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

Predict nutrition-related adverse outcomes in head and neck cancer patients undergoing radiotherapy: A systematic review

BACKGROUND

Acute nutrition-related adverse outcomes are common in head and neck cancer patients undergoing radiotherapy. Predictive models can assist in identifying high-risk patients to enable targeted intervention. We aimed to systematically evaluate predictive models for predicting severe acute nutritional symptoms, insufficient intake, tube feeding, sarcopenia, and weight loss.

METHODS

We searched PubMed, Web of Science, EBSCO, Embase, WanFang, CNKI, and SinoMed. We selected studies developing predictive models for the aforementioned outcomes. Data were extracted using a predefined checklist. Risk of bias and applicability assessment were assessed using the Prediction model Risk of Bias Assessment Tool. A narrative synthesis was conducted to summarize the model characteristics, risk of bias, and performance.

RESULTS

A total of 2941 studies were retrieved and 19 were included. Study outcome measure were different symptoms (n = 11), weight loss (n = 5), tube feeding (n = 3), and symptom or tube feeding (n = 1). Predictive factors mainly encompassed sociodemographic data, disease-related data, and treatment-related data. Seventeen studies reported area under the curve or C-index values ranging from 0.610 to 0.96, indicating moderate to good predictive performance. However, candidate predictors were incomplete, outcome measures were diverse, and the risk of bias was high. Most of them used traditional model development methods, and only two used machine learning.

CONCLUSIONS

Most current models showed moderate to good predictive performance. However, predictors are incomplete, outcome are inconsistent, and the risk of bias is high. Clinicians could carefully select the models with better model performance from the available models according to their actual conditions. Future research should include comprehensive and modifiable indicators and prioritize well-designed and reported studies for model development.

Nutritional Prognosis of Patients Submitted to Radiotherapy and Its Implications in Treatment

Oncological patients show intense catabolic activity, as well as a susceptibility to higher nutritional risk and clinical complications. Thus, tools are used for monitoring prognosis. Our objective was to analyze the nutrition prognosis of patients who underwent radiotherapy, correlating it with outcomes and complications. We performed a retrospective transversal study based on secondary data from hospital records of patients who started radiotherapy between July 2022 and July 2023. We established Prognostic Scores through a combination of Prognostic Nutritional Index (PNI) and a Subjective Global Assessment (SGA), assessed at the beginning and end of treatment. Score 3 patients, with PNI ≤ 45.56 and an SGA outcome of malnutrition, initially presented a higher occurrence of odynophagia, later also being indicative of reduced diet volume, treatment interruption, and dysphagia. SGA alone showed sensitivity to altered diet volume, dysphagia, and xerostomia in the second assessment. Besides this, PNI ≤ 45.56 also indicated the use of alternative feeding routes, treatment interruption, and hospital discharge with more complications. We conclude that the scores could be used to indicate complications; however, further studies on combined biomarkers are necessary.

Perioperative change trajectories and predictors of swallowing function and swallowing-related quality of life in patients with oral cancer: a longitudinal observational study

OBJECTIVE

To determine change trajectories and predictors of swallowing function and swallowing-related quality of life (QoL) in perioperative patients with oral cancer.

DESIGN

Longitudinal observational study.

SETTING

A tertiary cancer hospital in Hunan Province, China.

PARTICIPANTS

Patients with oral cancer scheduled for surgery were recruited using convenience sampling.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were swallowing function and swallowing-related QoL. The secondary outcomes were the predictors of the swallowing function and swallowing-related QoL.

METHODS

The participants completed the sociodemographic and clinical data questionnaire, Nutritional Risk Screening 2002 and MD Anderson Dysphagia Inventory before surgery, 7 days after operation and 1 month after operation. Data were analysed using t-test, analysis of variance and generalised linear models.

RESULTS

Among 138 participants who completed all the three surveys, 41 (29.71%) had moderate to severe dysphagia before surgery. Swallowing function and swallowing-related QoL changed over time, showing the trend of decline first and then increase. Preoperative swallowing function and swallowing-related QoL were affected by sex, lymphocyte level, preoperative nutritional risk and primary tumour site. At 7 days postoperatively, tracheotomy affected swallowing function. At 1 month postoperatively, age and marital status influenced swallowing function, whereas age, type of job and preoperative nutritional risk influenced swallowing-related QoL.

CONCLUSIONS

Our study demonstrates that perioperative patients with oral cancer generally faced swallowing disorders, especially in the acute phase after surgery. Healthcare providers should pay attention to the swallowing function of perioperative patients with oral cancer, especially those with preoperative nutritional risk, tongue tumour, tracheotomy, age <60 years, and no spouse and the employed patients, and provide available interventions, such as swallowing and nutritional therapy, as early as possible to improve their swallowing function. Meanwhile, doctors should recommend the most evidence-based treatment options, such as reconstruction or not, preoperative chemotherapy or not, to patients.

Changes in Nutritional Status of Cancer Patients Undergoing Proton Radiation Therapy Based on Real-World Data

Methods

Observational study on 47 adult hospitalized cancer patients including 27 males and 20 females who received proton beam radiotherapy during December 2021 and August 2022. Nutritional assessments, 24 h dietary survey, handgrip strength (HGS) test, anthropometrical measurements, and hematological parameters were conducted or collected at the beginning and the completion of treatment.

Results

The rate of nutritional risk and malnutrition among the total of 47 enrolled patients was 4.3% and 12.8% at the onset of proton radiation and raised up to 6.4% and 27.7% at the end of the treatment. 42.6% of patients experienced weight loss during the proton radiotherapy, and 1 of them had weight loss over 5%, and in general, the average body weight was stable over radiotherapy. The changes in patients' 24 h dietary intakes, HGS, and anthropometrical parameters, including triceps skinfold thickness (TSF), midupper arm circumference (MUAC), and midupper arm muscle circumference (MAMC), were statistically insignificant over the treatment (all p values > 0.05). The changes in patients' hematological parameters, including total protein (TP) and serum albumin (ALB), were not statistically significant over the treatment (all p values >0.05), and the level of hemoglobin (HGB) at the end of treatment was higher than that at the onset (p < 0.05).

Conclusion

The results of this study demonstrated that proton radiotherapy might have a lighter effect on the nutritional status of cancer patients.

A Multi-Site, International Audit of Malnutrition Risk and Energy and Protein Intakes in Patients Undergoing Treatment for Head Neck and Esophageal Cancer: Results from INFORM

Patients with foregut tumors are at high risk of malnutrition. Nutrition care focuses on identifying individuals at risk of malnutrition and optimizing nutrient intake to promote the maintenance of body weight and lean body mass. This multi-center prospective, longitudinal study audited nutrition care practices related to screening for risk of malnutrition (Patient-Generated Subjective Global Assessment Short Form; PG-SGA SF), and nutrition interventions prescribed (route; adequacy of energy and protein intakes). Audits occurred at four time periods: baseline (before treatment) and at 2, 4, and 6 months after starting cancer treatment; 170 patients (esophageal (ESO; n = 51); head and neck (HN; n = 119)) were enrolled. Nutrition risk (PG-SGA SF score ≥ 4) was prevalent at every time period: HN (baseline: 60%; 6 months 66%) and ESO (77%; 72%). Both groups had significant (p < 0.001) weight losses over the 6 month audit period (HN = 13.2% ESO = 11.4%). Enteral nutrition (EN) was most likely to be prescribed at 2 months for HN and at 4 and 6 months for ESO. Target prescribed energy and protein intakes were not met with any nutrition intervention; although adequacy was highest for those receiving EN. Nutrition care practices differed for HN and ESO cancers and there may be time points when additional nutrition support is needed.

Acute effects of radiation treatment to submental muscles on burrowing and swallowing behaviors in a rat model

Swallowing impairments are a major complication of radiation treatment for oropharyngeal cancers, influencing oral intake and quality of life. The timing and functional consequences of radiation treatment on the swallowing process is not clearly understood. A rodent radiation injury model was used to investigate the onset of oral and pharyngeal dysfunctions in deglutition related to radiation treatment. This study tested the hypothesis that (Wall et al., 2013) alterations in normal biting, licking, and swallowing performance would be measurable following 64Gy of fractionated radiation to the submental muscles; and (Kotz et al., 2004) radiation will affect the animal’s general well-being as measured via burrowing activity. Seven rats received radiation using a clinical linear accelerator given in 8 fractions of 8Gy and another seven animals received sham anesthesia only treatment. Swallowing bolus transit/size was assessed via videofluoroscopy, tongue movement during drinking was measured via an electrical lick sensor, and biting was analyzed from acoustic recordings of a vermicelli pasta test. Burrowing activity was measured by the amount of gravel substrate displaced within a container. Measurements were taken at baseline, during treatment (1–4 weeks), and after completion of treatment (weeks 5 & 6). Decreases in licking frequency and increases in inter-lick interval were observed 5- and 6-weeks post-treatment. Significant decreases in burrowing performance, swallowing frequency, and inter-swallow interval were observed starting the last week of treatment and continuing up to 2-weeks after completion. Results suggest that tongue dysfunction is one of the first treatment related feeding problems to present immediately after the completion of radiation to the submental muscles.

Association of Loss of Occlusal Pairs of Teeth with Sarcopenia in a Chinese Population of Community-Dwelling Elderly

OBJECTIVES

Tooth loss, which usually leads to malnutrition, is common in the elderly. However, limited information is available regarding its association with sarcopenia. This study aimed to investigate the relationship between loss of occlusal pairs of tooth and sarcopenia.

DESIGN

A cross-sectional retrospective study was performed.

SETTING

The elderly who participated in the National Basic Public Health Project in the Maigaoqiao Community Medical Center in Nanjing, Jiangsu Province, China.

PARTICIPANTS

A total of 2850 individuals aged ≥60 years were enrolled.

MEASUREMENTS

Sarcopenia was defined according to the criteria proposed by the Asian Working Group for Sarcopenia. A trained dentist assessed oral health status and counted the number of present teeth. Logistic regression analyses were performed to evaluate the association between the loss of occlusal pairs and sarcopenia.

RESULTS

The prevalence of sarcopenia was 7.1% (201/2850). Univariate logistic regression analysis showed that loss of occlusal pairs was associated with sarcopenia [anterior occlusal pairs (AOPs): odd ratio (OR) = 1.292, 95% confidence interval (CI) = 1.158-1.442; posterior occlusal pairs (POPs): OR = 1.147, 95% CI = 1.018-1.221]. Multivariate logistic regression analysis indicated that loss of POPs was still an independent risk for sarcopenia (OR = 1.108, 95% CI = 1.007-1.220) after adjustment for traditional confounders. Subgroup analysis showed that loss of POPs was more significantly linked to sarcopenia in those with advanced age (≥80years) (OR = 1.307, 95% CI = 1.116-1.532) and in females (OR = 1.165, 95%CI = 1.038-1.308). Compared to individuals with ≥5 occluding pairs of POPs, those with <5 occluding pairs of POPs had a higher incidence of sarcopenia.

CONCLUSIONS

Loss of POPs is associated with an increased risk of sarcopenia in the elderly in a Chinese population. Further research on the mechanism of the observed causal relationship is needed.

The association of oral function with dietary intake and nutritional status among older adults: Latest evidence from epidemiological studies

Inadequate and poor quality of diet and malnutrition are common and associated with adverse health outcomes, including morbidity and mortality, among older persons. This review aimed to establish the latest evidence from studies investigating the association between oral function and nutrition among older adults. An electronic search of MEDLINE using PubMed for literature published in English between March 2018 and March 2021 was conducted, and 27 papers were identified. The selected studies comprised 23 observational studies (17 cross-sectional and 6 longitudinal studies) and 4 interventional studies. Most of the observational studies demonstrated the following associations in older adults: older adults with poor oral function are likely to have poorer dietary intake and poorer nutritional status, and malnourished older adults are likely to have poorer oral function. The results of the intervention studies demonstrated that the combination of prosthodontic treatment and dietary counseling is more effective for improving dietary intake and nutritional status in older persons with tooth loss than the prosthodontic treatment alone. Our review confirmed that a relationship exists between oral function and nutrition and revealed the need for additional high-quality studies investigating comprehensive oral function, rather than a single aspect of oral function, with regard to nutritional status.