The changing face of head and neck cancer: are patients with human papillomavirus-positive disease at greater nutritional risk? A systematic review

Exploring the role of human papillomavirus (HPV) status in body composition and nutritional features in patients with oropharyngeal cancer

BACKGROUND AND AIMS

Patients with oropharyngeal squamous cell carcinoma (OPSCC) are highly prone to malnutrition and sarcopenia due to the tumor's location and treatment-related toxicity. Human papillomavirus (HPV)-related and HPV-unrelated OPSCC represent two distinct biological entities. This study aimed to assess nutritional characteristics and body composition differences at diagnosis, as well as 3- and 6-months post- (chemo) radiation treatment, stratified by HPV status in OPSCC patients.

METHODS

Retrospective data analysis of a prospective cohort of OPSCC patients diagnosed and treated with curative intent from 2016 to 2022 at our center. Sociodemographic, clinical, and nutritional data were retrieved from medical records from diagnosis to 6 months post-treatment. Body composition parameters were assessed by analyzing the cross-sectional area of the third lumbar vertebra (L3) using available positron emission tomography (PET) and computed tomography (CT) scans at baseline, 3- and 6-months post-treatment.

RESULTS

Seventy patients were included, 33 (47.1 %) of whom had HPV-related OPSCC. HPV-related patients had higher body mass index (27.3 vs 21.9 kg/m2; p < 0.001) and better baseline nutritional status (p = 0.023), but no differences in skeletal muscle index (SMI, p = 0.103) compared to HPV-unrelated patients. At 3- and 6-months post-treatment the two groups showed similar SMI and total adipose tissue index loss (p > 0.05 for both). HPV status was not independently associated with body composition changes over time (p = 0.624).

CONCLUSIONS

Although HPV-related patients were better nourished than HPV-unrelated patients at diagnosis, by the end of treatment, both groups exhibited similar nutritional deterioration.

Nutritional characterization of patients with oropharyngeal cancers: impact of human papillomavirus status

BACKGROUND

Oropharyngeal squamous cell carcinoma (OPSCC) of human papillomavirus (HPV)-positive status is increasing relative to HPV-negative disease. Nutritional features of OPSCC patients according to HPV status is unclear.

SUBJECTS/METHODS

Canadian and Spanish patients with OPSCC were assessed for body mass index (BMI), weight loss grade (WLG), and computed tomography-defined skeletal muscle index (SMI). Chi-square, t-test, Mann-Whitney-U, Kruskal-Wallis tests were conducted to compare HPV positive and negative groups. Overall survival (OS) was assessed by univariable Kaplan-Meier and Cox proportional hazard methods.

RESULTS

No differences in BMI, WLG, SMI, and adipose tissue index between the 308 (Canada) and 134 (Spain) patients according to HPV status; hence cohorts were pooled (n = 442). HPV-positive patients (n = 317) were overweight/obese (72.8%), had WLG of 0/1 (59.6%) and high SMI (83.4%) while HPV-negative patients were normal/underweight (61.5%), had high WLG 3/4 (50.8%), and moderate/severe SMI depletion (46.9%) (p < 0.003). These overall differences notwithstanding, there was crossover i.e. 35% of HPV-positive patients had high WLG and/or moderate/severe muscle depletion and 29% of HPV-negative patients had minimal weight loss and high SMI. HPV-negative patients had a higher risk of mortality (HR 3.78, 95% CI 2.70-5.29, P < 0.001) and this difference was retained after multivariable adjustment for WLG, SMI, age, disease stage, and planned treatment (HR 3.30, 95% CI 2.17-5.02, P < 0.001).

CONCLUSION

Nutrition features of patients with OPSCC did not differ between Canada and Spain. Distinctive nutrition features exist in patients according to HPV status. The high heterogeneity of individual nutritional profiles invites an individualized approach to nutrition care.

Nutritional factors and survival in a cohort of patients with oral cancer

Background

Malnutrition commonly affects patients with oral squamous cell carcinoma (OSCC), which contributes to worsening prognosis. Moreover, specific strategies for diagnosing and managing malnutrition in OSCC are lacking. We aimed to investigate if the modality of nutritional treatment as standard oral (ON) or artificial enteral nutrition (AN), assigned by a dedicated nutritional team or not, influences survival in patients with OSCC. Moreover, given the difficulties in obtaining adequate nutritional evaluation in patients with OSCC we preliminary evaluated the magnetic resonance imaging volumetric reconstruction of posterior paraspinal muscles at the level of the third cervical vertebra (MRI-C3) as a tentative new approach to investigate sarcopenia.

Methods

This retrospective study included 52 consecutive patients with OSCC who underwent surgery at the University Hospital of Palermo (I) from Jan 2020 to May 2023. In-hospital nutritional support was provided by a dedicated team. The patients were retrospectively compared with a control group of 11 patients who were surgically treated for OSCC between January and December 2019 in the same unit of surgery, in the absence of a dedicated nutritional team. Upon discharge, the nutritional treatment consisted of ON or AN. In 2020-2023, industrially produced special medical food formulations were used rather than natural foods as it was in use in 2019; also, adequate protein supplements were assigned in order to reach the recommended protein intake of 1-0-1.2 g/kg ideal body weight. The MRI-C3 volumetric reconstruction was obtained in 16 patients.

Findings

As per-protocol, the patients were categorized according to pre-surgery TNM stage: groups A (TNM stages I-III) and B (IVa-IVc). The prevalence of group A patients was 59.6% in the case group and 85.7% in the control group (p < 0.001), with higher survival rates at follow-up in the control group (80.5% vs. 27.3%), therefore, the two historical groups were not comparable. Given the limited number of cases, all patients were included in a unique group. Advanced stages of OSCC (log-rank test, p < 0.001) and AN (p < 0.001) were independently associated with a lower survival rates. The 3-12 month post-surgery MRI_C3 volume increased in patients who received ON treatment and decreased in those who received AN treatment (p < 0.001).

Conclusion

AN is associated with lower survival probability than ON in patients with OSCC. The MRI-C3 measurement of paravertebral muscles is a promising technique for detecting sarcopenia that needs to be confirmed by further studies including larger groups of patients.

Prognostic Impact of Sarcopenia's Occurrence during Radiotherapy in Oropharyngeal Cancer Patients

The current study aims to profile sarcopenic condition (both at baseline and developed during treatment) in oropharyngeal carcinoma (OPC) patients treated with curative radiotherapy (RT) +/- chemotherapy and to evaluate its impact on oncological outcomes and toxicity. A total of 116 patients were included in this retrospective single-center study. Sarcopenia assessment at baseline and at 50 Gy re-evaluation CT was obtained from two different methodologies: (i) the L3-skeletal muscle index (SMI) derived from the contouring of the cross-sectional area (CSA) of the masticatory muscles (CSA-MM); and (ii) the paravertebral and sternocleidomastoid muscles at the level of the third cervical vertebra (CSA-C3). Based on L3-SMI from CSA-MM, developing sarcopenic condition during RT (on-RT sarcopenia) was associated with worse progression-free survival (PFS) (p = 0.03) on multivariable analysis and a trend of correlation with overall survival (OS) was also evident (p = 0.05). According to L3-SMI derived from CSA-C3, on-RT sarcopenia was associated with worse PFS (p = 0.0096) and OS (p = 0.013) on univariate analysis; these associations were not confirmed on multivariable analysis. A significant association was reported between becoming on-RT sarcopenia and low baseline haemoglobin (p = 0.03) and the activation of nutritional counselling (p = 0.02). No significant associations were found between sarcopenia and worse RT toxicity. Our data suggest that the implementation of prompt nutritional support to prevent the onset of sarcopenia during RT could improve oncological outcomes in OPC setting.

Prevalence and Impact of Computed Tomography-Defined Sarcopenia on Survival in Patients with Human Papillomavirus-Positive Oropharyngeal Cancer: A Systematic Review

Sarcopenia is a known independent prognostic factor for decreased survival in patients with head and neck cancer; yet, its importance for the growing number of younger patients diagnosed with human papillomavirus (HPV)-positive oropharyngeal carcinoma (OPC+) has not been established. This systematic literature review aimed to determine the prevalence and impact of computed tomography (CT)-defined sarcopenia on survival outcomes for adult OPC+ patients (>18 y) undergoing any treatment modality. Prospective studies were searched using PubMed, Embase, CENTRAL, CINAHL, and Web of Science up until and including February 2022. Bias was assessed using the Quality In Prognosis Studies (QUIPS) tool, and certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. In total, 9 studies (total pooled OPC+ patients, n  = 744) were identified and included in this review; 2 at low, 6 at moderate, and 1 at high risk of bias. All studies varied in sarcopenia assessment methods and skeletal muscle index threshold cutoff values. These studies demonstrated the cumulative prevalence of sarcopenia for OPC+ patients to be 42.9% (95% CI: 37.8%, 47.9%). While overall survival (3 studies, n = 253) and progression-free survival (1 study, n = 117) was lower in sarcopenic OPC+ patients, this was not statistically significant. GRADE certainty of evidence for impact of pretreatment sarcopenia on overall survival was low and progression-free survival was very low. Although these studies showed there to be a high prevalence of pretreatment sarcopenia in patients with OPC+, which may decrease survival, the impact on progression-free survival is very uncertain. Further, high-quality research utilizing consistent sarcopenia definitions and assessment methods that are conducted specifically in OPC+ is required to strengthen evidence certainty and determine if sarcopenia is an independent prognostic factor for this population.