Chronic Nutrition Impact Symptoms Are Associated with Decreased Functional Status, Quality of Life, and Diet Quality in a Pilot Study of Long-Term Post-Radiation Head and Neck Cancer Survivors.

BACKGROUND: As a result of tumor location and treatment that is aggressive, head and neck cancer (HNC) survivors experience an array of symptoms impacting the ability and desire to eat termed nutrition impact symptoms (NISs). Despite increasing cancer survival time, the majority of research studies examining the impact of NISs have been based on clinical samples of HNC patients during the acute phase of treatment. NISs are often chronic and persist beyond the completion of treatment or may develop as late side effects. Therefore, our research team examined chronic NIS complications on HNC survivors' functional status, quality of life, and diet quality. METHODS: This was a cross-sectional study of 42 HNC survivors who were at least 6 months post-radiation. Self-reported data on demographics, NISs, quality of life, and usual diet over the past year were obtained. Objective measures of functional status included the short physical performance battery and InBody© 270 body composition testing. NISs were coded so a lower score indicated lower symptom burden, (range 4-17) and dichotomized as ≤10 vs. >10, the median in the dataset. Wilcoxon rank sum tests were performed between the dichotomized NIS summary score and continuous quality of life and functional status outcomes. Diet quality for HNC survivors was calculated using the Healthy Eating Index 2015 (HEI-2015). Wilcoxon rank sum tests examined the difference between the HNC HEI-2015 as compared to the National Health and Nutrition Examination Survey (NHANES) data calculated using the population ratio method. RESULTS: A lower NIS score was statistically associated with higher posttreatment lean muscle mass (p = 0.002). A lower NIS score was associated with higher functional (p = 0.0006), physical (p = 0.0007), emotional (p = 0.007), and total (p < 0.0001) quality of life. Compared to NHANES controls, HNC survivors reported a significantly lower HEI-2015 diet quality score (p = 0.0001). CONCLUSIONS: Lower NIS burden was associated with higher lean muscle mass and functional, physical, emotional, and total quality of life in post-radiation HNC survivors. HNC survivors reported a significantly lower total HEI-2015 as compared to healthy NHANES controls, providing support for the hypothesis that chronic NIS burden impacts the desire and ability to eat. The effects of this pilot study were strong enough to be detected by straight forward statistical approaches and warrant a larger longitudinal study. For survivors most impacted by NIS burden, multidisciplinary post-radiation exercise and nutrition-based interventions to manage NISs and improve functional status, quality of life, and diet quality in this survivor population are needed.

Taste and Smell Function in Head and Neck Cancer Survivors.

Survivors of head and neck squamous cell cancers (HNSCC) frequently complain of taste dysfunction long after radiation therapy is completed, which contradicts findings from most sensory evaluation studies that predict dysfunction should resolve few months after treatment. Therefore, it remains unclear whether taste and smell function fully recovers in HNSCC survivors. We evaluated HNSCC survivors (n = 40; age 63 ± 12 years, mean ± standard deviation) who received radiation therapy between 6 months and 10 years before recruitment and compared their responses to those of a healthy control group (n = 20) equivalent in age, sex, race, smoking history, and body mass index. We assessed regional (tongue tip) and whole-mouth taste intensity perception using the general Labeled Magnitude Scale and smell function using the University of Pennsylvania Smell Identification Test (UPSIT). To determine possible differences between groups in retronasal smell perception, we used solutions of sucrose with strawberry extract, citric acid with lemon extract, sodium chloride in vegetable broth, and caffeine in coffee and asked participants to rate perceived smell and taste intensities with and without nose clips. We found groups had similar UPSIT and taste intensity scores when solutions were experienced in the whole mouth. However, HNSCC survivors were less likely to identify low concentrations of bitter, sweet, or salty stimuli in the tongue tip relative to healthy controls. Our findings suggest persistent and subtle localized damage to the chorda tympani or to the taste buds in the fungiform papillae of HNSCC survivors, which could explain their sensory complaints long after completion of radiotherapy.

Quality of life, coping strategies, and supportive care needs in head and neck cancer survivors: a qualitative study.

PURPOSE: The purpose of this qualitative study was to better understand the lived experience of head and neck cancer (HNC) survivors between 6 months to 9 years post-radiation. Quality of life, coping strategies, concerns for the future, and preferences for supportive care were explored. METHODS: Semi-structured interviews were conducted in 31 HNC survivors from a Midwestern hospital. Interviews were recorded, transcribed verbatim and analyzed using qualitative thematic analysis. RESULTS: Survivors described restrictions on daily living, social eating, and financial concerns. Despite these restrictions, survivors reported an overall high mentality and enjoyment of life. Coping considerations included adapting to a new normal and increased involvement in cancer support and faith groups. Preferences for supportive care included receiving more information about and being more involved in the treatment care plan, referrals to therapy and support groups, and more comprehensive follow-up in survivorship. CONCLUSIONS: While long-term HNC survivors adapt to daily living restrictions, a high proportion continue to have unmet needs. This data can guide the development of HNC survivorship interventions to inform optimal clinical guidelines based on patients' perceived needs. This qualitative study uncovered distinct perceived needs of HNC survivors which can inform future service development. Incorporating referrals to supportive care services including speech language pathologist, physical therapists, and dietitians into the standard of care before, during, and after treatment would assist survivors in adapting to life after treatment and managing long-term health consequences of their disease.

Head and Neck Cancer Survivors' Experiences with Chronic Nutrition Impact Symptom Burden after Radiation: A Qualitative Study.

BACKGROUND: Head and neck cancer (HNC) survivors may face an array of nutrition impact symptoms (NIS), including dysphagia, xerostomia, taste alterations, and difficulty chewing, which occur as a result of tumor location and treatment with radiation. Few qualitative studies have assessed the chronic impact of NIS on everyday life. OBJECTIVE: The aim of this study was to obtain a comprehensive understanding of the lived experience of chronic NIS burden on HNC survivors. DESIGN AND PARTICIPANTS: Semi-structured, face-to-face interviews were conducted with 31 HNC survivors to address the research aims and objectives. An interview guide was utilized to consider themes that had been generated through the review of literature and through the researchers' clinical experience within the field. There were probes within the interview for participants to raise unanticipated issues and flexibility to follow such leads. Interviews were conducted between March 2018 and May 2019. ANALYSIS: A single researcher conducted the interviews to maintain consistency in data collection. Interviews lasted approximately 1 hour and were audio-recorded. All interview transcripts were professionally transcribed verbatim and checked for accuracy to ensure a complete account of participants' responses. Two researchers applied qualitative thematic content analysis to identify major themes. RESULTS: The following 4 major thematic categories emerged from the interview data: symptom presence, dietary preferences, eating adjustments, and addressing symptoms. The most common symptoms were dysphagia, xerostomia, taste alterations, and bothered chewing. As a result of dietary preferences, survivors avoided citrus fruits, dry foods, raw vegetables, sweets, and meats. Survivors preferred soft and moist foods, spices or seasonings, and sauces or gravies. Eating adjustments were described as increased time to consume meals, cutting food into smaller pieces, consuming less food, and consuming more fluid. As a result of food preference changes and eating adjustments, survivors reported dietary pattern changes from pre to post treatment. All survivors experienced 1 or more chronic NIS, yet nearly 40% were unaware before treatment that NIS had the potential to persist chronically. CONCLUSIONS: The results of this study provide unique qualitative insight into the lived experience of chronic NIS burden on HNC survivors. By recognizing the daily challenges, health care team members can better support HNC survivors in the transition from active treatment to follow-up care.

Pretreatment Dietary Patterns Are Associated with the Presence of Nutrition Impact Symptoms 1 Year after Diagnosis in Patients with Head and Neck Cancer.

BACKGROUND: Dietary inflammatory potential could impact the presence and severity of chronic adverse treatment effects among patients with head and neck cancer. The objective of this study was to determine whether pretreatment dietary patterns are associated with nutrition impact symptoms (NIS) as self-reported 1 year after diagnosis. METHODS: This was a longitudinal study of 336 patients with newly diagnosed head and neck cancer enrolled in the University of Michigan Head and Neck Specialized Program of Research Excellence. Principal component analysis was utilized to derive pretreatment dietary patterns from food frequency questionnaire data. Burden of seven NIS was self-reported 1 year after diagnosis. Associations between pretreatment dietary patterns and individual symptoms and a composite NIS summary score were examined with multivariable logistic regression models. RESULTS: The two dietary patterns that emerged were prudent and Western. After adjusting for age, smoking status, body mass index, tumor site, cancer stage, calories, and human papillomavirus status, significant inverse associations were observed between the prudent pattern and difficulty chewing [OR 0.44; 95% confidence interval (CI), 0.21-0.93; P = 0.03], dysphagia of liquids (OR 0.38; 95% CI, 0.18-0.79; P = 0.009), dysphagia of solid foods (OR 0.46; 95% CI, 0.22-0.96; P = 0.03), mucositis (OR 0.48; 95% CI, 0.24-0.96; P = 0.03), and the NIS summary score (OR 0.45; 95% CI, 0.22-0.94; P = 0.03). No significant associations were observed between the Western pattern and NIS. CONCLUSIONS: Consumption of a prudent diet before treatment may help reduce the risk of chronic NIS burden among head and neck cancer survivors. IMPACT: Dietary interventions are needed to test whether consumption of a prudent dietary pattern before and during head and neck cancer treatment results in reduced NIS burden.

Nutrition impact symptoms and associated outcomes in post-chemoradiotherapy head and neck cancer survivors: a systematic review.

PURPOSE: It is estimated that more than 90% of head and neck cancer (HNC) survivors who underwent chemoradiotherapy experience one or more nutrition impact symptoms (NIS) in the months or years thereafter. Despite the high prevalence, there is limited research addressing long-term impact of NIS on outcomes such as nutrition and quality of life in HNC survivors treated with chemoradiotherapy. OBJECTIVE: To conduct a systematic review of the literature pertaining to the presence of nutrition impact symptoms and their associated outcomes in post-chemoradiotherapy head and neck cancer survivors. EVIDENCE REVIEW: A systematic review was conducted across three databases according to PRISMA guidelines and used to identify current literature regarding NIS in HNC survivors. A keyword search was conducted in PubMed, Scopus, and Web of Science from 2007 to 2017. Studies that met all of the following criteria were included in the review: (1) studies must include human subjects with a HNC diagnosis; (2) study participants must have received chemoradiotherapy; (3) study participants must have been post-treatment for a minimum of 3 months at the time of data collection; (4) full-text articles must have appeared in peer-reviewed journals; (5) papers must have been published in English; (6) studies must be quantitative in nature; (7) studies must have reported at least one NIS; and (8) studies must address at least one of the following outcomes: nutrition, functional status, or quality of life. Two independent reviewers assessed study quality using a predefined set of criteria. FINDINGS: A systematic search yielded 1119 papers, of which 15 met the inclusion criteria. The study reviewed existing evidence of NIS in a variety of HNC survivors ranging from 3 months to greater than 10 years post-chemoradiotherapy treatment. Eight hundred forty-nine study participants were included in the review. Of the 15 studies, 10 were designed as prospective cohort studies, 4 were cross-sectional studies, and 1 was a retrospective cohort study. Functional impairments as a result of chemoradiotherapy to the head and neck are prevalent in research and include dysphagia, xerostomia, trismus, salivary issues, mucositis, and oral pain. CONCLUSIONS: NIS negatively influence HNC survivors beyond the acute phase of treatment. These symptoms are associated with decreased nutrition and quality of life. Interventions are necessary to improve survivors' eating challenges beyond the completion of treatment. If practitioners do not follow patients long term, patients may suffer consequences of NIS including malnutrition risk, weight loss, and decreased food intake and quality of life. IMPLICATIONS FOR CANCER SURVIVORS: The prevalence and consequences of nutrition impact symptoms are substantial among head and neck cancer survivors beyond the acute phase of cancer treatment. Oncology clinicians should continuously monitor and manage these symptoms throughout the cancer continuum.