Head and neck cancer patients' perceptions of quality of life and how it is affected by the disease and enteral tube feeding during treatment

Role of Percutaneous Endoscopic Gastrostomy for the Nutrition of Head and Neck Cancer Patients before and up to 6 Months after Cancer Treatment

This retrospective monocentric cohort study analyzed patients with head and neck cancer according their nutritional status and association of percutaneous endoscopic gastrostomy (PEG) from admission to six months after treatment at a tertiary hospital in Germany from 2017 to 2019. A total of 289 patients (76.5% men; median age 62 years; 63.3% stage IV) were included. Univariate analyses and ANOVAs with repeated measures were performed to analyze differences over time. The percentage of patients requiring PEG was 14.9% (43 of 289 patients) before start of treatment (Z0), 14% (40 of 286 patients alive) after one week (Z1), 22.7% (58 of 255 patients) after six weeks (Z2) and 23% (53 of 230 patients) after six months (Z3) from the end of treatment. PEG placement was associated with alcohol or nicotine consumption, in oropharyngeal and hypopharyngeal carcinoma, squamous cell carcinoma, cancer stage III/IV, chemotherapy and impairment of food intake (all p < 0.05). Weight loss between Z1 and Z3 with PEG did not differ from patients without PEG at Z0 (p = 0.074), although patients with PEG at Z0 had a lower mean weight at the beginning. PEG was important for a quarter of the patients alive at Z3 and helped to prevent weight loss.

A Discourse of Deviance: Blame, Shame, Stigma and the Social Construction of Head and Neck Cancer

Cancer of the head and neck is a confronting condition, as the disease and its treatments alter the appearance and function of body organs associated with physical appearance and identity. Many of the risk factors for head and neck cancers, including tobacco, alcohol, and human papilloma virus, can also have significant negative social and moral permutations. Language and action (discourse) plays an important role in constructing disease and illness and shape the way it is managed, both institutionally and socially. This research used a critical constructionist lens to investigate how the common discourses surrounding head and neck cancer are constructed within the healthcare context and how this influences patients and healthcare professionals' responses to the illness. Data were collected through semi-structured interviews, field noting, journaling and literature reviews. Analysis was guided by a three-dimensional approach to critical discourse analysis that investigated text, discursive practices, and social context. The overarching finding was that deviance dominates the common discourse and shapes head and neck cancer and responses to it. Deviance is channelled through metaphors, adjectives, descriptors, and collective nouns and is made overt through labelling, avoidance, blaming, shame, and categorization. Discourse is contextualized by a sociocultural understanding that when someone deviates from what is perceived as normal, they are devalued. Open dialogue and reflection on head and neck cancer discourse could enable better understanding of how people experience their condition and inform more supportive responses.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The psychosocial experiences of human papillomavirus (HPV) positive oropharyngeal cancer patients following (chemo)radiotherapy: A systematic review and meta-ethnography

OBJECTIVE

The UK incidence of oropharyngeal cancer has risen sharply over the last 30 years with an increase in human papillomavirus (HPV) associated diagnoses, most prevalent in younger, working age populations. This meta-ethnography explores the psychosocial needs of HPV+ve oropharyngeal cancer patients during early recovery following (chemo)radiotherapy.

METHODS

Meta-ethnography methods were used, based on the approach of Noblit and Hare. Systematic searches for relevant qualitative studies were conducted in five electronic databases (MEDLINE, PubMed, CINAHL, PsycINFO and Cochrane database) between 2010 and 2021, followed by citation searching.

RESULTS

Twenty-three papers exploring the psychosocial needs of HPV+ve oropharyngeal cancer patients after treatment were included. Findings were synthesised to develop five constructs: 'gaps in continuity of support from healthcare professionals' reflecting unmet needs; 'changes to self-identity' revealing the comprehensive disruption of this disease and treatment; 'unrealistic expectations of recovery' highlighting the difficulty of preparing for the impact of treatment; 'finding ways to cope' describing the distinct complexity of this experience; and 'adjusting to life after the end of treatment' exploring how coping strategies helped patients to regain control of their lives.

CONCLUSIONS

Completing (chemo)radiotherapy signalled a transition from hospital-based care to home-based support, challenging patients to address the constructs identified. An unexpectedly difficult and complex recovery meant that despite a favourable prognosis, poor psychosocial well-being may threaten a successful outcome. The provision of tailored support is essential to facilitate positive adjustment.

Evaluation of a novel pre-treatment model of nutrition care for patients with head and neck cancer receiving chemoradiotherapy

AIMS

Weight loss and malnutrition occur frequently in patients with head and neck cancer and are associated with reduced survival. This pragmatic study aimed to determine the effect of a novel pre-treatment model of nutrition care on nutrition outcomes for patients with head and neck cancer receiving chemoradiotherapy.

METHODS

This health service evaluation consisted of an evaluation of the new model of care implementation (Phase 1) and an evaluation of patient outcomes (Phase 2) in pre- and post-implementation cohorts (n = 64 and n = 47, respectively). All Phase 2 patients received a prophylactic gastrostomy. The new model of care consisted of dietary counselling and commencement of proactive supplementary enteral nutrition via a prophylactic gastrostomy, in addition to normal oral intake, prior to treatment commencement. Nutrition outcomes were collected at baseline (pre-treatment) and 3 months post-radiotherapy completion.

RESULTS

The new model of care was successfully incorporated into practice with high referral (96.5%) and attendance (91.5%) rates to the counselling session, and high adherence rates to proactive tube feeding (80.9%). Patients in the post-implementation cohort had less weight-loss (1.2%; p = 0.338) and saw less of a decline in nutritional status compared to patients in the pre-implementation cohort (23% vs. 30%, respectively; p = 0.572), deemed clinically important. However, patients still experienced critical weight loss overall (mean 9.9%).

CONCLUSION

Pre-treatment nutrition care was feasible in standard clinical practice and demonstrated clinically relevant outcome improvements for patients. Future high-quality research is warranted to investigate further multidisciplinary strategies to attenuate weight-loss further, inclusive of patient-reported barriers and enablers to nutrition interventions.

Palliative Surgery for Advanced Cancer: Clinical Profile, Spectrum of Surgery and Outcomes from a Tertiary Care Cancer Centre in Low-Middle-Income Country

Objectives:

Palliative surgery for cancer plays an important role in the overall management, especially in low-middle countries with a significant burden of advanced cancers. There is a paucity of literature related to the field of palliative surgery. In this study, we present the clinical spectrum, profile of surgical interventions and outcomes of palliative surgical procedures performed at a tertiary cancer centre involving multiple organ systems.

Materials and Methods:

A retrospective analysis of prospectively maintained surgical oncology database of a tertiary care cancer centre was performed. Patients fulfilling the criteria of palliative surgery were analysed for clinical spectrum, indications for surgery, palliative surgical procedures and post-operative outcomes.

Results:

A total of 678 out of 8300 patients fulfilled the criteria for palliative surgery. Palliative surgical procedures were performed most commonly for gastro-oesophageal malignancies (36.4%) followed by colorectal cancers (24%) and breast cancer (12%). Palliative mastectomy was the most common procedure performed for advanced breast cancer and 7% of sarcoma patients had amputations. Symptom relief could be achieved in 80–90% of patients and post-operative morbidity was relatively high among hepatobiliary, gastrointestinal and gynaecological cancer patients.

Conclusion:

Globally, a significant number of cancer patients need palliative surgical intervention, especially in LMIC with a high burden of advanced cancers. Results of the current study indicate that gastrointestinal cancer patients constitute a major proportion of patients undergoing palliative surgery. Overall results of the current study indicate that excellent palliation can be achieved in majority of patients with acceptable morbidity and hospital stay.

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

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

Survey of Psychosocial Issues of Nasogastric Tube Feeding in Head-and-Neck Cancer Patients

Background:

Because of some psychosocial reasons and misbelieves regarding nasogastric(NG) tube feeding, many patients refuse for NG tube insertion.

Aim:

Primary aim was to do survey of psychological reasons for refusal of NG tube insertion and feeding in head and neck cancer patients. Secondary aim was to assess impact of psychological counseling of patient who did not accept NG tube feeding.

Method:

This cross sectional study was conducted on patients referred to palliative medicine department and needed NG tube feeding but refused for the same. We prepared our own questionnaire which includes the most common cause for enteral feeding refusal which we found during our routine OPD since last five years response to those questions were recorded. Then we did psychological counseling of patients and again we assessed patient's acceptability for NG tube feeding by Likert scale and record their response.

Results:

Most common psychological reasons for patient's refusal were “it will disrupt my body image”(88.33%), “unable to go outside/mix with people”(80%) and “dependency on others for activities”(66.66%). Post psychological counseling out of 60 patients 47 patients were agreed while 13 patients did not agree with NG tube feeding (P value 0.000062<0.5).

Conclusion:

We conclude that though NG tube feeding is necessary for some head and neck cancer, there are lots of psychosocial problem regarding its acceptance for patients. For that adequate psychological assessment and counseling is necessary for patients' acceptance, compliance and good quality of life.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Symptom patterns, physical function and quality of life among head and neck cancer patients prior to and after surgical treatment: A prospective study

PURPOSE

This study aimed to evaluate patterns of symptoms, physical function and quality of life (QoL) among patients with head and neck cancer (HNC) prior to, 3-9 days post-surgery, and one month post-surgery.

METHODS

A prospective, repeated-measures design with consecutively-identified sampling was used to recruit HNC patients undergoing surgical treatment. Data collected included demographic and clinical characteristics, symptoms by M.D. Anderson Symptom Inventory-Head and Neck Module-Chinese version (MDASI-H&N-C), physical function and QoL by Function Subscales of European Cancer Research Treatment Organization Quality of Life Core Scale (EORTC QLQ C30).

RESULTS

105 HNC patients suffered multiple symptoms prior to and after surgery. Pain, difficulty with voice/speech, disturbed sleep and problems with mucus (30.48%~91.43%) were the most prevalent symptoms prior to and post-surgery. Numbers of symptoms as well as specific symptoms, such as fatigue, dry mouth, problems with mucus, pain and disturbed sleep, were significantly associated with poor physical function (p < 0.05). Tracheostomy, feeding tube and age were also linked with poor physical function and poor QoL (p < 0.05).

CONCLUSIONS

Findings of our study underscore the importance of managing symptoms in HNC patients to ensure patients' physical function and QoL prior to and after surgical treatment. Further research should focus on developing targeted interventions for symptoms that are linked to HNC patients' poor physical function and QoL.

Best interest versus advance decisions to refuse treatment in advance care planning for neurodegenerative illness

This article describes the role of nurses assisting people with degenerative illness in advance care planning (ACP) for a time when they may lose decision-making capacity. It looks at the concept of advance decisions to refuse treatment (ADRT), as defined in the Mental Capacity Act 2005 , exploring the legal, ethical and philosophical ramifications of carrying out, or overriding, formerly expressed wishes of someone who has subsequently lost decision-making capacity. It uses an illustrative composite case study of an individual with Huntington's disease whose prognosis includes future deterioration in swallowing, together with consideration of whether to have or refuse a percutaneous endoscopic gastrostomy. The author, who as part of his role cares for people with neurodegenerative conditions, including Huntington's disease, discusses the difficulties and dilemmas that nurses experience with ADRTs, drawing on personal experience. He suggests that, rather than focusing on ADRTs, ACP may be most effective in preparing people and their surrogates to make real-time decisions, based on a shared understanding of the individual's values.

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.

Tube feeding during treatment for head and neck cancer - Adherence and patient reported barriers

OBJECTIVES

The main aim was to investigate the incidence of patient adherence to nutritional tube feeding recommendations in patients with head and neck cancer and to determine patient barriers to meeting tube feeding prescription.

MATERIALS AND METHODS

This was an observational study from a randomised controlled trial in patients with head and neck cancer deemed at high nutritional risk with prophylactic gastrostomy (n=125). Patients were randomised to receive early tube feeding prior to treatment (intervention group) or standard care. All patients in the intervention and standard care groups then commenced clinical tube feeding as required during treatment. Patients maintained a daily record of gastrostomy intake, main nutrition impact symptom necessitating gastrostomy use, and reasons for not meeting nutrition prescription. Adherence was defined as meeting ≥75% of total prescribed intake.

RESULTS

Patients were predominantly male (89%), median age 60, with oropharyngeal tumours (78%), stage IV disease (87%) treated with chemoradiotherapy (87%). Primary reasons for gastrostomy use were poor appetite/dysgeusia (week 2-3) and odynophagia/mucositis (week 4-7). Early tube feeding adherence was 51%. Clinical tube feeding adherence was significantly higher in the intervention group (58% vs 38%, p=0.037). Key barriers to both phases of tube feeding were; nausea, early satiety and treatment factors (related to hospital healthcare processes).

CONCLUSIONS

Early tube feeding can improve patient adherence to clinically indicated tube feeding during treatment. Low adherence overall is a likely explanation for clinically significant weight loss despite intensive nutrition interventions. Optimising symptom management and strategies to overcome other barriers are key to improving adherence.

CLINICAL TRIAL REGISTRATION

This trial has been registered in the Australian New Zealand Clinical Trials registry as ACTRN12612000579897.