Teresa Brown

Updated evidence-based practice guidelines for the nutritional management of patients receiving radiation therapy and/or chemotherapy

Aims: The aim of this paper was to update the evidence-based practice guidelines for the nutritional management of patients receiving radiation therapy and broaden the scope to include chemotherapy. Methods: The following databases were searched using a range of keywords: Cochrane Database, CENTRAL, MEDLINE (via Ebscohost), EMBASE, CINAHL (Ebscohost), Web of Science, Health Source: Nursing/Academic Edition and PubMed. Relevant papers (n = 47) were reviewed by at least two members of the steering committee and assigned a level of evidence and a quality rating. Results: There were no new published randomised controlled trials (RCTs) of nutrition intervention in radiation therapy. Most statements in the previous radiation therapy guidelines have strong evidence supporting nutrition intervention. There were 12 studies in chemotherapy including five RCTs. While these studies provided strong evidence that simple nutrition intervention improves nutritional outcomes such as dietary intake and weight, they did not find an improvement in quality of life or survival. Several RCTs found no benefits of nutrition support in patients undergoing chemotherapy. None of the RCTs in chemotherapy used medical nutrition therapy (MNT) as the intervention, but rather simple dietary advice and/or supplements. Conclusions: The evidence to support nutrition intervention in patients receiving radiation therapy remains strong. However, the benefits of nutrition intervention in chemotherapy are less clear. Further studies are required to evaluate the impact of MNT as opposed to simple dietary advice in chemotherapy patients. This update contributes to a move towards comprehensive evidence-based guidelines for the nutritional management of patients with cancer.

Decreased hospital stay and significant cost savings after routine use of prophylactic gastrostomy for high-risk patients with head and neck cancer receiving chemoradiotherapy at a tertiary cancer institution.

Evidence‐based nutritional and swallowing guidelines were developed to identify patients at high risk of developing malnutrition during chemoradiation for head and neck cancer. These guidelines recommended a prophylactic gastrostomy and were actively implemented at our institution in January 2007. This study assesses the effect of this policy change on patient outcomes.

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

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.

Protocol for a randomized controlled trial of early prophylactic feeding via gastrostomy versus standard care in high risk patients with head and neck cancer

BackgroundPatients with head and neck cancer are at high risk of malnutrition and dysphagia. Enteral tube feeding via a gastrostomy or nasogastric tube is often required in response to dysphagia, odynophagia or side effects of treatment that lead to dehydration and/or weight-loss. A recent systematic review concluded that the optimal method of tube feeding remains unclear; however prophylactic gastrostomy, placed in anticipation of its use during and after treatment, is common practice, following a number of demonstrated benefits. However the majority of these studies have been undertaken in patients receiving radiotherapy alone. More recent studies in patient populations receiving concurrent chemoradiotherapy are showing that despite prophylactic gastrostomy placement significant weight loss still occurs, placing the patient at risk of the consequences of malnutrition. Therefore we set out to investigate innovative prophylactic nutrition support via the gastrostomy to optimise the nutritional outcomes of patients with head and neck cancer.Methods/DesignPatients with head and neck cancer will be eligible for this single centre randomised controlled trial if they are identified for referral for a prophylactic gastrostomy using local guidelines. Patients will be excluded if they are: under the age of eighteen; pregnant; unable to give informed consent; or severely malnourished or moderately malnourished with significant dysphagia requiring a liquid or puree diet. All eligible patients who consent for the study will be allocated randomly to either the intervention or control group (usual care). The intervention group will commence prophylactic supplementary nutrition support via the gastrostomy immediately following placement compared to usual care where nutrition support is commenced via the gastrostomy when clinically indicated during treatment. Key outcome measures will be percentage weight loss, body composition, nutritional status and quality of life, measured at baseline and three months post treatment.DiscussionTo our knowledge this is the first study to evaluate the effectiveness of early prophylactic tube feeding compared to commencement of feeding during treatment, as per current standard practice, in patients undergoing prophylactic gastrostomy prior to treatment for head and neck cancer.Trial registrationThis trial has been registered in the Australian New Zealand Clinical Trials registry as ACTRN12612000579897.

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.

New radiotherapy techniques do not reduce the need for nutrition intervention in patients with head and neck cancer

Background/Objectives:Since 2007, our institution has used validated guidelines for the insertion of proactive gastrostomy feeding tubes in patients with head and neck cancer. Helical intensity-modulated radiotherapy (H-IMRT) delivered by Tomotherapy, is an advanced radiotherapy technique introduced at our centre in 2010. This form of therapy reduces long-term treatment-related toxicity to normal tissues. The aim of this study is to compare weight change and need for tube feeding following H-IMRT (n=53) with patients that would have previously been treated with three-dimensional conformal radiotherapy (n=134).Subjects/Methods:Patients with head and neck cancer assessed as high nutritional risk with recommendation for proactive gastrostomy were identified from cohorts from 2007 to 2008 and 2010 to 2011. Retrospective data were collected on clinical factors, weight change from baseline to completion of treatment, incidence of severe weight loss (⩾10%) and tube feeding. Statistical analyses to compare outcomes between the two treatments included χ2-test, Fisher’s exact and two-sample Wilcoxon tests (P<0.05).Results:The H-IMRT cohort had higher proportions of patients with definitive chemoradiotherapy (P=0.032) and more advanced N stage (P<0.001). Nutrition outcomes were not significantly different between H-IMRT and conformal radiotherapy, respectively: need for proactive gastrostomy (n=49, 92% versus n=115, 86%, P=0.213), median percentage weight change (−7.2% versus −7.3%, P=0.573) and severe weight loss incidence (28% versus 27%, P=0.843).Conclusions:Both groups had median weight loss >5% and high incidences of tube feeding and severe weight loss. Nutrition intervention remains critical in this patient population, despite advances in radiotherapy techniques, and no changes to current management are recommended.

Validation of an updated evidence-based protocol for proactive gastrostomy tube insertion in patients with head and neck cancer

Background/Objectives:Evidence-based practice guidelines are available to assist in the decision making for nutrition interventions in patients with head and neck cancer. Re-assessment of guideline recommendations is important with changing demographics, new treatment regimens, advancing radiotherapy techniques, such as helical intensity-modulated radiotherapy, and the emergence of new literature. The aim of this study was to validate the updated high-risk category definition in our local hospital protocol for the swallowing and nutrition management of patients with head and neck cancer to determine the ongoing predictive ability for identifying proactive gastrostomy requirement in a new cohort.Subjects/Methods:Patients attending a major tertiary hospital for head and neck cancer treatment from 2010 to 2011 were included (n=270). Data were collected on patient demographics (age and gender), clinical factors (tumour site, staging and treatment), nutrition outcome measures (weight, enteral feeding) and protocol adherence. Sensitivity and specificity were calculated and compared with the original validation study.Results:Proactive gastrostomy tubes were inserted in 86 patients. Overall protocol adherence was 93%. Sensitivity improved to 72% (increase of 18%) and specificity improved to 96% (increase of 3%) compared with the original validation study where patients received three-dimensional (3-D) conformal radiotherapy.Conclusions:The results of this study confirm that the updated high-risk category in the protocol for the swallowing and nutrition management of patients with head and neck cancer remains valid to predict proactive gastrostomy in a mixed population receiving helical intensity-modulated radiotherapy and 3-D conformal radiotherapy. The protocol has an improved sensitivity and specificity and hence remains just as relevant for advanced techniques of radiation treatment delivery.

Gastrostomy in head and neck cancer: current literature, controversies and research

PURPOSE OF REVIEW This article explores the literature on the role of gastrostomy tube feeding use in the management of head and neck cancer, with special attention to its indications, timing of insertion, advantages, complications and quality of life issues. RECENT FINDINGS The current guidelines in place across different countries and two ongoing randomized controlled trials are discussed in detail, and placed in the context of current evidence. SUMMARY There remains a lack of consensus about when and which enteral feeding routes (gastrostomy or nasogastric tube) should be used and controversy about the long-term effects on swallowing function as well as quality of life for patients. Local guidelines should be used or generated to guide practice or patients enrolled into existing trials until higher level evidence is generated.

Implementation of an evidenced based nutrition support pathway for haematopoietic progenitor cell transplant patients

BACKGROUND AND AIMS The type of nutrition support given during haematopoietic progenitor cell transplantation (HPCT) varies greatly between transplant units and often includes enteral nutrition (EN) and/or parenteral nutrition (PN). The aims of this study were to develop an evidenced based nutrition support pathway for HPCT patients and then evaluate changes in nutrition support practices post implementation of the pathway into clinical practice. METHODS A retrospective audit of 66 consecutive patients who underwent HPCT during the six months prior to the development of the pathway was undertaken, followed by a prospective audit of 61 consecutive patients undertaking HPCT during the six months post implementation. Data collected included type and timing of nutrition support given. RESULTS Post implementation of the pathway the use of PN for allogeneic HPCT patients reduced significantly from 86% to 50% (p < 0.001) and use of oral nutrition support increased significantly from 14% to 45% (p = 0.003). Autologous HPCT recipients had shorter lengths of inadequate intake with only 30% of patients having a poor intake for greater than one week compared to 72% prior to implementation of the pathway (p = 0.02). CONCLUSION Implementation of a nutrition support pathway impacts significantly on appropriate use of nutritional support in recipients of HPCT.

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.