ABOUT THE MENACE
Cancers that are known collectively as head and neck cancers usually begin in the squamous cells that line the moist, mucosal surfaces inside the head and neck (for example, inside the mouth, the nose, and the throat). These squamous cell cancers are often referred to as squamous cell carcinomas of the head and neck.
Head and neck cancer (HNC) (cancer of the oral cavity, oropharynx, hypopharynx and larynx) is the seventh most common malignancy in the world but oral cancer is rampant in indian subcontinent due habit of chewing tobacco.The majority of patients with HNC present with locally advanced disease, for which treatment is complex and aggressive, with a therapeutic goal of achieving a cure while minimizing toxicity.
NUTRITIONAL AND ITS IMPORTANCE
Nutritional support and intervention is an integral component of head and neck cancer management. Fifty to 60 % of Head and neck cancer patients are frequently malnourished at the time of diagnosis and prior to the beginning of treatment this is due inability to chew & swallow , pain, decrease mouth opening. Chemo-radiotherapy (CRT) causes or exacerbates symptoms, such as alteration or loss of taste, mucositis, xerostomia, fatigue, nausea and vomiting, with consequent worsening of malnutrition. During radiation therapy 40- 50% patient lose weight .
Dr. Mudit Aggarwal is adept cancer specialist who gives Nutritional counselling (NC) and oral nutritional supplements (ONS) which are used to increase dietary intake and to prevent therapy-associated weight loss and interruption of radiation therapy. If obstructing cancer and/or mucositis interfere with swallowing, enteral nutrition is delivered by tube.
A specialist dietitian is a part of the our multidisciplinary team for treating head and neck cancer patients throughout the continuum of care as frequent dietetic contact has been shown to have enhanced outcomes.
IMPACT OF MALNUTRITION
A dutch study done on head & neck cancer patients undergoing surgery have shown better cancer control rates if these patients were given immunonutrition with Arginine supplement for seven days after surgery. Patients with head and neck cancer are at risk of malnutrition as a result of the site of their cancer, the disease process and the treatment. Patients may have long standing dietary habits and detrimental lifestyle factors such as alcohol misuse that may predispose them to malnutrition. Regardless of presenting body mass index (BMI), unintentional weight loss of 10 per cent or greater in the preceding six months may lead to a range of problems as highlighted in below:
MALNUTRITION ASSOCIATED MORBIDITY
- Increased risk of infection
- Delayed wound healing
- Impaired function of cardiac and respiratory systems
- Muscle weakness
- Poor Quality of life
- Increased risk of post-operative complications
- Reduced response to chemotherapy and radiotherapy
- Increased mortality rate
STEPS TAKEN FOR FURBISHING NUTRITION REQUIREMENTS
- Patients with head and neck cancer should be nutritionally screened using a validated screening tool at diagnosis and then repeated at intervals through each stage of treatment.
- Patients at high risk should be referred to the dietitian for early intervention.
- Treatment is offered for malnutrition and appropriate nutrition support without delay given the adverse impact on clinical, patient reported and financial outcomes.
- Use of a validated nutrition assessment tool (e.g. scored Patient Generated–Subjective Global Assessment or Subjective Global Assessment) to assess nutritional status.
- Offer pre-treatment assessment prior to any treatment as intervention aims to improve, maintain or reduce decline in nutritional status of head and neck cancer patients who have malnutrition or are at risk of malnutrition.
- Patients identified as well-nourished at baseline but whose treatment may impact on their future nutritional status should receive dietetic assessment and intervention at any stage of the pathway.
- Aim for energy intakes of at least 30 kcal/kg/day is advised. As energy requirements may be elevated post-operatively, monitor weight and adjust intake as required.
- Aim for energy and protein intakes of at least 30 kcal/kg/day and 1.2 g protein/kg/day in patients receiving radiotherapy or chemo radiotherapy. Patients should have their weight and nutritional intake monitored regularly to determine whether their energy requirements are being met
Dr. Mudit Aggarwal advice for repeated screening, weekly for inpatients. For outpatients, weight should be recorded at each outpatient visit and weight loss of 2 kg or more within a two-week period is reported to the dietitian.
TYPES OF NUTRITION SUPPORT OFFERED
Nutritional intervention is tailored to meet the needs of the patient and be realistic for the patient to achieve. There are three main methods of nutrition support: oral, enteral and parenteral. Parenteral nutrition support is rarely used in the head and neck setting. It should however be considered if required.
Oral nutrition support
Nutritional interventions include relaxation of previous therapeutic diets to minimise further nutritional compromise and to positively influence Quality of life outcomes. Food fortification is first line advice; however, this may not necessarily be appropriate due to the side effects and intensity of treatment regimens. Patients may require more intensive nutritional support methods from the beginning of treatment over and above traditional food fortification methods with the early use of oral nutrition support, e.g. nutritionally complete liquid supplements. This can be initiated at any point from diagnosis. There are a variety of oral nutritional support products available. The choice will depend on patient preference, current macro and micro nutrient intake and local policy.
Enteral nutrition (EN) support
The choice of feeding route will depend upon local arrangements, however clinical considerations include: site of tumour, treatment plan and intent, predicted duration of enteral feeding and patient choice.
The types of tubes available are nasogastric, nasojejunal, tracheo – oesophageal fistulae tubes, orogastric, gastrostomy, gastro-jejunostomy and jejunostomy. Nasogastric, nasojejunal, oro gastric, trachea – oesophageal fistulae tubes are all recommended for short-term use (less than four weeks). If enteral feeding is expected to be required for longer than four weeks then we recommend gastrostomy insertion. Consideration should be made with regard to the timing and method of gastrostomy placement. Screening and assessment for suitability and method of gastrostomy insertion by endoscopic, radiological or surgical approach is essential. Assessment of co-morbidities and contraindications should be undertaken in order to prevent complications of tube insertion prior to oncological. Appropriate decision making around prophylactic tube feeding considers all factors that impact on nutrition including patient demographics, tumour site and staging, impact of treatment modalities on the patient’s ability to meet and sustain nutritional requirements, nutritional status, dysphagia, type and placement technique of feeding tube and associated morbidity. In clinical studies, gastrostomy tube is used as a proxy measure for poor swallowing in the absence of reviewing nutritional outcome data, intensity and frequency of dietary counselling and swallowing rehabilitation and co-ordination of these services before, during and after treatment.
Immuno-nutrition are feeds containing amino acids, nucleotides and lipids. There are no additional benefits to immunonutrition pre-operatively over standard nutrition support. Preliminary data suggest that in the pre-operative period, N-3 enriched nutrition support may improve nutritional outcomes including weight, lean body mass and fat mass, reduce post-operative infections and reduce hospital stay.
MONITORING NUTRITIONAL SUPPORT
Monitoring nutritional intervention is essential, as compliance with recommendations can be a problem. Monitoring involve the multidisciplinary team, including dietitians, medical teams, speech and language therapist and clinical nurse specialists.
- Start nutritional therapy if undernutrition already exists or if it is anticipated that the patient will be unable to eat for more than 7 days. Enteral nutrition should also be started if an inadequate food intake (60 per cent of estimated energy expenditure) is anticipated for more than 10 days
- Use standard polymeric feed( give a link for explanantion)
- Consider gastrostomy insertion if long-term tube feeding is necessary (greater than four weeks) (figure of gastrostomy ………….. and ryles tube or nasogastric tube …………..)
- Monitor nutritional parameters regularly throughout the patient’s cancer journey
NUTRITION CONSIDERATIONS DURING SURGICAL TREATMENT
Enhanced recovery after surgery programmes are starting to be developed and implemented across Head and Neck Centres. Nutritional interventions are part of enhanced recovery and should be considered at all stages of the pathway from diagnosis to survivorship and wellbeing.
Inadequate oral intake for more than 14 days is associated with a higher mortality. Patients with severe nutritional risk should receive nutrition support for 10–14 days prior to major surgery even if surgery has to be delayed. Carbohydrate loading is becoming standard practice for all patients undergoing head and neck cancer surgery. The type of carbohydrate-loading products used will depend on local contractual arrangements. Enteral nutrition is indicated even in patients without obvious undernutrition, if it is anticipated that patients will be unable to eat for more than 7 days at the time of operation (peri-operative).
Early post-operative tube feeding (within 24 hours) is indicated in patients in whom early oral nutrition cannot be initiated. Nutrition support, especially enteral nutrition, reduces morbidity. Standard polymeric enteral feeds are suggested post-operatively.
CRITERIA FOR INITIATING PRE-OPERATIVE NUTRITIONAL SUPPORT :
- Weight loss >10–15 per cent in 6 months
- Body mass index <18.5 kg/m2
- Subjective Global Assessment Grade C
- Serum albumin <30 g/l
- Unable to maintain intake above 60 per cent of recommended intake for more than 10 days
- 30-50% head neck cancer patients are having malnutrition.
- Dietician should be a part of multidisciplinary team which guided nutrition ,depending on the score , nutrition is implemented.
- Monitoring & Surveillance is necessary maintaining nutritional status