Enteral nutrition support and treatment toxicities in patients with head and neck cancer receiving definitive or adjuvant helical intensity-modulated radiotherapy with concurrent chemotherapy.

BACKGROUND: Enteral nutrition (EN) is often required in patients with head and neck cancer (HNSCC); however, initiation criteria is limited or inconsistent. This study aimed to describe the relationship of treatment toxicities and requirement for EN and investigate toxicity and baseline characteristics association with EN duration. METHODS: Acute toxicities and baseline characteristics were collected from patients with HNSCC (n = 110) undergoing H-IMRT. Percentage EN contributing to estimated requirements and EN duration were measured. RESULTS: The threshold for patients needing ≥50% of estimated requirements via EN increased from week 3 to 4 for grade ≥2 oral/pharyngeal mucositis, dysgeusia, thick saliva and nausea, and for grade 3 dysphagia. Patients with grade 2-3 dysphagia had a reduced risk of ceasing EN compared to those with grade 0-1 dysphagia. CONCLUSIONS: Using acute toxicities in clinical practice may be a useful tool to inform prompt initiation of EN prior to decline in nutritional status and anticipate EN duration.

Patient and carer experience of nutrition care throughout and beyond treatment for head and neck cancer: a qualitative longitudinal study.

Nutrition care plays a critical role in optimising outcomes for patients receiving treatment for head and neck cancer (HNC), with carers playing an important role in supporting patients to maintain nutrition intake. This study explores patient and carer experience of nutrition care from diagnosis of HNC to 1 year post treatment completion to identify areas for improvement of service delivery. A longitudinal qualitative study design was used with a heterogeneous sample of 20 patients and 15 carers of patients undergoing curative intent treatment for HNC. Interviews conducted at four time points provided a total of 117 interview datasets that were analysed using reflexive thematic analysis based on Gadamerian hermeneutic inquiry. Patient and carer experiences were reflected in two primary themes: (1) the battle to maintain control and (2) navigating the road ahead. This research identifies the need to co-design strategies to improve nutrition care that is inclusive of patients and carers.

Patient and carer experience of nutrition care throughout treatment for head and neck cancer: a systematic qualitative review and thematic synthesis.

Nutrition care plays a critical role in the provision of best practice care to head and neck cancer (HNC) patients, with carers playing an important role in supporting patients to maintain nutrition intake. This qualitative systematic review investigated patient and carer experience of nutrition care throughout and beyond HNC treatment. Five databases were systematically searched for qualitative studies reporting on patient and carer experience of nutrition care throughout HNC. Twenty-five studies including 435 patients and 46 carers were identified, revealing three themes: information and support in the healthcare setting, enteral feeding challenges and management, and life outside hospital. Findings highlight the importance of providing individualised person-centred nutrition care to patients with HNC and their carers. Further qualitative research is needed to inform healthcare professionals about the needs of patients and carers to provide appropriate support throughout the treatment trajectory across and between different treatment modalities.

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

BACKGROUND: The optimal method of tube feeding for patients with head and neck cancer remains unclear. A validated protocol is available that identifies high-nutritional-risk patients who would benefit from prophylactic gastrostomy tube placement. Adherence to this protocol is ultimately determined by clinical team discretion or patient decision. OBJECTIVE: The study aim was to compare outcomes after adherence and nonadherence to this validated protocol, thus comparing a prophylactic and reactive approach to nutrition support in this patient population. DESIGN: We conducted a prospective comparative cohort study. Patients were observed during routine clinical practice over 2 years. PARTICIPANTS/SETTING: Patients with head and neck cancer having curative-intent treatment between August 2012 and July 2014 at a tertiary hospital in Queensland, Australia, were included if assessed as high nutrition risk according to the validated protocol (n=130). Patients were grouped according to protocol adherence as to whether they received prophylactic gastrostomy (PEG) per protocol recommendation (prophylactic PEG group, n=69) or not (no PEG group, n=61). MAIN OUTCOME MEASURES: Primary outcome was percentage weight change during treatment. Secondary outcomes were feeding tube use and hospital admissions. STATISTICAL ANALYSIS PERFORMED: Fisher's exact, χ2, and two sample t tests were performed to determine differences between the groups. Linear and logistic regression were used to examine weight loss and unplanned admissions, respectively. RESULTS: Patients were 88% male, median age was 59 years, with predominantly stage IV oropharyngeal cancer receiving definitive chemoradiotherapy. Statistically significantly less weight loss in the prophylactic PEG group (7.0% vs 9.0%; P=0.048) and more unplanned admissions in the no PEG group (82% vs 75%; P=0.029). In the no PEG group, 26 patients (43%) required a feeding tube or had ≥10% weight loss. CONCLUSIONS: Prophylactic gastrostomy improved nutrition outcomes and reduced unplanned hospital admissions. Additional investigation of characteristics of patients with minimal weight loss or feeding tube use could help refine and improve the protocol.

Randomised controlled trial of early prophylactic feeding vs standard care in patients with head and neck cancer.

BACKGROUND: Weight loss remains significant in patients with head and neck cancer, despite prophylactic gastrostomy and intensive dietary counseling. The aim of this study was to improve outcomes utilising an early nutrition intervention. METHODS: Patients with head and neck cancer at a tertiary hospital in Australia referred for prophylactic gastrostomy prior to curative intent treatment were eligible for this single centre randomised controlled trial. Exclusions included severe malnutrition or dysphagia. Patients were assigned following computer-generated randomisation sequence with allocation concealment to either intervention or standard care. The intervention group commenced supplementary tube feeding immediately following tube placement. Primary outcome measure was percentage weight loss at three months post treatment. RESULTS: Recruitment completed June 2015 with 70 patients randomised to standard care (66 complete cases) and 61 to intervention (56 complete cases). Following intention-to-treat analysis, linear regression found no effect of the intervention on weight loss (10.9±6.6% standard care vs 10.8±5.6% intervention, P=0.930) and this remained non-significant on multivariable analysis (P=0.624). No other differences were found for quality of life or clinical outcomes. No serious adverse events were reported. CONCLUSIONS: The early intervention did not improve outcomes, but poor adherence to nutrition recommendations impacted on potential outcomes.

Investigation of p16 status, chemotherapy regimen, and other nutrition markers for predicting gastrostomy in patients with head and neck cancer.

BACKGROUND: The purpose of this study was to determine if p16 status, chemotherapy regimen, or other nutrition markers could improve protocol accuracy in predicting proactive gastrostomy in patients with head and neck cancer. METHODS: Patients who received curative treatment from July 2010 to June 2011 were included (n = 269). Associations among dependent variables (age, sex, tumor site, staging, treatment, p16 status, albumin, and Malnutrition Screening Tool [MST] score), the protocol risk rating, and requirement for proactive gastrostomy were examined. RESULTS: Current protocol correctly identified 81 of 88 high-risk patients (92%) for gastrostomy, but incorrectly classified 32 of 181 low-risk patients (18%). Analysis of low-risk patients with oral or oropharyngeal cancers, found p16-positive disease had 4.4 times greater odds (p = .049), and those at risk of malnutrition had 4.5 times greater odds (p = .019) of requiring gastrostomy. CONCLUSION: Malnutrition risk and p16 status could be used to identify further patients who may benefit from proactive gastrostomy. © 2017 Wiley Periodicals, Inc. Head Neck 39: 868-875, 2017.

Improving guideline sensitivity and specificity for the identification of proactive gastrostomy placement in patients with head and neck cancer.

BACKGROUND: Swallowing and nutrition guidelines for patients with head and neck cancer are available for identification of proactive gastrostomy placement in patients with high nutritional risk. The purpose of this study was to investigate improvements to the validity of these guidelines. METHODS: A multivariate analysis was fitted to the original dataset (n = 501) to examine the variables that may predict gastrostomy placement (eg, tumor site, treatment, sex, and age). Using these factors, the high risk category was modified and retrospectively validated in the same cohort to provide new measures of sensitivity and specificity. RESULTS: The following were positive predictors of gastrostomy placement: T3 (p = .01), T4 (p < .001), and chemoradiotherapy (p < .001). Laryngeal (p = .02) and skin cancer (p < .001) were negative predictors. Modification of the high risk definition improved sensitivity to 58% and maintained specificity at 92%. CONCLUSION: Minor modifications to the high risk definition in the guidelines have improved the guideline sensitivity for future use. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1163-E1171, 2016.

Swallowing outcomes and PEG dependence in head and neck cancer patients receiving definitive or adjuvant radiotherapy +/- chemotherapy with a proactive PEG: a prospective study with long term follow up.

OBJECTIVES: This study examined long term swallowing outcomes of a cohort of head and neck cancer (HNC) patients identified at high risk of experiencing significant side effects from cancer treatment and were provided with a proactive PEG. MATERIAL AND METHODS: Ninety-five HNC patients receiving definitive or adjuvant radiotherapy +/- chemotherapy were identified for proactive PEG placement using validated guidelines and followed for up to 3years. Functional swallowing status was recorded at regular time points and data were collected on PEG use and duration in situ. RESULTS: Mean duration of enteral feeding was 125days. PEGs remained in situ for approximately 7months. PEG removal was achieved by 52% by 6months and 86% by 1year. Only 3 (3%) remained PEG dependent at 3years. Over half (55%) had resumed a full non-texture modified diet by PEG removal. CONCLUSION: Proactive PEG placement did not lead to high proportion of long term tube dependence in this high risk group and the majority achieved good swallowing outcomes.

Validated swallowing and nutrition guidelines for patients with head and neck cancer: identification of high-risk patients for proactive gastrostomy.

BACKGROUND: The "Swallowing and Nutrition Guidelines for Patients with Head and Neck Cancer" were developed to guide early identification and management of dysphagia and nutritional risk before, during, and after cancer treatment. The purpose of this study was to validate these guidelines. METHODS: Patients attending a Combined Head and Neck Clinic at a major tertiary hospital in 2007 to 2008 were assessed using the guidelines, with high-risk category patients recommended for proactive gastrostomy. Data were collected on guideline adherence, gastrostomy tube insertion, and weight. Sensitivity, specificity, and positive predictive value were calculated for validation. RESULTS: Proactive gastrostomy tubes were inserted in 173 of 501 patients (25%). Overall guideline adherence was 87%. High-risk category adherence was 75%. Validation outcomes were sensitivity 54%, specificity 93%, and positive predictive value 82%. CONCLUSION: The risk categories in the guidelines are valid to assist early identification of swallowing and nutritional risk and guide decision-making on proactive gastrostomy tube insertion.