Nutrition impact symptoms and weight loss in head and neck cancer during radiotherapy: a longitudinal study

Effect of nonpharmacological interventions on nutrition status, complications and quality of life in head and neck cancer patients undergoing radiotherapy: A systematic review and meta-analysis

PURPOSE

To evaluate the effect of nonpharmacological therapies on nutrition status, complications and quality of life in head and neck cancer patients and to provide a basis for clinical practice.

METHODS

This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis statement. Ten databases were systematically searched for all available articles from construction to November 2023. Two researchers independently conducted literature screening, data extraction and quality evaluation. Cochrane Review Manager 5.3 was used for meta-analysis.

RESULTS

Finally, 27 RCT studies including 2814 patients with head and neck cancer were included. Five categories of interventions were used: nutritional support, exercise, swallowing function training, psychological intervention and low-level laser therapy. Nonpharmacological interventions can improve body weight loss in patients with HNC at the end of treatment (MD: 1.66 kg; 95% CI: 0.80 to 2.51), and subgroup analysis showed that nutritional support, psychological intervention and low-level laser therapy were effective. Nonpharmacological interventions can also ameliorate decreases in BMI (MD: 0.71; 95% CI: 0.16 to 1.26) and reduce the incidence of malnutrition (RR: 0.76; 95% CI: 0.67 to 0.86), oral mucositis (RR: 0.54; 95% CI: 0.37 to 0.80) and gastrointestinal complications (RR: 0.61; 95% CI: 0.38 to 0.96) during radiotherapy; however, no significant differences were found in other complications and quality of life.

CONCLUSION

Nonpharmacological interventions can improve the nutrition status of patients with head and neck cancer and reduce the incidence of severe oral mucositis and gastrointestinal complications during radiotherapy but have no significant impact on quality of life.

Nutritional risk factors in patients with nasopharyngeal carcinoma: a cross-sectional study

Background

Patients with nasopharyngeal carcinoma are notably susceptible to high nutritional risks. If not addressed, this susceptibility can lead to malnutrition, resulting in numerous adverse clinical outcomes. Despite the significance of this issue, there is limited comprehensive research on the topic.

Objective

The objective of our study was to identify nutritional risk factors in patients with nasopharyngeal carcinoma.

Methods

For this cross-sectional study, we recruited a total of 377 patients with nasopharyngeal carcinoma. The Nutritional Risk Screening 2002 tool was used to assess their nutritional risk. These patients were divided into a well-nourished group (n = 222) and a nutritional risk group (n = 155). Potential risk factors were screened out using univariate analysis (p < 0.1). These factors were subsequently analyzed with multivariate logistic regression analysis (p < 0.05) to identify the nutritional risk factors for these patients.

Results

Our findings indicated that increasing age (OR = 1.085, 95%CI: 1.053-1.117, p < 0.001), high number of radiation treatments (OR = 1.103, 95%CI: 1.074-1.132, p < 0.001), low BMI (OR = 0.700, 95%CI: 0.618-0.793, p < 0.001), and low albumin levels (OR = 0.852, 95%CI: 0.789-0.921, p < 0.001) are significant nutritional risk factors in patients with nasopharyngeal carcinoma.

Conclusion

Increasing age, high number of radiation treatments, low BMI, and low albumin levels are significant nutritional risk factors in patients with nasopharyngeal carcinoma.

Investigating oral somatosensory perception and oral symptoms of head and neck cancer patients: insights on eating behaviour

PURPOSE

Sensory alterations and oral manifestations are prevalent among head and neck cancer (HNC) patients. While taste and smell alterations have been thoroughly investigated, studies on their oral somatosensory perception remain limited. Building upon our previous publication that primarily focused on objective somatosensory measurements, the present work examined self-reported sensory perception, including somatosensation and oral symptoms, in HNC patients and evaluated their link with eating behaviour.

METHODS

A cross-sectional study was conducted using self-reported questionnaires on sensory perception, oral symptoms, sensory-related food preference, and eating behaviour among HNC patients (n = 30). Hierarchical clustering analysis was performed to categorise patients based on their sensory perception. Correlations between oral symptoms score, sensory perception, sensory-related food preference, and eating behaviour were explored.

RESULTS

Two distinct sensory profiles of patients were identified: no alteration (n = 14) and alteration (n = 16) group. The alteration group showed decreased preference towards several sensory modalities, especially the somatosensory. Concerning eating behaviour, more patients in the alteration group agreed to negatively connotated statements (e.g. having food aversion and eating smaller portions), demonstrating greater eating difficulties. In addition, several oral symptoms related to salivary dysfunction were reported. These oral symptoms were correlated with sensory perception, sensory-related food preference, and eating behaviour.

CONCLUSION

This study presented evidence demonstrating that sensory alterations in HNC patients are not limited to taste and smell but cover somatosensory perception and are linked to various aspects of eating. Moreover, patients reported experiencing several oral symptoms. Those with sensory alterations and oral symptoms experienced more eating difficulties.

Risk factors and the nomogram model for malnutrition in patients with nasopharyngeal carcinoma

BACKGROUND

For patients with nasopharyngeal carcinoma (NPC), the incidence of malnutrition is quite high, and malnutrition has severe effects on NPC patients. However, there is currently no recognized gold standard or specific nutritional assessment tool available to assess malnutrition in NPC patients. Our objective was to develop and verify a new nomogram model for NPC patients.

METHODS

Data were collected from NPC patients. To evaluate risk factors for malnutrition, univariate and multivariate logistic regression analyses were used. Based on the risk factors, a new nomogram model was developed. The efficacy of the model was evaluated and validated.

RESULTS

Logistic regression analysis showed that age ≥ 65 years, the number of chemotherapy cycles completed ≥ 1, a high total radiation dose received, low body mass index (BMI), low albumin, and low chloride were the risk factors. The assessment effect of the new model was good by evaluation and validation; it can be used as an assessment tool for malnutrition in NPC patients.

CONCLUSIONS

Age ≥ 65 years, completing ≥ 1 chemotherapy cycles, a high total radiation dose received, low BMI, low albumin, and low chloride levels are risk factors for malnutrition in NPC patients. The assessment effect of the new model, developed based on these risk factors, is good, and it can be used as an assessment tool for malnutrition in NPC patients.

A Prospective Study of Nurse-Led Oral Mucositis Management: Impact on Health Outcomes of Patients Receiving Radiotherapy for Head and Neck Cancer and Lung Cancer

OBJECTIVES

The study aimed to evaluate the impact of nurse-led mucositis management on the health outcomes of patients receiving radiotherapy for head and neck cancer and lung cancer. The study adopted a holistic approach that involved the patient in the care process by screening, providing education and counseling about mucositis management and integrating it into daily life by the radiotherapy nurse.

DATA SOURCES

In this prospective, longitudinal cohort study, 27 patients were assessed and monitored through use of the WHO Oral Toxicity Scale and Oral Mucositis Follow-up Form and educated on mucositis during their radiotherapy through use of the Mucositis Prevention and Care Guide. At the end of radiotherapy, an evaluation of the radiotherapy process was performed. In this study, each patient was followed for 6 weeks from the start of radiotherapy.

CONCLUSION

The worst clinical data for oral mucositis and its variables emerged at week 6 of treatment. While the Nutrition Risk Screening score increased over time, weight decreased was observed to decrease. The mean stress level was 4.74 ± 0.33 in the first week and 5.77 ± 0.35 in the last week. It was observed that 88.9% of the patients showed good compliance with the treatment.

IMPLICATIONS FOR NURSING PRACTICE

Nurse-led mucositis management contributes to better patient outcomes during the radiotherapy process. Such an approach improves oral care management in patients receiving radiotherapy for head and neck and lung cancer, demonstrating its positive impact on additional patient-focused outcomes.

Perioperative nutritional risk and its influencing factors in patients with oral cancer: a longitudinal study

Introduction

We aimed to investigate the nutritional risk status and dynamic changes in patients with perioperative oral cancer at different stages and analyze the factors influencing nutritional risk and the correlation among body mass index, nutrition-related symptoms, and nutritional risk.

Methods

In total, 198 patients with oral cancer who were hospitalized in the Head & Neck Surgery Departments of a tertiary cancer hospital in Hunan Province, China, from May 2020 to January 2021, were selected as participants. The Nutritional Risk Screening 2002 scale and Head and Neck Patient Symptom Checklist were used to assess patients on admission day, 7 days post-surgery, and 1 month post-discharge. Multivariate analysis of variance, paired t-test, and generalized estimating equation were used to analyze the trajectory and influencing factors of nutritional risk in patients with perioperative oral cancer. Spearman's correlation analysis was used to explore the correlation among body mass index, symptoms, and nutritional risk.

Results

The nutritional risk scores of patients with oral cancer at the three time points were 2.30 ± 0.84, 3.21 ± 0.94, and 2.11 ± 0.84, respectively, and the differences were significant (p < 0.05). The incidences of nutritional risk were 30.3, 52.5, and 37.9%, respectively. The factors influencing nutritional risk included education level, smoking status, clinical stage, flap repair, and tracheotomy (β = -0.326, 0.386, 0.387, 0.336, and 0.240, respectively, p < 0.05). Nutritional risk was negatively correlated with body mass index (r_s = -0.455, p < 0.01) and positively correlated with pain, loss of appetite, sore mouth, bothersome smells, swallowing difficulty, taste changes, depression, chewing difficulty, thick saliva, and anxiety (r_s = 0.252, 0.179, 0.269, 0.155, 0.252, 0.212, 0.244, 0.384, 0.260, and 0.157, respectively, p < 0.05).

Conclusion

The incidence of nutritional risk in patients with perioperative oral cancer was high, and the trajectory of nutritional risk changed over time. Strengthening the nutritional monitoring and management of postoperative patients or those with low education level, advanced-stage cancer, flap repair, tracheotomy, and low body mass index; strengthening tobacco control management; and controlling nutrition-related discomfort symptoms in perioperative oral cancer patients are necessary.

Associations between Human Papillomavirus Status, Weight Change, and Survival of Oropharyngeal Cancer Patients

This study examined associations between HPV status and weight change in oropharyngeal cancer (OPC). OPC patients receiving concurrent chemoradiotherapy in Toronto, Canada were included. Relationships were assessed between HPV status and weight loss grade (WLG, combining weight loss and current body mass index); weight change during treatment; and HPV status and WLG/weight change on overall (OS) and cancer-specific (CSS) survival. Of 717 patients, WLG pre-radiation was less severe among HPV-positive compared to HPV-negative, though weight loss during treatment was greater. The adjusted odds ratio for greater WLG among HPV-positive versus HPV-negative was 0.47 (95%CI 0.28-0.78). Grade-4 WLG (worst category) experienced poorer OS and CSS (OS adjusted hazard ratio (aHR) 4.08; 95%CI 1.48-11.2, compared to Grade-0); and was non-significant for HPV-negative (aHR 2.34; 95%CI 0.69-7.95). Relationships between weight change before/during treatment and survival had similar direction between HPV-positive and HPV-negative, but of greater magnitude in HPV-positive patients.

Nutrition impact symptoms: Noteworthy prognostic indicators for lung cancer

BACKGROUND

Nutrition impact symptoms (NIS) in head and neck cancer are well-studied and are found to be heavy contributors of poor outcome. However, the prevalence and role of NIS in other cancer are less addressed. In this study, we investigated the incidence and prognostic role of NIS in patients with lung cancer.

METHODS

NIS, evaluated by patient-generated subjective global assessment (PG-SGA) in a multicenter real-world prospective study, included loss of appetite, nausea, vomiting, mouth ulcer, constipation, diarrhea, dry mouth, taste change, altered smell, dysphagia, early satiety, and pain. The endpoints were the patients' overall survival (OS) and quality of life (QoL). The COX analysis was used to investigate the relationship between NIS and OS. Interaction analysis and mediation analysis were performed to determine the modifiers and mediator.

RESULTS

3634 patients with lung cancer were enrolled in this study, of which 1533 patients had NIS. During the average follow-up of 22.65 months, 1875 deaths occurred. The OS of patients with lung cancer with NIS was lower than that of patients without NIS. NIS (HR, 1.181, 95% CI, 1.073-1.748), loss of appetite (HR, 1.266, 95% CI, 1.137-1.409), vomiting (HR, 1.282, 95% CI, 1.053-1.561), and dysphagia (HR, 1.401, 95% CI, 1.079-1.819) were independent prognostic factors in patients with lung cancer. There were interactions between chemotherapy and primary tumor on NIS . In the relationship between different types of NIS (NIS, loss of appetite, vomiting, dysphagia) and prognosis, the mediating effects of inflammation accounted for 15.76%, 16.49%, 26.32%, and 18.13%, respectively. Meanwhile, these three NIS were closely associated with the occurrence of severe malnutrition and cancer cachexia.

CONCLUSIONS

42% patients with lung cancer experienced different types of NIS. NIS were independent indicators of malnutrition, cancer cachexia and shorter OS, and closely related to QoL. NIS management is of clinical significance.

Predictive effect of pretreatment nutritional risk and GLIM-defined malnutrition on the nutrition impact symptom clusters in patients with head and neck cancer undergoing radiotherapy

BACKGROUND

Evidence supporting predictive effects of pretreatment nutritional risk and nutritional status on nutrition impact symptom (NIS) clusters during radiotherapy in patients with head and neck cancer (HNC) is insufficient.

METHODS

At baseline (T₁ ), we collected severity and interference of NIS (Head and Neck Patient Symptom Checklist), nutritional risk, and nutritional status. During (T₂ ) and at the end of radiotherapy (T₃ ), we re-evaluated NIS. Symptom clusters were identified by exploratory factor analysis using mean scores of NIS severity at T₂ and T₃ . Predictive effects were explored by generalized estimating equations.

RESULTS

Five hundred thirty-seven patients were recruited and 334 of them completed. Four clusters were identified; the oropharyngeal symptom cluster was the most severe and had the greatest interference with diet. Patients with pretreatment nutritional risk or malnutrition experienced more severe oropharyngeal symptom cluster.

CONCLUSIONS

Pretreatment nutritional risk or malnutrition could predict the oropharyngeal symptom cluster in patients with HNC undergoing radiotherapy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of nutrition screening tools and calf circumference in estimating the preoperative prevalence of malnutrition among patients with aerodigestive tract cancers-a prospective observational cohort study

PURPOSE

There is paucity of data on the prevalence of malnutrition among cancer patients in India and a brief tool to identify the same would be an asset. Our aim was to evaluate two nutrition screening tools and calf circumference (CC) with the European Society for Clinical Nutrition and Metabolism (ESPEN) consensus guidelines for malnutrition among patients with head and neck (H&N) and gastrointestinal (GI) cancers.

METHODS

Nutritional evaluation was performed preoperatively using Malnutrition Universal Screening Tool (MUST), Short Form of Mini Nutritional Assessment (MNA-SF), and calf circumference (CC) in 206 patients. The diagnostic accuracy of these tools was compared with the ESPEN criteria for malnutrition. Patients evaluated were grouped as normal or malnourished. The incidence of infection, antibiotic days, antibiotic escalation, and length of stay was compared among the groups. Clavien-Dindo score at discharge, 30-day readmission, and mortality were also examined.

RESULTS

A total of 28.6% were malnourished as per ESPEN criteria and 25.2% had CC less than the cut-off. With respect to ESPEN criteria, MUST and MNA-SF had 100% sensitivity and negative predictive value. CC had the highest specificity and positive predictive value for the total population (91.16%, 75% respectively). The agreement between the tools was acceptable except in MNA-SF (MNA-SF-ESPEN κ = 0.228, MUST-ESPEN κ = 0.565, CC-ESPEN κ = 0.594). There was no difference in postoperative outcomes between the malnourished and normal.

CONCLUSION

Thus, more than a quarter of patients with H&N and GI cancers are malnourished preoperatively. As the best agreement between the screening tools was for MUST-ESPEN and CC-ESPEN, either of them can be used to identify malnutrition at admission.

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.

A Predictive Model for Qualitative Evaluation of PG-SGA in Tumor Patients Through Machine Learning

Objective

Patient-Generated Subjective Global Assessment (PG-SGA) was a nutritional status assessment technique specifically tailored for patients with oncology. The goal of this study was to develop a machine learning (ML) prediction model for predicting PG-SGA categorization of patients with tumor.

Methods

From 2014 to 2020, patients at the First Hospital of Jilin University performed laboratory testing, bioelectrical impedance, physical measures, and the PG-SGA scale. A total of 8230 patients were involved in the study. Patients with missing or partial data were removed, leaving 7287 patients, of which 3743 were males and 3544 were females. ML was used to design a clinical prediction model for PG-SGA categories.

Results

Through the least absolute shrinkage and selection operator (LASSO) and the correlation matrix, 135 variables were screened and 6 variables were retained; ML was performed among the remaining variables. The accuracy of neural network prediction models was 70.3% and 70.4% for males and females in the training cohort, respectively, and 74.4% and 73.2% for males and females in the validation cohort, respectively. The area under curve (AUC) of males was 0.87 for PG-SGA scores “0–3”, 0.70 for PG-SGA scores “4–8” and 0.74 for PG-SGA scores “>8”. As for females, the AUC was 0.85 for PG-SGA scores “0–3”, 0.65 for PG-SGA scores “4–8” and 0.76 for PG-SGA scores “>8”. The results of confusion matrix showed that the models were of good predictive validity. The prediction model was nearly 90% accurate for predictions that do not require nutritional support.

Conclusion

We demonstrated that neural network learning is the best clinical prediction model using ML. The model can work as a prediction for the PG-SGA classification of patients with cancer and can be promoted further in the clinic.

Nutritional counseling was not enough to maintain dietary intake and nutritional status in head and neck cancer patients undergoing radiotherapy: a historical control study for future intervention in China

Objective

Methods

Results

Conclusions

•

Nutritional counseling could improve intake, weight and nutritional status of HNC patients during RT to some degree.

•

Only nutritional counseling is not enough to keep adequate intake and good nutritional status.

•

Healthcare professionals should build multidisciplinary teams and conduct the stepwise nutritional support.

Tooth extractions prior to chemoradiation or bioradiation are associated with weight loss during treatment for locally advanced oropharyngeal cancer

PURPOSE

Prior to radiotherapy combined with chemotherapy (CRT) or biotherapy (BRT) for oropharyngeal squamous cell carcinoma (OPSCC), teeth with poor prognosis that pose a risk for post-RT osteoradionecrosis (ORN) are removed. The effect of tooth loss on body weight loss and tube feeding (TF) dependency during CRT/BRT is unknown. This study aimed to evaluate the effect of incomplete dentition, tooth extractions prior to CRT/BRT, and the subsequent loss of functional units on (1) weight loss during CRT/BRT and (2) the need for TF during CRT/BRT for OPSCC.

METHODS

OPSCC patients treated with CRT/BRT between 2013 and 2016 were included in this retrospective cohort study. Dental status was determined during the dental assessment at first visit and after tooth extractions prior to the start of CRT/BRT. Weight loss during CRT/BRT was scored dichotomously, comparing weight loss > 5% to stable or increased weight. Potential factors associated with weight loss were identified, including patient, tumor, and treatment characteristics.

RESULTS

Seventy-seven OPSCC patients were included. Forty patients (52%) experienced weight loss > 5% during CRT/BRT. Extractions were performed in 66% of the OPSCC patients. The mean number of extracted teeth was 4.1 ± 5.6 per patient. Tooth extractions prior to CRT/BRT were associated with weight loss > 5% during CRT/BRT (HR 1.130 (95% CI 1.011-1.262), p = 0.031). None of the dental status-related parameters showed any significant associative value for TF during CRT/BRT.

CONCLUSIONS

Pre-CRT/BRT tooth extractions intended to reduce the risk of ORN, are a risk factor for weight loss during CRT/BRT for OPSCC.

TRIAL REGISTRATION NUMBER

This study was approved by the medical ethics committee of the MUMC + (METC 2020-1589) on July 28, 2020.

Development and external validation of a prediction model for tube feeding dependency for at least four weeks during chemoradiotherapy for head and neck cancer

BACKGROUND & AIMS

Patients who receive chemoradiotherapy or bioradiotherapy (CRT/BRT) for locally advanced head and neck squamous cell carcinoma (LAHNSCC) often experience high toxicity rates interfering with oral intake, causing tube feeding (TF) dependency. International guidelines recommend gastrostomy insertion when the expected use of TF exceeds 4 weeks. We aimed to develop and externally validate a prediction model to identify patients who need TF ≥ 4 weeks and would benefit from prophylactic gastrostomy insertion.

METHODS

A retrospective multicenter cohort study was performed in four tertiary head and neck cancer centers in the Netherlands. The prediction model was developed using data from University Medical Center Utrecht and the Netherlands Cancer Institute and externally validated using data from Maastricht University Medical Center and Radboud University Medical Center. The primary endpoint was TF dependency ≥4 weeks initiated during CRT/BRT or within 30 days after CRT/BRT completion. Potential predictors were extracted from electronic health records and radiotherapy dose-volume parameters were calculated.

RESULTS

The developmental and validation cohort included 409 and 334 patients respectively. Multivariable analysis showed predictive value for pretreatment weight change, texture modified diet at baseline, ECOG performance status, tumor site, N classification, mean radiation dose to the contralateral parotid gland and oral cavity. The area under the receiver operating characteristics curve for this model was 0.73 and after external validation 0.62. Positive and negative predictive value for a risk of 90% or higher for TF dependency ≥4 weeks were 81.8% and 42.3% respectively.

CONCLUSIONS

We developed and externally validated a prediction model to estimate TF-dependency ≥4 weeks in LAHNSCC patients treated with CRT/BRT. This model can be used to guide personalized decision-making on prophylactic gastrostomy insertion in clinical practice.