High prevalence of cachexia in newly diagnosed head and neck cancer patients: An exploratory study

Impact of low skeletal muscle mass in oropharyngeal cancer patients treated with radical chemo-radiotherapy: A mono-institutional experience

AIMS

Low skeletal muscle mass index (SMI) has recently emerged as an independent prognostic factor in oncological patients and it is linked with poor survival and higher treatment toxicity. The present study aims to determine the possible impact of low SMI on survival and acute toxicity in oropharyngeal patients.

METHODS

Seventy-six patients with locally advanced oropharyngeal squamous cell carcinoma (stage III-IVC) were treated in our institution with Helical TomoTherapy® (HT - Accuray, Maddison, WI, USA) between 2005 and 2021. All patients received concomitant platinum-based chemotherapy (CT) (at least 200 mg/m2). The SMI was determined using the calculation of cross-sectional area at C3. Twenty patients (26%) presented pre-treatment low SMI, according to Chargi definitions.

RESULTS

All patients concluded the treatment. Thirteen patients with low SMI (65%) and 22 patients with normal SMI (39%) presented acute toxicity greater than or equal to grade 3, but this difference was not statistically significant (p-value = 0.25). Overall survival was analyzed in 65 patients, excluding those who finished CT-RT less than six months before the analysis. Overall survival was significantly lower in low SMI versus normal SMI patients (p-value = 0.035). Same difference was observed in N0-N2a patients, suggesting an important role of SMI also in lower nodal burden and putatively better prognosis.

CONCLUSIONS

Although the results are limited to a small population, our case series has the advantage to be very homogeneous in patients and treatment characteristics. In our setting, SMI demonstrated a crucial impact on overall survival. Further investigation with larger samples is necessary to confirm our results to improve patient outcomes.

Thoracic skeletal muscle index is effective for CT-defined sarcopenia evaluation in patients with head and neck cancer

PURPOSE

Computed tomography (CT)-defined sarcopenia, as a measurement of low skeletal muscle (SM), is a poor prognostic indicator in patients with head and neck cancer (HNC), independent of weight or nutritional status. We used SM measures at the second thoracic vertebra (T2) to determine T2-SM index (SMI) thresholds for sarcopenia, and investigate the impact of low T2-SMI on overall survival (OS), and weight loss during radiotherapy (RT).

METHODS

Adult patients with newly diagnosed HNC with a diagnostic PET-CT or RT planning CT scan were included. SM was analysed at T2 and a model applied to predict SM at L3. T2-SMI thresholds for sarcopenia were established with predicted measures, stratified by BMI and sex. Impact of sarcopenia and low T2-SMI on OS and weight loss during RT was investigated.

RESULTS

A total of 361 scans were analysed (84% males, 54% oropharynx tumours). Sarcopenia was found in 49%, demonstrating worse OS (p = 0.037). T2-SMI cutoff values were: females-74 cm2/m2 [area under the curve (AUC): 0.89 (95%CI 0.80-0.98)], males (BMI < 25)-63 cm2/m2 [AUC 0.93 (95%CI 0.89-0.96)], males (BMI ≥ 25)-88cm2/m2 [AUC 0.86 (95%CI 0.78-0.93)]. No difference in OS with T2-SMI categories. Lowest T2-SMI quartile of < 63 cm2/m2 demonstrated worse OS (p = 0.017). Weight loss during RT was higher in patients; who were not sarcopenic (6.2% vs 4.9%, p = 0.023); with higher T2-SMI (6.3% vs 4.9%, p = 0.014) and; in the highest quartiles (3.6% vs 5.7% vs 7.2%, p < 0.001).

CONCLUSIONS

These T2-SMI thresholds are effective in assessing CT-defined sarcopenia in HNC. Further assessment of clinical application is warranted.

Accelerated loss of lean body mass in head and neck cancer patients during cisplatin-based chemoradiation

BACKGROUND

This study investigated changes in body weight, lean body mass (LBM), fat mass (FM), muscle strength and functional performance during radiation treatment in head and neck cancer (HNSCC) patients. Secondly, it investigated the impact of cisplatin-based chemoradiation (CCRT) on LBM loss compared with radiation alone.

METHODS

48 patients (all tumor sites) received either 6 weeks of radiation alone (n = 16) with 66-68 Gy in 33-34 Fx, 5-6 Fx/week or CCRT, adding weekly cisplatin or carboplatin (n = 32). LBM and FM was evaluated using Dual-energy X-ray Absorptiometry bi-weekly from pre- to two weeks post-treatment. Maximal muscle strength (knee extension, leg - and chest press) and functional performance (stair climb, chair rise, and arm curl) were assessed pre- and post-treatment.

RESULTS

Body weight and LBM had declined significantly already week 2 into treatment and declined significantly further through week 4 and 6 before leveling off after week 6. Bi-weekly, from treatment start to week 2, 2-4, and 4-6, LBM declined 1.2 ± 0.4 kg (p = .002; 95% CI: 0.4;2.0), 2.0 ± 0.4 kg (p < .0001; 1.2;2.8) and 1.4 ± 0.4 kg (p = .001; 0.6;2.2). With a two-week delay, FM declined significantly from week 2-8. All measures of muscle strength declined significantly from pre- to post-treatment. Functional performance was unchanged. LBM loss from pre- to post-treatment was significantly associated with impaired muscle strength (R2 = 0.3-0.5). CCRT patients lost 3.1 ± 0.8 kg of LBM (p = .0001; 1.5;4.7) more from pre- to post-treatment compared with patients receiving radiation alone. Analyses adjusting for nimorazole, tumor stage, baseline BMI, mean radiation dose to constrictor muscles and oral cavity confirmed this.

CONCLUSION

Accelerated and substantial LBM loss was already initiated within the first two weeks of treatment - before the onset of radiation-induced mucositis. LBM loss was associated with muscle strength impairment. Patients receiving CCRT experienced significantly larger LBM loss than patients receiving radiation alone. Registered on clinincaltrials.gov (Identifier: NCT05890859).

Cachexia and head and neck squamous cell carcinoma: A scoping review

OBJECTIVE

The objective of this paper was to provide an understanding of cachexia in relation to oral squamous cell carcinoma relevant to oral health care. The paper is a scoping review of aspects of the clinical presentation, aetiology and management of cachexia in relation to oral health and oral health care.

METHODS

A combined search of MEDLINE and EMBASE databases (via OVID) was conducted using the terms ([Head and Neck] OR [Oral Squamous Cell Carcinoma]) AND (Cachexia). Duplicates were removed and results were subsequently limited to studies published between 2000 and 2023, humans and English language. After screening and full-text assessment a total number of 87 studies were included in the review.

RESULTS

It is evident that cachexia is a not uncommon feature of patients with advanced malignancy of the head and neck driven by a multitude of mechanisms, induced by the tumour itself, that lead to reduced nutritional intake, increased metabolism and loss of adipose and skeletal tissue.

CONCLUSION

While a variety of nutritional, physical, psychological and pharmacological interventions may improve quality and duration of life, ultimately the diagnosis of cachexia in relation to head and neck cancer remains an indicator of poor life expectancy.

Cancer cachexia: molecular mechanisms and treatment strategies

Muscle wasting is a consequence of physiological changes or a pathology characterized by increased catabolic activity that leads to progressive loss of skeletal muscle mass and strength. Numerous diseases, including cancer, organ failure, infection, and aging-associated diseases, are associated with muscle wasting. Cancer cachexia is a multifactorial syndrome characterized by loss of skeletal muscle mass, with or without the loss of fat mass, resulting in functional impairment and reduced quality of life. It is caused by the upregulation of systemic inflammation and catabolic stimuli, leading to inhibition of protein synthesis and enhancement of muscle catabolism. Here, we summarize the complex molecular networks that regulate muscle mass and function. Moreover, we describe complex multi-organ roles in cancer cachexia. Although cachexia is one of the main causes of cancer-related deaths, there are still no approved drugs for cancer cachexia. Thus, we compiled recent ongoing pre-clinical and clinical trials and further discussed potential therapeutic approaches for cancer cachexia.

The use of the second thoracic vertebral landmark for skeletal muscle assessment and computed tomography-defined sarcopenia evaluation in patients with head and neck cancer

BACKGROUND

The cross-sectional area (CSA) of skeletal muscle (SM) at the third lumbar vertebra (L3) is used to determine computed tomography (CT)-defined sarcopenia. We investigated the feasibility of SM assessment at the second thoracic vertebra (T2) in patients with head and neck cancer (HNC).

METHODS

Diagnostic PET-CT scans were used to develop a prediction model for L3-CSA using T2-CSA. Effectiveness of the model and cancer-specific survival (CSS) were investigated.

RESULTS

Scans of 111 patients (85% male) were evaluated. The predictive formula: L3-CSA (cm² ) = 174.15 + [0.212 × T2-CSA (cm² )] - [40.032 × sex] - [0.928 × age (years)] + [0.285 × weight (kg)] had good correlation r = 0.796, ICC = 0.882 (p < 0.001). SM index (SMI) mean difference (bias) was -3.6% (SD 10.2, 95% CI -8.7% to 1.3%). Sensitivity (82.8%), specificity (78.2%), with moderate agreement (ƙ = 0.540, p < 0.001). Worse 5-year CSS with lower quartile T2-SMI (51%, p = 0.003).

CONCLUSIONS

SM at T2 can be effectively used for CT-defined sarcopenia evaluation in HNC.

Oropharyngeal dysphagia and cachexia: Intertwined in head and neck cancer

BACKGROUND

This study aims to investigate the relationship between cancer cachexia and oropharyngeal dysphagia (OD) in patients with head and neck cancer (HNC) prior to chemoradiotherapy or bioradiotherapy (CRT/BRT).

METHODS

A prospective cohort study with patients with HNC undergoing CRT/BRT (2018-2021) was conducted. Body composition and skeletal muscle function were evaluated using bioelectrical impedance analysis, handgrip strength, and the short physical performance battery (SPPB). The M. D. Anderson Dysphagia Inventory (MDADI), Eating Assessment Tool (EAT)-10 questionnaire, and patient characteristics were collected. A standardized videofluoroscopic swallowing study was offered to patients.

RESULTS

Sixty-six patients were included. Twenty-six patients scored EAT-10 ≥ 3 and seventeen were cachectic. ACE-27 score >1, cachexia, abnormal SPPB-derived repeated chair-stand test, lower MDADI scores, and higher overall stage grouping showed potential predictive value (p ≤ 0.10) for EAT-10 ≥ 3. Using multivariable regression analysis, only cachexia remained a significant predictor of EAT-10 ≥ 3 (HR 9.000 [95%CI 2.483-32.619], p = 0.001).

CONCLUSION

Cachexia independently predicted the presence of patient-reported OD.

Muscle mass, quality, and strength; physical function and activity; and metabolic status in cachectic patients with head and neck cancer

BACKGROUND & AIMS

Cancer cachexia is commonly associated with poor prognosis in patients with head and neck cancer (HNC). However, its pathophysiology and treatment are not well established. The current study aimed to assess the muscle mass/quality/strength, physical function and activity, resting energy expenditure (REE), and respiratory quotient (RQ) in cachectic patients with HNC.

METHODS

This prospective cross-sectional study analyzed 64 patients with HNC. Body composition was measured via direct segmental multifrequency bioelectrical impedance analysis, and muscle quality was assessed using echo intensity on ultrasonography images. Muscle strength was investigated utilizing handgrip strength and isometric knee extension force (IKEF). Physical function was evaluated using the 10-m walking speed test and the five times sit-to-stand (5-STS) test. Physical activity was examined using a wearable triaxial accelerometer. REE and RQ were measured via indirect calorimetry. These parameters were compared between the cachectic and noncachectic groups.

RESULTS

In total, 23 (36%) patients were diagnosed with cachexia. The cachectic group had a significantly lower muscle mass than the noncachectic group. Nevertheless, there was no significant difference in terms of fat between the two groups. The cachectic group had a higher quadriceps echo intensity and a lower handgrip strength and IKEF than the noncachectic group. Moreover, they had a significantly slower normal and maximum walking speed and 5-STS speed. The number of steps, total activity time, and time of activity (<3 Mets) did not significantly differ between the two groups. The cachectic group had a shorter time of activity (≥3 Mets) than the noncachectic group. Furthermore, the cachectic group had a significantly higher REE/body weight and REE/fat free mass and a significantly lower RQ than the noncachectic group.

CONCLUSIONS

The cachectic group had a lower muscle mass/quality/strength and physical function and activity and a higher REE than the noncachectic group. Thus, REE and physical activity should be evaluated to determine energy requirements. The RQ was lower in the cachectic group than that in the noncachectic group, indicating changes in energy substrate. Further studies must be conducted to examine effective nutritional and exercise interventions for patients with cancer cachexia.

Development and validation of the modified index of fragility in head and neck cancer surgery

BACKGROUND

This study aims to develop and validate, a clinically useful modified index of fragility (mIFG) to identify patients at risk of fragility and to predict postoperative adverse events.

METHOD

An observational study was performed using the American College of Surgeons National Surgical Quality Improvement Program database, from 2006 to 2018. All patients undergoing nonemergency head and neck cancer surgery were included. A seven-item index (mIFG) was developed using variables associated with frailty, cachexia, and sarcopenia, drawn from the literature (weight loss, low body mass index, dyspnea, diabetes, serum albumin, hematocrit, and creatinine). Multivariable logistic regression was used to model the association between mIFG, postoperative adverse events and death. A validation cohort was then used to ascertain the diagnostic accuracy of the mIFG.

RESULTS

A total of 23,438 cases were included (16,407 in the derivation group and 7031 in the validation group). There was a total of 4273 postoperative major adverse events (AE) and deaths, 1023 postoperative pulmonary complications and 1721 wound complications. Using the derivation cohort, the 7-item mIFG was independently associated with death, major AEs, pulmonary and wound complications, when controlling for significant covariates. The mIFG predicted death and major adverse events using the validation cohort with an accuracy of 0.70 (95% CI: 0.63-0.76) and 0.64 (95% CI: 0.63-0.66), respectively. The mIFG outperformed the modified Frailty index.

CONCLUSION

The modified index of fragility is a reliable and easily accessible tool to predict risk of postoperative adverse events and death in patients undergoing head and neck cancer surgery.

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.

A Multi-Site, International Audit of Malnutrition Risk and Energy and Protein Intakes in Patients Undergoing Treatment for Head Neck and Esophageal Cancer: Results from INFORM

Patients with foregut tumors are at high risk of malnutrition. Nutrition care focuses on identifying individuals at risk of malnutrition and optimizing nutrient intake to promote the maintenance of body weight and lean body mass. This multi-center prospective, longitudinal study audited nutrition care practices related to screening for risk of malnutrition (Patient-Generated Subjective Global Assessment Short Form; PG-SGA SF), and nutrition interventions prescribed (route; adequacy of energy and protein intakes). Audits occurred at four time periods: baseline (before treatment) and at 2, 4, and 6 months after starting cancer treatment; 170 patients (esophageal (ESO; n = 51); head and neck (HN; n = 119)) were enrolled. Nutrition risk (PG-SGA SF score ≥ 4) was prevalent at every time period: HN (baseline: 60%; 6 months 66%) and ESO (77%; 72%). Both groups had significant (p < 0.001) weight losses over the 6 month audit period (HN = 13.2% ESO = 11.4%). Enteral nutrition (EN) was most likely to be prescribed at 2 months for HN and at 4 and 6 months for ESO. Target prescribed energy and protein intakes were not met with any nutrition intervention; although adequacy was highest for those receiving EN. Nutrition care practices differed for HN and ESO cancers and there may be time points when additional nutrition support is needed.

Subjective Global Assessment of Nutritional Status in Head and Neck Cancer Patients Treated with Radiotherapy - A Prospective Observational Study from North East India

Head and neck cancer (HNC) patients undergoing curative radiotherapy (RT) are at risk of malnutrition due to disease process as well as effects of therapy. Identifying the nutritional status of these patients at the earliest, helps to introduce adequate and timely interventions that can improve compliance and outcomes of treatment. Various tools for nutritional assessment in cancer patients have been proposed. In this prospective observational study we used the Subjective Global Assessment (SGA) questionnaire in a cohort of HNC patients receiving definitive RT at a regional cancer center of North East India. Recording of data was done at baseline, at two weekly intervals during treatment, at end of radiotherapy (EORT) and at follow-up upto 6 months. We observed that despite proper nutrition counseling, our patients suffered from malnutrition throughout their course of RT, which was at its peak by EORT but gradually improved over six months of follow-up. Pain on eating and swallowing were the most debilitating symptoms which caused significant decline of nutrient intake, body fat and muscle mass among patients together with deteriorating SGA ratings. Our results will hopefully help us design better strategies for nutrition management while delivering curative (chemo)radiotherapy for HNC patients of this region- which has one of the highest incidences of HNC in the world.

Nutritional prehabilitation in head and neck cancer: a systematic review

PURPOSE

Prehabilitation affords an opportunity to support the management of malnutrition that is strongly associated with head and neck cancer. The purpose of this systematic review was to identify the components of nutritional prehabilitation interventions and their effects on nutritional and health outcomes in head and neck cancer patients.

METHODS

A comprehensive search was completed within Medline (including PubMed), CINHAL, Cochrane database, EMBASE, PRoQUEST, clinical trials registries, and grey literature to identify studies involving a nutritional intervention pre-treatment in head and neck cancer patients receiving any form of curative therapy. Nutritional intervention was defined as a specified period pre-treatment and outcome measures had to include assessment of nutritional status or body composition. Quality of included studies was assessed using Cochrane risk of bias 2.

RESULTS

From 557 identified studies, two met the inclusion criteria. Due to the low number of studies, a meta-analysis was not indicated. Both studies conducted a nutritional intervention using an "enriched formula" in malnourished patients prior to surgery. Neither study reported the intervention was effective for reducing weight loss, physical function, surgical complications, or length of stay versus the comparison.

CONCLUSION

There is limited nutritional prehabilitation research within head and neck cancer. An "enriched formula" provided in the prehabilitation period appears no more advantageous than routine standard nutritional formula in mitigating against the weight loss experienced in malnourished head and neck patient. Due to the malnutrition risks on diagnosis and the negative impact of poor nutritional status on clinical and functional outcomes, robust nutritional prehabilitation research is required to inform clinical practice.

Predicting Progression of Oral Lesions to Malignancy Using Machine Learning

OBJECTIVE

To use large-scale electronic health record (EHR) data to develop machine learning models predicting malignant transformation of oral lesions.

METHODS

A multi-institutional health system database was used to identify a retrospective cohort of patients with biopsied oral lesions. The primary outcome was malignant transformation. Chart review and automated system database queries were used to identify a range of demographic, clinical, and pathologic variables. Machine learning was used to develop predictive models for progression to malignancy.

RESULTS

There were 2192 patients with a biopsied oral lesion, of whom 1232 had biopsy proven oral dysplasia. There was malignant transformation in 34% of patients in the oral lesions dataset, and in 54% of patients in the dysplasia subset. Multiple machine learning-based models were trained on the data in two experiments, (a) including all patients with biopsied oral lesions and (b) including only patients with biopsy-proven dysplasia. In the first experiment, the best machine learning models predicted malignant transformation among the biopsied oral lesions with an area under the curve (AUC) of 86%. In the second experiment, the random forest model predicted malignant transformation among lesions with dysplasia with an AUC of 0.75. The most influential features were dysplasia grade and the presence of multiple lesions, with smaller influences from other features including anemia, histopathologic description of atypia, and other prior cancer history.

CONCLUSION

With diverse features from EHR data, machine learning approaches are feasible and allow for generation of models that predict which oral lesions are likely to progress to malignancy.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Postoperative consequences of cancer cachexia after head and neck free flap reconstruction

BACKGROUND

Cachexia is detrimental for patients with head and neck cancer (HNC). However, postoperative consequences of HNC cachexia remain unknown.

METHODS

A 2014-2019 retrospective review was performed of adults undergoing aerodigestive HNC resection with free tissue reconstruction. Propensity score matching using inverse probability of treatment weighting (IPTW) of cachectic and control groups was employed to adjust for covariate imbalances followed by binary logistic regression on postoperative outcomes.

RESULTS

Out of 252 total patients, 135 (53.6%) had cancer cachexia. The cohort was predominantly white (94.4%) males (65.1%) aged 61.5 ± 11.5 years with stage III-IV (84.1%) malignancy of the oral cavity (66.3%). After matching cohort pre- and intra-operative covariates using IPTW, cancer cachexia remained a strong, significant predictor of serious National Surgical Quality Improvement Program (NSQIP) complications (OR [95%CI] = 3.84 [1.80-8.21]) and major Clavien-Dindo complications (OR [95%CI] = 3.00 [1.18-7.60]).

CONCLUSIONS

Cancer cachexia is associated with worse HNC free flap reconstruction outcomes.

Molecular Mechanisms and Current Treatment Options for Cancer Cachexia

Simple Summary

The primary characteristics of cancer cachexia are weakness, weight loss, atrophy, fat reduction, and systemic inflammation. Cachexia is strongly associated with cancers involving the lungs, pancreas, esophagus, stomach, and liver, which account for half of all cancer deaths. TGF-β, MSTN, activin, IGF-1/PI3K/AKT, and JAK-STAT signaling pathways are known to underlie muscle atrophy and cachexia. Anamorelin (appetite stimulation), megestrol acetate, eicosapentaenoic acid, phytocannabinoids, targeting MSTN/activin, and molecules targeting proinflammatory cytokines, such as TNF-α and IL-6, are being tested as treatment options for cancer cachexia.

Abstract

Cancer cachexia is a condition marked by functional, metabolic, and immunological dysfunctions associated with skeletal muscle (SM) atrophy, adipose tissue loss, fat reduction, systemic inflammation, and anorexia. Generally, the condition is caused by a variety of mediators produced by cancer cells and cells in tumor microenvironments. Myostatin and activin signaling, IGF-1/PI3K/AKT signaling, and JAK-STAT signaling are known to play roles in cachexia, and thus, these pathways are considered potential therapeutic targets. This review discusses the current state of knowledge of the molecular mechanisms underlying cachexia and the available therapeutic options and was undertaken to increase understanding of the various factors/pathways/mediators involved and to identify potential treatment options.

Impact of sarcopenia on acute radiation-induced toxicity in head and neck cancer patients

BACKGROUND AND PURPOSE

Sarcopenia is related to late radiation-induced toxicities and worse survival in head and neck cancer (HNC) patients. This study tested the hypothesis that sarcopenia improves the performance of current normal tissue complication probability (NTCP) models of radiation-induced acute toxicity in HNC patients.

MATERIAL/METHODS

This was a retrospective analysis in a prospective cohort of HNC patients treated from January 2007 to December 2018 with (chemo)radiotherapy. Planning CT-scans were used for evaluating skeletal muscle mass. Characteristics of sarcopenic and non-sarcopenic patients were compared. The impact of sarcopenia was analysed by adding sarcopenia to the linear predictors of current NTCP models predicting physician- and patient-rated acute toxicities.

RESULTS

The cut-off values of sarcopenia in the study population (n=977) were established at skeletal muscle index <42.0 cm2/m2 (men) and <31.2 cm2/m2 (women), corresponding to the lowest sex-specific quartile. Compared to non-sarcopenic patients, sarcopenic patients were more frequently smokers (61% vs. 48%, p<0.001), had more often advanced stage of disease (stage III-IV, p=0.004), higher age (67 vs. 63 years, p<0.001) and experienced more pretreatment complaints, such as dysphagia (grade ≥2, p<0.001). Sarcopenia remained statistically significant, next to the linear predictor, only for physician-rated grade ≥3 dysphagia (week 3-6 during RT, p<0.01). However, sarcopenia did not improve the performance of these NTCP models (p>0.99).

CONCLUSION

Sarcopenia in HNC patients was an independent prognostic factor for radiation-induced physician-rated acute grade ≥3 dysphagia, which might be explained by its impact on swallowing muscles. However, addition of sarcopenia did not improve the NTCP model performance.

Effects of Immunonutrition in Head and Neck Cancer Patients Undergoing Cancer Treatment – A Systematic Review

Background and Aims

Malnutrition is prevalent among head and neck cancer (HNC) patients and leads to undesirable outcomes such as reduced treatment response and increased treatment-related side effects. This systematic review summarizes the recent evidence regarding the effect of immunonutrition in HNC patients undergoing radiotherapy and chemotherapy.

Methods

A literature search was conducted of the CENTRAL, ProQuest, MEDLINE, EBSCOhost, Web of Science and CINAHL databases; and further supplemented with internet and manual searches. Studies published between January 2011 and May 2021 were identified, screened, retrieved, and data extraction was performed.

Results

Twenty studies involving 1535 patients were included, 15 were randomized controlled trials (RCTs), three were retrospective study and two were comparative cohort studies. Five out of seven studies reported improvement or maintenance of nutrition status with continuous supplementation using immunonutrient-enriched formula. Three studies reported functional status as an outcome, with one study reporting significant improvement, one study reporting maintenance, and another study reporting no difference in the functional status of patients supplemented with immunonutrient-enriched formulas. Supplementation with glutamine did not reduce the overall incidence of mucositis but delayed the onset of oral mucositis and had significantly less incidence of severe oral mucositis.

Conclusion

Supplementation with immunonutrient-enriched formulas in HNC patients during radiotherapy and chemotherapy may improve or maintain nutrition status. Supplementation with glutamine during HNC radiotherapy and chemotherapy may delay the onset of oral mucositis and reduce incidences of severe oral mucositis. Further investigations are required, focusing on the timing, dosage, and duration of immunonutrition.

Systematic Review Registration: PROSPERO, identifier CRD42021241817.

Nutritional status at diagnosis is prognostic for pharyngeal cancer patients: a retrospective study

BACKGROUND

Malnutrition in head and neck cancer (HNC) patients is associated with increased morbidity and mortality. Several nutrition indicators have been reported to be related to the prognosis of HNC. However, the prognostic effect of these multiple nutrition factors in HNC is not well elucidated. The aim of this study was to evaluate the prognostic effect of these factors, including the novel hemoglobin, albumin, lymphocyte, and platelet (HALP) score, for pharyngeal cancers.

MATERIAL AND METHODS

From 2008 to 2019, a total of 319 pharyngeal cancer patients were recruited. We collected adult patients with a diagnosis of nasopharyngeal carcinoma, oropharyngeal carcinoma and hypopharyngeal carcinoma. Patients who completed definite staging workup and treatment were selected for analysis. We traced nutritional and hematological parameters, including body mass index (BMI), albumin, and complete blood count, for survival analysis.

RESULTS

We found that multiple nutritional markers, including BMI, hemoglobin, albumin, prognostic nutritional index (PNI), nutritional risk index (NRI) and HALP score, were important predictors for pharyngeal cancers in univariate Cox regression analysis. In multivariate analysis, we found that the HALP score was still an independent factor (HR: 1.62, 1.13-2.32 for overall survival [OS]) after adjusting of gender, age, cancer site, clinical stage, and BMI. The PNI was the most important independent factor for OS (HR: 3.12, 2.18-4.47) and cancer-specific survival (HR: 2.88, 1.88-4.41) in multivariate analysis.

CONCLUSION

We found that multiple nutrition markers, including BMI, hemoglobin, albumin, PNI, NRI and HALP score, are important predictors for pharyngeal cancers. This is the first report confirming the prognostic effect of the HALP score for HNCs. Nutritional status at diagnosis should be given more attention in pharyngeal cancer patients.

Perception and Performance of Physical Activity Behavior after Head and Neck Cancer Treatment: Exploration and Integration of Qualitative and Quantitative Findings

Maintaining or increasing physical activity (PA) may prevent loss of muscle mass and strength after completion of head and neck cancer (HNC) treatment. However, the exercise level of HNC patients may not meet PA guidelines. We aimed to explore HNC survivors' views on PA, their report of PA, and to compare these with objectively measured PA. Combined qualitative and quantitative data of HNC survivors were explored post-treatment. Data from semi-structured interviews, questionnaires, and objective measurements of PA were collected, analyzed, and integrated. This resulted in the identification of five themes related to prioritizing, day-to-day life, intention, positive feelings, and social support, respectively, in nine HNC survivors (male: n = 5; age: 52-67 years). Objectively measured PA levels were sedentary to low. The lack of intention to increase PA may be related to HNC survivors' perception that their current activity level is sufficient, despite low levels of measured PA. While some participants feel they need no help with PA, others are insecure about possible harms. Healthcare professionals may be able to help improve PA in HNC survivors with a tailored approach that reduces fear of harm and helps to incorporate higher intensity PA in daily activities.

Physiologic and molecular characterization of a novel murine model of metastatic head and neck cancer cachexia

BACKGROUND

Cancer cachexia is a metabolic disorder characterized by the progressive loss of fat and lean mass that results in significant wasting, ultimately leading to reduced quality of life and increased mortality. Effective therapies for cachexia are lacking, potentially owing to the mismatch in clinically relevant models of cachexia. Specifically, cachexia observed in a clinical setting is commonly associated with advanced or late-stage cancers that are metastatic, yet pre-clinical metastatic models of cachexia are limited. Furthermore, the prevalence of cachexia in head and neck cancer patients is high, yet few pre-clinical models of head and neck cancer cachexia exist. In addition to these shortcomings, cachexia is also heterogeneous among any given cancer, whereas patients with similar disease burden may experience significantly different degrees of cachexia symptoms. In order to address these issues, we characterize a metastatic model of human papilloma virus (HPV) positive head and neck squamous cell carcinoma that recapitulates the cardinal clinical and molecular features of cancer cachexia.

METHODS

Male and female C57BL/6 mice were implanted subcutaneously with oropharyngeal squamous cell carcinoma cells stably transformed with HPV16 E6 and E7 together with hRas and luciferase (mEERL) that metastasizes to the lungs (MLM). We then robustly characterize the physiologic, behavioural, and molecular signatures during tumour development in two MLM subclones.

RESULTS

Mice injected with MLM tumour cells rapidly developed primary tumours and eventual metastatic lesions to the lungs. MLM3, but not MLM5, engrafted mice progressively lost fat and lean mass during tumour development despite the absence of anorexia (P < 0.05). Behaviourally, MLM3-implanted mice displayed decreased locomotor behaviours and impaired nest building (P < 0.05). Muscle catabolism programmes associated with cachexia, including E3 ubiquitin ligase and autophagy up-regulation, along with progressive adipose wasting and accompanying browning gene signatures, were observed. Tumour progression also corresponded with hypothalamic and peripheral organ inflammation, as well as an elevation in neutrophil-to-lymphocyte ratio (P < 0.05). Finally, we characterize the fat and lean mass sparing effects of voluntary wheel running on MLM3 cachexia (P < 0.05).

CONCLUSIONS

This syngeneic MLM3 allograft model of metastatic cancer cachexia is reliable, consistent, and readily recapitulates key clinical and molecular features and heterogeneity of cancer cachexia. Because few metastatic models of cachexia exist-even though cachexia often accompanies metastatic progression-we believe this model more accurately captures cancer cachexia observed in a clinical setting and thus is well suited for future mechanistic studies and pre-clinical therapy development for this crippling metabolic disorder.

Understanding Cachexia in Head and Neck Cancer

One of the major comorbidities of cancer and cancer therapy is posing a global health problem in cancer cachexia. Cancer cachexia is now considered a multifactorial syndrome that presents with drastic loss of body weight, anorexia, asthenia, and anemia. Head and neck cancer (HNC) patients are at a greater risk for development and severity of cachexia syndrome as there is direct involvement of structures associated with nutritional intake. Yet, the scientific evidence, approach, and management of cachexia in HNCs are yet to be largely explored. The article aims to succinctly review the concepts of cancer cachexia with relevance to HNCs and summarizes the current findings from recent research.

The Role of Nurse in the Multidisciplinary Management of Cancer Cachexia

Cancer cachexia is a complex syndrome for which multidisciplinary management through collaboration has the potential to improve patient outcomes and efficiency of care, through the integration of nursing into practice. These authors conducted a literature review of PubMed, EBSCO, OVID, and ProQuest for publications on the roles and responsibilities of nurses who are working in multidisciplinary teams for the management of cancer cachexia. We limited our search parameters for the literature review such that: (1) the included papers were published in the English language from January 2000 to February 2021 and (2) the included papers featured an adult patient population. Based on this review, cancer cachexia can be characterized as an involuntary loss of body weight that is combined with a dysregulation in the control of energy homeostasis and protein loss, which leads to poor clinical outcomes in patients. Cancer cachexia has been recognized as having multidimensional etiologies that are related to the nutritional and metabolic systems, as well as other physical and physiological systems, and to symptoms that manifest concurrently to the cachexia. While the clinical identification and taxonomic classification of cancer cachexia are usually associated with an observable degree of weight loss and muscular atrophy in a patient, clinical evidence of inflammation and related symptoms should be considered (in addition to the weight loss and muscular atrophy) in the diagnosis and evaluation of cancer cachexia, as will be argued in this paper. Early diagnosis, appropriate clinical assessment, and evaluation of cancer cachexia are crucial to predicting the onset of the condition and managing its symptoms when it occurs. Various tools have been developed for the clinical evaluation and diagnosis of cancer cachexia which reflect the multitudinous manifestations of the condition. Due to the diversity of its manifestations, multimodal therapy has gained popularity for the management of cancer cachexia. Multimodal therapy includes combined pharmacologic intervention, nutrition supplements, nutritional consultation, physical exercise, and symptom control. As these authors will demonstrate in this paper, this mode of multidisciplinary team management is increasingly supported by scientific evidence and as such, can be seen as essential for high-quality cancer cachexia management. Nursing plays an important role in the multidisciplinary care team model for cancer cachexia management, as nurses are well situated to perform screening, referral, coordination, nutritional consultation, physical exercise consultation, direct nutritional nursing, psychosocial support, symptom control, and hospice care. However, an increased focus on education, skills training, and tool development (as well as adoption of tools) on the part of nurses and other multidisciplinary team members is required to meet the goal of efficient care and improved outcomes for patients with cancer cachexia. These authors demonstrate that increasing roles and responsibilities for nurses in the management of cancer cachexia is a valuable area to explore in the literature and to implement in clinical practice. Our review aims to summarize the etiology and epidemiology, mechanisms-of-action, and multitudinous manifestations of cancer cachexia, the therapies that are used in cancer cachexia care and the management approaches by which this care is organized. Finally, these authors emphasize nurses' responsibilities in this mode of cancer cachexia multidisciplinary team management, which represents a fruitful benefit both in the research literature and in clinical settings.

Identifying Patient-Reported Outcome Measures (PROMs) for Routine Surveillance of Physical and Emotional Symptoms in Head and Neck Cancer Populations: A Systematic Review

The aims of this review were to identify symptoms experienced by head and neck cancer (HNC) patients and their prevalence, as well as to compare symptom coverage identified in HNC specific patient-reported outcome measures (PROMs). Searches of Ovid Medline, Embase, PsychInfo, and CINAHL were conducted to identify studies. The search revealed 4569 unique articles and identified 115 eligible studies. The prevalence of reported symptoms was highly variable among included studies. Variability in sample size, timing of the assessments, and the use of different measures was noted across studies. Content mapping of commonly used PROMs showed variability and poor capture of prevalent symptoms, even though validation studies confirmed satisfactory reliability and validity. This suggests limitations of some of the tools in providing an accurate and comprehensive picture of the patient's symptoms and problems.

The Emerging Role of Interleukin 1β (IL-1β) in Cancer Cachexia

Treatment of cancer cachexia remains an unmet need. The host-tumour interface and the resulting sequestration of the pro-inflammatory cytokine Il-1β is critical in cachexia development. Neuroinflammation mediated via IL-1β through the hypothalamic pituitary axis results in increased muscle proteolysis and adipose lipolysis, thus creating a prolonged stress-like environment with loss of appetite and increased resting energy expenditure. Recent trials using a monoclonal antibody targeting IL-1β, canakinumab, have shown a potential role in lung cancer; however, a potential role of targeting IL-1β to treat cachexia in patients with lung cancer is unclear, yet the underlying pathophysiology provides a sound rationale that this may be a viable therapeutic approach.

Nutritional Deficiencies in Radiotherapy-Treated Head and Neck Cancer Patients

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

Cancer Cachexia Affects Patients with Head and Neck Cancer in All Stages of Disease: A Prospective Cross-Sectional Study

The aim of the study was to determine the prevalence of cancer cachexia according to the clinical stage and determine differences in body composition, usual energy intake, and pro-inflammatory profile between cachectic and non-cachectic patients newly diagnosed with head and neck squamous cell carcinoma (HNSCC). A cross-sectional study was conducted in adult patients diagnosed with HNSCC admitted to the oncology unit before starting cancer treatment. Cancer cachexia was assessed according to Fearon criteria, and patients were divided into two groups: cachectic and non-cachectic patients. Body composition measured by bioelectrical impedance, energy intake, and biochemical and inflammatory markers were assessed. Comparative analyses were performed Student's-T test, using one-way ANOVA, chi-square and Mann Whitney-U test. Of the 79 consecutive patients included in the analysis, 72% (n = 57; 61 ± 15 years) were classified as cachectic and 28% (n = 22;59 ± 10 years) as non-cachectic. According to clinical stage, the prevalence of cachexia was stage I = 8.8%, stage II = 15.8%, stage III = 33.3% and stage IV = 42.1% (P = 0.564) and phase angle showed to be different between these groups (P < 0.05). Body composition showed that fat-free mass and total body water were significantly lower in patients with cachexia (p < 0.05). No differences were observed in phase angle, food intake or inflammatory markers between cachectic and non-cachectic patients. Cancer-cachexia is prevalent in all clinical stages in newly diagnosed patients with HNSCC. Early identification of cancer cachexia will allow initiate specialized nutrition support in a timely manner.

European white paper: oropharyngeal dysphagia in head and neck cancer

Purpose

To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe.

Methods

Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion.

Results

Twenty-four sections on HNC-specific OD topics.

Conclusion

This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

Polymorphism of The Regulatory Region of the ITGAM Gene (-323G>A) as a Novel Predictor of a Poor Nutritional Status in Head and Neck Cancer Patients Subjected to Intensity-Modulated Radiation Therapy

Background: The most serious disturbance of the nutritional status is neoplastic cachexia. The main factor contributing to the development of cachexia is the ongoing inflammatory process. The gene associated with the development of the inflammatory response is ITGAM. Therefore, the aim of the study was to assess the relationship between a single nucleotide polymorphism (SNP)-323G>A of the ITGAM gene and the occurrence of nutritional disorders in patients undergoing radiotherapy (RT) due to head and neck cancers (HNC). Methods: The study involved 71 patients with HNC treated with intensity-modulated radiotherapy (IMRT). SNP analysis of the ITGAM gene (-323G>A) was performed using commercial molecular probes and Real-Time PCR. Results: The presence of the A allele of the ITGAM gene significantly (over 14-fold) reduced the risk of severe disturbances in nutritional status assessed according to the subjective global assessment (SGA) scale (odds ratio (OR) = 0.07; p = 0.0213). The GG genotype of this gene was associated with an over three-fold higher risk of shortened overall survival (OR = 3.01; p = 0.0376). Conclusions: Determination of the SNP (-323G>A) of the ITGAM gene may prove to be a useful marker in the assessment of the risk of nutritional disorders in patients with HNC undergoing RT.

Nutritional outcomes in head and neck cancer patients: is intensive nutritional care worth it?

OBJECTIVE

This study aimed to compare nutritional outcomes before and after implementation of weekly dietetic counseling (intensive nutritional care) in head and neck cancers patients.

METHODS

A retrospective study with all head and neck patients, who received radiotherapy between January 2010 and December 2017 were performed. The main outcome was significant weight loss. Compliance to caloric and protein recommendations were also evaluated.

RESULTS

In all, 472 patients were included. Weight loss was not different between before and after implementation (-6.7%; IQ -10.5/-1.9 vs -5.0%; IQ -9.8/-0.7;p=0.06).There were no significant difference in terms of meeting the recommended intake. Higher baseline body mass index and oral nutritional support predicted significant weight loss.

CONCLUSION

Implementation of intensive nutritional care did not have an impact on weight loss and energy and protein intake in head and neck cancer patients. Further research would be of value to determine the appropriate service-delivery model to achieve optimal patient outcomes.

Toxicities Caused by Head and Neck Cancer Treatments and Their Influence on the Development of Malnutrition: Review of the Literature

Malnutrition poses a significant problem for oncology patients, resulting in fatalities within this population. Patients with head and neck cancer (HNC) are at high risk, with up to 90% developing malnutrition. Common treatments used for HNC can often lead to adverse side effects, including oral health conditions, gastrointestinal upsets, and several metabolic changes. Consequently, treatments can cause inadequate nutritional intake, resulting in a reduction in energy consumption, and alterations in energy utilization, contributing to the development of malnutrition. Furthermore, the presence of these treatment toxicities, and the related malnutrition can lead to reduced quality of life, weight loss, and psychological distress. There are interventions available (nutritional, medicinal, and physical therapies) that have demonstrated potential effectiveness in reducing the severity of symptomatic toxicities, reducing the risk of malnutrition, and improving survival outcomes of patients with HNC. Based on the findings of this review, there is an urgent need for the implementation or continuation of multi-disciplinary strategies, as well as updated and improved guidelines to assist in the prevention and treatment of malnutrition caused by treatment-related toxicities in patients with HNC.

Cancer cachexia and its pathophysiology: links with sarcopenia, anorexia and asthenia

Cancer cachexia is a multifactorial syndrome characterized by a progressive loss of skeletal muscle mass, along with adipose tissue wasting, systemic inflammation and other metabolic abnormalities leading to functional impairment. Cancer cachexia has long been recognized as a direct cause of complications in cancer patients, reducing quality of life and worsening disease outcomes. Some related conditions, like sarcopenia (age-related muscle wasting), anorexia (appetite loss) and asthenia (reduced muscular strength and fatigue), share some key features with cancer cachexia, such as weakness and systemic inflammation. Understanding the interplay and the differences between these conditions is critical to advance basic and translational research in this field, improving the accuracy of diagnosis and contributing to finally achieve effective therapies for affected patients.

Dentition, nutritional status and adequacy of dietary intake in treatment naïve head and neck cancer patients

OBJECTIVES

To examine the relationship of reduced numbers of occluding teeth and dietary intake (DI), nutrition impact symptoms (NIS), and weight loss (WL) in head and neck cancer (HNC) patients.

METHODS

As a part of the standard of care, treatment-naïve HNC patients (n = 104) completed dental evaluation (number of teeth, total anterior/posterior occlusal teeth, Eichner Index (EI) classification), WL, DI questionnaire and HNC Symptom Checklist©. Descriptive statistics (Kruskal-Wallis, Fisher-exact, χ² tests) and (uni-) multi-variable logistic regression.

RESULTS

Overall, 42, 45 and 13% of patients were in EI-class A, B and C with a median of 8, 3, and 0 total posterior occlusal teeth. EI-class B/C patients were older, more likely to have impaired DI (OR = 3.88; 95%CI:1.63-9.26; P = 0.002) and reported interference with DI by 11 NIS (p < 0.05). DI was, however, reported as unimpaired in 77, 49 and 39% of patients in EI-class A, B and C, respectively. The subset of EI-class B/C patients with impaired DI, had more NIS interference with DI (P < 0.05; difficulty chewing, pain, early satiety, lack of energy); EI-class C patients additionally had dry mouth, thick saliva and dysphagia (P < 0.05). In logistic regression, EI-classes B/C patients with reduced (vs unimpaired) DI were more likely to have ≥5% WL (OR = 10.1; 95%CI:2.0-50.0), higher NIS interference (range OR 4.3-10.7).

CONCLUSIONS

More than half of these HNC patients had reduced numbers of occlusal teeth or were edentulous. EI-class B/C patients did not necessarily have impaired DI, however the combination of EI-class B/C and a constellation of NIS, associated with reduced DI.

CLINICAL SIGNIFICANCE

Treatment naïve head and neck cancer (HNC) patients with reduced occlusal and masticatory performance (Eichner Index B/C) and reduced dietary intake are at high risk for weight loss. Identifying HNC patients at risk may improve their oral health, dietary intake and reduce their risk of weight loss.

Disease-induced and treatment-induced alterations in body composition in locally advanced head and neck squamous cell carcinoma

BACKGROUND

Chemoradiation or bioradiation treatment (CRT/BRT) of locally advanced head and neck squamous cell carcinoma (LAHNSCC) comes with high toxicity rates, often leading to temporary tube feeding (TF) dependency. Cachexia is a common problem in LAHNSCC. Yet changes in body composition and muscle weakness during CRT/BRT are underexplored. Strong evidence on the effect of TF on body composition during treatment is lacking. The aim of this cohort study was to assess (i) the relationship of fat-free mass index (FFMI) and handgrip strength (HGS) with CRT/BRT toxicity and outcome, (ii) body composition in patients treated with chemoradiation (cisplatin) vs. bioradiation (cetuximab), and (iii) the effect of the current TF regime on body composition and muscle strength.

METHODS

Locally advanced head and neck squamous cell carcinoma patients treated with CRT/BRT between January 2013 and December 2016 were included (n = 137). Baseline measurements of body composition (bioelectrical impedance analysis) and HGS were performed. Toxicity grades (Common Terminology Criteria for Adverse Events) were scored. In a subset of 69 patients, weight loss, body composition, and HGS were additionally assessed during and after CRT/BRT. TF was initiated according to the Dutch guidelines for malnutrition.

RESULTS

In this cohort (68% male, mean age 59 ± 8 years), the incidence of baseline muscle wasting, defined as FFMI < P₁₀ , was 29%. Muscle wasting was present in 23 of 100 (23%) chemoradiation patients and 17 of 37 (46%) bioradiation patients (P = 0.009). Muscle-wasted patients required more unplanned hospitalizations during CRT (P = 0.035). In the chemoradiation subset, dose-limiting toxicity was significantly higher in wasted vs. non-wasted patients (57% vs. 25%, P = 0.004). Median follow-up was 32 months. Multivariate Cox regression analysis identified muscle wasting as independent unfavourable prognostic factor for overall survival [hazard ratio 2.1 (95% CI 1.1-4.1), P = 0.022] and cisplatin as favourable prognostic factor [hazard ratio 0.3 (95% CI 0.2-0.6), P = 0.001]. Weight and HGS significantly decreased during CRT/BRT, -3.7 ± 3.5 kg (P < 0.001) and -3.1 ± 6.0 kg (P < 0.001), respectively. Sixty-four per cent of the patients required TF 21 days (range 0-59) after CRT/BRT initiation. Total weight loss during CRT/BRT was significantly (P = 0.007) higher in the total oral diet group (5.5 ± 3.7 kg) compared with the TF group (3.0 ± 3.2 kg). Loss of FFM and HGS was similar in both groups.

CONCLUSIONS

In LAHNSCC patients undergoing CRT/BRT, FFMI < P₁₀ is an unfavourable prognostic factor for overall survival, treatment toxicity, and tolerance. Patients experience significant weight and FFM loss during treatment. Current TF regime attenuates weight loss but does not overcome loss of muscle mass and function during therapy. Future interventions should consider nutritional intake and additional strategies specifically targeting metabolism, loss of muscle mass, and function.

Definitive chemoradiotherapy in patients with squamous cell cancers of the head and neck - results from an unselected cohort of the clinical cooperation group "Personalized Radiotherapy in Head and Neck Cancer"

BACKGROUND

Definitive chemoradiotherapy (dCRT) is a standard treatment for patients with locally advanced head and neck cancer. There is a clinical need for a stratification of this prognostically heterogeneous group of tumors in order to optimize treatment of individual patients. We retrospectively reviewed all patients with head and neck squamous cell carcinoma (HNSCC) of the oral cavity, oropharynx, hypopharynx, or larynx, treated with dCRT from 09/2008 until 03/2016 at the Department of Radiation Oncology, LMU Munich. Here we report the clinical results of the cohort which represent the basis for biomarker discovery and molecular genetic research within the framework of a clinical cooperation group.

METHODS

Patient data were collected and analyzed for outcome and treatment failures with regard to previously described and established risk factors.

RESULTS

We identified 184 patients with a median follow-up of 65 months and a median age of 64 years. Patients received dCRT with a median dose of 70 Gy and simultaneous chemotherapy in 90.2% of cases, mostly mitomycin C / 5-FU in concordance with the ARO 95-06 trial. The actuarial 3-year overall survival (OS), local, locoregional and distant failure rates were 42.7, 29.8, 34.0 and 23.4%, respectively. Human papillomavirus-associated oropharynx cancer (HPVOPC) and smaller gross tumor volume were associated with significantly improved locoregional tumor control rate, disease-free survival (DFS) and OS in multivariate analysis. Additionally, lower hemoglobin levels were significantly associated with impaired DFS und OS in univariate analysis. The extent of lymph node involvement was associated with distant failure, DFS and OS. Moreover, 92 patients (50%) of our cohort have been treated in concordance with the ARO 95-06 study, corroborating the results of this study.

CONCLUSION

Our cohort is a large unselected monocentric cohort of HNSCC patients treated with dCRT. Tumor control rates and survival rates compare favorably with the results of previously published reports. The clinical data, together with the available tumor samples from biopsies, will allow translational research based on molecular genetic analyses.

Chronic Systemic Symptoms in Head and Neck Cancer Patients

The systemic effects and manifestations of disease and treatment have been of interest for millennium. Until recently, basic and clinical research is just now reaching a watershed. Systemic symptoms usually do not occur in isolation but rather in clusters; however, much of the cutting-edge research pertaining to the etiology, mechanism, manifestations, and moderators of systemic symptoms in humans has been directed at individual symptoms, thus creating silos of knowledge. Breaching these silos and bridging the knowledge from disparate arenas of investigation to build a comprehensive depiction of acute and chronic systemic symptoms has been a challenge. In addition, much of the recent work in systemic symptoms has been conducted in the setting of nonmalignant disease. The degree to which the findings from other chronic disease processes can be translated into the oncologic realm is unknown. This article will explore inflammation as a major contributing factor to systemic symptoms and sickness behavior, discuss the most common manifestations in cancer survivors, and, where available, discuss specific data pertaining to head and neck cancer survivors.

Nutrition and swallowing therapy strategies for patients with head and neck cancer

Patients with head and neck cancer experience many problems with eating which make them at high risk of malnutrition. Pre-habilitation swallowing exercises as overseen by a speech pathologist can improve swallowing function. A multidisciplinary approach to care, including effective nutritional screening, assessment and intervention has demonstrated improved outcomes in terms of meet nutritional requirements, improved nutritional status and quality of life. Nutritional recommendations are 1.2-1.5 g protein per kilogram per day and 125kJ/kg body weight per day but as these are guides close monitoring of intake and weight is important. Multidisciplinary teams and telehealth have shown better outcomes for nutrition and swallowing status for head and neck cancer patients and ongoing support is required for best patient care.

Does perioperative oxandrolone improve nutritional status in patients with cachexia related to head and neck carcinoma?

Background

Cancer cachexia affects up to over 50% of advanced head and neck cancer (HNC) patients. To date, the potential utility of anabolic steroids in perioperative cachectic HNC patients has not been determined.

Methods

Retrospective review of pre- and post-oxandrolone administration prealbumin levels in 18 perioperative HNC patients between October 2007 and October 2014 at a tertiary academic medical center.

Results

The median pretreatment prealbumin was 88.5 mg/L. The median post-treatment prealbumin was 227 mg/L. The median interval improvement of the prealbumin level was 131.5 mg/L. The median differences between the pretreatment and post-treatment prealbumin levels were found to be statistically significant (P < .001). Subjective improvement in wound healing was also observed.

Conclusions

Perioperative administration of oxandrolone resulted in objective improvements in prealbumin levels and subjective improvements in surgical wounds. Oxandrolone administered 10 mg twice daily (BID) for 10 days may be a useful adjunct in the perioperative care of nutritionally deficient HNC patients who are at risk for or have demonstrated impaired wound healing.

Level of Evidence

3.

Prevalence and prognostic significance of malnutrition in patients with cancers of the head and neck

BACKGROUND & AIMS

Head and neck cancer (HNC) are at high nutritional risk; however the prevalence and severity of malnutrition in contemporary patients with HNC are unclear. Diagnostic criteria for cancer-associated weight loss grading (WLG) (Grades 0 to 4) [1] have been validated and are recommended in oncology nutrition clinical practice guidelines [2-3]. The aim was to determine the prevalence using WLG in HNC patients and determine the extent to which reduced dietary intake (DI) explained variation of WLG.

METHODS

A population-based cohort of HNC patients (N = 1756) in northern Alberta, Canada included consecutive new patients, 2004-2016. At referral to the regional cancer center weight history and DI categories were collected. Multinomial logistic regression (MLR) identified predictors of weight loss (WL) severity. Overall survival (OS) in relation to WL Grade and DI was determined by multivariable Cox proportional hazard.

RESULTS

WL was absent in 42.9% and the remainder had Grade 1 (18%), Grade 2 (14.7%), Grade 3 (15.9%) and Grade 4 (8.5%) WL. Independent predictors of WLG in adjusted MLR model, included stage (P < 0.000), performance status (PS) (P < 0.000) and DI categories (P < 0.000); sex, age and disease site were not significant. Compared to "normal food in normal amount" adjusted Odds Ratio for WL Grade 4 was 4.0 (2.1-7.5) "normal food, but less than normal amount"; 25.2 (10.7-59.1) "little solid food"; 51.8 (10.5-255.3) "very little of anything"; 42.4 (11.0-163.0) "only liquids"; 25.9 (7.1-94.3) "only nutritional supplements". In the Cox model controlled for age, sex, cancer stage and site and PS, both WLG ((P < 0.000) and DI categories (P = 0.003) independently predicted OS.

CONCLUSION

Data from this population cohort provide a benchmark for prevalence of cancer associated WL severity at diagnosis. Patient reported DI categories are strong predictors of WL and prognostic for OS.

The Head and Neck Squamous Cell Carcinoma Microenvironment as a Potential Target for Cancer Therapy

Similarly to other types of malignant tumours, the incidence of head and neck cancer is increasing globally. It is frequently associated with smoking and alcohol abuse, and in a broader sense also with prolonged exposure to these factors during ageing. A higher incidence of tumours observed in younger populations without a history of alcohol and tobacco abuse may be due to HPV infection. Malignant tumours form an intricate ecosystem of cancer cells, fibroblasts, blood/lymphatic capillaries and infiltrating immune cells. This dynamic system, the tumour microenvironment, has a significant impact on the biological properties of cancer cells. The microenvironment participates in the control of local aggressiveness of cancer cells, their growth, and their consequent migration to lymph nodes and distant organs during metastatic spread. In cancers originating from squamous epithelium, a similarity was demonstrated between the cancer microenvironment and healing wounds. In this review, we focus on the specificity of the microenvironment of head and neck cancer with emphasis on the mechanism of intercellular crosstalk manipulation for potential therapeutic application.

Low muscle mass is associated with early termination of chemotherapy related to toxicity in patients with head and neck cancer

BACKGROUND & AIMS

We studied whether low pre-treatment muscle mass, measured with CT at thoracic (T4) or lumbar level (L3) associates with early termination of chemotherapy related to toxicity in head and neck cancer (HNC) patients.

METHODS

This was a retrospective chart and image review. Adult HNC patients treated with (surgery and) platinum-based chemo-radiotherapy were included if a pre-treatment CT scan at T4 or L3 level was available. Muscle mass was evaluated by assessment of skeletal muscle index (SMI; cm²/m²). T4 and L3 SMI measurements were corrected for deviation from their respective means and were merged into one score for SMI difference (cm²/m²). All cases were assessed for presence of toxicity-related unplanned early termination of chemotherapy ('early termination'). Univariate and multivariate logistic regression models were used to investigate associations between pooled SMI and early termination.

RESULTS

213 patients (age: 57.9 ± 10.3 y, male: 77%, T4 image: 45%) were included. A significant association between SMI as a continuous variable and early termination was found, both in the univariate analysis (p = 0.007, OR = 0.96 [0.94-0.99]) and the multivariate analysis (p = 0.021, OR 0.96 [0.92-0.99]). The multivariate models identified potential associations with type of chemotherapy, presence of co-morbidity, a combination of (former) smoking and alcohol consumption, and sex.

CONCLUSION

Lower muscle mass was robustly associated with higher odds of early termination of chemotherapy in HNC patients. Further prospective studies are required to tailor the care for patients with low muscle mass and to avoid early termination of chemotherapy.

Preoperative low skeletal muscle mass as a risk factor for pharyngocutaneous fistula and decreased overall survival in patients undergoing total laryngectomy

Background

Low skeletal muscle mass (SMM) is associated with postoperative complications, prolonged hospital stay, and short overall survival (OS) in surgical oncology. We aimed to investigate this association in patients undergoing total laryngectomy (TL).

Methods

A retrospective study was performed of patients undergoing TL. SMM was measured using CT or MRI scans at the level of the third cervical vertebra (C3).

Results

In all, 235 patients were included. Low SMM was observed in 109 patients (46.4%). Patients with low SMM had more pharyngocutaneous fistulas (PCFs) than patients with normal SMM (34.9% vs 20.6%; P = .02) and prolonged hospital stay (median, 17 vs 14 days; P < .001). In multivariate analysis, low SMM (hazards ratio, 1.849; 95% confidence interval, 1.202‐2.843) and high N stage were significant prognosticators of decreased OS.

Conclusion

Low SMM is associated with PCF and prolonged hospital stay in patients undergoing TL. Low SMM is an independent prognostic factor for shorter OS.

Prognosis of osteosarcomas in the mandible: 15-year experience of 55 patients

Our goal was to evaluate the prognosis of osteosarcomas (OS) in the mandible for finding out the best treatment.Patients diagnosed with OS in the mandible from January 2000 to December 2015 were retrospectively enrolled. Demographic, tumor-specific, treatment, and survival data were collected and analyzed.A total of 55 patients (35 male and 20 female) were included, all patients had first manifestation of swelling. Cachexia occurred in 15 (27.3%) patients. Chondroblastic type was the most common histology subtype followed by osteoblastic type. High grade tumors were found in 30 (63.6%) patients. 33 (60%) patients received an operation of hemimandibulectomy, and free fibula reconstruction was performed in 20 (36.4%) patients. The 5-year recurrence-free survival (RFS) and disease-specific survival (DSS) rates were 73.6% and 66.9%, respectively. Univariate prognostic analysis reported risk factors of tumor grade, reconstruction type (free fibula flap vs non-free flap), and operation extent were significant for the recurrence, and reconstruction type and operation extent were significant for the disease-specific death, but in multivariate analysis, only the factor of operation extent was significantly associated with both the recurrence and death.A wide excision extent such as hemimandibulectomy is suggested for OS in the mandible for achieving good prognosis.

Preoperative anemia and perioperative blood transfusion in head and neck squamous cell carcinoma

OBJECTIVES

To evaluate the impact of preoperative anemia and perioperative blood transfusion (PBT) on disease free (DFS) and overall survival (OS) of patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

Retrospective study of 354 patients primarily treated with surgery between 2006 and 2016. Cases were selected according to completeness and accuracy of available clinical data. Thus, a selection bias cannot be excluded. Patients who received PBT were identified by our controlling department and verified by our blood bank data base.

RESULTS

Both, preoperative anemia and PBT significantly decreased OS in univariate analysis. Although PBT was needed more frequently by older patients in worse physical conditions with more advanced HNSCC, subgroup analysis also demonstrate a profoundly negative effect of PBT on OS in younger patients and early stage HNSCC. According to a restrictive transfusion policy at our hospital the transfusion rate was comparably low. We could not verify increasing effects of PBT on cancer recurrence rates as it was previously shown.

DISCUSSION

Preoperative anemia is the most common paraneoplastic syndrome in HNSCC. Despite its devastating prognostic effect we suggest a restrictive transfusion policy whenever possible. Our data also show that anemia as an independent prognostic factor in head and neck surgical oncology is defined not only by low hemoglobin concentrations but low red blood cell counts as well.

Nutritional status in patients with head and neck cancer undergoing radiotherapy: a longitudinal study

PURPOSE

Patients with head and neck cancers are susceptible to malnutrition during radiotherapy. This study aimed to determine the changes in the nutritional status and its determinants in patients with head and neck cancer during radiotherapy.

METHODS

This prospective observational study was performed in an outpatient Radiation Oncology clinic with a sample of 54 patients. An interview form (including anthropometric and laboratory parameters), the Patient-Generated Subjective Global Assessment to assess nutritional status, quality of life scales, and toxicity criteria were used for data collection at the baseline, the end of radiotherapy and 1 and 3 months after radiotherapy.

RESULTS

While the majority of the patients (90%) were well nourished at baseline, most of the patients (74%) were malnourished at the end of radiotherapy (p < 0.001). During radiotherapy, patients developed malnutrition, reflected in a decrease in food intake, approximately 5% loss of body weight, a reduction in mid-arm upper circumference and mid-arm muscle mass, and reduced serum protein and albumin levels. The nutritional status was worse in oropharyngeal cancers (p = 0.021), advanced stage (p = 0.004), use of concomitant chemotherapy (p = 0.041), and worse toxicity (p < 0.001). Furthermore, the nutritional status was strongly associated with the quality of life.

CONCLUSIONS

This study demonstrated negative impact of radiotherapy on the nutritional status of patients with head and neck cancer. The study also showed the association of the nutritional status and the quality of life. The nutritional status should be assessed during different periods in the trajectory of treatment due to its significant contribution to the quality of life.