Prediction model for tube feeding dependency during chemoradiotherapy for at least four weeks in head and neck cancer patients: A tool for prophylactic gastrostomy decision making

6040 Background: Patients who receive chemoradiation or bioradiation (CRT/BRT) for locally advanced head and neck squamous cell carcinoma (LAHNSCC) often experience high toxicity rates, which may interfere with oral intake, leading to (temporary) tube feeding (TF) dependency. International guidelines recommend gastrostomy insertion when the expected use of TF exceeds four weeks. In this study we aimed to update and externally validate a prediction model to identify patients in need for TF for at least four weeks, meeting the international criteria for prophylactic gastrostomy insertion. Methods: This retrospective multicenter cohort study was performed in four tertiary referral head and neck cancer centers in the Netherlands. The prediction model was developed using data from the University Medical Center Utrecht and the Netherlands Cancer Institute. The model was externally validated in patients from the Maastricht University Medical Center and Radboud University Medical Center. The primary endpoint was TF, initiated during or within 30 days after completion of CRT/BRT, and administered for at least four weeks. Potential predictors were retrieved from patient medical records and radiotherapy dose-volume parameters were calculated. Results: The developmental and validation cohort included 409 and 334 patients respectively. Multivariable analysis showed significant predictive value (p < 0.05) for adjusted diet at start of CRT/BRT, percentage weight change prior to treatment initiation, WHO performance status, tumor-site, nodal stage, mean radiation dose to the contralateral parotid gland, and mean radiation dose to the oral cavity. The area under the receiver operating characteristics curve for the updated model was 0.73 and after external validation 0.64. Positive and negative predictive value at 90% cut off were 80.0% and 48.2% respectively. Conclusions: This externally validated prediction model to estimate TF-dependency for at least four weeks in LAHNSCC patients performs well. This model, which will be presented, can be used in clinical practice to guide personalized decision making on prophylactic gastrostomy insertion.

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Comparison between nasogastric tube feeding and percutaneous fluoroscopic gastrostomy in advanced head and neck cancer patients

European Archives of Oto-Rhino-Laryngology ◽

10.1007/s004050000311 ◽

2001 ◽

Vol 258 (2) ◽

pp. 89-92 ◽

Cited By ~ 70

Author(s):

Nicolas Magné ◽

P. Y. Marcy ◽

C. Foa ◽

M. N. Falewee ◽

M. Schneider ◽

...

Keyword(s):

Head And Neck Cancer ◽

Head And Neck ◽

Cancer Patients ◽

Neck Cancer ◽

Nasogastric Tube ◽

Tube Feeding ◽

Advanced Head ◽

Nasogastric Tube Feeding

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Nutritional management in head and neck cancer: United Kingdom National Multidisciplinary Guidelines

The Journal of Laryngology & Otology ◽

10.1017/s0022215116000402 ◽

2016 ◽

Vol 130 (S2) ◽

pp. S32-S40 ◽

Cited By ~ 70

Author(s):

B Talwar ◽

R Donnelly ◽

R Skelly ◽

M Donaldson

Keyword(s):

Head And Neck Cancer ◽

Nutritional Status ◽

Head And Neck ◽

Cancer Patients ◽

Neck Cancer ◽

Tube Feeding ◽

Nutritional Intervention ◽

Nutrition Support ◽

Subjective Global Assessment ◽

Chyle Leak

AbstractNutritional support and intervention is an integral component of head and neck cancer management. Patients can be malnourished at presentation, and the majority of patients undergoing treatment for head and neck cancer will need nutritional support. This paper summarises aspects of nutritional considerations for this patient group and provides recommendations for the practising clinician.Recommendations• A specialist dietitian should be part of the 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. (R)• 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. (R)• Patients at high risk should be referred to the dietitian for early intervention. (R)• Offer treatment for malnutrition and appropriate nutrition support without delay given the adverse impact on clinical, patient reported and financial outcomes. (R)• Use a validated nutrition assessment tool (e.g. scored Patient Generated–Subjective Global Assessment or Subjective Global Assessment) to assess nutritional status. (R)• 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. (G)• 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. (G)• Aim for energy intakes of at least 30 kcal/kg/day. As energy requirements may be elevated post-operatively, monitor weight and adjust intake as required. (R)• 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 chemoradiotherapy. Patients should have their weight and nutritional intake monitored regularly to determine whether their energy requirements are being met. (R)• Perform nutritional assessment of cancer patients frequently. (G)• Initiate nutritional intervention early when deficits are detected. (G)• Integrate measures to modulate cancer cachexia changes into the nutritional management. (G)• 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. (R)• Use standard polymeric feed. (G)• Consider gastrostomy insertion if long-term tube feeding is necessary (greater than four weeks). (R)• Monitor nutritional parameters regularly throughout the patient's cancer journey. (G)• Pre-operative:○ Patients with severe nutritional risk should receive nutrition support for 10–14 days prior to major surgery even if surgery has to be delayed. (R)○ Consider carbohydrate loading in patients undergoing head and neck surgery. (R)• Post-operative:○ Initiate tube feeding within 24 hours of surgery. (R)○ Consider early oral feeding after primary laryngectomy. (R)• Chyle Leak:○ Confirm chyle leak by analysis of drainage fluid for triglycerides and chylomicrons. (R)○ Commence nutritional intervention with fat free or medium chain triglyceride nutritional supplements either orally or via a feeding tube. (R)○ Consider parenteral nutrition in severe cases when drainage volume is consistently high. (G)• Weekly dietetic intervention is offered for all patients undergoing radiotherapy treatment to prevent weight loss, increase intake and reduce treatments interruptions. (R)• Offer prophylactic tube feeding as part of locally agreed guidelines, where oral nutrition is inadequate. (R)• Offer nutritional intervention (dietary counselling and/or supplements) for up to three months after treatment. (R)• Patients who have completed their rehabilitation and are disease free should be offered healthy eating advice as part of a health and wellbeing clinic. (G)• Quality of life parameters including nutritional and swallowing, should be measured at diagnosis and at regular intervals post-treatment. (G)

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