The Effects of Compliance with Nutritional Counselling on Body Composition Parameters in Head and Neck Cancer Patients under Radiotherapy

Adherence to Oral Nutritional Supplements: A Review of Trends in Intervention Characteristics and Terminology Use Since the Year 2000

Research on disease-related malnutrition and adherence to oral nutritional supplements (ONS) has increased in recent years. To guide future studies, it is important to identify trends in terminology use and intervention characteristics. This review aimed to map characteristics of research investigating adherence to ONS in patients with disease-related malnutrition and explore changes over time. This review is a secondary analysis of quantitative studies from a systematic mixed-studies review. Online databases, including PubMed, Cinahl, Cochrane Central Register of Controlled Trials, and APA PsycInfo, were searched to identify studies published from 2000 to March 2022. A quantitative content analysis of extracted data was performed, and the Mixed Methods Appraisal Tool (MMAT) was used to assess methodological risk of bias. This review includes 137 articles, over half of which are randomized controlled trials (52%). The term "oral nutritional supplements" was used in 40% of the studies. Adherence to ONS was mainly described by the term "compliance" (69%). It was most common to offer ready-made milk-based ONS (56%) and ONS as a sole intervention (51%). The prescribed dose of ONS was fixed in 64% of studies and individualized in 22% of studies. There was variation in the methods used to assess adherence to ONS, and adherence was not reported in nearly a fifth of studies. There was an increase in methodological quality over time (p = 0.024). To ensure better understanding and increase the rigor and reproducibility of ONS intervention research, it is crucial to standardize the terminology used and to describe the interventions clearly.

Understanding the complexity of barriers and facilitators to adherence to oral nutritional supplements among patients with malnutrition: a systematic mixed-studies review

The aim of this systematic mixed-studies review is to summarise barriers/facilitators to adherence to and/or consumption of oral nutritional supplements (ONS) among patients with disease-related malnutrition. In March 2022, the Cochrane CENTRAL, PUBMED, PsycINFO (Ovid) and CINAHL were searched for articles with various study designs, published since 2000. Articles were identified on the basis of 'population' (patients ≥18 years with malnutrition/at nutritional risk), 'intervention' (ONS with ≥2 macronutrients and micronutrients), 'comparison' (any comparator/no comparator) and 'outcome' (factors affecting adherence or consumption) criteria. A sequential exploratory synthesis was conducted: first, a thematic synthesis was performed identifying barriers/facilitators; and second, the randomised controlled trials (RCTs) were used to support these findings. The five WHO dimensions of adherence guided the analysis. Study inclusion, data extraction, analysis and risk-of-bias assessment (MMAT 2018) were carried out independently by two researchers. From 21 835 screened articles, 171 were included with 42% RCTs and 20% qualitative studies. The two major populations were patients with malignancies (34%) and older adults (35%). In total, fifty-nine barriers/facilitators were identified. Patients' health status, motivation, product tolerance and satisfaction as well as well-functioning healthcare routines and support were factors impacting ONS consumption. Few barriers/facilitators (n = 13) were investigated in RCTs. Two of those were serving a small ONS volume and integrating ONS into ward routines. Given the complexity of ONS adherence, non-adherence to ONS should be addressed using a holistic approach. More studies are needed to investigate the effect of different approaches to increase adherence to ONS.

Prevention of weight loss in patients with head and neck cancer in ongoing radiation or chemoradiation therapy-A systematic review and meta-analysis

PURPOSE

This systematic review (PROSPERO: CRD4202345740) identified and synthesised existing evidence on nutrition interventions performed by healthcare professionals, and the contents of the interventions that prevented weight loss in patients with HNC undergoing RT/CRT.

METHODS

We included quantitative studies. PubMed, CINAHL, Cochrane Library, and Scopus were searched, and the outcomes of interest were weight change and nutritional status. A narrative synthesis was undertaken to elaborate on the findings across the included studies. Furthermore, a meta-analysis was conducted.

RESULTS

A total of 27 studies were identified. Most focused on the effect of oral nutritional supplements (ONS) and individualised nutrition counselling (INC). A beneficial effect of ONS combined with weekly INC were identified, and compliance, management of adverse effects, involvement of family as well as the knowledge and approach of the healthcare professionals were identified as key elements when supporting the management of nutrition intake in HNC patients during RT/CRT. The meta-analysis showed a non-significant effect of ONS, yet significant when combined with INC, and no overall effect of INC, but significant effect in the RCTs.

CONCLUSION

Our results suggest an optimal effect of ONS combined with weekly INC, requiring a focus on enhancing compliance as well as support from a multidisciplinary team to manage adverse treatment effects. Compliance must be emphasised to provide maximum support to the patient, as well as focus on the knowledge of the health care professionals performing the intervention. Further research on strategies to enhance patient compliance and involvement is needed.

Dietary Counseling Interventions During Radiation Therapy: A Systematic Review of Feasibility, Safety, and Efficacy

Radiotherapy is a common cancer treatment, and concurrent nutritional interventions can maintain nutritional status and improve clinical and supportive care outcomes. However, optimal nutritional interventions during radiotherapy are not firmly established. Herein, we assessed the feasibility, safety, and efficacy of dietary counseling interventions without oral nutrition supplements on health outcomes in adults receiving radiotherapy for cancer in a systematic review. Prospective clinical trials that implemented nutritional counseling interventions during radiotherapy were identified from four databases from inception through December 2023. Feasibility, safety, and efficacy were extracted from 32 articles that described 23 randomized and 4 non-randomized clinical trials. The interventions included individualized nutritional counseling (n = 14 articles), nutritional counseling plus exercise (n = 4), and nutritional counseling focused on increasing or reducing intake of specific nutrients (n = 9). Trials targeted head and neck (n = 12), pelvic cancers (n = 14), and/or breast (n = 5) cancers. Control groups had variable designs and included general nutrition education and intervention as needed. Studies recruited 120 ± 104 participants (range 26-468). Interventions tended to be feasible regarding retention and attendance at sessions, though feasibility metrics varied among different interventions. Most interventions were safe with no studies reporting adverse events attributable to dietary intervention. Individualized dietary counseling interventions tended to lead to between-group differences favoring the intervention group in regard to improved nutritional status, maintenance or attenuation of loss of body mass, improved quality of life, and reduced radiation-induced toxicities. Diets that encouraged/discouraged specific nutrients tended to recruit patients receiving radiation to the pelvic area and resulted in positive or neutral effects on gastrointestinal symptoms. In conclusion, nutritional interventions appear to be feasible, safe, and effective during radiotherapy for various symptom outcomes.

Evaluation of a new two-step frailty assessment of head and neck patients in a prospective cohort

PURPOSE

Assessing frailty, in head and neck cancer (HNC) patients is key when choosing appropriate treatment. Optimal screening is challenging, as it should be feasible and should avoid over-referral for comprehensive geriatric assessment (CGA) This study aims to evaluate the association between geriatric assessment using a new two-step care pathway, referral to geriatrician and adverse outcomes.

METHODS

This institutional retrospective analysis on a prospective cohort analysed the multimodal geriatric assessment (GA) of newly diagnosed HNC patients. Uni- and multivariable logistic regression was performed to study the association between the screening tests, and referral to the geriatrician for complete geriatric screening, and adverse outcomes.

RESULTS

This study included 539 patients, of whom 276 were screened. Patients who underwent the GA, were significantly older and more often had advanced tumour stages compared to non-screened patients. Referral to the geriatrician was done for 30.8% of patients. Of the 130 patients who underwent surgery, 26/130 (20%) experienced clinically relevant postoperative complications. Of the 184 patients who underwent (radio)chemotherapy, 50/184 (27.2%) had clinically relevant treatment-related toxicity. Age, treatment intensity, polypharmacy and cognitive deficits, were independently associated with referral to geriatrician. A medium to high risk of malnutrition was independently associated with acute radiation induced toxicity and adverse outcomes in general.

CONCLUSION

The current study showed a 30.8% referral rate for CGA by a geriatrician. Age, treatment intensity, cognitive deficits and polypharmacy were associated with higher rates of referral. Furthermore, nutritional status was found to be an important negative factor for adverse treatment outcomes, that requires attention.

Compliance with oral nutritional supplements and its influencing factors in postoperative patients with digestive tract tumors: a cross-sectional study

BACKGROUND

Oral nutritional supplements are one of the preferred methods of nutritional support for postoperative patients. This study aims to investigate the current status of oral nutritional supplements compliance in postoperative patients with digestive tract tumors and its influencing factors.

METHODS

Convenience sampling was employed to select 242 patients who underwent surgery for digestive tract tumors at a tertiary hospital in Shanghai from October 2022 to July 2023 as the study subjects. Data following a normal distribution were analyzed using independent sample t-tests, ANOVA single-factor analysis, Pearson correlation analysis, and multiple linear regression analysis to determine the factors influencing compliance with oral nutritional supplements.

RESULTS

A total of 252 questionnaires were distributed, with 10 invalid questionnaires excluded, resulting in an effective questionnaire rate of 96.03%. The compliance score for oral nutritional supplements in postoperative patients with digestive tract tumors was (2.40 ± 1.45), General Self-efficacy Scale (GSES) score was (24.72 ± 4.86), Multidimensional Scale of Perceived Social Support Scale (MSPSS) score was (58.67 ± 11.09), and Belief about Medicines Questionnaire Scale (BMQ) score was (0.17 ± 2.78). Multiple linear regression analysis revealed that age, adverse reactions, educational level, self-efficacy, medication beliefs, and social support were factors influencing compliance with oral nutritional supplements in postoperative patients with digestive tract tumors (P < 0.05).

CONCLUSION

Our study revealed that the compliance to oral nutritional supplements among postoperative patients with digestive tract tumors was at a moderate level and was closely associated with age, educational level, adverse reactions to oral nutritional supplements, medication beliefs, social support, and self-efficacy. Nursing staff should conduct nursing assessments based on the specific circumstances of patients and their families, provide personalized health education management plans based on the patients' educational level, enhance patients' nutrition knowledge, improve patient self-efficacy, and enhance social support for patients, while further improving patient nutrition management.

Evidence summary on managing radiotherapy-induced oral mucositis in patients with head and neck cancer

Objective

To summarize the best evidence for managing radiotherapy-induced oral mucositis in patients with head and neck cancer, and improve the quality of care.

Methods

According to the "6S" evidence pyramid model, we searched local and other part of world published clinical guidelines, expert consensus, evidence summary, and systematic review. The literature quality assessment followed the Appraisal of Guidelines for Research and Evaluation (AGREE II). for guidelines, AMSTAR-2 for systematic reviews, and Joanna Briggs Institute (JBI) Evidence-Based Health Care Center's quality evaluation tool for expert opinions and expert consensus articles. The quality of other literature was evaluated according to the type of original literature. If there were any conflicts about the conclusions drawn from different sources of evidence, this study followed the principle of high-quality evidence priority and the latest published authoritative literature priority. The "JBI Evidence Pre-grading and Evidence Recommendation Level System 2014" was adopted for the evidence lacking a grading system. Quality evaluation, evidence extraction, and summary were performed by 2 or more researchers, combined with the advice of the head and neck cancer radiotherapy professionals.

Results

Finally, a total of ten pieces of literature were included. Twenty-two best evidence items for radiotherapy-induced oral mucositis management were summarized from six aspects, including multidisciplinary management, oral assessment, basic oral care, pain management, nutritional support, and application of honey or propolis.

Conclusions

This study provides clinical caregivers with the evidence-based measures on managing radiotherapy-induced oral mucositis. Clinical backgrounds, patients' condition, willingness, economy, and cost-effectiveness should be fully considered when promoting evidence transformation. Applying evidence-based approaches with high feasibility, strong appropriateness, clinical significance and high effectiveness could reduce the incidence of severe radiotherapy-induced oral mucositis in patients with head and neck cancer.

Systematic review registration

This study has been registered on the Fudan University Centre for Evidence-based Nursing. Registration No. is ES20232732.

Quality of weight loss during chemoradioherapy in patients with nasopharyngeal cancers

PURPOSE

Radiation therapy with chemotherapy (CCR) is currently the gold standard treatment for nasopharyngeal carcinoma (NPC). Anatomical changes are mainly due to weight loss. Our prospective study aimed to evaluate the nutritional status and the quality of weight loss in our patients to adapt the subsequent nutritional management of patients during treatment for NPC.

PATIENTS AND METHODS

A prospective, single-center study of 27 patients with non-metastatic NPC treated in our oncology radiotherapy department between August 2020 and March 2021. Data from interrogation, physical examination, and bioelectrical impedancemetry (weight [W], body mass index [BMI], fat index [GI], fat mass [FM], and fat-free mass (FFM]) were collected at the beginning, the mid, and the end of treatment.

RESULTS

Weight loss from mid to end of treatment (median=-4kg [-9.4; -0.9]) was greater than that from baseline to mid-treatment (median=-2.9kg [-8.8; 1.8]) (P=0.016). Weight loss during the entire treatment was -6.2kg [-15.6; -2.5] (8.4%). The losses of FM were identical between the beginning-mid treatment and the mid-end treatment; they were respectively -1.4kg [-8.5; 4.2] and -1.4kg [-8.2; 7.8] (P=0.4). FFM losses between the mid- and the end of treatment (-2.5kg [-27.8; 0.5]) were greater than those between baseline and mid-treatment (-1.1kg [-7.1; 4.7]) (P=0.014). Median FFM loss during treatment was -3.6kg [-28.1; 2.6]).

CONCLUSION

The results of our study show that weight loss during CCR for NPC is complex and is not just about loss but about a disruption of body composition. Regular follow-ups by nutritionists are required to prevent denutrition during treatment.

Weight loss in children undergoing allogeneic hematopoietic stem cell transplantation within the first 100 days: Its influencing factors and impact on clinical outcomes

Purpose/Objective

This study aimed to evaluate the nutritional status of children subjected to allogeneic hematopoietic stem cell transplantation (alloHSCT) in the first 100 days. Objectives were to clarify the effect of weight loss on clinical outcomes, and to analyze factors influencing weight loss.

Methods

Eighty pediatric patients receiving alloHSCT were enrolled in the study. Body mass index (BMI) z-scores and weight for age (WFA) z-scores were collected. A multivariate regression model was set up to investigate factors affecting weight loss. Post-transplant clinical outcomes relative to weight loss on 100 days after transplantation were analyzed.

Results

At admission, eight patients (10%) were underweight, the number had increased to 23 (30.67%) by 100 days post-HSCT. On day + 100, only nutrition screening tool for childhood cancer (SCAN) scores ≥ 3 (OR: 4.474, 95% CI: 1.215, 16.472; P = 0.024) and acute graft versus host disease (aGVHD) (OR: 9.915, 95% CI: 3.302, 29.771; P < 0.001) were regarded as significant influencing factors of weight loss. The Weight loss ≥ 5% group was associated with longer hospital stays (P = 0.001), greater cost of inpatient treatment (P = 0.001), and a higher incidence of 100-day re-admission and intensive care unit (ICU) transfer (P = 0.03 and P = 0.033, respectively). Cumulative number of fever days (P = 0.023) and antibiotic use (P = 0.007) also increased significantly. The Weight loss ≥ 5% group had a significantly lower one-year overall survival rate compared with the Weight loss < 5% group (P = 0.015).

Conclusion

Pediatric patients' nutritional status declined significantly after HSCT. Weight loss within the first 100 days influenced short-term clinical outcomes and one-year overall survival.

Barriers and Facilitators of Adherence to Oral Nutritional Supplements Among People Living With Cancer: A Systematic Review

This study aims to synthesize the barriers and facilitators of oral nutritional supplement adherence in people with cancer and assess levels of adherence. Databases including Embase, PubMed, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, Wanfang Database, and Chinese Scientific Journal Database, were used to search articles before January 4, 2021. Eighteen studies with 1,267 participants met the inclusion criteria. All studies reported rates of adherence, ranging from 6.0% to 96.9%. Gastrointestinal intolerances and disliked tastes were considered common barriers to cancer patients' adherence, whereas the ONS management strategy was considered the most crucial facilitator of adherence. Health professionals can improve adherence through regular monitoring and guidance and incentive strategies, and paying attention to the management and prevention of adverse reactions when prescribing nutritional products.

Impact of a ketogenic diet intervention during radiotherapy on body composition: V. Final results of the KETOCOMP study for head and neck cancer patients

PURPOSE

Patients with head and neck cancer (HNC) are at risk of malnutrition, especially during radiochemotherapy. We aimed to study the impact of a ketogenic diet (KD) versus an unspecified standard diet (SD) on body composition and survival in HNC patients undergoing radio(chemo)therapy.

METHODS

As part of a controlled clinical trial, non-metastasized HNC patients were enrolled into either a KD (N = 11) or an SD (N = 21) group between May 2015 and May 2021. Body composition was measured weekly by bioimpedance analysis and analyzed using linear mixed effects models. Overall and progression-free survival was assessed during regular follow-up.

RESULTS

A total of 7 KD and 21 SD patients completed the study and were eligible for comparative analysis. Chemotherapy was significantly associated with declines in all body composition parameters, while the KD had opposing, yet nonsignificant effects. In patients receiving chemotherapy, average weekly reductions of body mass (BM) and skeletal muscle mass (SMM) were 0.9 kg and 0.31 kg in the KD group versus 1.2 kg and 0.57 kg in the SD group, respectively. Patients in the KD group receiving no chemotherapy achieved an average increase of 0.04 kg BM and 0.12 kg SMM per week. After a median follow-up of 42 months (range 6.7-78 months) there were no significant differences in progression-free or overall survival between the groups.

CONCLUSION

The KD may partially counteract the detrimental effects of radiochemotherapy on body composition in HNC patients. This should encourage further research into KDs in frail cancer patient populations and motivate their implementation as complementary therapy for selected patients.

Subjective Global Assessment of Nutritional Status in Head and Neck Cancer Patients Treated with Radiotherapy - A Prospective Observational Study from North East India

Head and neck cancer (HNC) patients undergoing curative radiotherapy (RT) are at risk of malnutrition due to disease process as well as effects of therapy. Identifying the nutritional status of these patients at the earliest, helps to introduce adequate and timely interventions that can improve compliance and outcomes of treatment. Various tools for nutritional assessment in cancer patients have been proposed. In this prospective observational study we used the Subjective Global Assessment (SGA) questionnaire in a cohort of HNC patients receiving definitive RT at a regional cancer center of North East India. Recording of data was done at baseline, at two weekly intervals during treatment, at end of radiotherapy (EORT) and at follow-up upto 6 months. We observed that despite proper nutrition counseling, our patients suffered from malnutrition throughout their course of RT, which was at its peak by EORT but gradually improved over six months of follow-up. Pain on eating and swallowing were the most debilitating symptoms which caused significant decline of nutrient intake, body fat and muscle mass among patients together with deteriorating SGA ratings. Our results will hopefully help us design better strategies for nutrition management while delivering curative (chemo)radiotherapy for HNC patients of this region- which has one of the highest incidences of HNC in the world.

Novel methodology to quantify dehydration in head and neck cancer radiotherapy using DIXON MRI

INTRODUCTION

Head and neck cancer (HNC) patients are at risk of weight change, due to inadequate nutrition intake or dehydration, when receiving radiotherapy (RT). This study aimed to develop methodology to measure water content changes on magnetic resonance imaging (MRI) scans of the head and neck region over the course of RT.

METHODS

Retrospective datasets of 54 patients were analysed. Eligible patients had been treated for HNC with cisplatin chemoradiation (CRT) or RT alone and underwent a minimum of 2 MRI scans from weeks 0, 3 and 6 of their treatment. Anatomical regions consisting of ≥90% water, on T2-weighted DIXON MRI sequences, were contoured. Water volume changes of all patients were evaluated, within an anatomically standardised external volume, by comparing the absolute water fraction volume (cc) (VEx90WF) and relative water fraction volume (%) (RelVEx90WF) at weeks 0 and 6 of RT.

RESULTS

There was a statistically significant difference between the RelVEx90WF at weeks 0 and 6 (P = 0.005). However, no statistically significant difference was identified between weeks 0 and 6 VEx90WF (P = 0.064). There were no statistically significant differences identified between patients who received CRT versus RT alone.

CONCLUSION

This study developed a novel method for measuring changes in water fraction volumes over time, using T2-weighted DIXON MRIs. The methodology created in this study requires further validation through phantom imaging, with known fat and water values.

The association of frailty and outcomes of geriatric assessment with acute radiation-induced toxicity in patients with head and neck cancer

BACKGROUND AND PURPOSE

Geriatric impairments and frailty are highly prevalent in patients with head and neck cancer (HNC). This study investigated the association of frailty and outcomes of geriatric assessment (GA) with radiation-induced toxicity (RIT) in patients undergoing (chemo)radiotherapy ((C)RT) for HNC.

MATERIALS AND METHODS

Between October 2014 and April 2016, patients with HNC were prospectively included in OncoLifeS, an institutional data-biobank. Before treatment initiation, patients underwent GA and frailty screening (Groningen Frailty Indicator and Geriatric 8). The main outcome of this study was RIT (weight loss, mucositis, salivary gland inflammation, oral pain, sore throat, hoarseness, dry mouth, dysgeusia, dysphagia and general pain) according to the common terminology criteria of adverse events (CTCAE) version 4.0. Linear mixed models were performed, to analyse factors associated with increasing mean RIT over time during the treatment period.

RESULTS

160 patients were included. 114 (71.3%) were male and the mean age was 66.1 years. Age ≥ 65 (β = 0.03(95 %CI = 0.01;0.05), p = 0.01), regional RT (β = 0.05(95 %CI = 0.02;0.09), p = 0.004), and concurrent chemotherapy (β = 0.04(95 %CI = 0.02;0.07), p = 0.001), were independent factors associated with increasing toxicity during the 7-week treatment period, adjusted for relevant covariates. None of the single items of GA, as well as the frailty screening instruments, were associated with increasing RIT.

CONCLUSION

In this study, frailty and GA were not associated with additional RIT during treatment. These results suggest that (C)RT is equally tolerated in frail and non-frail patients, with respect to acute RIT. RT could be a suitable alternative to surgery in selected frail patients.

Confounding factors in the assessment of oral mucositis in head and neck cancer

Treatment of locally advanced head and neck carcinoma not amenable for surgical resection or resected with high-risk features is usually based on (chemo-)radiation treatment. Oral mucositis represents one of the main side effects of (chemo-)radiation, with an important impact on quality of life and causing approximately 20% of early interruption of treatment, leading to a suboptimal dose administered. Treatment and prevention of oral mucositis have a central role in the therapeutic pathways of head and neck cancer patients but remains quite challenging. Although extensive research is conducted to identify interventions for the management of mucositis, very few interventions had sufficient evidence to generate an international expert consensus. This may be partially explained by confounding factors that could influence the development and assessment of oral mucositis. Little is known about the confounding factors of oral mucositis, which, if not well balanced in an experimental study, could lead to non-solid results. The current paper aims to review the main oral mucositis confounding factors related to head and neck cancer patients.

Exercise-Based Interventions to Counteract Skeletal Muscle Mass Loss in People with Cancer: Can We Overcome the Odds?

Addressing skeletal muscle mass loss is an important focus in oncology research to improve clinical outcomes, including cancer treatment tolerability and survival. Exercise is likely a necessary component of muscle-mass-preserving interventions for people with cancer. However, randomized controlled trials with exercise that include people with cancer with increased susceptibility to more rapid and severe muscle mass loss are limited. The aim of the current review is to highlight features of cancer-related skeletal muscle mass loss, discuss the impact in patients most at risk, and describe the possible role of exercise as a management strategy. We present current gaps within the exercise oncology literature and offer several recommendations for future studies to support research translation, including (1) utilizing accurate and reliable body composition techniques to assess changes in skeletal muscle mass, (2) incorporating comprehensive assessments of patient health status to allow personalized exercise prescription, (3) coupling exercise with robust nutritional recommendations to maximize the impact on skeletal muscle outcomes, and (4) considering key exercise intervention features that may improve exercise efficacy and adherence. Ultimately, the driving forces behind skeletal muscle mass loss are complex and may impede exercise tolerability and efficacy. Our recommendations are intended to foster the design of high-quality patient-centred research studies to determine whether exercise can counteract muscle mass loss in people with cancer and, as such, improve knowledge on this topic.

Weight Loss in Post-Chemoradiotherapy Head and Neck Cancer Patients

Background: Weight loss is well-known among head and neck (HNC) patients during radiotherapy and could continue after the treatment is completed. Weight monitoring is essential for treatment outcomes and cancer surveillance. The purpose of the study is to evaluate the weight loss during and post-treatment among HNC patients. Methods: A total of 45 out of 50 patients post-treatment were included in this secondary treatment. Data were collected at baseline, at the completion of radiotherapy and one month after completion of radiotherapy. Results: The mean weight loss was 4.53 ± 2.87 kg (7.4%) during treatment and 1.38 ± 2.65 kg (2.1%) post-treatment. There were significant improvements one month after completion of radiotherapy in Patient-Generated Subjective Global Assessment (PGSGA), muscle mass, nutrition impact symptoms (NIS) score, energy and protein from oral intake (p < 0.0001). Energy and protein from oral nutritional supplements (ONS) decreased significantly (p < 0.0001). Conclusions: The results of this study underline the importance of early identification and monitoring post-treatment in HNC patients. The post-treatment recovery stage is very important for HNC patients to ensure a healing process.

Clinically significant changes in health-related quality of life in head and neck cancer patients following intensive nutritional care during radiotherapy

PURPOSE

This study aimed to explore whether adherence to intensive nutritional care during radiotherapy would avoid a meaningful worsening in quality of life in head and neck cancer patients; and whether adherence was associated with better nutritional outcomes.

METHODS

Observational prospective study that assessed head and neck cancer patients treated with radiotherapy at a large oncology hospital, between August 2018 and April 2019. The main outcome was minimal clinically important difference in quality of life, assessed with EORTC QLQ-C30 and EORTC QLQ H&N35, between baseline and 12 weeks. To illustrate clinically significant changes in quality of life over timeby adherence, a heat map analysis was performed. We also evaluated nutritional outcomes.

RESULTS

Eighty patients were included, half of them (53.8%) were considered adherent. There were no significant difference in quality of life between groups at baseline, with the exception of swallowing (p = 0.029) and coughing (p < 0.01). After treatment, the heat map demonstrated that adherent patients had nonsignificant clinical change in function scales, while non-adherent patients had a clinically significant worsening in physical, cognitive and social function. The prevalence of malnutrition increased significantly only in non-adherent patients (p < 0.01).

CONCLUSION

Adherence to intensive nutritional care may be able to avoid a meaningful worsening in quality of life and result in better nutritional outcomes in head and neck cancer patients. Our results may help to increase the awareness of the assessment of adherence and minimal clinically important difference in quality of life for research purposes and clinical practice.

Protein intake and muscle mass maintenance in patients with cancer types with high prevalence of sarcopenia: a systematic review

RATIONALE

Cancer is associated with muscle wasting. However, optimal protein intake has not been determined, limiting the efficacy of nutritional interventions. This systematic review aims to assess the effect of protein intake on muscle mass of patients with cancer types with high prevalence of sarcopenia during treatment, in longitudinal studies.

METHODS

MEDLINE, CINAHL, and Scopus databases were searched following PRISMA guidelines. Longitudinal studies written in English, including adults with high sarcopenia prevalence cancer diagnosis, submitted to (chemo)radiotherapy, with assessment of protein intake and muscle changes during treatment, published until 4 October 2020 were included. Studies including supplementation with substances, such as n-3 fatty acids, specific amino acids, or proteins, were excluded. Study appraisal was independently conducted by two reviewers, and a qualitative research synthesis was performed.

RESULTS

Overall, 575 records were identified, of which, eight studies were included (one randomized clinical trial and seven uncontrolled before and after studies). Patients with head and neck (n = 5), lung (n = 2), and esophageal cancer (n = 1) were included, comprising a total of 554 participants. The studies presented heterogeneous methodologies, objectives, and methods to assess body composition. Overall, participant groups with a mean protein intake below 1.2 g/kg presented muscle wasting, with one exception, while those reporting a mean intake above 1.4 g/kg, maintained muscle during treatment.

CONCLUSIONS

Our findings show that protein intakes below 1.2 g/kg, even when within the recommendations, have been associated with muscle wasting during treatment. Only intakes above 1.4 g/kg have been associated with muscle maintenance. High-quality research is needed to establish an optimal dose response.

Adherence to nutritional interventions in head and neck cancer patients: a systematic scoping review of the literature

BACKGROUND

Dietary counselling provided by a dietitian, with or without oral nutritional supplements, can impact on nutritional and clinical outcomes in head and neck cancer (HNC) patients undergoing radiotherapy. However, little is known about the role of adherence to oral nutritional interventions in this population. This review aimed to map the literature for evidence of adherence to oral nutritional interventions in HNC patients undergoing radiotherapy and to identify gaps in knowledge in this field.

METHODS

A scoping review methodology was used to identify studies, extract data, and collate and summarise results. We searched Medline, Embase, Cochrane Central and CINAHL, from the earliest available time up to 8 January 2020.

RESULTS

In total, 2315 unique articles were identified, 163 studies were assessed in full and niner were included in the scoping review. The use of different measures to assess adherence and variability in the timing of the assessments was noted across studies. Despite identifying studies that have measured adherence to oral nutritional interventions, very few studies monitored its influence on clinical and nutritional outcomes in HNC patients or reported factors related to adherence.

CONCLUSIONS

A robust evidence base is lacking for adherence to oral nutritional intervention in HNC patients. Overall, further studies evaluating the impact of oral nutritional interventions in HNC patients undergoing radiotherapy should measure adherence to the intervention. Early recognition of non-adherence and the contributing factors could ensure intensification of nutritional support and better health outcomes.

Head and neck cancer patients under (chemo-)radiotherapy undergoing nutritional intervention: Results from the prospective randomized HEADNUT-trial

PURPOSE/OBJECTIVE

Patients with squamous cell carcinoma of the head and neck undergoing (chemo-)radiotherapy are at high risk of malnutrition. Nevertheless, there is still a lack of prospective, randomized trials investigating the influence of nutritional status on therapy-related toxicity and patients' outcome.

MATERIALS AND METHODS

Between October 2018 and October 2020, 61 patients were randomized into an intervention and control group. Questionnaires (MUST, NRS-2002, and Nutriscore), clinical examinations, laboratory analyses, and bioelectrical impedance analysis (BIA) were used to assess nutritional status for all patients at the beginning and end of therapy as well as every 2 weeks during therapy. The intervention consisted of an individualized nutritional counseling every 2 weeks during therapy.

RESULTS

Median baseline BMI for all participants was 23.8 (14.5-37.2) kg/m² and dropped to 22.9 (16.8-33) kg/m² after therapy (p < 0.001). In all patients, median baseline fat-free mass index (FFMI) was 18.1 (14-24.7) kg/m² and decreased to 17.8 (13.4-21.6) kg/m² till the end of therapy (p < 0.001). Compliant patients with a BMI < 22 kg/m² presented with less weight loss in the intervention group compared to the control (p = 0.015, CI: 0.33-2.95). At baseline, MUST was the only screening-test which showed both good sensitivity (86%) and specificity (88%) in detecting malnutrition. Median follow-up was 15 (1-26) months and is still ongoing. 2-year overall survival rate was 70% in the control and 79% in the intervention group (log-rank p = 0.79). Pretherapeutic phase angle, posttherapeutic FFMI and albumin level were prognostic indicators for overall survival (log-rank p = 0.002, p = 0.008 and p = 0.016).

CONCLUSIONS

Malnutrition negatively impacts patients' outcome under (chemo-)radiotherapy. Baseline phase angle, posttherapeutic FFMI and albumin level are proposed as reliable indicators for overall survival. This study was registered within the German Clinical Trials Register (DRKS00016862).

Nutritional Support in Head and Neck Radiotherapy Patients Considering HPV Status

Malnutrition is a common problem in patients with head and neck cancer (HNC), including oropharyngeal cancer (OPC). It is caused by insufficient food intake due to dysphagia, odynophagia, and a lack of appetite caused by the tumor. It is also secondary to the oncological treatment of the basic disease, such as radiotherapy (RT) and chemoradiotherapy (CRT), as a consequence of mucositis with the dry mouth, loss of taste, and dysphagia. The severe dysphagia leads to a definitive total impossibility of eating through the mouth in 20–30% of patients. These patients usually require enteral nutritional support. Feeding tubes are a commonly used nutritional intervention during radiotherapy, most frequently percutaneous gastrostomy tube. Recently, a novel HPV-related type of OPC has been described. Patients with HPV-associated OPC are different from the HPV− ones. Typical HPV− OPC is associated with smoking and alcohol abuse. Patients with HPV+ OPC are younger and healthy (without comorbidities) at diagnosis compared to HPV− ones. Patients with OPC are at high nutritional risk, and therefore, they require nutritional support in order to improve the treatment results and quality of life. Some authors noted the high incidence of critical weight loss (CWL) in patients with HPV-related OPC. Other authors have observed the increased acute toxicities during oncological treatment in HPV+ OPC patients compared to HPV− ones. The aim of this paper is to review and discuss the indications for nutritional support and the kinds of nutrition, including immunonutrition (IN), in HNC, particularly OPC patients, undergoing RT/CRT, considering HPV status.

Nutritional outcomes in head and neck cancer patients: is intensive nutritional care worth it?

OBJECTIVE

This study aimed to compare nutritional outcomes before and after implementation of weekly dietetic counseling (intensive nutritional care) in head and neck cancers patients.

METHODS

A retrospective study with all head and neck patients, who received radiotherapy between January 2010 and December 2017 were performed. The main outcome was significant weight loss. Compliance to caloric and protein recommendations were also evaluated.

RESULTS

In all, 472 patients were included. Weight loss was not different between before and after implementation (-6.7%; IQ -10.5/-1.9 vs -5.0%; IQ -9.8/-0.7;p=0.06).There were no significant difference in terms of meeting the recommended intake. Higher baseline body mass index and oral nutritional support predicted significant weight loss.

CONCLUSION

Implementation of intensive nutritional care did not have an impact on weight loss and energy and protein intake in head and neck cancer patients. Further research would be of value to determine the appropriate service-delivery model to achieve optimal patient outcomes.

Yusop NB, Ibrahim Z, Abdul Rahman Z, Jamhuri N. Changes in Nutrition Impact Symptoms, Nutritional and Functional Status during Head and Neck Cancer Treatment

Background: The purpose of this study is to evaluate changes in nutrition impact symptoms (NIS) and nutritional and functional status that occur throughout radiotherapy in head and neck cancer (HNC) patients. Methods: A prospective observational study of HNC inpatients who underwent radiotherapy with or without chemotherapy were recruited to participate. Fifty patients were followed for the periods before, in the middle and at the end of radiotherapy. Nutritional parameters were collected throughout radiotherapy. Results: According to Patient-Generated Subjective Global Assessment (PG-SGA), there was an increase from a baseline of 56% malnourished HNC patients to 100% malnourished with mean weight loss of 4.53 ± 0.41kg (7.39%) at the end of radiotherapy. Nutritional parameters such as muscle mass, fat mass, body mass index, dietary energy and protein intake decrease significantly (p < 0.0001) while NIS score, energy and protein intake from oral nutritional supplements (ONS) increased significantly (p < 0.0001). Hand grip strength did not differ significantly. All HNC patients experienced taste changes and dry mouth that required ONS at the end of treatment. ONS compliance affected the percentage of weight loss (p = 0.013). Conclusions: The intensive nutritional care time point was the middle of RT. The PG-SGA and NIS checklist are useful for monitoring nutrition for HNC patients.

Predictors of Weight Loss in Patients With Head and Neck Cancer Receiving Radiation or Concurrent Chemoradiation Treated at a Tertiary Cancer Center

BACKGROUND

Radiation therapy (RT) has remained the mainstay treatment approach for head and neck cancers. Weight loss due to tumor or tumor-related factors remains a major health issue among head and neck cancer patients.

METHODS

A total of 357 patients were identified for the study. Possible weight-loss predictors were determined in the patients undergoing RT based on the patient demographics, tumor site, and treatment characteristics.

RESULTS

The mean age of patients was 52 years, whereas the median age was 51 years (range, 18-87). Two hundred and thirteen (66%) patients had oral cavity cancers, 43 (14%) had oropharyngeal cancer, 26 (8%) had hypopharyngeal cancer, 13 (6%) had larynx cancer, and 19 (6%) had other site involvement. A total of 192 patients received 3-dimensional conformal radiation therapy (3DCRT), whereas 127 patients received intensity modulated radiation therapy-image guided radiation therapy (IMRT-IGRT), 212 (66%) received concurrent chemotherapy, and 107 (34%) patients did not receive concurrent chemotherapy. A total of 127 (40%) of the patients gained weight during the first week of RT; on the other hand, maximum weight loss among patients was occurred during the third and fourth weeks of RT.

CONCLUSION

Analysis by logistic regression determined there is significant weight loss (>10%) in patients receiving radical RT as compared with adjuvant RT. Better outcomes were observed in patients receiving RT by IMRT-IGRT technique as compared with 3DCRT technique.

Defining barriers to implementation of nutritional advice in patients with cachexia

BACKGROUND

Cancer cachexia is a multidimensional wasting syndrome and a reduced dietary intake is both common and strongly correlated with degree of weight loss. Many patients with cachexia do not achieve recommended dietary intake even after nutritional counselling. Prior reports suggest this is likely due to barrier symptoms, but other potential contributory factors have not been studied in detail.

METHODS

Dietitian-assigned barriers to successful nutritional intervention were recorded at each visit in all patients attending a multidisciplinary clinic for management of cancer cachexia. The barriers were grouped into 15 categories and classified as either symptom-related or not symptom-related. In addition, symptom scores, dietary intake, and weight change were recorded.

RESULTS

Data on 94 new patients showed that 89% of patients had at least one major barrier. Four of the five most common barriers and 65% of all barriers identified were not symptom-related. Over sequential visits the specific barrier(s) in any one patient changed approximately 50% of the time. However, the presence of barriers did not render patients refractory to nutritional intervention and with intervention from the CNR-JGH team, mean dietary intake increased significantly.

CONCLUSIONS

In advanced cancer patients with cachexia, non-symptom-related barriers to nutritional intervention are more common than symptom-related. Barriers are dynamic, and repeated careful evaluation over time is required to achieve optimal impact with nutritional intervention in cancer cachexia. Members of the multidisciplinary team need appropriate expertise to address the barriers identified and achieve optimal results with nutritional intervention.

Body Composition Evaluation in Head and Neck Cancer Patients: A Review

Introduction: Head and neck cancer (HNC) patients show a high risk of malnutrition due to the lifestyle habits adopted prior to the diagnosis as well as to the compromising impact of both the anatomical location of the tumor and the treatment modalities on food intake. Weight change, measurement of skinfold thickness, biochemical parameters, bioelectrical impedance analysis (BIA), computed tomography (CT), magnetic resonance (MRI), or dual-energy x-ray absorptiometry (DXA) are available techniques to evaluate nutritional status and/or body composition in the clinical practice. Evaluating body composition alterations in HNC patients is essential to be able to offer the best therapeutical interventions. In this paper, we review the existing literature regarding body composition evaluation in HNC patients to determine, which is the most suitable method for this population, regarding availability in the day-to-day practice, patient burden, cost, sensibility, and specificity.

Methodology: A literature search for relevant papers indexed in MEDLINE, Cochrane Library and Scielo was conducted, with no publication date restriction and for all published articles until the 31 January, 2019. All the papers written in English, with interventions in humans, exclusively considering HNC patients were selected.

Results: A total of 41 studies with different methodologies were included in this review. In 15 studies BIA was the used assessment method and three of them also evaluated skinfold thickness and one was a bioelectric impedance vector analysis (BIVA). Body composition assessment was made with DXA in eight studies, one of which also included muscle biopsies. In two studies the chosen method was both BIA and DXA. CT/ positron emission tomography-CT was applied in 11 studies and one also included MRI. In two studies body composition was assessed with skinfold measurements alone and one study only used BIVA.

Conclusions: Despite the different existing body composition assessment tools, it seems that skeletal muscle mass (SMM) measurement at the level of cervical spine C3 vertebra may be a reliable method for SMM assessment as it strongly correlates with cross-sectional area measures at the level of L3 and it allows a cost-effective body composition assessment without the need for additional radiation exposure.

Association of the Patient Protection and Affordable Care Act With Insurance Coverage for Head and Neck Cancer in the SEER Database

Importance

Patients with head and neck squamous cell cancer (HNSCC) are often uninsured or underinsured at the time of their diagnosis. This access to care has been shown to influence treatment decisions and survival outcomes.

Objective

To examine the association of the Patient Protection and Affordable Care Act (ACA) health care legislation with rates of insurance coverage and access to care among patients with HNSCC.

Design, Setting, and Participants

Prospectively gathered data from the Surveillance, Epidemiology, and End Results (SEER) database were used to examine rates of insurance coverage and access to care among 89 038 patients with newly diagnosed HNSCC from January 2007 to December 2014. Rates of insurance were compared between states that elected to expand Medicaid coverage in 2014 and states that opted out of the expansion. Statistical analysis was performed from January 1, 2007, to December 31, 2014.

Main Outcomes and Measures

Rates of insurance coverage and disease-specific and overall survival.

Results

Among 89 038 patients newly diagnosed with HNSCC (29 384 women and 59 654 men; mean [SD] age, 59.8 [7.6] years), there was an increase after implementation of the ACA in the percentage of patients enrolled in Medicaid (16.2% after vs 14.8% before; difference, 1.4%; 95% CI, 1.1%-1.7%) and private insurance (80.7% after vs 78.9% before; difference, 1.8%; 95% CI, 1.2%-2.4%). In addition, there was a large decrease in the rate of uninsured patients after implementation of the ACA (3.0% after vs 6.2% before; difference, 3.2%; 95% CI, 2.9%-3.5%). This decrease in the rate of uninsured patients and the associated increases in Medicaid and private insurance coverage were only different in the states that adopted the Medicaid expansion in 2014. No survival data are available after implementation of the ACA, but prior to that point, from 2007 to 2013, uninsured patients had reduced 5-year overall survival (48.5% vs 62.5%; difference, 14.0%; 95% CI, 12.8%-15.2%) and 5-year disease-specific survival compared with insured patients (56.6% vs 72.2%; difference, 15.6%; 95% CI, 14.0%-17.2%).

Conclusions and Relevance

Access to health care for patients with HNSCC was improved after implementation of the ACA, with an increase in rates of both Medicaid and private insurance and a 2-fold decrease in the rate of uninsured patients. These outcomes were demonstrated only in states that adopted the Medicaid expansion in 2014. Uninsured patients had poorer survival outcomes.

Enteral Nutrition in Pediatric High-risk Head and Neck Cancer Patients Receiving Proton Therapy: Identifying Risk Factors and Quality of Life Concerns to Optimize Care

BACKGROUND

Radiotherapy for pediatric head and neck tumors often results in mucositis and pain, limiting oral intake and compromising patients' nutrition. There are little pediatric data available regarding enteral tube use and risk factors. Our objective was to estimate nutrition needs, identify risk factors contributing to nutritional decline and explore quality of life measures regarding enteral nutrition during proton radiotherapy.

PROCEDURE

Nutritional metrics and status were collected throughout radiation treatment for 32 patients. We surveyed patients/caregivers about their perceptions of enteral nutrition. Risk factors for progression to non-oral nutrition or >5% weight loss were evaluated using univariate analysis.

RESULTS

Patients who received any esophageal radiation or >30 Gy mean dose to the pharyngeal constrictors were more likely to experience >5% weight loss. These patients, as well as those who received a mean dose >30 Gy to the oropharynx or concurrent chemotherapy, were also more likely to require non-oral supplementation. Patients expressed the importance of maximizing nutrition and feared pain associated with a tube placement.

CONCLUSIONS

Pediatric patients with head and neck cancer can be risk-stratified based on clinical and dosimetric factors. This data, combined with parent and patient perceptions, is key to the development of rational guidelines.

Longitudinal Body Composition Changes and the Importance of Fat-Free Mass Index in Locally Advanced Nasopharyngeal Carcinoma Patients Undergoing Concurrent Chemoradiotherapy

Aim: This was a prospective investigation of longitudinal body composition changes in patients with nasopharyngeal carcinoma undergoing concurrent chemoradiotherapy (CCRT) and a comparison of the Patient-Generated Subjective Global Assessment (PG-SGA) and the ESPEN (European Society for Clinical Nutrition and Metabolism) diagnostic criteria (EDC) as evaluation methods. Methods: All patients received standard CCRT according to 2 centers’ current practices. Body composition parameters were determined by bioelectrical impedance analysis and obtained weekly from baseline until the end of treatment. The nutritional status of all patients was evaluated by the PG-SGA and EDC. Results: Forty-eight patients were eligible for analysis. Most body composition parameters, including body cell mass, fat mass, fat-free mass, and skeletal mass, as well as body weight, body mass index, and PG-SGA score, significantly decreased during CCRT (P = .00). The PG-SGA was shown to have better sensitivity than the EDC; however, the 2 different evaluation methods were found to have a perfect concordance at Week 4 and Week 6 (κ = 0.91 and 0.96, P = .00 and .00, respectively). Pearson correlation analyses showed that fat-free mass index and body weight were positively correlated with global quality of life score (r = 0.81, P = .00; r = 0.78, P = .00, respectively). Conclusions: This study has shown that body composition parameters, especially fat-free mass index, are valuable for diagnosing malnutrition in patients with nasopharyngeal carcinoma receiving CCRT. We recommend that these bioelectrical impedance analysis techniques should be increasingly implemented in nutritional assessments.

Nutritional status in patients with head and neck cancer undergoing radiotherapy: a longitudinal study

PURPOSE

Patients with head and neck cancers are susceptible to malnutrition during radiotherapy. This study aimed to determine the changes in the nutritional status and its determinants in patients with head and neck cancer during radiotherapy.

METHODS

This prospective observational study was performed in an outpatient Radiation Oncology clinic with a sample of 54 patients. An interview form (including anthropometric and laboratory parameters), the Patient-Generated Subjective Global Assessment to assess nutritional status, quality of life scales, and toxicity criteria were used for data collection at the baseline, the end of radiotherapy and 1 and 3 months after radiotherapy.

RESULTS

While the majority of the patients (90%) were well nourished at baseline, most of the patients (74%) were malnourished at the end of radiotherapy (p < 0.001). During radiotherapy, patients developed malnutrition, reflected in a decrease in food intake, approximately 5% loss of body weight, a reduction in mid-arm upper circumference and mid-arm muscle mass, and reduced serum protein and albumin levels. The nutritional status was worse in oropharyngeal cancers (p = 0.021), advanced stage (p = 0.004), use of concomitant chemotherapy (p = 0.041), and worse toxicity (p < 0.001). Furthermore, the nutritional status was strongly associated with the quality of life.

CONCLUSIONS

This study demonstrated negative impact of radiotherapy on the nutritional status of patients with head and neck cancer. The study also showed the association of the nutritional status and the quality of life. The nutritional status should be assessed during different periods in the trajectory of treatment due to its significant contribution to the quality of life.

Amino acid kinetics and the response to nutrition in patients with cancer

PURPOSE

Amino acids are involved in many physiological processes in the body and serve as building blocks of proteins which are the main component of muscle mass. Often patients with cancer experience muscle wasting, which is associated with poor outcomes. The purpose of this paper is to discuss amino acid kinetics in cancer, review the evidence on the response to nutrition in patients with cancer, and to give recommendations on the appropriate level of amino acid or protein intake in cancer. Current evidence shows that amino acid kinetics in patients with cancer are disturbed, as reflected by increased and decreased levels of plasma amino acids, an increased whole body turnover of protein and muscle protein breakdown. A few studies show beneficial effects of acute and short-term supplementation of high protein meals or essential amino acid mixtures on muscle protein synthesis.

CONCLUSIONS

Cancer is associated with disturbances in amino acid kinetics. A high protein intake or supplementation of amino acids may improve muscle protein synthesis. Future research needs to identify the optimal level and amino acid mixtures for patients with cancer, in particular for those who are malnourished.

Nutrition management for head and neck cancer patients improves clinical outcome and survival

Up to 80% of patients with head and neck cancers are malnourished because of their lifestyle and the risk factors associated with this disease. Unfortunately, nutrition management systems are not implemented in most head and neck cancer clinics. Even worse, many head and neck surgeons as well as hospital management authorities disregard the importance of nutrition management in head and neck cancer patients. In addition, the often extensive resection and reconstruction required for tumors in the upper aerodigestive tract pose special challenges for swallowing and sufficient food intake, placing special demands on nutrition management. This article presents the basics of perioperative metabolism and nutrition management of head and neck cancer patients and makes recommendations for clinical practice. Implementing a nutrition management system in head and neck cancer clinics will improve the clinical outcome and the survival of the patients.

Evidence-Based Support for Nutrition Therapy in Head and Neck Cancer

PURPOSE OF REVIEW

Patients diagnosed with head and neck (H&N) cancer often present in a malnourished state for varied reasons; nutritional optimization is therefore critical to the success of treatment for these complex patients. This article aims to review the current nutrition literature pertaining to H&N cancer patients and to present evidence-based strategies for nutritional support specific to this population.

RECENT FINDINGS

Aggressive nutritional intervention is frequently required in the H&N cancer patient population. Rehabilitating nutrition during operative and nonoperative treatment improves compliance with treatment, quality of life, and clinical outcomes. When and whether to establishing alternative enteral access are points of controversy, although recent evidence suggests prophylactic enteral feeding tube placement should not be universally applied. Perioperative nutritional optimization including preoperative carbohydrate loading and provision of arginine-supplemented immunonutrition has been shown to benefit at-risk H&N cancer patients.

SUMMARY

With multidisciplinary collaboration, H&N cancer patients can receive individualized nutritional support to withstand difficult cancer treatment regimens and return to acceptable states of nutritional health.

Nutritional changes in patients with locally advanced head and neck cancer during treatment

OBJECTIVE

The purpose of the study is to evaluate changes in body composition and nutritional status that occur throughout the oncological treatment in head and neck cancer patients.

METHODS

A prospective cohort observational study in patients diagnosed with head and neck squamous cell carcinoma (HNSCC) that underwent treatment with induction chemotherapy (iCT) followed by chemoradiotherapy or bioradiotherapy were invited to participate. All patients had dietetic counseling from the diagnosis and a close monitoring throughout the treatment implementing nutritional support as needed.

RESULTS

From June 2011 until October 2012, 20 patients were included. Nutritional and anthropometric parameters were collected at diagnosis, post iCT, after radiotherapy, 1 and 3months post radiotherapy. According to Patient Generated Subjective Global Assessment, 30% of patients were malnourished at diagnosis. After iCT there was an increase in weight, body mass index (BMI) and fat free mass (FFM) with almost complete improvement in dysphagia and odynophagia. Nevertheless a significant nutritional deterioration (p=0.0022) occurred at the end of radiotherapy with 95% of patients becoming severe or moderate malnourished. Nutritional parameters such as weight, BMI and hand grip strength also decrease significantly during treatment.

CONCLUSIONS

Despite an intensive nutritional support from the diagnosis throughout the oncological treatment in advanced HNSCC cancer patients, nutritional status deteriorates during radiotherapy. Our findings suggest that iCT may help improve nutritional status by ameliorating the symptoms that limit the oral intake. This improvement in the nutritional status could contribute to minimize further deterioration. Further investigations are needed involving novel approaches to avoid nutritional deterioration.

Randomised controlled trial of early prophylactic feeding vs standard care in patients with head and neck cancer

Background:

Weight loss remains significant in patients with head and neck cancer, despite prophylactic gastrostomy and intensive dietary counseling. The aim of this study was to improve outcomes utilising an early nutrition intervention.

Methods:

Patients with head and neck cancer at a tertiary hospital in Australia referred for prophylactic gastrostomy prior to curative intent treatment were eligible for this single centre randomised controlled trial. Exclusions included severe malnutrition or dysphagia. Patients were assigned following computer-generated randomisation sequence with allocation concealment to either intervention or standard care. The intervention group commenced supplementary tube feeding immediately following tube placement. Primary outcome measure was percentage weight loss at three months post treatment.

Results:

Recruitment completed June 2015 with 70 patients randomised to standard care (66 complete cases) and 61 to intervention (56 complete cases). Following intention-to-treat analysis, linear regression found no effect of the intervention on weight loss (10.9±6.6% standard care vs 10.8±5.6% intervention, P=0.930) and this remained non-significant on multivariable analysis (P=0.624). No other differences were found for quality of life or clinical outcomes. No serious adverse events were reported.

Conclusions:

The early intervention did not improve outcomes, but poor adherence to nutrition recommendations impacted on potential outcomes.