Investigating adherence to Australian nutritional care guidelines in patients with head and neck cancer

Use of oral nutritional supplements in irradiated patients with head and neck cancer

OBJECTIVES

Malnutrition is common among patients with head and neck cancer (HNC) and associated with poorer outcomes. Oral nutritional supplements (ONS) are often prescribed, with concerns raised about their cariogenicity. This study examined ONS use and caries experience in patients with HNC 12 months post-diagnosis.

METHODS

Fifty-four patients with HNC referred for pre-radiotherapy dental assessment were recruited. Data collected included: age, gender, residential postcode, smoking, alcohol use, HNC characteristics, dental history, oral hygiene habits, dietary advice and ONS use. Data was collected at diagnosis, during radiotherapy and 6 weeks, three, six- and 12-months post-treatment completion.

RESULTS

Fifty-one subjects completed the study. 76.5% of the participants used ONS for an average of 13.8 weeks. Caries developed in 22.9% of ONS users and 11.1% of non-users (p = 0.6585). The mean overall duration of ONS use was 18.7 weeks for the caries group and 8.5 weeks for the caries-free group (p = 0.1507). Lack of collaboration and disconnection was noted between dietary advice given by dieticians and dentists.

CONCLUSIONS

ONS use is common among patients with HNC. Larger studies are needed to establish the reasons for caries development and impacts of ONS use on oral health. Importance of multidisciplinary management of malnutrition is highlighted.

Clinical practice guidelines on nutrition management in head and neck cancer: a systematic quality appraisal using the Appraisal of Guidelines for Research and Evaluation 2nd edition instrument

OBJECTIVE

Several guidelines have been produced for the management of nutrition in patients with head and neck cancer. However, no systematic evaluation of the quality of these guidelines has been performed to date.

METHOD

A comprehensive search was conducted up to August 2020. The quality of guidelines was assessed by four independent reviewers using the Appraisal of Guidelines for Research and Evaluation, 2nd edition.

RESULTS

Nine guidelines were assessed for critical evaluation. Only two guidelines were classified as 'high quality'. The 'scope and purpose' domain achieved the highest mean score (75.5 ± 17.0 per cent), and the lowest domain mean score was 'applicability' (37.6 ± 23.0 per cent).

CONCLUSION

These findings highlight the variability in the methodological quality of guidelines for the management of nutrition in head and neck cancer. These results may help to improve the reporting of future guidelines and guide the selection for use in clinical practice.

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.

Preoperative Nutrition Intervention in Patients Undergoing Resection for Upper Gastrointestinal Cancer: Results from the Multi-Centre NOURISH Point Prevalence Study

Background: Preoperative nutrition intervention is recommended prior to upper gastrointestinal (UGI) cancer resection; however, there is limited understanding of interventions received in current clinical practice. This study investigated type and frequency of preoperative dietetics intervention and nutrition support received and clinical and demographic factors associated with receipt of intervention. Associations between intervention and preoperative weight loss, surgical length of stay (LOS), and complications were also investigated. Methods: The NOURISH Point Prevalence Study was conducted between September 2019 and May 2020 across 27 Australian tertiary centres. Subjective global assessment and weight were performed within 7 days of admission. Patients reported on preoperative dietetics and nutrition intervention, and surgical LOS and complications were recorded. Results: Two-hundred patients participated (59% male, mean (standard deviation) age 67 (10)). Sixty percent had seen a dietitian preoperatively, whilst 50% were receiving nutrition support (92% oral nutrition support (ONS)). Patients undergoing pancreatic surgery were less likely to receive dietetics intervention and nutrition support than oesophageal or gastric surgeries (p < 0.001 and p = 0.029, respectively). Neoadjuvant therapy (p = 0.003) and malnutrition (p = 0.046) remained independently associated with receiving dietetics intervention; however, 31.3% of malnourished patients had not seen a dietitian. Patients who received ≥3 dietetics appointments had lower mean (SD) percentage weight loss at the 1-month preoperative timeframe compared with patients who received 0–2 appointments (1.2 (2.0) vs. 3.1 (3.3), p = 0.001). Patients who received ONS for >2 weeks had lower mean (SD) percentage weight loss than those who did not (1.2 (1.8) vs. 2.9 (3.4), p = 0.001). In malnourished patients, total dietetics appointments ≥3 was independently associated with reduced surgical complications (odds ratio 0.2, 95% confidence interval (CI) 0.1, 0.9, p = 0.04), and ONS >2 weeks was associated with reduced LOS (regression coefficient −7.3, 95% CI −14.3, −0.3, p = 0.04). Conclusions: Despite recommendations, there are low rates of preoperative dietetics consultation and nutrition support in this population, which are associated with increased preoperative weight loss and risk of increased LOS and complications in malnourished patients. The results of this study provide insights into evidence–practice gaps for improvement and data to support further research regarding optimal methods of preoperative nutrition support.

Nutritional Deficiencies in Radiotherapy-Treated Head and Neck Cancer Patients

Nutritional deficiencies (malnutrition, cachexia, sarcopenia, and unfavorable changes in the body composition) developing as a side effect of radiotherapy (RT) currently represents a significant but still inaccurately studied clinical problem in cancer patients. The incidence of malnutrition observed in head and neck cancer (HNC) patients in oncological radiology departments can reach 80%. The presence of malnutrition, sarcopenia, and cachexia is associated with an unfavorable prognosis of the disease, higher mortality, and deterioration of the quality of life. Therefore, it is necessary to identify patients with a high risk of both metabolic syndromes. However, the number of studies investigating potential predictive markers for the mentioned purposes is still significantly limited. This literature review summarizes the incidence of nutritional deficiencies in HNC patients prior to therapy and after the commencement of RT, and presents recent perspectives for the prediction of unfavorable nutritional changes developing as a result of applied RT.

The experience of nutritional care according to patients with head and neck cancer involved with a combined dietitian, specialist nurse and speech pathologist clinic in a regional Australia: a qualitative longitudinal study

PURPOSE

Malnutrition is a co-morbidity of head and neck cancer (HNC) that has negative consequences for patients. Evidence-based guidelines (EBGs) provide recommendations to prevent and manage malnutrition. A clinic that combines the services of a dietitian, specialist oncology nurse and speech pathologist may promote the implementation of nutritional EBGs in regional Australia. This study aimed to explore the nutritional care experience that patients with HNC had in this setting.

METHODS

A qualitative longitudinal study collected data via semi-structured interviews with HNC patients who were treated in one regional cancer care network in Australia. Interviews were conducted at key points in their HNC journey from diagnosis to 4 months post-radiotherapy. Data was analysed using a grounded theory approach.

RESULTS

Ten participants completed a total of thirty-six interviews. The findings were grouped into four categories: "preparing for nutritional challenges", "multidisciplinary care directed by patient needs", "the battle to eat", and "incongruence between patient values and nutritional priorities".

CONCLUSION

These findings highlight the nutritional burden associated with HNC and barriers to patients accepting nutritional support from healthcare professionals. Information provided by doctors and nurses prior to treatment may help patients prepare for the nutritional challenges ahead and accept support from dietitians. Furthermore, clinics that promote continuity through treatment and allow dietitians to lead aspects of nutritional care, in collaboration with nurses, speech pathologists and doctors, may also enhance the nutritional care experience. More qualitative research within HNC teams would provide further insight on enhancing the implementation of nutritional EBGs to improve outcomes for these patients.

Adherence to intensive nutrition care in head and neck cancer patients undergoing radiotherapy

PURPOSE

The aim of this study was to determine the prevalence and effect of adherence to intensive nutritional care on nutritional outcomes and survival in head and neck cancer patients undergoing radiotherapy.

METHODS

Three-hundred and seventeen head and neck cancer patients referred to intensive nutrition support during radiotherapy were retrospectively analyzed. Patients who missed less than 25% of their appointments with the dietitian were considered adherent. Primary outcome was percentage weight loss during treatment. Secondary outcomes were overall survival and patients' capacity to accomplish their caloric and protein recommendations. Logistic regression was used to examine predictors of weight loss and Kaplan-Meier to estimate survival.

RESULTS

Less than half of the patients (n = 145, 45.7%) were adherent. Statistically significant less weight loss in the adherent group (42.8% vs 55.8%; p = 0.02) was found, despite no difference in energy or protein intake. Logistic regression models after adjusting for other variables demonstrated that adherence resulted in 43% protection from significant weight loss (odds ratio 0.57, 95% CI 0.34-0.97). Overall survival was not different between groups.

CONCLUSION

Findings demonstrated that patients who were adherent to weekly contacts with the dietitian had less weight loss, but not better survival or nutritional intake. Additional investigation of factors that may act as barriers or enablers for adherence could help improve the outcomes in this population.

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.

Efficacy of EPA-enriched supplement compared with standard formula on body weight changes in malnourished patients with head and neck cancer undergone surgery: a randomized study

BACKGROUND

Eicosapentaenoic acid (EPA) containing nutritional supplement can reverse weight loss and increase lean body mass in a perioperative period of patients with head and neck cancer. To study effects of an EPA-enriched supplement compared with a conventional supplement in malnourished patients with head and neck cancer following surgery is primary objective.

METHODS

The patients were randomized into EPA-enriched and standard formula group. The supplements were prescribed 7 days preoperative through 14 days postoperative. Body weight and composition including serum parameters were measured from 7 days preoperative until 4 months postoperative. The hospitalized courses were recorded.

RESULTS

Thirty-one patients in each group consumed EPA-enriched and standard formula supplements. There was no significant body weight or composition changes perioperative. No significant differences in the hospitalized days and postoperative complications was observed.

CONCLUSIONS

Body weight changes in malnourished patients with head and neck cancer following surgery were not influenced by EPA additives to perioperative nutritional supplements.