry mouth and sticky saliva, swallowing and skin symptoms, senses and teeth problems. A high frequency of altered and clinically meaningful values were observed for most of domains, ranging from 6 to 74%.

CONCLUSIONS

The QoL became worse at approximately one month after treatment beginning in HNC patients, and this remained until the end of therapy. Protocols directing to early nutritional counseling and management of symptoms of nutritional impact are important to improve clinical outcomes. This is part of preventive actions aiming to make the exhausting treatment process less traumatic and easier to complete.

Effects of a Multidisciplinary Residential Nutritional Rehabilitation Program in Head and Neck Cancer Survivors-Results from the NUTRI-HAB Randomized Controlled Trial

Head and neck cancer survivors frequently experience nutritional challenges, and proper rehabilitation should be offered. The trial objective was to test the effect of a multidisciplinary residential nutritional rehabilitation programme addressing physical, psychological, and social aspects of eating problems after treatment. In a randomized controlled trial, 71 head and neck cancer survivors recruited through a nationwide survey were randomized to the program or a wait-list control group. Inclusion was based on self-reported interest in participation. The primary outcome was change in body weight. Secondary outcomes included physical function, quality of life, and symptoms of anxiety and depression. Differences between groups at the 3-month follow-up were tested. No significant differences were seen in body weight change, but there were overall trends towards greater improvements in physical function (hand grip strength: p = 0.042; maximal mouth opening: p = 0.072) and quality of life ("Role functioning": p = 0.041; "Speech problems": p = 0.040; "Pain": p = 0.048) in the intervention group. To conclude, a multidisciplinary residential nutritional rehabilitation program had no effect on body weight in head and neck cancer survivors with self-reported interest in participation, but it may have effect on physical function and quality of life. Further research on relevant outcomes, inclusion criteria, and the program's effect in different subgroups is needed.

Patient and carer experience of nutrition care throughout treatment for head and neck cancer: a systematic qualitative review and thematic synthesis

Nutrition care plays a critical role in the provision of best practice care to head and neck cancer (HNC) patients, with carers playing an important role in supporting patients to maintain nutrition intake. This qualitative systematic review investigated patient and carer experience of nutrition care throughout and beyond HNC treatment. Five databases were systematically searched for qualitative studies reporting on patient and carer experience of nutrition care throughout HNC. Twenty-five studies including 435 patients and 46 carers were identified, revealing three themes: information and support in the healthcare setting, enteral feeding challenges and management, and life outside hospital. Findings highlight the importance of providing individualised person-centred nutrition care to patients with HNC and their carers. Further qualitative research is needed to inform healthcare professionals about the needs of patients and carers to provide appropriate support throughout the treatment trajectory across and between different treatment modalities.

Swallowing functional outcomes and nutritional status in head and neck cancer radiotherapy: longitudinal study

Objective

To explore the relationships between swallowing functional outcomes and nutritional status in patients with head and neck cancer undergoing radiotherapy (RT).

Methods

This longitudinal study included 122 patients. Data were collected at three time points: baseline (T1), the third week of RT (T2) and the completion of RT (T3). The Common Terminology Criteria for Adverse Events was used to assess the symptom of dysphagia and other toxicities; the MD Anderson Dysphagia Inventory (MDADI) was used to assess the patient-perceived swallowing functional outcomes; the nutritional status was evaluated by the weight ratio and the Patient-Generated Subjective Global Assessment (PG-SGA). The generalised estimating equation (GEE) was used to measure the correlation of MDADI with the weight ratio or PG-SGA and also to analyse the influential factors of swallowing functional outcomes.

Results

The participants’ acute dysphagia rates were 5.7% at T1, 69.7% at T2 and 77.9% at T3. The swallowing functional outcomes worsen over RT (p<0.001) and were associated with weight ratio (β=0.032, p=0.008) and PG-SGA (β=−0.115, p<0.001). GEE models showed that patients with cancer of the pharynx region, advanced stage, chemoradiotherapy and high RT dose perceived worse swallowing functional outcomes. Oral mucositis, pharynx mucositis and salivary gland inflammation were positively correlated with swallowing functional outcomes, and the pharynx mucositis presented the highest absolute value of β.

Conclusion

The swallowing functional outcomes were negatively correlated with nutritional status. Healthcare professionals should identify early on the population at higher risk and focus on multiple toxicities, especially the management of pharynx mucositis, to improve nutritional status.

Mapping the frequency of malnutrition in patients with head and neck cancer using the GLIM Criteria for the Diagnosis of Malnutrition

BACKGROUND & AIMS

Patients with head and neck cancer are defined as high-risk patients for malnutrition, but the inconsistent practice of diagnosing malnutrition is a barrier in comparing studies and in assessing patients in clinical practice. The aim of the study was to describe the frequency of malnutrition over time in patients treated for head and neck cancer using the GLIM Criteria for the Diagnosis of Malnutrition.

METHODS

Data from a prospective observational study on patients with head and neck cancer were used (n = 210). Patients were assessed for malnutrition using the combination of one phenotypic and one etiologic criterion. The following phenotypic criteria for malnutrition were used: body weight loss (either >5% within the past six months or >10% beyond six months), body mass index (<20 kg/m² if <70 years or <22 kg/m² if ≥70 years), and fat free mass index measured by bioelectrical impedance analysis (<17 FFM/m² for males and <15 FFM/m² for females). The following etiologic criteria for malnutrition were used: reduced food intake (partial or no food intake with the need for artificial nutrition) and C-reactive protein (>5 mg/L).

RESULTS

For all eight possible combinations of GLIM, the frequency of malnutrition reached its highest point at seven weeks after the start of treatment. A total of 32% of the patients fulfilled the criteria for malnutrition using weight loss >5% within the past six months (phenotypic) in combination with C-reactive protein >5 mg/L (etiologic).

CONCLUSIONS

GLIM Criteria for the Diagnosis of Malnutrition can be used to assess malnutrition in patients with head and neck cancer during treatment. Using the same criteria to define malnutrition in nutritional research will make it possible to produce multiple lines of evidence on malnutrition in head and neck cancer and its adverse effects on treatment, prognosis, and survival.

Rationale and design of a randomised controlled trial investigating the effect of multidisciplinary nutritional rehabilitation for patients treated for head and neck cancer (the NUTRI-HAB trial)

Background

Eating problems frequently affect quality of life and physical, psychological and social function in patients treated for head and neck cancer (HNC). Residential rehabilitation programmes may ameliorate these adverse effects but are not indicated for all individuals. Systematic assessment of rehabilitation needs may optimise the use of resources while ensuring referral to rehabilitation for those in need. Yet, evidence lacks on which nutrition screening and assessment tools to use. The trial objectives are: 1) To test the effect of a multidisciplinary residential nutritional rehabilitation programme compared to standard care on the primary outcome body weight and secondary outcomes health-related quality of life, physical function and symptoms of anxiety and depression in patients curatively treated for HNC and 2) To test for correlations between participants’ development in outcome scores during their participation in the programme and their baseline scores in Nutritional Risk Screening 2002 (NRS 2002), the Scored Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF), and M. D. Anderson Dysphagia Inventory (MDADI) and to assess sensitivity, specificity and predictive values of the three tools in relation to a clinically relevant improvement in outcome scores.

Methods

In a randomised controlled trial, 72 patients treated for HNC recruited through a nationwide survey will be randomised to a multidisciplinary residential nutritional rehabilitation programme or to a wait-list control group. Data are collected at baseline, three and six months. Primary outcome is change in body weight, and secondary outcomes include changes in quality of life, physical function and symptoms of anxiety and depression. Potential correlations between intervention effect and baseline scores in NRS 2002, PG-SGA-SF and MDADI will be tested, and sensitivity, specificity and predictive values of the three tools in relation to a clinically relevant improvement in outcome scores will be assessed.

Discussion

This is the first randomised controlled trial to test the effect of a multidisciplinary residential nutritional rehabilitation programme in patients treated for HNC. Recruitment through a nationwide survey gives a unique possibility to describe the trial population and to identify potential selection bias. As the trial will explore the potential of different nutrition screening and assessment tools in the assessment of rehabilitation needs in patients treated for HNC, the trial will create knowledge about how selection and prioritisation of nutritional rehabilitation aimed at patients treated for HNC should be offered. The results may contribute to a better organisation and use of existing resources in benefit of patients treated for HNC.

Trial registration

The trial is registered by The Danish Data Protection Agency (registration 2012-58-0018, approval number 18/14847) and the Regional Committees on Health Research Ethics for Southern Denmark (journal number 20182000–165). ClinicalTrials.gov Identifier: NCT03909256. Registered April 9, 2019.

Living with cancer of the head and neck: A qualitative inquiry into the experiences of South African patients

OBJECTIVE

To describe the experiences of South African patients living with head and neck cancer.

METHODS

We used a qualitative descriptive design and conducted unstructured interviews with 18 (n = 18) purposive selected participants. Data saturation determined the sample size. Qualitative content analysis was used to analyse the data.

RESULTS

The majority of the sample were Black males; on average, 50.8 years (SD ± 13.6) old. Two themes and eight subthemes arose from the data. The themes were living with the consequences of the illness and treatment, and coping with a changed life. The lives the participants knew before becoming sick changed and became a living hell; pain was a major problem as was eating and for some, communicating. The participants were stigmatised, ridiculed and rejected which added to their suffering. Receiving support from family and friends and their faith in God assisted them to cope with their changed lives.

CONCLUSION

Our study poses various challenges to clinical practice. Pain management is of the utmost importance; the nutritional status of these patients should be monitored and best practices in terms of management applied. Raising awareness of cancer and its complications could improve knowledge and decrease blame, stigmatisation and rejection and improve patient outcomes.

Coping strategies among patients with malignant lymphoma- a qualitative study from the perspectives of Swedish patients

PURPOSE

There is a dearth of research on coping strategies of patients with malignant lymphoma. The aim of this article is to explore how these patients cope with cancer in everyday life.

METHOD

Semi-structured interviews were conducted with nine patients in Sweden. A thematic analysis was made, inspired by Antonovsky's theory of sense of coherence. The SRQR checklist was used.

RESULTS

Patient's coping strategies are shown within three themes: 'Life experiences supported coping strategies during treatment', 'Between completed treatment and (possible) cure', and 'Illness brought closeness and distance in social relationships'. Three different coping strategies were identified during treatment: trying to control the situation, seeing opportunities in difficulties, and doing other activities to limit thoughts about disease and treatment. Four different coping strategies were identified after treatment ended, namely projecting responsibility and anger onto the healthcare system, maintaining the outer facade as a strong person who had control over the situation, talking about disease, side effects and emotions and putting the focus on the future, and managing life by anticipating death. Family =and friends were a part of patients' coping strategies, but to different extents and in different ways. Diagnosis and treatment for malignant lymphoma brought closeness and distance in social relationships.

CONCLUSION

Patients with malignant lymphoma cope with cancer in different ways in everyday life influenced by their life experiences and life conditions. Further research should focus on cancer patients' coping strategies in a relational perspective, as coping and coping opportunities are embedded in social context and social relationships.

To eat is to practice-managing eating problems after head and neck cancer

PURPOSE

The purpose of this qualitative study was twofold: (1) to explore head and neck cancer (HNC) survivors' experiences of everyday life with eating problems after cancer treatment and (2) to explore their experiences of participating in a multidisciplinary residential rehabilitation program with a primary focus on physical, psychological, and social aspects of eating problems after treatment.

METHODS

Semi-structured focus group interviews were conducted with 40 Danish HNC survivors who participated in a 5-day residential rehabilitation program with follow-up after 3 months. The transcribed interviews were analyzed through qualitative content analysis.

RESULTS

Physical nutrition impact symptoms and unmet needs for support were frequent. Participants experienced a feeling of loss due to impaired eating abilities. Eating had become an obligation or a training situation, and the eating problems challenged the relationship with their relatives when well-meaning encouragement was perceived as a pressure. Social eating was a challenge, and this often led to social withdrawal. The residential program was a safe and supportive environment to practice eating skills, and participants benefited from meeting peers. The program provided participants with knowledge and skills that many of them had been missing during and after treatment.

CONCLUSIONS

Eating problems after treatment have substantial effects on the everyday life of HNC survivors. A multidisciplinary residential rehabilitation program may be beneficial to meet their rehabilitation needs.

IMPLICATIONS FOR CANCER SURVIVORS

The results are useful for future planning of rehabilitation services and clinical studies that may contribute to improving current clinical practice and benefit HNC survivors.