Nutritional support for head and neck cancer patients receiving radiotherapy: a systematic review

Does nutritional support prevent severe mucositis in patients with head and neck cancer treated with chemoradiotherapy? A systematic review and meta-analysis

BACKGROUND

For patients with advanced head and neck cancer (HNC) chemoradiotherapy (CHRT) is the main treatment option. CHRT is a severe treatment with a high ratio of side effects which may be even more pronounced due to mucosities related malnutrition. Nutritional intervention like nutritional counseling (NC) and oral nutritional supplements (ONS) may prevent malnutrition. A systematic review and meta-analysis was performed to assess the effect of NC with or without ONS (NC±ONS) on CHRT-related grade ≥3 mucositis in patients with HNC undergoing CHRT.

METHODS

PubMed/MEDLINE, Web of Science, and Scopus were searched to identify randomized and non-randomized clinical studies of HNC patients undergoing CHRT, where mucositis grade ≥3 data were provided. Comparative and proportional meta-analyses were performed to calculate the odds ratio (OR) and incidence of a mucositis grade ≥3 in the included studies (%) with 95% confidence intervals (95% CI).

RESULTS

There were seven studies fulfilling inclusion criteria with 655 participants included. NC±ONS revealed no risk reduction of grade ≥3 mucositis (OR: 1.2, 95%CI: 0.7-1.9). The overall mucositis rate was 38.3% (95% CI: 24.8%-52.6%) and 32.8% (95% CI: 14.9%-53.5%) (P = 0.67) in NC+ONS and NC-ONS respectively.

CONCLUSION

Despite the undeniable role of NC±ONS for patients with HNC undergoing CHRT, we found it insufficient to avoid grade ≥3 CHRT-related mucositis. Further research should be conducted to determine recomendations how to decrease the risk of oral mucosities and, in consequence, how to prevent malnutrition in patients with CHRT.

SEOM clinical guidelines for cancer anorexia-cachexia syndrome (2023)

Cancer-related anorexia-cachexia syndrome (CACS) is a debilitating condition afflicting up to 80% of advanced-stage cancer patients. Characterized by progressive weight loss, muscle wasting, and metabolic abnormalities, CACS significantly compromises patients' quality of life and treatment outcomes. This comprehensive review navigates through its intricate physiopathology, elucidating its stages and diagnostic methodologies. CACS manifests in three distinct stages: pre-cachexia, established cachexia, and refractory cachexia. Early detection is pivotal for effective intervention and is facilitated by screening tools, complemented by nutritional assessments and professional evaluations. The diagnostic process unravels the complex interplay of metabolic dysregulation and tumor-induced factors contributing to CACS. Management strategies, tailored to individual patient profiles, encompass a spectrum of nutritional interventions. These include dietary counseling, oral nutritional supplements, and, when necessary, enteral nutrition and a judicious use of parenteral nutrition. Specific recommendations for caloric intake, protein requirements, and essential nutrients address the unique challenges posed by CACS. While pharmacological agents like megestrol acetate may be considered, their use requires careful evaluation of potential risks. At its core, this review underscores the imperative for a holistic and personalized approach to managing CACS, integrating nutritional interventions and pharmacological strategies based on a nuanced understanding of patient's condition.

Bridging gaps in cancer cachexia Care: Current insights and future perspectives

Cachexia is characterized by severe weight loss and skeletal muscle depletion, and is a threat to cancer patients by worsening their prognosis. International guidelines set indications for the screening and diagnosis of cancer cachexia and suggest interventions (nutritional support, physical exercise, and pharmacological treatments). Nevertheless, real-life experience not always aligns with such indications. We aimed to review the current state of the field and the main advancements, with a focus on real-life clinical practice from the perspectives of oncologists, nutrition professionals, and radiologists. Pragmatic solutions are proposed to improve the current management of the disease, emphasizing the importance of increasing awareness of clinical nutrition's benefits, fostering multidisciplinary collaboration, promoting early identification of at-risk patients, and leveraging available resources. Given the distinct needs of patients who are receiving oncologic anti-cancer treatments and those in the follow-up phase, the use of tailored approaches is encouraged. The pivotal role of healthcare professionals in managing patients in active treatment is highlighted, while patient and caregiver empowerment should be strengthened in the follow-up phase. Telemedicine and web-based applications represent valuable tools for continuous monitoring of patients, facilitating timely and personalized intervention through effective communication between patients and healthcare providers. These actions can potentially improve the outcomes, well-being, and survival of cancer patients with cachexia.

Pre-rehabilitation interventions for patients with head and neck cancers: A systematic review and meta-analysis

OBJECTIVE

To investigate the effect of pre-rehabilitation interventions such as nutrition and exercise for patients with head and neck cancer (HNC).

METHODS

Web of Science, PubMed, Scopus, Google Scholar, and Cochrane databases were searched up to December 2022. Quality of life, length of hospital stay, postoperative complications, change in body mass index or muscle mass, and functional assessments were the primary outcomes. PRISMA guidelines were adhered to, and the study was registered on PROSPERO. The Cochrane Collaboration tool and Newcastle Ottawa scale assessed the quality of included studies. Pooled data are presented as odds ratios (OR) and 95% confidence intervals (CI). Analysis was conducted using RevMan5.4.

RESULTS

A total of 31 articles were included for quantitative analysis and 15 for qualitative synthesis. Nutrition alone resulted in significant weight retention (2.60; 2.32, 2.88, p < 0.00001), length of stay (-4.00; -6.87, -1.13), p = 0.0006) and complications (0.64; 0.49, 0.83, p = 0.0009). Nutrition and psychoeducation resulted in a significant reduction in mortality rate (0.70; 0.49, 1.00, p = 0.05 and 0.60; 0.48, 0.74, p < 0.00001), and exercise resulted in a significant reduction in dysphagia (0.55; 0.35, 0.87, p = 0.01). Exercise with nutrition resulted in significant improvements in weight loss, length of stay, complications, and dysphagia. Randomized controlled trials (RCTs) had a moderate risk of bias and cohort studies were of fair to good quality.

CONCLUSION

Prehabilitation programs based on exercise, nutrition, or psychoeducation demonstrated improved post-interventional outcomes in HNC, such as quality of life, and mortality and morbidity. Studies with longer follow-ups and larger sample sizes, and investigations comparing nutritional supplements with exercise programs are needed.

Practical cancer cachexia management in palliative care - a review of current evidence

PURPOSE OF REVIEW

To explore the current evidence relating to the practical management of cancer cachexia in palliative care.

RECENT FINDINGS

The authors found a growing evidence base including the publication of several expert guidelines since 2020. Guidelines identified the need for individualised nutritional and physical exercise support as the mainstay of cachexia management. Dietician and allied health professional referrals are recommended for the best patient outcomes. Limitations of nutritional support and exercise are acknowledged. Patient outcomes from multimodal anti-cachexia therapy are awaited at this time. Communication about the mechanisms of cachexia and nutritional counselling are identified as ways to reduce distress. Evidence supporting the use of pharmacological agents remains insufficient to make recommendations. Corticosteroids and progestins may be offered for symptom relief in refractory cachexia, taking into consideration well-documented side effects. Emphasis is placed on adequately managing nutritional impact symptoms. A specific role for palliative care clinicians and the use of existing palliative care guidelines in managing cancer cachexia were not identified.

SUMMARY

Current evidence recognises the inherently palliative nature of cancer cachexia management, and practical guidance correlates with the tenets of palliative care. Individualised approaches to support nutritional intake, physical exercise and alleviate symptoms that accelerate cachexia processes are currently recommended.

Multidisciplinary tumor board for head and neck cancer from the perspective of medical oncologists-optimizing its effectiveness

Head and neck cancer (HNC) treatment is becoming increasingly multidisciplinary, and patient characteristics vary. Therefore, a multidisciplinary tumor board (MTB) is essential in clinical practice. This review provides insights into the benefits and tips for improving head and neck MTB from the perspective of medical oncologists. The MTB is a platform to discuss the optimal application of the standard of care to each case, reach a consensus, and establish a recommendation to support patients' decision-making. A productive and educational MTB also provides an opportunity to share information on ongoing clinical trials with physicians. Case presentations should be systematic to discuss all new and challenging cases before, during, and after the treatment. Human resource development, particularly of head and neck medical oncologists, is crucial. The type of multidisciplinary network between medical staff and the extent of patient intervention differs among MTB teams. Subsequently, a virtual MTB can establish a medical network between institutions that will contribute to the equalization and centralization of head and neck oncologic care.

Using coword analysis and chord diagrams to examine the effect of nutritional counseling and support (DCNS) on patients with oral and oropharyngeal cancer

BACKGROUND

Dietary counseling and nutritional support (DCNS) are generally accepted as being necessary for patients with oral cancer and oropharyngeal cancer (OC). However, there is no evidence that dietary counseling plays a significant role in weight loss. In this study, we examined the DCNS based on persistent weight loss during and after treatment in oral cancer and OC patients, as well as the effect of body mass index (BMI) on survival in both groups.

METHODS

A retrospective chart review was conducted on 2622 patients diagnosed with cancer between 2007 and 2020, including 1836 oral and 786 oropharyngeal patients. In comparison with the sample of patients treated by DCNS, differences in proportional counts for key factors associated with survival were compared between oral cancer and OC patients using the forest plot. An analysis of cowords was conducted to determine CNS associated with weight loss and overall survival. The Sankey diagram was used to display DCNS effectiveness. The log-rank test was used to evaluate the chi-squared goodness of fit test on the null assumption model of equal survival distributions between the groups.

RESULTS

Almost 41% of the patients (=1064/2262) received DCNS, with a frequency ranging from 1 to 44. Counts for 4 DCNS categories were 566, 392, 92, and 14, respectively, against BMI increases or decreases from much to less with counts of 3, 44, 795, 219, and 3, respectively. In the first year following treatment, DCNS decreased sharply to 50%. One year after hospital discharge, the overall weight loss increased from 3 to 9% (mean = -4%, standard deviation = 14%). Patients with a BMI above average had a significantly longer survival time (P < .001). Statistically, OC patients have a significantly higher survival rate than oral cancer patients.

CONCLUSION

Despite receiving frequent DCNS, patients continued to lose body weight during and 1 year after treatment. The survival time of an individual with a BMI above average appears to be increased. Future studies should preferably use randomized trials to compare standard DCNS with more intensive DCNS, which includes earlier and/or prolonged treatment.

The potential role of prebiotics, probiotics, and synbiotics in adjuvant cancer therapy especially colorectal cancer

Cancer is a global health issue that is rising swiftly with younger people and an increased number of patients. The role of human microbiota in the pathophysiology of tumors has been paid more and more attention. Microecologics including prebiotics, probiotics, and synbiotics are among the best validated/proven resources for the application of microbiological prophylaxis and therapy. There is strong evidence that microecologics have anti-cancer activity and their potential association with cancer is significant. In this review, we will focus on the role of prebiotics, probiotics, and synbiotics in tumor suppression in maintaining the colon barrier, metabolism, immune regulation, inhibition of host tumor cell proliferation, and epidemiological-based recommendations. Besides, other signs illuminate the role of microecological agents to adjunct the cancer treatment and counter the toxic side effects of cancer drugs. In addition, we will explore their role in chemotherapy, where these probiotics can be used as an adjunct to chemotherapy, counteracting the toxic side effects of chemotherapy drugs to minimize or optimize the therapeutic effect. In the treatment of cancer, we can see the role of prebiotics, probiotics, synbiotics, and their application in cancer patients, and the effectiveness effect can be considered as a clinical benefit. PRACTICAL APPLICATIONS: A large number of studies have shown that microecologics including prebiotics, probiotics, and synbiotics play an important role in regulating intestinal microecology and contribute to the prevention and treatment of cancer, indicating that prebiotics, probiotics, and synbiotics have the potential to be used as microecological modulators in the adjuvant therapy of cancer. However, it is not clear what is the anti-tumor mechanism of these microecologics and how they antagonize the side effects of cancer chemotherapy and protect normal cells. This paper reviews the role of prebiotics, probiotics, and synbiotics in tumor suppression in maintaining the colon barrier, metabolism, immune regulation, and prevention of rapid growth of host cells, as well as their potential role in cancer chemotherapy. This review helps to better understand the relationship between prebiotics, probiotics, and synbiotics with immune regulation, intestinal microecology, metabolic regulation, and cell proliferation and provides strong evidence for their potential application as microecologics in cancer adjuvant therapy.

Clinical Impact of Cachexia in Head and Neck Cancer Patients Who Received Chemoradiotherapy

Purpose

There have been few reports on the evaluation of cancer cachexia based on skeletal muscle mass index (SMI) in patients with head and neck cancer.

Patients and Methods

One hundred and ninety-two head and neck cancer patients were enrolled. In definitive and adjuvant chemoradiotherapy settings, clinical outcomes were compared between cachexia and non-cachexia patients.

Results

Forty patients were diagnosed with cachexia (20.8%). In the definitive setting, overall survival (OS) was significantly shorter in the cachexia group (3-year OS: 50.0% vs 88.5%; p < 0.01), and multivariate analysis identified UICC stage IV, baseline albumin of <4 and cachexia as poor prognostic factors. However, cachexia was not significant in the adjuvant setting.

Conclusion

Cancer cachexia was negatively associated with prognosis in patients with HNC who received definitive chemoradiotherapy. Nutritional intervention during chemoradiotherapy may improve survival in these patients.

The effect of navigation programme on the management of symptoms related to head and neck radiotherapy

BACKGROUND

This study aims to determine the effect of navigation programme in the management of symptoms related to head and neck cancer (HNC) radiotherapy.

METHODS

This randomized, controlled and experimental study was conducted between November 2018 and March 2020 with the participation of 88 patients with HNC receiving radiotherapy. Referring to the pre-prepared randomization checklist, 41 people were randomized to the experimental group and 47 to the control group. While the standard treatment approaches of the hospital were applied to all patients, the patients in the experimental group were applied an additional nursing navigation program. At the beginning of the navigation program, the patients were given a 30-minute visual training on the first day of radiotherapy and a handbook related to the expected adverse effects. Throughout subsequent seven weeks, the patient continued to be followed up via phone reminders, providing daily counseling and a weekly follow-up. Patient identification form, CTCAE v5.0 toxicity criteria and EORTC QLQ-30, H&N35 assessment questionnaires were used in the study. The first result was the difference observed in quality of life scores at the beginning, middle and end of radiotherapy.

RESULTS

Data obtained from the study revealed that the quality of life scores (p < 0.05) improved while the navigation program reduced the severity of symptoms such as mucositis, dysphagia, oral pain and weight loss (p < 0.05).

CONCLUSION

It was concluded that navigation programme is an effective approach for patients receiving head and neck radiotherapy.

TRIAL REGISTRATION

NCT04857749.

Weight loss and its impact on outcome in head and cancer patients during chemo-radiation

BACKGROUND

Weight loss during chemotherapy and its impact on the cancer outcomes have been invariably reported in the literature. We also did a post-hoc analysis of a randomized phase III trial to see the same.

MATERIALS AND METHODS

The database of a recently published randomized study comparing cisplatin-radiation with nimotuzumab cisplatin-radiation was used for this analysis. Week-wise weight loss during the course of treatment was noted. The impact of severe weight loss (grade 2-3) on progression-free survival (PFS), locoregional control (LRC) and overall survival (OS) was studied using the Kaplan Meier method. Binary logistic regression analysis was used to see the effect of various factors.

RESULTS

Out of a total of 536 patients, weight loss was captured in 524. Out of these 524 patients, any degree of weight loss was seen in 293 (55.91%) patients. Grade 1 weight loss was noted in 192 (36.6%) patients, grade 2 in 96 (18.3%) and grade 3 in 5 (1%) patients. The 2-year PFS was 53% and 57.1% in severe and non-severe weight loss groups respectively (p-value = 0.36). The 2-year LRC was 60% in patients with severe weight loss, while it was 63.5% in those with non-severe weight loss (p-value = 0.47). The 2-year OS was 59.3% versus 62.2% in severe and non-severe weight loss cohorts respectively (p-value = 0.21). None of the factors was found to be associated with severe weight loss.

CONCLUSION

Severe weight loss was uncommon in our patients. Weight loss during treatment was not associated with poor survival outcomes.

A predictive model for swallowing dysfunction after oral cancer resection

Aggressive therapy of oral cancers is associated with significant postoperative morbidity. Patients with feeding issues may require nutritional support. In our unit, patients identified as developing feeding issues are reactively referred for specialist input through a feeding issues multidisciplinary team meeting (FiMDT). Reactive feeding increases length of patient stay (LOS) and may contribute to patient morbidity. We aimed to develop a model to pre-emptively identify patients likely to develop feeding issues postoperatively, to facilitate the establishment of a preoperative referral pathway to increase patient flow. All referrals to a Head and Neck multidisciplinary team meeting over a five-year period were identified and preoperative factors were extracted. Linear regression was used to confirm that FiMDT was an independent predictor of LOS. Logistic regression was used to determine if referral to FiMDT could be predicted based on preoperative factors only. A total of 203 patients met inclusion criteria for analysis. Inpatient referral to FiMDT was an independent predictor of LOS. Significant predictors of inpatient FiMDT referral included tracheostomy, patient age, and alcohol intake. The resulting model was 90% sensitive and 93.8% specific with a threshold of 0.2. We have shown that inpatient FiMDT referral is an independent predictor of patient length of stay, and that the odds of referral can be robustly predicted. We aim to use this model in redirecting emphasis to a preoperative referral pathway for improved patient flow.

Cancer cachexia in adult patients: ESMO Clinical Practice Guidelines☆

•This ESMO Clinical Practice Guideline provides key recommendations for managing cancer-related cachexia. •It covers screening, assessment and multimodal management of cancer cachexia. •All recommendations were compiled by a multidisciplinary group of experts. •Recommendations are based on available scientific data and the author's expert opinion.

Optimal frequency of individualised nutrition counselling in patients with head and neck cancer receiving radiotherapy: A systematic review

BACKGROUND

Head and neck cancers (HNC) are strongly associated with malnutrition. This systematic review aimed to investigate the optimal frequency of individualised nutrition counselling (INC) pre-, peri- and post-treatment for patients with HNC.

METHODS

Pubmed, EMBASE, Cinahl and Scopus were searched from inception through to April 2020 to identify randomised controlled trials (RCTs) that focused on the INC frequency for adult patients with HNC (Registration no. 178868). The outcomes assessed were nutritional status, dietary intake, weight change, treatment interruptions, unplanned hospital admissions, quality of life, complications and morbidity. Certainty of evidence was assessed using Grades of Recommendation, Assessment, Development and Evaluation (GRADE).

RESULTS

Four RCTs were identified with five papers (n = 500 total participants). The certainty of evidence was 'high' for nutritional status and quality of life, 'moderate' for treatment interruptions and unplanned hospital admissions, and 'low' for percentage weight change, complications/morbidity and dietary intake. Compared to control groups, there were consistent improvements for nutritional status, quality of life, treatment interruptions, unplanned hospital admissions, dietary intake, percentage weight change and morbidity when weekly INC was provided peri-treatment and fortnightly INC was provided post-treatment. No statistical significance was found for treatment interruptions, dietary intake and weight change when INC was provided fortnightly peri-treatment only. There were no RCTs in the current review that offered INC pre-treatment.

CONCLUSIONS

This systematic review shows beneficial effects with weekly INC peri-treatment and fortnightly INC post-treatment for patients with HNC in all outcomes studied. Future research should focus on models of care to address the optimal frequency of pre-treatment INC as well as the duration of post-treatment INC.

Impact of geniohyoid and masseter muscle masses on dysphagia after salvage surgery and radiotherapy in head and neck cancer

This study aimed to determine whether geniohyoid and/or masseter muscle mass can predict the severity of dysphagia after salvage surgery for head and neck cancer. We conducted a retrospective cohort study of 45 male patients with head and neck cancer (median age, 68 years) who underwent salvage surgery. The preoperative geniohyoid and masseter muscle masses were evaluated using computed tomography and the severity of dysphagia was evaluated by Penetration Aspiration Scale (PAS), Functional Oral Intake Scale (FOIS) and Oropharyngeal swallow efficiency (OPSE). The median PAS, FOIS and OPSE scores after surgery were 7 (interquartile range [IQR] 1–8), 6 (IQR 2–7) and 95.8 (IQR 67.1–116.2), respectively. The mean geniohyoid muscle masses were 3.13 ± 0.78 cm² and the mean masseter muscle masses were 4.37 ± 0.99 cm², respectively. The multivariate analysis showed that the geniohyoid muscle mass was significantly associated with the PAS, FOIS and OPSE scores. Conversely, the masseter muscle mass was not significantly associated with the PAS score but was significantly associated with the FOIS and OPSE scores. Geniohyoid muscle mass may predict the severity of dysphagia after salvage surgery.

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.

Exercise and Nutrition Interventions in Patients with Head and Neck Cancer during Curative Treatment: A Systematic Review and Meta-Analysis

The aim of this meta-analysis was to examine the effects of nutritional and physical exercise interventions and interventions combining these interventions during radiotherapy treatment for patients with head and neck cancer on body composition, objectively measured physical function and nutritional status. Systematic electronic searches were conducted in MEDLINE (PubMed interface), EMBASE (Ovid interface), CINAHL (EBSCO interface) and Cochrane Library (Wiley interface). We identified 13 randomized controlled trials (RCTs) that included 858 patients. For body composition, using only nutrition as intervention, a significant difference between treatment and control group were observed (SMD 0.42 (95CI 0.23-0.62), p < 0.001). Only pilot RCTs investigated combination treatment and no significant difference between the treatment and control groups were found (SMD 0.21 (95CI -0.16-0.58), p = 0.259). For physical function, a significant difference between treatment and control group with a better outcome for the treatment group were observed (SMD 0.78 (95CI 0.51-1.04), p < 0.001). No effects on nutritional status were found. This meta-analysis found significantly positive effects of nutrition and physical exercise interventions alone in favor of the treatment groups. No effects in studies with combined interventions were observed. Future full-scaled RCTs combining nutrition and physical exercise is warranted.

Reliability and validity of the mandarin version of the supportive care needs survey short-form (SCNS-SF34) and the head and neck cancer-specific supportive care needs (SCNS-HNC) module

Background

This study aimed to translate the English version of the supportive care needs scale of head and neck cancer patients (SCNS-HNC) questionnaire into Mandarin and to test the reliability and validity of the SCNS-SF34 and SCNS-HNC module in head and neck cancer patients.

Methods

The Mandarin version of the Supportive Care Needs Survey Short-Form (SCNS-SF34) and SCNS-HNC scales were used to assess 206 patients with head and neck cancer in Chengdu, China. Among them, 51 patients were re-tested 2 or 3 days after the first survey. The internal consistency of the scale was evaluated by Cronbach’s alpha coefficient, the retest reliability of the scale was evaluated by retest correlation coefficient r, the structural validity of the scale was evaluated by exploratory factor analysis, and the ceiling and floor effects of the scale were evaluated.

Results

The Mandarin version of the SCNS-HNC had Cronbach’s alpha coefficients greater than 0.700 (0.737 ≤ 0.962) for all of the domains. Except for the psychological demand dimension (r = 0.674) of the SCNS-SF34 scale, the retest reliability of the other domains was greater than 0.8. Three common factors were extracted by exploratory factor analysis, and the cumulative variance contribution rate was 64.39%.

Conclusions

The Mandarin version of the SCNS-SF34 and SCNS-HNC demonstrated satisfactory reliability and validity and is able to measure the supportive care needs of Chinese patients with head and neck cancer.

Trial registration

ChiCTR, ChiCTR1900026635. Registered 16 October 2019- Retrospectively registered.

Cancer cachexia and treatment toxicity

PURPOSE OF REVIEW

Cancer cachexia is a metabolic disturbance resulting in a loss of skeletal muscle mass that is generally not reversed through traditional nutritional interventions. We review on both the impact of nutritional status on cancer treatment side effects, as well as cancer- specific outcomes.

RECENT FINDINGS

Cancer-specific cachexia and sarcopenia are associated with increased treatment-associated toxicity, and overall worse cancer-specific outcomes across all cancer types in surgical, chemotherapeutic, and radiotherapeutic populations. Despite the fact that cancer cachexia is generally thought to be irreversible, there is some evidence that nutritional intervention can be helpful.

SUMMARY

Nutritional status is an important factor to consider in determining cancer therapy. Patients with poor nutritional status should be identified prior to the initiation of therapy and be monitored judiciously.

How Should We Approach Locally Advanced Squamous Cell Carcinoma of Head and Neck Cancer Patients Ineligible for Standard Non-surgical Treatment?

PURPOSE OF REVIEW

Cisplatin has been established as one of the most important agents in multidisciplinary treatment for head and neck cancer (HNC). However, since HNC patients are often elderly and typically have several comorbidities, a limited number of patients can tolerate high-dose cisplatin in real-world HNC populations. We will provide a review of therapeutic alternatives to high-dose cisplatin-based treatment in the setting of definitive and postoperative chemoradiotherapy (CRT) or induction chemotherapy.

RECENT FINDINGS

Clinical criteria for CDDP ineligibility have been discussed in HNC. When considering cisplatin-based chemotherapy as part of a non-surgical approach, precise evaluation of the patient's physical condition, nutritional status, and comorbidities is needed. Upfront surgery is an important option with high curability, if a de-intensified non-surgical approach is estimated to be unavoidable. Although no prospective data are available regarding alternatives to definitive cisplatin-based combination therapy for patients undergoing a non-surgical approach, cetuximab, carboplatin, or split-dose cisplatin-based regimens may be employed for cisplatin-ineligible patients in clinical practice. The combination of immune checkpoint inhibitors with radiotherapy may be a promising novel approach, and some trials are currently targeting the specific cohort of patients ineligible for high-dose cisplatin. There are no standard treatments for patients ineligible for high-dose cisplatin. A personalized treatment strategy should be proposed based on the individual benefit-to-risk ratio of each treatment option in patients ineligible for the standard of care. Prospective clinical trials for cisplatin-ineligible patients with locally advanced HNC still need to be performed.

A prospective nutritional assessment using Mini Nutritional Assessment-short form among patients with head and neck cancer receiving concurrent chemoradiotherapy

BACKGROUND

No gold standard of nutritional assessment is established among patients with head and neck cancer (HNC) receiving concurrent chemoradiotherapy (CCRT). This study aimed to evaluate the clinical significance of pre-treatment nutritional status using the Mini Nutritional Assessment-short form (MNA-SF) among HNC patients receiving CCRT.

METHODS

A total of 461 consecutive patients with newly diagnosed HNC treated with definitive CCRT at three medical institutes were prospectively enrolled. Nutritional status was assessed using MNA-SF within 7 days before CCRT initiation. Patients were classified as having normal nutrition, at risk of malnutrition, and malnourished groups according to MNA-SF for comparison.

RESULTS

The 1-year overall survival rates were 89.8%, 76.8%, and 67.7% in the normal nutrition, at risk of malnutrition, and malnourished groups, respectively. Patients with normal nutrition had significantly lower rates of uncompleted radiotherapy and chemotherapy (4.5% and 4.1%, respectively) compared with patients at risk for malnutrition (14.1% and 11.5%, respectively) and those malnourished (11.1% and 11.1%, respectively). Patients with normal nutrition had significantly lower treatment-related complication rates regarding emergency room visits, hospital admission, and need for tubal feeding than those with at risk of malnutrition and malnourished. Patients with normal nutrition had significantly fewer severe hematologic toxicities (p = 0.044) and severe non-hematologic toxicities (p = 0.012) of CCRT than those malnourished.

CONCLUSION

Pre-CCRT nutritional status identifies HNC patients vulnerable to treatment interruption and treatment complications. We suggest that nutritional assessment with MNA-SF should be incorporated in pre-CCRT evaluation for all HNC patients.

[Nutritional aspects of the palliative care of head and neck cancer patients]

Nutrition remains a relevant issue until the end of life, both for patients and their relatives. This is particularly true for palliative patients with advanced head and neck cancer. In addition to local problems caused by the disease and its treatment, patients suffer from social aspects such as isolation, decreasing strength, and reduced mobility. Effective nutritional counselling and therapy are necessary to retain quality of life and self-care for as long as possible. Dialogue between the palliative care team and ENT oncologists should serve as the basis for developing an individual plan for each patient in this difficult situation. A special section of this manuscript focuses on the value of traditional herbal medicine for different ENT symptoms in the context of nutrition. The aim of this review is to promote qualified discussion between patient, relatives, and professionals.

Head and Neck Cancers, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

Treatment is complex for patients with head and neck (H&N) cancers with specific site of disease, stage, and pathologic findings guiding treatment decision-making. Treatment planning for H&N cancers involves a multidisciplinary team of experts. This article describes supportive care recommendations in the NCCN Guidelines for Head and Neck Cancers, as well as the rationale supporting a new section on imaging recommendations for patients with H&N cancers. This article also describes updates to treatment recommendations for patients with very advanced H&N cancers and salivary gland tumors, specifically systemic therapy recommendations.

Association between nutritional risk index and outcomes for head and neck cancer patients receiving concurrent chemo-radiotherapy

BACKGROUND

Patients receiving chemoradiotherapy for head and neck cancer (HNC) are often malnourished. We assessed the utility of nutritional risk index (NRI) in HNC patients undergoing chemoradiotherapy.

METHODS

A population-based retrospective review of HNC patients treated with curative chemoradiation was performed. Demographics, anthropometrics, overall survival (OS), and the composite treatment complication rate (G-tube dependence, radiation incompletion, 90-day mortality, and unplanned hospitalization) were collected.

RESULTS

Two hundred ninety-two patients were identified. Average pretreatment and posttreatment NRI were 110 (SD 3) and 99 (SD 12), respectively (P < .01). Pretreatment NRI risk category, age, ECOG status, and tumor subsites were associated with OS on multivariate analysis. Pretreatment NRI risk category was associated with risk of treatment related complications.

CONCLUSIONS

There was a significant decrease between pretreatment and posttreatment NRI in HNC patients receiving chemoradiation. Pretreatment NRI risk category may predict OS and composite treatment complications. Investigation of NRI as a prognostic factor is warranted.

AHNS Series - Do you know your guidelines?: Assessment and management of malnutrition in patients with head and neck cancer: Review of the NCCN Clinical Practice Guidelines In Oncology (NCCN Guidelines)

This article is a part of the "Do you know your guidelines" series by the Education Committee of the American Head and Neck Society. The aim is to summarize the core principles outlined by the NCCN Clinical Practice Guidelines In Oncology (NCCN Guidelines^® ) on management of malnutrition in patients with head and neck cancer. We outline the current recommendations from the National Comprehensive Cancer Network^® (NCCN^® ) for the screening and management of malnutrition, including indications for nutritional supplementation and placement of a nasogastric or gastrostomy tube. We also include a brief review of the available literature on additional screening tools, alternative guidelines, as well as an update on the emerging data surrounding the use of immune-enhancing nutrition.

Clinical, dietary and demographic characteristics interfering on quality of life of cancer patients

OBJECTIVE

To estimate the dietary intake of cancer patients and its relation with clinical and demographic characteristics, and to assess the contribution of dietary intake, appetite/symptoms and clinical and demographic characteristics to their quality of life.

METHODS

The consumption of energy and macronutrients of patients was estimated. The relation between dietary intake and clinical and demographic characteristics was evaluated by analysis of variance. The intake of energy and macronutrient of the patients was compared to the nutritional recommendations using 95% confidence interval. The Cancer Appetite and Symptom Questionnaire (CASQ) and the European Organization for Research and Treatment of Cancer (EORTC QLQ C-30) were used to assess appetite/symptoms and quality of life, respectively. The psychometric properties of the instruments were estimated. A structural equation model was prepared.

RESULTS

In this study, 772 cancer patients (63.1% women) participated. There was a significant relation between dietary intake and work activity, economic class, specialty field of cancer, type of treatment and nutritional status. Patients' energy and macronutrients intake was below recommended values. Both CASQ and EORTC QLQ C-30 were refined to fit the data. In the structural model, impaired appetite, more symptoms, presence of metastasis, being female and of higher economic classes were characteristics that significantly contributed to interfering in patients' quality of life.

CONCLUSION

The dietary intake of oncology patients did not reach the recommended values. Different characteristics impacted on quality of life of patients and should be considered in clinical and epidemiological protocols.

Attitudes of radiation oncologists to percutaneous endoscopic gastrostomy in patients with head and neck cancer and eating difficulties: A survey in China

Objective To investigate the attitudes of radiation oncologists towards using percutaneous endoscopic gastrostomy (PEG) to solve nutritional problems in patients with head and neck cancer (HNC) undergoing radiotherapy. Methods A self-reported questionnaire was developed and used to assess the willingness of radiation oncologists from 26 hospitals throughout several provinces in China to use the nutritional method. Results Of the 433 radiation oncologists who were contacted and returned questionnaires, 361 were completed correctly and used in the study (83.4% completion rate). Years of working and degree of understanding PEG were significantly related to the willingness of oncologists to use PEG in patients with HNC. Radiation oncologists who were willing to accept PEG training were more willing to use PEG. Main reasons for unwillingness to use PEG were poor understanding of the operation or cost and fear of side effects causing medical disputes. Conclusions The findings of the survey suggest that attitudes of radiation oncologists in China towards using PEG in patients with HNC requiring nutritional support may be improved by providing accessible training in the technique.

Consensus and clinical recommendations for nutritional intervention for head and neck cancer patients undergoing chemoradiotherapy in Taiwan

Because of the anatomical location, patients with head and neck cancer (HNC) frequently experience dysphagia and malnutrition at the time of diagnosis and these conditions are often exacerbated after chemoradiotherapy. There is an emerging medical need to establish a consensus on nutritional intervention for these patients. A panel of 30 senior physicians and experts from multidisciplinary teams drafted clinical recommendations to improve the management of nutritional interventions in Taiwan and to provide updated treatment strategy recommendations in hope of improving the nutritional status of patients with HNC. This clinical review describes the resulting consensus document, including the impact of malnutrition on clinical outcomes, the role of prophylactic tube feeding, the choice of tube feeding, and the benefit of oral nutritional supplements in patients with HNC undergoing chemoradiotherapy. The outcomes of this review will support clinicians in their efforts to improve the nutritional status of patients with HNC.

A phase II study of HMB/Arg/Gln against oral mucositis induced by chemoradiotherapy for patients with head and neck cancer

PURPOSE

This phase II trial assessed the clinical benefit of beta-hydroxy-beta-methylbutyrate, arginine, and glutamine (HMB/Arg/Gln) for preventing chemoradiotherapy (CRT)-induced oral mucositis (OM) in patients with head and neck cancer (HNC).

METHODS

Patients with HNC receiving definitive or postoperative cisplatin-based CRT were enrolled. HMB/Arg/Gln was administered orally or per percutaneous endoscopic gastrostomy from the first day of CRT up to its completion. All patients received opioid-based pain control and oral care programs that we previously reported. The primary endpoint was the incidence of grade ≥ 3 OM (functional/symptomatic) according to the Common Terminology Criteria of Adverse Events version 3.0. Quality of life (EORTC QLQ-C30/PROMS) at baseline and upon radiotherapy at a dosage of 50 Gy were assessed.

RESULTS

Thirty-five patients with HNC were enrolled. Sixteen of them (45.7%) developed grade ≥ 3 OM (i.e., functional/symptomatic). The incidence of grade ≤ 1 OM (functional/symptomatic) was 51.5% at 2 weeks and 82.9% at 4 weeks after radiotherapy completion. Clinical examination revealed that 10 patients (28.6%) developed grade ≥ 3 OM. The incidence of grade ≤ 1 OM (clinical exam) was 80.0% at 2 weeks and 100% at 4 weeks after radiotherapy completion. Adverse events related to HMB/Arg/Gln were an increase in blood urea nitrogen and diarrhea, but were easily managed.

CONCLUSIONS

The addition of HMB/Arg/Gln to opioid-based pain control and oral care programs was feasible but still insufficient at reducing the incidence of CRT-induced severe OM. However, the benefit of HMB/Arg/Gln should not be neglected given the findings of clinical examinations and the rapid recovery from severe OM.

TRIAL REGISTRATION

UMIN000016453.

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.

Nutritional management in head and neck cancer: United Kingdom National Multidisciplinary Guidelines

Nutritional support and intervention is an integral component of head and neck cancer management. Patients can be malnourished at presentation, and the majority of patients undergoing treatment for head and neck cancer will need nutritional support. This paper summarises aspects of nutritional considerations for this patient group and provides recommendations for the practising clinician.

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

Background. Radiotherapy (RT) has been associated with increased risk of malnutrition in cancer patients, particularly in those with head and neck cancer (HNC). The aim of this prospective study was to evaluate the effects of compliance of patients with individual dietary counselling on body composition parameters in HNC patients under RT. Material and Methods. Sixty-nine consecutive patients (mean age: 61.0 ± 13.8) were prospectively followed. Bioelectrical impedance analysis (BIA) was performed to determine body composition parameters before, in the middle of, and at the end of RT. All patients received nutritional counselling and majority of them (94.6%) received oral nutritional supplement (ONS) during RT or chemoradiotherapy. If a patient consumed ≥75% of the recommended energy and protein intake via ONS and regular food, he/she was considered to be “compliant” (n = 18), while those who failed to meet this criteria were considered to be “noncompliant” (n = 30). Results. Body mass index, weight, fat percentage, fat mass, fat free mass, and muscle mass did not decrease significantly over time in compliant patients, but in noncompliant patients, all of these indices decreased significantly from baseline compared to the end of treatment (p < 0.001). Hand grip strength did not differ significantly between the two groups at baseline and over time in each group. When retrospectively evaluated, heavy mucositis was less commonly observed in compliant than noncompliant patients (11.1% versus 88.9%, resp.) (p < 0.009). Conclusion. We conclude that body composition parameters were better in head and neck cancer patients considered as compliant with nutritional counselling than noncompliant ones during RT period.

Comparison of Nutritional and Clinical Outcomes in Patients with Head and Neck Cancer Undergoing Chemoradiotherapy Utilizing Prophylactic versus Reactive Nutrition Support Approaches

BACKGROUND

The optimal method of tube feeding for patients with head and neck cancer remains unclear. A validated protocol is available that identifies high-nutritional-risk patients who would benefit from prophylactic gastrostomy tube placement. Adherence to this protocol is ultimately determined by clinical team discretion or patient decision.

OBJECTIVE

The study aim was to compare outcomes after adherence and nonadherence to this validated protocol, thus comparing a prophylactic and reactive approach to nutrition support in this patient population.

DESIGN

We conducted a prospective comparative cohort study. Patients were observed during routine clinical practice over 2 years.

PARTICIPANTS/SETTING

Patients with head and neck cancer having curative-intent treatment between August 2012 and July 2014 at a tertiary hospital in Queensland, Australia, were included if assessed as high nutrition risk according to the validated protocol (n=130). Patients were grouped according to protocol adherence as to whether they received prophylactic gastrostomy (PEG) per protocol recommendation (prophylactic PEG group, n=69) or not (no PEG group, n=61).

MAIN OUTCOME MEASURES

Primary outcome was percentage weight change during treatment. Secondary outcomes were feeding tube use and hospital admissions.

STATISTICAL ANALYSIS PERFORMED

Fisher's exact, χ², and two sample t tests were performed to determine differences between the groups. Linear and logistic regression were used to examine weight loss and unplanned admissions, respectively.

RESULTS

Patients were 88% male, median age was 59 years, with predominantly stage IV oropharyngeal cancer receiving definitive chemoradiotherapy. Statistically significantly less weight loss in the prophylactic PEG group (7.0% vs 9.0%; P=0.048) and more unplanned admissions in the no PEG group (82% vs 75%; P=0.029). In the no PEG group, 26 patients (43%) required a feeding tube or had ≥10% weight loss.

CONCLUSIONS

Prophylactic gastrostomy improved nutrition outcomes and reduced unplanned hospital admissions. Additional investigation of characteristics of patients with minimal weight loss or feeding tube use could help refine and improve the protocol.

Prognostic Factors and Multidisciplinary Postoperative Chemoradiotherapy for Clinical T4a Tongue Cancer

OBJECTIVE

The prognosis of patients with locally advanced squamous cell carcinoma (SCC) of the tongue is poor. Postoperative chemoradiotherapy (CRT) improves locoregional control and survival in high-risk patients. We investigated the prognostic factors for clinical T4a tongue SCC, and elucidated whether postoperative CRT has a benefit for patients with poor prognosis in terms of survival.

METHODS

We performed a retrospective analysis of 61 patients with stage T4a SCC of the tongue who underwent primary resection and neck dissection.

RESULTS

The median follow-up was 53.8 months. Multivariate analysis revealed a 4.26× relative risk of death for patients with the involvement of ≥5 regional lymph nodes (pN ≥5) compared with those with pN 0-4 (p = 0.002). In Kaplan-Meier analysis, patients with pN ≥5 who received CRT had longer overall survival rates than those who did not (hazard ratio = 0.31; p = 0.041).

CONCLUSIONS

pN ≥5 is the most powerful prognostic factor for clinical T4a SCC of the tongue. Postoperative CRT is recommended in patients with pN ≥5.

Association of Body Composition With Survival and Locoregional Control of Radiotherapy-Treated Head and Neck Squamous Cell Carcinoma

IMPORTANCE

Major weight loss is common in patients with head and neck squamous cell carcinoma (HNSCC) who undergo radiotherapy (RT). How baseline and posttreatment body composition affects outcome is unknown.

OBJECTIVE

To determine whether lean body mass before and after RT for HNSCC predicts survival and locoregional control.

DESIGN, SETTING, AND PARTICIPANT

Retrospective study of 2840 patients with pathologically proven HNSCC undergoing curative RT at a single academic cancer referral center from October 1, 2003, to August 31, 2013. One hundred ninety patients had computed tomographic (CT) scans available for analysis of skeletal muscle (SM). The effect of pre-RT and post-RT SM depletion (defined as a CT-measured L3 SM index of less than 52.4 cm2/m2 for men and less than 38.5 cm2/m2 for women) on survival and disease control was evaluated. Final follow-up was completed on September 27, 2014, and data were analyzed from October 1, 2014, to November 29, 2015.

MAIN OUTCOMES AND MEASURES

Primary outcomes were overall and disease-specific survival and locoregional control. Secondary analyses included the influence of pre-RT body mass index (BMI) and interscan weight loss on survival and recurrence.

RESULTS

Among the 2840 consecutive patients who underwent screening, 190 had whole-body positron emission tomography-CT or abdominal CT scans before and after RT and were included for analysis. Of these, 160 (84.2%) were men and 30 (15.8%) were women; their mean (SD) age was 57.7 (9.4) years. Median follow up was 68.6 months. Skeletal muscle depletion was detected in 67 patients (35.3%) before RT and an additional 58 patients (30.5%) after RT. Decreased overall survival was predicted by SM depletion before RT (hazard ratio [HR], 1.92; 95% CI, 1.19-3.11; P = .007) and after RT (HR, 2.03; 95% CI, 1.02-4.24; P = .04). Increased BMI was associated with significantly improved survival (HR per 1-U increase in BMI, 0.91; 95% CI, 0.87-0.96; P < .001). Weight loss without SM depletion did not affect outcomes. Post-RT SM depletion was more substantive in competing multivariate models of mortality risk than weight loss-based metrics (Bayesian information criteria difference, 7.9), but pre-RT BMI demonstrated the greatest prognostic value.

CONCLUSIONS AND RELEVANCE

Diminished SM mass assessed by CT imaging or BMI can predict oncologic outcomes for patients with HNSCC, whereas weight loss after RT initiation does not predict SM loss or survival.

Multicenter phase II study of an oral care program for patients with head and neck cancer receiving chemoradiotherapy

PURPOSE

This multicenter phase II trial assessed the clinical benefit of a multidisciplinary oral care program in reducing the incidence of severe chemoradiotherapy-induced oral mucositis (OM).

METHODS

Patients with head and neck cancer (HNC) who were scheduled to receive definitive or postoperative chemoradiotherapy were enrolled. The oral care program included routine oral screening by dentists and a leaflet containing instructions regarding oral care, nutrition, and lifestyle. Oral hygiene and oral care were evaluated continuously during and after the course of chemoradiotherapy. The primary endpoint was the incidence of grade ≥3 OM assessed by certified medical staff according to the Common Terminology Criteria of Adverse Events version 3.0.

RESULTS

From April 2012 to December 2013, 120 patients with HNC were enrolled. Sixty-four patients (53.3 %) developed grade ≥3 OM (i.e., functional/symptomatic). The incidence of grade ≤1 OM at 2 and 4 weeks after radiotherapy completion was 34.2 and 67.6 %, respectively. Clinical examination revealed that 51 patients (42.5 %) developed grade ≥3 OM during chemoradiotherapy. The incidence of grade ≤1 OM at 2 and 4 weeks after radiotherapy completion was 54.7 and 89.2 %, respectively. The incidences of grade 3 infection and pneumonitis throughout chemoradiotherapy were <5 %. Only 6.7 % of patients had unplanned breaks in radiotherapy, and 99.2 % completed treatment.

CONCLUSIONS

A systematic oral care program alone is insufficient to decrease the incidence of severe OM in patients with HNC being treated with chemoradiotherapy. However, systematic oral care programs may indirectly improve treatment compliance by decreasing infection risk.

TRIAL REGISTRATION NUMBER

UMIN000006660.

The provision of enteral nutritional support during definitive chemoradiotherapy in head and neck cancer patients

Combination chemoradiation is the gold standard of management for locally advanced squamous cell carcinomas of the head and neck. One of the most significant advantages of this approach to treatment is organ preservation which may not be possible with radical surgery. Unfortunately, few treatments are without side-effects and the toxicity associated with combined modality treatment causes meaningful morbidity. Patients with head and neck cancer (HNC) may have difficulties meeting their nutritional requirements as a consequence of tumour location or size or because of the acute toxicity associated with treatment. In particular, severe mucositis, xerostomia, dysgeusia and nausea and vomiting limit intake. In addition to this, dysphagia is often present at diagnosis, with many patients experiencing silent aspiration. As such, many patients will require enteral nutrition in order to complete chemoradiotherapy (CRT). Feeding occurs via catheters placed transnasally (nasogastric tubes) or directly into the stomach through the anterior abdominal wall (percutaneous gastrostomy tubes). In the absence of clear evidence concerning the superiority of one method over another, the choice of feeding tube tends to be dependent on clinician and patient preference. This review examines key issues associated with the provision of enteral nutritional support during definitive CRT in HNC patients, including feeding methods, patient outcomes and timing of tube insertion and use.

Prediction of critical weight loss during radiation treatment in head and neck cancer patients is dependent on BMI

PURPOSE

The aims of the present study were to explore pre-treatment predictors of weight loss during radiation treatment only in head and neck cancer (HNSCC) patients and investigate the weight loss in patients with or without a feeding tube.

METHODS

Retrospectively, weight change during curative radiotherapy was investigated in 476 consecutive HNSCC patients. Independent predictors were identified using multivariate regression analysis with weight loss below or above 5 % as the primary dependent variable.

RESULTS

Baseline BMI, tumor site, and stage predicted weight loss above 5 %. The odds of weight loss above 5 % in patients with BMI >25 were 3.00 ± 0.64 times higher compared with patients with BMI <25 (p < 0.0001). Patients with pharyngeal, oral cavity, or supraglottic tumors had 3.12 ± 0.80 times higher odds of weight loss above 5 % compared with glottic cancer patients (p < 0.0001), and the odds were 1.68 ± 0.40 times higher in stage III-IV patients compared with stage I-II patients (p = 0.03). Seperate analyses revealed that tumor site and stage only predicted weight loss in patients with BMI >25 but not in patients with BMI <25. Patients receiving a feeding tube weighed less than patients without (73.8 vs 78.3 kg) and feeding tube reduced, but did not prevent, weight loss which averaged 6.7 ± 4.7 kg (7.4 ± 4.7 %) compared with 4.7 ± 5.9 kg (5.5 ± 6.0 %) in patients without a feeding tube (P < 0.0001).

CONCLUSION

Pre-treatment BMI, tumor site and stage predicted weight loss above 5 % in HNSCC patients during radiotherapy. BMI should be considered when analyzing weight loss in HNSCC patients receiving curative radiotherapy.

[What nutritional management in patients with head and neck cancers undergoing radiotherapy? An overview]

Radiotherapy is an effective treatment for head and neck cancers but patients often experience side effects, which lead to malnutrition. Morbidity related to weight loss during treatment may include dehydration, hospitalization, compromised treatment efficacy, and reduced quality of life and may impact survival hence the importance of early nutritional management prior to radiotherapy. Multiple interventions have been implemented to help ameliorate the impact of treatment on weight loss and nutritional status, including the use of percutaneous endoscopic gastrostomy tubes. The goal of this overview is to search the predictive factors of malnutrition and an overview of the different types of nutritional interventions and their impact on the local control of the disease, mortality and quality of life of patients treated with radiotherapy or concomitant chemoradiotherapy.

Supportive Management of Mucositis and Metabolic Derangements in Head and Neck Cancer Patients

Oral mucositis (OM) is among the most undesirable, painful, and expensive toxicities of cytotoxic cancer therapy, and is disheartening for patients and frustrating for caregivers. Accurate assessment of the incidence of OM has been elusive, but accumulating data suggests that reported OM frequency is significantly less than its actual occurrence. It has been suggested that over 90% of head and neck cancer (HNC) patients receiving radiotherapy (RT) with concurrent cisplatin experience severe OM with symptoms of extreme pain, mucosal ulceration and consequent limitations in swallowing and achieving adequate nutritional intake. This panoply of symptoms inevitably impacts a patients' quality of life and their willingness to continue treatment. In spite of all the advances made in understanding the pathophysiology of OM, there is still no prophylactic therapy with proven efficacy. Strategies to limit the extent of OM and to manage its symptomatology include basic oral care, supportive medications, nutritional support and targeting aggressive treatments to high-risk patients. This review focuses on OM recognition, preventive measurements, and symptom-management strategies.

Squamous cell carcinoma of the lip: depth of invasion, local recurrence and regional metastases. Experience of a rural multidisciplinary head and neck unit

BACKGROUND

The internationally recognised American Joint Committee on Cancer (tumour-node-metastasis) staging system utilises tumour size to determine stage. Other factors (i.e. tumour depth) may provide additional prognostic information.

METHOD

A thorough retrospective analysis was performed of 68 patients with primary lip squamous cell carcinoma operated on or discussed by the Darling Downs Health Service between 2005 and 2013.

RESULTS

Twelve patients developed lymphatic spread. There was a statistically significant increased risk of nodal metastasis in: patients with tumours of increased thickness (U = 103.50; degrees of freedom = 68; p < 0.001), those with a larger overall tumour size (U = 163.50; degrees of freedom = 68; p = 0.005) and patients living further from the treatment centre (U = 199.00; degrees of freedom = 68; p = 0.018).

CONCLUSION

It may be reasonable that other factors are considered for staging of lip squamous cell carcinomas, in combination with tumour-node-metastasis staging. Depth of invasion may have utility in prognosis and treatment; however, larger prospective analysis needs to be performed. Patients living in a more rural setting presented with more advanced disease, suggesting an ongoing rural-metropolitan gap in healthcare.

Eating As Treatment (EAT) study protocol: a stepped-wedge, randomised controlled trial of a health behaviour change intervention provided by dietitians to improve nutrition in patients with head and neck cancer undergoing radiotherapy

INTRODUCTION

Maintaining adequate nutrition for Head and Neck Cancer (HNC) patients is challenging due to both the malignancy and the rigours of radiation treatment. As yet, health behaviour interventions designed to maintain or improve nutrition in patients with HNC have not been evaluated. The proposed trial builds on promising pilot data, and evaluates the effectiveness of a dietitian-delivered health behaviour intervention to reduce malnutrition in patients with HNC undergoing radiotherapy: Eating As Treatment (EAT).

METHODS AND ANALYSIS

A stepped-wedge cluster randomised design will be used. All recruitment hospitals begin in the control condition providing treatment as usual. In a randomly generated order, oncology staff at each hospital will receive 2 days of training in EAT before switching to the intervention condition. Training will be supplemented by ongoing supervision, coaching and a 2-month booster training provided by the research team. EAT is based on established behaviour change counselling methods, including motivational interviewing, cognitive-behavioural therapy, and incorporates clinical practice change theory. It is designed to improve motivation to eat despite a range of barriers (pain, mucositis, nausea, reduced or no saliva, taste changes and appetite loss), and to provide patients with practical behaviour change strategies. EAT will be delivered by dietitians during their usual consultations. 400 patients with HNC (nasopharynx, hypopharynx, oropharynx, oral cavity or larynx), aged 18+, undergoing radiotherapy (>60 Gy) with curative intent, will be recruited from radiotherapy departments at 5 Australian sites. Assessments will be conducted at 4 time points (first and final week of radiotherapy, 4 and 12 weeks postradiotherapy). The primary outcome will be a nutritional status assessment.

ETHICS AND DISSEMINATION

Ethics approval from all relevant bodies has been granted. Study findings will be disseminated widely through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12613000320752.

Dietary counselling and nutritional support in oropharyngeal cancer patients treated with radiotherapy: persistent weight loss during 1-year follow-ups

BACKGROUND/OBJECTIVES

The need for dietary counselling and nutritional support in oropharyngeal cancer patients is generally accepted. However, evidence for the effectiveness is sparse. The aim of this study was to describe dietary counselling, nutritional support, body weight and toxicity during and after treatment, and investigate the effect of pre-treatment body mass index (BMI) on survival in oropharyngeal cancer patients.

SUBJECTS/METHODS

A retrospective chart review was made in 276 oropharyngeal cancer patients treated with radiotherapy (RT). End points were dietary consultations, weight loss, toxicity, overall survival and disease-free survival.

RESULTS

Almost all oropharyngeal cancer patients received dietary counselling (94%) and nutritional support (99%). Dietary counselling decreased sharply shortly after treatment to 38% at 1 year after treatment. Overall weight loss increased during the first year of follow-up and ranged from 3% at start of RT, until 11% at 1 year after RT. Overall survival was significantly longer for patients with a BMI above average (P=0.01). Acute dysphagia (P=0.001), mucositis (P=0.000) and toxicity grade 3 (P=0.002) were significantly more prevalent in patients who had lost 10% or more of their body weight.

CONCLUSIONS

This study showed that patients continue to lose body weight during and until 1 year after treatment, despite nutrition support and frequent dietetic consultation. A BMI above average appears to increase survival time. Future studies, preferably randomized trials, are needed to compare standard dietary counselling with more intensive dietary counselling that consists of earlier and/or prolonged treatment.

Exploration of risk factors for weight loss in head and neck cancer patients

Introduction

Head and neck cancer patients receiving radiotherapy can experience a number of toxicities, including weight loss and malnutrition, which can impact upon the quality of treatment. The purpose of this retrospective cohort study is to evaluate weight loss and identify predictive factors for this patient group.

Materials and methods

A total of 40 patients treated with radiotherapy since 2012 at the study centre were selected for analysis. Data were collected from patient records. The association between potential risk factors and weight loss was investigated.

Results

Mean weight loss was 5 kg (6%). In all, 24 patients lost >5% starting body weight. Age, T-stage, N-stage, chemotherapy and starting body weight were individually associated with significant differences in weight loss. On multiple linear regression analysis age and nodal status were predictive.

Conclusion

Younger patients and those with nodal disease were most at risk of weight loss. Other studies have identified the same risk factors along with several other variables. The relative significance of each along with a number of other potential factors is yet to be fully understood. Further research is required to help identify patients most at risk of weight loss; and assess interventions aimed at preventing weight loss and malnutrition.

Nutritional interventions in head and neck cancer patients undergoing chemoradiotherapy: a narrative review

The present review aimed to define the role of nutritional interventions in the prevention and treatment of malnutrition in HNC patients undergoing CRT as well as their impact on CRT-related toxicity and survival. Head and neck cancer patients are frequently malnourished at the time of diagnosis and prior to the beginning of treatment. In addition, chemo-radiotherapy (CRT) causes or exacerbates symptoms, such as alteration or loss of taste, mucositis, xerostomia, fatigue, nausea and vomiting, with consequent worsening of malnutrition. Nutritional counseling (NC) and oral nutritional supplements (ONS) should be used to increase dietary intake and to prevent therapy-associated weight loss and interruption of radiation therapy. If obstructing cancer and/or mucositis interfere with swallowing, enteral nutrition should be delivered by tube. However, it seems that there is not sufficient evidence to determine the optimal method of enteral feeding. Prophylactic feeding through nasogastric tube or percutaneous gastrostomy to prevent weight loss, reduce dehydration and hospitalizations, and avoid treatment breaks has become relatively common. Compared to reactive feeding (patients are supported with oral nutritional supplements and when it is impossible to maintain nutritional requirements enteral feeding via a NGT or PEG is started), prophylactic feeding does not offer advantages in terms of nutritional outcomes, interruptions of radiotherapy and survival. Overall, it seems that further adequate prospective, randomized studies are needed to define the better nutritional intervention in head and neck cancer patients undergoing chemoradiotherapy.

Protocol for a randomized controlled trial of early prophylactic feeding via gastrostomy versus standard care in high risk patients with head and neck cancer

Background

Patients with head and neck cancer are at high risk of malnutrition and dysphagia. Enteral tube feeding via a gastrostomy or nasogastric tube is often required in response to dysphagia, odynophagia or side effects of treatment that lead to dehydration and/or weight-loss. A recent systematic review concluded that the optimal method of tube feeding remains unclear; however prophylactic gastrostomy, placed in anticipation of its use during and after treatment, is common practice, following a number of demonstrated benefits. However the majority of these studies have been undertaken in patients receiving radiotherapy alone. More recent studies in patient populations receiving concurrent chemoradiotherapy are showing that despite prophylactic gastrostomy placement significant weight loss still occurs, placing the patient at risk of the consequences of malnutrition. Therefore we set out to investigate innovative prophylactic nutrition support via the gastrostomy to optimise the nutritional outcomes of patients with head and neck cancer.

Methods/Design

Patients with head and neck cancer will be eligible for this single centre randomised controlled trial if they are identified for referral for a prophylactic gastrostomy using local guidelines. Patients will be excluded if they are: under the age of eighteen; pregnant; unable to give informed consent; or severely malnourished or moderately malnourished with significant dysphagia requiring a liquid or puree diet. All eligible patients who consent for the study will be allocated randomly to either the intervention or control group (usual care). The intervention group will commence prophylactic supplementary nutrition support via the gastrostomy immediately following placement compared to usual care where nutrition support is commenced via the gastrostomy when clinically indicated during treatment. Key outcome measures will be percentage weight loss, body composition, nutritional status and quality of life, measured at baseline and three months post treatment.

Discussion

To our knowledge this is the first study to evaluate the effectiveness of early prophylactic tube feeding compared to commencement of feeding during treatment, as per current standard practice, in patients undergoing prophylactic gastrostomy prior to treatment for head and neck cancer.

Trial registration

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