Nutritional prehabilitation in head and neck cancer: A systematic review of literature

Exploratory Research: Patient-Reported Factors Contributing to Decreased Oral Intake During Radiotherapy in Head and Neck Cancer

BACKGROUND

Radiotherapy (RT) in head and neck cancer (HNC) can cause multiple side effects such as nausea, pain, taste loss, fatigue, oral mucositis, xerostomia, and acute radiation-associated dysphagia (RAD). These factors threaten patients' oral intake (OI) during this RT. Reduced OI can cause weight loss, dehydration, malnutrition, and various comorbidities. On top, reduced OI significantly affects quality of life and may contribute to RAD through the disuse of swallowing muscles. With the aim of maximizing the retention of a patient's OI, it is important to gain an insight into the factors that have the greatest impact. Therefore, this study aims to identify the impact of contributing factors on decreased OI during RT.

METHODS

During their treatment, 55 HNC patients completed an OI questionnaire at 5 different time points: during weeks 1, 2, 3, and 4 and at the end of RT (week 7). First, patients rated the OI compared to pre-RT on a 100 mm visual analogue scale (VAS). Subsequently, patients reported on separate VAS the degree to which pain, fatigue, loss of taste, loss of smell, loss of interest in food, nausea, and loss of hunger contributed to the decrease in OI (0: no contribution; 100: complete contribution). SPSS version 27 was used to analyze the results.

RESULTS

OI decreased over time during RT, with the lowest OI at the end of RT. During the first 4 weeks of RT, the impact of all factors with pain, loss of taste, loss of interest in food, and loss of hunger pointed out as strongest contributing factors to a decreased OI. The most important patient-reported impacting factor on OI was loss of taste. At the end of RT, the importance of pain and nausea still increases, while the contribution of the other factors drops slightly.

CONCLUSION

This cohort study shows that several factors contribute to a decreased OI in HNC patients during RT. This study is the first prospective analysis to identify self-reported factors contributing to reduced OI. Results demonstrate that taste has the greatest impact on OI followed by loss of interest in food, loss of hunger, and pain.

[Prehabilitation and enhanced recovery after surgery protocols for head and neck cancer : Value and application of these concepts]

Prehabilitation is gaining traction in complex oncological interventions and treatments. This CME article is focused on the basic principles of prehabilitation. We discuss the objective evaluation of physical fitness and how to improve it by physio- and speech therapy. Thereafter, we explain how to judge nutritional status, especially in oncological patients, and discuss modes of nutritional supplementation. Finally, the enhanced recovery after surgery concept is briefly explained and its current value in head and neck cancer patients discussed.

New trends in supportive care of head and neck cancers

PURPOSE OF REVIEW

Supportive care plays a vital role in the management of head and neck cancer (HNC) patients, as the disease often affects a frail and older population that is treated with multiple strategies and is associated with severe symptoms. We will focus on mucositis, dermatitis, dysphagia, pain, cachexia, and infections, as they are among the most common and challenging symptoms encountered.

RECENT FINDINGS

Efforts have focused on multiomics approaches to decipher the complex biological pathways that drive symptom onset and treatment-related toxicities, with the aim of developing novel therapeutic strategies. A notable example is ponsegromab, a monoclonal antibody designed to target cancer cachexia. Other promising areas of research, such as machine-learning models and the role of oral and gut microbiota on cachexia and mucositis, are actively being explored; however, their impact to date remains limited.

SUMMARY

In recent years, new knowledge has emerged regarding the underlying causes and predictive models for the supportive care of HNC patients. Unfortunately, this expanding body of knowledge primarily adds to complexity without translating into practical applications or substantial improvements for patients. Future efforts should prioritize the standardization of therapeutic algorithms, and the generation of robust evidence based on existing preclinical models.

Nutritional Strategies in Oncology: A Narrative Review of Advances in Folate-Targeted Therapeutic Approaches for Cancer Treatment

Folate, a water-soluble B vitamin crucial for DNA synthesis and repair, is internalized by cells through specific folate receptors (FRs), which are frequently overexpressed in various types of cancers. In this comprehensive study, we conducted a review of the literature from Google Scholar, PubMed, and Science Direct, focusing on research published between 1980 and 2024 to evaluate folate-targeted therapeutic strategies in oncology. Our study design involved a rigorous review of both preclinical and clinical research, emphasizing strategies such as folate-drug conjugates, antibody-drug conjugates, and folate-targeted nanoparticles. Key findings indicate that targeting FRs in cancers such as ovarian, breast, cervical, renal, and colorectal enhances drug delivery specificity to tumors, increases therapeutic efficacy, and decreases systemic toxicity compared to traditional chemotherapy. Several clinical trials reported improved progression-free survival and overall response rates among patients receiving folate-targeted therapies. In conclusion, our review highlights the significant potential of folate-targeted strategies in advancing precision oncology while these approaches provide substantial benefits in terms of efficacy and safety, further research is essential to refine drug design and expand clinical applications. Such initiatives will facilitate the development of more personalized cancer treatment protocols that maximize therapeutic outcomes while minimizing adverse effects.

Oral Cancer and Sleep Disturbances: A Narrative Review on Exploring the Bidirectional Relationship

Oral cancer is a common malignant tumor, and its incidence has steadily increased in recent years. Sleep disturbances, including insomnia and obstructive sleep apnea, are prevalent among patients with oral cancer and significantly impact their quality of life. Emerging research suggests a bidirectional relationship between oral cancer and sleep disorders. This article reviews how oral cancer induces or exacerbates sleep disorders, particularly obstructive sleep apnea (OSA), through factors such as pain, psychological stress, and treatment-related side effects (e.g., upper airway damage caused by chemotherapy, radiotherapy, or surgical interventions). Furthermore, it analyzes how sleep disorders may promote oral cancer progression via chronic inflammation, intermittent hypoxia, oxidative stress, and disruption of circadian rhythms. By elucidating these interactions, this review provides a theoretical foundation for optimizing clinical treatment plans through a holistic understanding of their shared pathophysiological mechanisms.

Surgery Versus Chemoradiation Therapy for Oropharyngeal Squamous Cell Carcinoma: A Multidimensional Cross-Sectional Study

BACKGROUND/OBJECTIVES

The management of oropharyngeal squamous cell carcinoma (OPSCC) often involves multidisciplinary decision-making to optimize patient outcomes. Surgery and chemoradiation therapy (CRT) represent the two main treatment modalities. The aim of this cross-sectional study was to provide a comprehensive analysis of quality of life, speech, swallowing, sleep, psychological distress, and nutritional status in OPSCC patients treated with either surgery or CRT.

METHODS

Thirty subjects were divided into two groups based on treatment modality (>12-month follow-up): (A) surgery ± adjuvant treatment (15 patients); (B) exclusive CRT (15 patients). A multidimensional evaluation was performed by means of validated questionnaires. The following parameters were analyzed: quality of life, speech, swallowing, sleep quality, risk of sleep apnea, sleepiness, psychological distress, pain, and nutritional status.

RESULTS

No statistically significant difference was found between the two study groups for every parameter. The EORTC QLQ-C30 globally showed a good quality of life in both groups. Poor sleep quality was observed in 9 (60%) subjects in group A and in 6 (40%) patients in group B, respectively. Low, intermediate and high risk of malnutrition was observed in 73.3%, 20.0% and 6.7% of cases in group A, and in 93.3%, 6.7% and 0.0% in group B, respectively.

CONCLUSIONS

Surgery and exclusive chemoradiotherapy appear to yield similar long-term outcomes across all evaluated dimensions, including quality of life, speech, swallowing, sleep, psychological distress, and nutritional status.

Multimodal Prehabilitation in Head and Neck Cancer Patients Undergoing Surgery: A Feasibility Study

BACKGROUND

Head and neck cancer (HNC) incidence is increasing, and surgery is frequently indicated as curative treatment. Unfortunately, complications and long-term functional impairment are common. Recent promising results of multimodal prehabilitation in colorectal cancer surgery show improved recovery and functional outcomes. The objective of this study is to assess the feasibility of multimodal prehabilitation, which is composed of high-intensity training, a protein-enriched diet, cessation of intoxications, mental support and speech support therapy, in HNC surgery.

METHODS

A feasibility study was conducted at a large teaching hospital, Northwest Clinics, Alkmaar, the Netherlands, between July 2022 and December 2023. The primary outcome was feasibility, defined as participation, dropout and adherence rate. The secondary outcome was functional capacity 6 weeks postoperatively.

RESULTS

The participation rate was 60% (30 of 50 patients), mainly limited due to the travel distance to the physiotherapist. A dropout rate of 7% was present, as two patients discontinued prehabilitation. Of the remaining 28 patients, 27 patients (96%) attended at least six sessions at the community physiotherapist practice. All functional tests increased by prehabilitation, with the 6-min walking test being significant (p ≤ 0.05). Six weeks postoperatively, all but steep ramp tests remained higher than baseline.

CONCLUSION

Feasibility of multimodal prehabilitation in HNC surgery patients in this study is limited by its participation rate of 60%. Addressing participation, a widespread network of oncologic physiotherapists or home-based multimodal prehabilitation by an app could possibly potentiate participation. More studies are needed to assess the optimal form of multimodal prehabilitation in this challenging population.

Prehabilitation Strategies: Enhancing Surgical Resilience with a Focus on Nutritional Optimization and Multimodal Interventions

Surgery imposes significant physiological and psychological stress, often leading to complications, delayed recovery, and prolonged hospital stays. Prehabilitation, a proactive strategy to optimize patients' resilience before surgery, has emerged as a transformative approach in perioperative care. Nutritional prehabilitation specifically addresses metabolic dysregulation, muscle loss, and immune suppression caused by surgical stress. This review highlights the critical role of nutritional prehabilitation within a multimodal framework, integrating exercise, psychological support, and emerging technologies. Although some evidence supports the effectiveness of prehabilitation in enhancing functional outcomes and improvements in rates of complications and mortality, its implementation faces challenges such as resources, lack of standardized protocols, and variability across healthcare settings, highlighting the need for greater standardization. Physical training as part of prehabilitation also improves mood, fosters patient engagement, and instills a sense of control over the disease process. These psychosocial benefits, alongside enhanced patient-reported outcomes and qualitative measures, reflect the holistic value of prehabilitation. Emerging technologies, such as wearable devices and telemedicine, offer scalable and personalized solutions for delivering prehabilitation, particularly in resource-limited settings. Future research should prioritize refining protocols, exploring long-term outcomes, and addressing the unique needs of high-risk populations. By emphasizing a proactive approach to perioperative care, this review aims to highlight the potential of nutritional prehabilitation as a foundational component of multimodal strategies designed to optimize surgical resilience, empower patients, and transform surgical recovery into a proactive and patient-centered journey.

Nutritional Assessment and Management of Patients with Brain Neoplasms Undergoing Neurosurgery: A Systematic Review

BACKGROUND/AIM

Nutritional management in neurosurgical patients with brain neoplasms is critical, as optimal nutritional status is potentially associated with improved clinical outcomes. This systematic review aimed to analyze the impact of pre- and postoperative nutritional assessment and effect of prepost interventions on the clinical outcomes.

METHODS

A systematic review was conducted using the PubMed, Cochrane Library, Embase, and CINAHL databases, complemented by a search of grey literature. Study quality was assessed using the Joanna Briggs Institute framework, and the certainty of evidence was graded according to the Oxford Centre for Evidence-Based Medicine levels.

RESULTS

Fourteen studies, encompassing a total of 11,224 adult patients with brain neoplasms, were included. Many of these studies were retrospective, had small sample sizes, and examined diverse nutritional protocols. Preoperative nutritional status assessment, including clinical parameters such as albumin (p < 0.001), Controlling Nutritional Status score (p = 0.001), and Prognostic Nutritional Index (p < 0.010), combined with postoperative oral nutritional supplements (p < 0.001), was significantly associated with postoperative clinical outcomes. Additionally, personalized nutritional counseling contributed to a reduction in complications and facilitated more effective functional recovery.

CONCLUSIONS

Nutritional care is vital in managing neurosurgical patients with brain neoplasms, reducing complications and enhancing postoperative recovery and overall clinical outcomes. A multidisciplinary team is key to optimal outcomes. Future research should aim to standardize protocols for broader applicability.

Free Flap Enhanced Recovery Protocols in Head and Neck Surgery

Enhanced recovery after surgery (ERAS) protocols facilitates a standardized patient care regimen with a goal of reducing the metabolic stress of surgery. Adapted to head and neck free flap reconstructive surgery in 2017, these protocols focused on several key domains such as perioperative nutritional optimization, multimodal pain control, and early mobilization. Studies have shown that in addition to ERAS implementation, the maintenance and improvement of ERAS protocol compliance rates improve perioperative outcomes such as hospital length of stay and decrease major postoperative complications.

Inconsistent Associations of Modified Frailty Index-5 With Adverse Head and Neck Reconstruction Outcomes

OBJECTIVES

To investigate the consistency of associations between modified frailty index-5 (mFI-5) and postoperative adverse outcomes in head and neck cancer (HNC) reconstruction.

METHODS

American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2017 to 2022 was utilized to identify HNC patients undergoing locoregional or microvascular free tissue transfers. Kaplan-Meier estimates and multivariable Cox regression analyses were utilized to compare risk of infections, bleeding, readmissions, reoperations, major adverse cardiovascular events (MACE), and mortality within the first postoperative month for each mFI-5 score with mFI-5 = 0 as reference. Further analyses investigated associations between individual mFI-5 components and the outcomes of interest.

RESULTS

We included 5,573 patients (median age: 64; 31.5% female), 63% (n = 3,519) of whom underwent microvascular free tissue transfers. Unadjusted univariate analyses associated higher mFI-5 scores with longer hospital stays. In locoregional tissue transfers, adjusted hazard ratios (aHRs) for reoperation were 1.37 (p = 0.03) for mFI-5 = 1 and 2.19 (p = 0.03) for mFI-5 ≥ 3. In microvascular free tissue transfers, aHRs for MACE were 1.93 (p = 0.04) for mFI-5 = 2 and 6.53 (p < 0.001) for mFI-5 ≥ 3, while aHRs for mortality was 3.88 (p = 0.04) for mFI-5 ≥ 3. No associations were observed between increasing mFI-5 scores and increased relative risk of infection, bleeding, or readmission. Individual component analysis associated congestive heart failure with aHRs of 3.92 (1.84-8.35; p < 0.001) for MACE and 5.30 (2.03-13.88; p < 0.001) for mortality. Additionally, COPD was associated with an aHR of 1.39 (1.16-1.67; p < 0.001) for infections.

CONCLUSION

The associations of higher mFI-5 scores with postoperative adverse outcomes following oncoplastic head and neck reconstruction were inconsistent and possibly driven by individual effects of its components.

LEVEL OF EVIDENCE

Level III (three) Laryngoscope, 2025.

Evolution of Nutritional Status in Patients Undergoing Autologous and Allogeneic Hematopoietic Cell Transplantation or CAR-T Therapy: A Retrospective Observational Study

BACKGROUND/OBJECTIVES

Hematopoietic cell transplantation (HCT) is a curative treatment for various hematological diseases but can lead to complications which increase malnutrition risk, particularly in allogeneic transplantation patients. This study evaluates the nutritional status evolution of patients undergoing HCT during hospitalization and follow-up.

METHODS

This retrospective observational study included 365 patients, divided into two groups: 134 underwent allogeneic HCT, while 231 underwent autologous transplantation or CAR-T therapy. Nutritional status was evaluated using Body Mass Index (BMI), Malnutrition Universal Screening Tool (MUST), and Global Leadership Initiative on Malnutrition (GLIM) criteria at four-time points: hospital admission, discharge, two-week follow-up, and one-month follow-up. Non-relapse-related complications were assessed based on hospital readmissions and reports during follow-up visits.

RESULTS

Patients experienced significant nutritional deterioration, with decreases in Body Mass Index (BMI) (p < 0.001) and increases in Malnutrition Universal Screening Tool (MUST) (p < 0.001) and Global Leadership Initiative on Malnutrition (GLIM) scores (p < 0.001), particularly among allogeneic transplant recipients (p = 0.025). Severe malnutrition or high malnutrition risk at discharge correlated with increased hospital readmissions during the follow-up (p = 0.024).

CONCLUSIONS

The observed decline in nutritional status and its associated complications highlight the necessity of multidisciplinary interventions, such as nutritional prehabilitation programs and nutritional support protocols, to enhance clinical outcomes and reduce complications in HCT patients.

Nutritional Prehabilitation Intervention in Hematological Patients Undergoing Bone Marrow Transplant: A Systematic Review of the Literature

BACKGROUND

Nutritional interventions play a critical role in bone marrow transplant (BMT) patients. This review evaluates the effectiveness of nutritional strategies in mitigating post-transplant malnutrition and improving clinical outcomes.

METHODS

A systematic review was conducted using PubMed, CINAHL, Cochrane Library, and Embase. The search terms included "bone marrow transplant", "malnutrition", and "preoperative nutritional interventions". The quality of studies and risk of bias were assessed using the JBI framework, while evidence certainty was evaluated with the Oxford OCEBM.

RESULTS

Six studies were included (n = 3545 screened). The studies demonstrated predominantly high methodological quality and a low risk of bias, although heterogeneity in the treatments investigated and small sample sizes limited the evidence. Nutritional interventions significantly increased energy intake (26 vs. 24 kcal/kg/day, p = 0.038) and improved body weight (25% vs. 9%) with protein supplementation. Clinical complications decreased, including severe acute graft-versus-host disease (17.1% vs. 43.4%, p = 0.001) and pneumonia (27.6% vs. 52.7%, p = 0.002). The length of hospital stay (27 vs. 32 days, p = 0.006) and the need for parenteral nutrition (53% vs. 62%, p = 0.03) were also reduced. Overall survival improved with ≥50% adherence to prescribed TGF-beta2 intake (33 vs. 25.1 months, p = 0.03).

CONCLUSIONS

Nutritional prehabilitation shows promise in improving BMT outcomes. Standardized nutritional programs could optimize care, although limitations in current evidence are clearly present. Larger randomized studies are needed to confirm findings and refine pre-transplant protocols.

Impact of Preoperative Malnutrition on Patients with Pancreatic Neoplasms Post-Duodenopancreatectomy: A Retrospective Cohort Study

BACKGROUND

Preoperative malnutrition is a significant factor in patients with pancreatic tumors undergoing pancreaticoduodenectomy. The aim of this study was to assess the association between preoperative malnutrition and delayed discharge within a ten-day timeframe and potential correlations between preoperative malnutrition and postoperative surgical complications.

METHODS

A retrospective cohort study was conducted, recruiting a final sample of 79 patients with benign or malignant cephalic pancreatic tumors from 2015 to 2022. The risk of malnutrition was assessed using the Malnutrition Universal Screening Tool, while length of hospital stay and relevant clinical data were extracted from clinical documentation.

RESULTS

The preoperative malnutrition risk was high in 21.52% of the sample, moderate in 36.71%, and low in 41.77%. Body mass index (BMI) (p = 0.007) and postoperative surgical complications (p < 0.001) were significantly correlated with delayed discharge. No statistically significant differences were found between levels of malnutrition risk and delayed discharge (p = 0.122), or postoperative surgical complications (p = 0.874).

CONCLUSIONS

Postoperative complications and BMI emerge as significant risk factors. The limited sample size may have compromised the collection of homogeneous and significant data. Future studies should evaluate the implementation of personalized nutritional screening tools, nutritional assessment plans, and the involvement of specialized health professionals.

Nutritional Prehabilitation in Patients Undergoing Cystectomy: A Systematic Review

BACKGROUND/AIM

Nutrition is a key element of the prehabilitation process prior to surgery. The aim of this study was to identify the clinical pathways of nutritional prehabilitation before cystectomy.

METHODS

A systematic literature review was conducted in PubMed, the Cochrane Library, CINAHL, Scopus and the Web of Science databases. Quality and risk of bias assessment was conducted adhering to the JBI framework and evidence was evaluated according to the Oxford Centre for Evidence Based Medicine levels of evidence.

RESULTS

Out of 586 records identified, six studies were included. Among them, only two were randomized controlled trials. Immunonutrition has been shown to improve postoperative bowel function (3.12 vs. 3.74 days; RR 0.82; CI, 0.73-0.93; p = 0.0029) and decrease postoperative complications (-36.7%; p = 0.008) and readmission rates (-15.38%; p = 0.03). Furthermore, oral nutritional supplements combined with nutritional counseling demonstrated an accelerated recovery of bowel function (-1 day; p < 0.01), a reduction in the length of hospital stay (-1.75 days; p = 0.01), an improvement in handgrip strength (+6.8%, p < 0.001), an increase in bone mass (+0.3 kg, p = 0.04), and a better BMI value (+2.3%, p = 0.001).

CONCLUSIONS

Nutritional prehabilitation demonstrates potential in enhancing postoperative outcomes following radical cystectomy. Oral supplements, immunonutrition, and counseling exhibit efficacy in improving postoperative results.

A methodological framework for rigorous systematic reviews: Tailoring comprehensive analyses to clinicians and healthcare professionals

Systematic reviews represent a fundamental study design, providing the highest level of evidence across diverse research inquiries, encompassing both public health and clinical research and practice. However, for healthcare professionals, the process of selecting, synthesizing, and interpreting evidence can be challenging, and requires specialized skills. Therefore, it is imperative to explore innovative solutions aimed at simplifying and making the traditional systematic review process more accessible while ensuring the validity and reliability of results. In this perspective, our research objective is to develop a systematic review framework that, while maintaining a rigorous methodological approach, streamlines the process for healthcare professionals. This study describes such approach in every phase, from the collection of evidence to the writing of the text, creating a guide for the healthcare professional who approaches this type of research. The qualitative and organizational analysis tools are also described, providing useful information for the use of non-paid programs. This systematic review aims to develop a framework with a rigorous methodological approach that allows simplify the process for clinicians and healthcare professionals. The implementation of this methodology in clinical practice offers new perspectives to ensure a thoughtful consideration and application of scientific evidence and opens the way to innovative and easily accessible solutions to facilitate the conduct of systematic reviews in the clinical care setting.

Non-pharmacological strategies to alleviate dysgeusia in patients undergoing chemotherapy: A systematic review

PURPOSE

Dysgeusia is a common side effect in oncology patients, significantly impacting their quality of life. This systematic review aims to evaluate the effectiveness of non-pharmacological strategies in treating dysgeusia in patients undergoing chemotherapy or radiotherapy.

METHODS

Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive literature search across five databases: PubMed, Embase, Cochrane Library, CINAHL, and the British Nursing Database. We used the Joanna Briggs Institute Critical Appraisal Tools to assess the quality of the included studies. A harvest plot was used to synthesise evidence about the differential effects of population-level interventions.

RESULTS

Nine studies of non-pharmacological strategies to manage dysgeusia were included. These studies encompassed a variety of interventions, including oral applications and supplements, instrumental techniques, and educational programs. The review identified promising interventions such as cryotherapy and Miraculine supplementation, which showed potential in mitigating taste alterations. Instrumental techniques like photobiomodulation therapy and complementary and integrative medicine approaches, including acupuncture and herbs, were also found to be beneficial. Educational and self-management strategies emerged as effective interventions for empowering patients to manage dysgeusia. Despite the diversity of interventions and the limitations of the included studies, such as small sample sizes and geographical differences, these findings underscore the potential of non-pharmacological strategies in managing dysgeusia.

CONCLUSION

The results support the integration of these strategies into clinical practice, highlighting the importance of multidisciplinary approaches to improve patient care. Further research should prioritize rigorous studies to enhance evidence and explore long-term effects.