Nutrition in Head and Neck Cancer

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Nutrition in Head and Neck Cancer

Head and Neck Surgery
Author Credentials 

Rizwan Aslam, DO, MSc
Assistant Professor of Otolaryngology
Department of Otolaryngology – Head and Neck Surgery
Tulane University School of Medicine
New Orleans, LA

Co-Author: Jeremy Barr, Neal Deot

Module Summary

The nutritional status of head and neck cancer patients is critically important to consider. Exciting advances have been made in the understanding of the mechanism of cancer anorexia-cachexia syndrome and how to best treat it. Patients with head and neck cancer have many possible reasons for malnutrition including the tumor burden, site of the tumor, pain, inability to take oral nutrition, xerostomia, and the effects of treatment (surgery, radiation and chemo- therapy). They are at high risk for malnutrition and studies have shown that they have better outcomes and quality of life if nutritional needs are aggressively addressed, especially during therapy. It is also important to recognize when a patient has cancer anorexia-cachexia syndrome and to understand that hypercaloric feeding will not reverse this process nor will a gastric feeding tube be appropriate in many cases.

Module Learning Objectives 
  1. Review the incidence and confounding factors contributing to malnutrition in the patient with head and neck squamous cell carcinoma (HNSCC).
  2. Define the ‘cancer anorexia-cachexia syndrome’ seen in cancer patients.
  3. Describe the effects of malnutrition at presentation or during treatment on patient prognosis.
  4. Review the criteria necessary for the diagnosis of malnutrition.
  5. Explain the advantages of nutritional supplementation in the preoperative and postoperative periods.
  6. Identify the major types and routes of nutritional supplementation and their advantages and disadvantages.
  7. Review how to treat the cancer anorexia-cachexia syndrome.
  8. Explain the ethical issues of recommending a percutaneous gastrostomy feeding tube in a patient who has cancer anorexia-cachexia syndrome.
  9. Recognize the potential complications of nutritional supplementation, including gastrostomy tubes.

Anatomy

Learning Objectives 
  1. Identify the five stages of digestion:
    1. Cephalic
    2. Oral
    3. Swallowing
    4. Gastric
    5. Intestinal
  2. Understand the physiology of swallowing, including the three phases of swallowing:
    1. Oral phase
    2. Pharyngeal phase
    3. Esophageal phase
  3. Be able to interpret Modified Barium Swallow Studies and their implications for head and neck cancer patients
References 
  1. Kashima HK and Berg WA.  Upper Digestive Tract Evaluation and Imaging. In: Bailey BJ editor. Head and Neck Surgery – Otolaryngology. 1993:501-519.
  2. Aviv JE. Prospective, randomized outcome study of endoscopy versus modified barium swallow in patients with dysphagia. Laryngoscope. 2000;110(4):563-74.
  3. Flint PW, Haughey BH, Robbins KT et al. Cummings Otolaryngology - Head and Neck Surgery E-Book. Elsevier Health Sciences; 2014.

Pathogenesis

Learning Objectives 
  1. Identify the common etiologies of HNSCC and how they may contribute to nutritional issues in these patients.
  2. Understand how HNSCC and its treatment regimens can impact a patient’s nutritional status.
  3. Describe the current understanding of how cancer can lead to malnutrition.
References 
  1. van Bokhorst-de, MA, van der Schueren, van Leeuwen AP, et al. The Impact of Nutritional Status on the Prognosis of Patients with Advanced Head and Neck Cancer. Cancer. 1999;89(3):519-27.
  2. Ravasco P, Monteiro-Grillo I, Vidal PM, Camilo ME. Nutritional deterioration in cancer:  the role of disease and diet. Clin Oncol. 2003:15(8):443-50.
  3. Logemann JA, Pauloski BR, Rademaker AW, Lazarus CL, Mittal B, Gaziano J, Stachowiak L, MacCracken E, Newman LA. Xerostomia: 12-month changes in salvia production and its relationship to perception and performance of swallow function, oral intake, and diet after chemoradiation. Head Neck. 2003;25:432-437.
  4. Chainai-Wu, N.  Diet and oral, pharyngeal, and esophageal cancer.  Nutr Cancer. 2002;44(2):104-26.
  5. Andre K, Schraub S, Mercier M, Bontemps P. Role of alcohol and tobacco in the aetiology of head and neck cancer: a case-control study in the Doubs region of France. Eur J Cancer B Oral Oncol.1995;31B(5):301-9.
  6. Guangxue C, Xiaolei G, Xinhua L. Role of human papillomavirus in head and neck squamous cell carcinomas. Hua Xi Kou Qiang Yi Xue Za Zhi. 2017;35(2):187-191.
  7. Kubrak C, Olson K, Jha N, et al. Nutrition impact symptoms: key determinants of reduced dietary intake, weight loss, and reduced functional capacity of patients with head and neck cancer before treatment. Head Neck. 2010;32(3):290-300.
  8. Tisdale MJ. Cachexia in cancer patients. Nat Rev Cancer. 2002;2(11):862-71.

Basic Science

Learning Objectives 
  1. Define the cancer anorexia-cachexia syndrome seen in cancer patients.
  2. Describe the roles of the following hormones and cytokines in this syndrome:
    1. Leptin
    2. Tumor necrosis factor – alpha
    3. Interleukin-1
    4. Interleukin-6
    5. Interferon-gamma
    6. Neuropeptide Y
    7. Lipid mobilizing factor (LMF)
  3. Define nutrients, basic nutritional requirements, and malnutrition: 
  4. Know that the advanced protein calorie malnutrition seen in cancer patients is manifested by a loss of body cell mass and is different from that seen in starvation.
  5. Define the characteristics of cancer versus starvation cachexia.
    1. Know the two components behind weight loss associated with cancer
    2. Be up to date on the Institute of Medicine’s established Dietary Reference Intakes (DRI) which includes the Recommended Dietary Allowance (RDA), Adequate Intake (AI), and Tolerable Upper Intake Level (UL) and their definitions.
  6. List the dietary antioxidants
References 
  1. Dawyer J.  Nutritional Requirements and Dietary Assessment. In: Harrison’s Textbook of Internal Medicine 15th edition, 2002. Chapter 73.
  2. Halsted CH. Malnutrition and Nutritional Assessment. In: Harrison’s Textbook of Internal Medicine 15th edition, 2002. Chapter 75.
  3. Isenring E, Capra S, Bauer J, Davies PS. The impact of nutrition support on body composition in cancer outpatients receiving radiotherapy. Acta Diabetol. 2003;40 Suppl1:S162-4.
  4. Norman HA, Buyrum RR, Feldman E, Heber D, Nixon D, Picciano MF, Rivlin R, Simopoulos A, Wargovich MJ, Weisburger EK, Zeisel SH. The Role of Dietary Supplements during Cancer Therapy. J Nutr. 2003:133:3794S-3799S.
  5. Angus F, Burakoff R. The Percutaneous Endoscopic Gastrostomy Tube: Medical and Ethical Issues in Placement. Am J Gastroenterol. 2003;98:272-277.
  6. Inui A. Cancer Anorexia-Cachexia Syndrome: Current Issues in Research and Management. CA Cancer J Clin. 2002 Mar-Apr;52(2):72-91.
  7. Tisdale MJ. Cachexia in cancer patients. Nat Rev Cancer. 2002;2(11):862-71.
  8. Couch ME, Dittus K, Toth MJ, et al. Cancer cachexia update in head and neck cancer: Definitions and diagnostic features. Head Neck. 2015;37(4):594-604.
  9. Flint PW, Haughey BH, Robbins KT et al. Cummings Otolaryngology - Head and Neck Surgery E-Book. Elsevier Health Sciences; 2014.

Incidence

Learning Objectives 
  1. Identify the patient populations at risk for HNSCC and how this may predispose them to nutritional issues.
  2. Understand the incidence of head and neck cancer and the incidence of malnutrition, the need for dietary supplementation and cancer anorexia-cachexia syndrome.
References 
  1. Inui A. Cancer Anorexia-Cachexia Syndrome: Current Issues in Research and Management. CA Cancer J Clin. 2002; 52:72-91.
  2. Ravasco P, Monteiro-Grillo I, Camilo ME. Does nutrition influence quality of life in cancer patients undergoing radiotherapy?  Radiotherapy Oncol. 2003;67:213-220.
  3. Sturgis EM, Cinciripini PM. Trends in head and neck cancer incidence in relation to smoking prevalence: an emerging epidemic of human papillomavirus-associated cancers? Cancer. 2007;110(7):1429-35.

Patient Evaluation

Learning Objectives 

Describe the diagnosis and laboratory evaluation of malnutrition.

References 
  1. Mekhail, TM, Adelstein, DJ, Rybicki LA, et al. Enteral nutrition during the treatment of head and neck carcinoma: is a percutaneous endoscopic gastrostomy tube preferable to a nasogastric tube? Cancer. 2001;91:1785-90.
  2. Khan S, Alibay TA, Merad M, Dipalma M, Raynard B, Antoun S. [Detection and evaluation of malnutrition in oncology: What tools, what type of cancer and for what purposes?]. Bull Cancer. 2016;103(9):776-85.
  3. Arribas L, Hurtós L, Milà R, Fort E, Peiró I. [Predict factors associated with malnutrition from patient generated subjective global assessment (PG-SGA) in head and neck cancer patients]. Nutr Hosp. 2013;28(1):155-63.
  4. Couch ME, Dittus K, Toth MJ, et al. Cancer cachexia update in head and neck cancer: Definitions and diagnostic features. Head Neck. 2015;37(4):594-604.

Measurement of Functional Status

Learning Objectives 
  1. Understand the methods of trending nutritional progress with cancer treatment
  2. Understand that weight loss in a post-treatment cancer patient may signal potential recurrence or metastasis.
  3. Under the importance of continuous nutritional screening during the disease course
  4. Know that nutritional status may be assessed by many tools such as the following:
    • Ottery’s Subjective Global Assessment (SGA), a patient-generated assessment tool validated for cancer patients.
    • Malnutrition Screening Tool
    • Malnutrition Universal Screening Tool (MUST)
  5. Understand which assessment tools are preferred in the outpatient versus inpatient settings.
  6. Understand how the age of the patient impacts nutritional screening
References 
  1. Ravasco P, Monteiro-Grillo I, Camilo ME. Does nutrition influence quality of life in cancer patients undergoing radiotherapy?  Radiotherapy Oncol. 2003; 67:213-220.
  2. Stratton RJ, Hackston A, Longmore D, et al. Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the 'malnutrition universal screening tool' ('MUST') for adults. Br J Nutr. 2004;92(5):799-808.
  3. Neelemaat F, Meijers J, Kruizenga H, Van ballegooijen H, Van bokhorst-de van der schueren M. Comparison of five malnutrition screening tools in one hospital inpatient sample. J Clin Nurs. 2011;20(15-16):2144-52.
  4. Huysentruyt K, Vandenplas Y, De schepper J. Screening and assessment tools for pediatric malnutrition. Curr Opin Clin Nutr Metab Care. 2016.

Imaging

Learning Objectives 
  1. Be able to interpret Modified Barium Swallow Studies and their implications for head and neck cancer patients.
  2. Be able to interpret MBS DIGEST versus Clinical CTCAE when grading severity of dysphagia.
References 
  1. Aviv JE. Prospective, randomized outcome study of endoscopy versus modified barium swallow in patients with dysphagia. Laryngoscope. 2000;110(4):563-74.
  2. Brady S, Donzelli J. The modified barium swallow and the functional endoscopic evaluation of swallowing. Otolaryngol Clin North Am. 2013;46(6):1009-22.
  3. Goepfert RP, Lewin JS, Barrow MP, et al. Grading Dysphagia as a Toxicity of Head and Neck Cancer: Differences in Severity Classification Based on MBS DIGEST and Clinical CTCAE Grades. Dysphagia. 2018 Apr;33(2):185-191.

Treatment

Learning Objectives 
  1. Understand the importance nutritional intervention during all stages of care, with particular emphasis on the pre-operative period.
  2. Recognize the impact of continuous nutrition counseling on treatment outcomes.
  3. Know the various methods and modalities of nutritional support and supplementation.
  4. Understand micronutrition and options for nutrient supplementation
  5. Appreciate system-wide barriers to nutrition-related care.
References 
  1. Mcclave SA, Kozar R, Martindale RG, et al. Summary points and consensus recommendations from the North American Surgical Nutrition Summit. JPEN J Parenter Enteral Nutr. 2013;37(5 Suppl):99S-105S.
  2. Müller-richter U, Betz C, Hartmann S, Brands RC. Nutrition management for head and neck cancer patients improves clinical outcome and survival. Nutr Res. 2017;48:1-8.
  3. Alshadwi A, Nadershah M, Carlson ER, Young LS, Burke PA, Daley BJ. Nutritional considerations for head and neck cancer patients: a review of the literature. J Oral Maxillofac Surg. 2013;71(11):1853-60.
  4. Vidal-casariego A, Calleja-fernández A, Villar-taibo R, Kyriakos G, Ballesteros-pomar MD. Efficacy of arginine-enriched enteral formulas in the reduction of surgical complications in head and neck cancer: a systematic review and meta-analysis. Clin Nutr. 2014;33(6):951-7.
  5. Gröber U, Holzhauer P, Kisters K, Holick MF, Adamietz IA. Micronutrients in Oncological Intervention. Nutrients. 2016;8(3):163.

Medical Therapies

Learning Objectives 
  1. Understand oral complications of cancer treatment.
  2. Know medical therapies indicated in:
    • stepwise treatment of mucositis, and the management of xerostomia and hyper- or hypocalcemia.
  3. Be well-versed in behavioral strategies to manage nutrition and appetite-related symptoms of cancer and its treatment, including xerostomia, dysphagia, taste change, and GI disturbance.
References 
  1. PDQ Supportive and Palliative Care Editorial Board. Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ®): Health Professional Version. 2016 Dec 16. In: PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-. 
  2. Body JJ, Niepel D, Tonini G. Hypercalcaemia and hypocalcaemia: finding the balance. Support Care Cancer. 2017;25(5):1639-1649.
  3. PDQ Supportive and Palliative Care Editorial Board. Nutrition in Cancer Care (PDQ®): Health Professional Version. 2017 Nov 17. In: PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-. 

Pharmacology

Learning Objectives 
  1. Recognize the treatment of goals cachexia management when considering pharmacotherapy 
  2. Familiarize yourself with medications used to treat cachexia-anorexia syndrome, including:
    • Progestational agents
    • Cannabinoids
    • Glucocorticoids 
    • Cyproheptidine
    • Anti-inflammatory agents
    • Combination therapies
    • Others
  3. Understand mechanistic and empiric treatment of nausea and vomiting, including the use of:
    • Prokinetic agents
    • Antihistamic agents
    • Dopamine receptor antagonists
    • Selective 5H3 Inhibitors
References 
  1. PDQ Supportive and Palliative Care Editorial Board. Nutrition in Cancer Care (PDQ®): Health Professional Version. 2017 Nov 17. In: PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-. 
  2. Suzuki H, Asakawa A, Amitani H, Nakamura N, Inui A. Cancer cachexia--pathophysiology and management. J Gastroenterol. 2013;48(5):574-94.
  3. Glare P, Miller J, Nikolova T, Tickoo R. Treating nausea and vomiting in palliative care: a review. Clin Interv Aging. 2011;6:243-59.

Surgical Therapies

Learning Objectives 
  1. Understand enteral and parenteral approaches to nutrition supplementation, and commonly implicated surgical interventions. They include:
    1. Gastrostomy Tube placement
      1. Open via Laparotomy
      2. Percutaneous Gastrostomy Tube (PEG)
        • Indications and techniques, pull versus push
        • The prophylactic vs reactive placement debate
        • Radiographic Placed Gastrostomy Tube
    2. Central Line Placement for TPN
  2. Understand the ethical issues involved with recommending a PEG tube to a cancer patient.
  3. Know that if the cancer patient has anorexia-cachexia syndrome and no physiologic benefit is expected, the physician has no obligation to offer a PEG.
References 
  1. Smith JS, Austen WG, and Souba WW. Nutrition and Metabolism. In: Greenfield L, editor. Surgery Scientific Principles and Practice, 3rd Edition. 2001: Chapter 2.
  2. Angus F, Burakoff R. The Percutaneous Endoscopic Gastrostomy Tube: Medical and Ethical Issues in Placement. Am J Gastroenterol. 2003; 98:272-277.
  3. Talwar B, Donnelly R, Skelly R, Donaldson M. Nutritional management in head and neck cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol. 2016;130(S2):S32-S40.
  4. Nugent B, Lewis S, O'sullivan JM. Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy. Cochrane Database Syst Rev. 2013;(1):CD007904.
  5. Rahnemai-azar AA, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT. Percutaneous endoscopic gastrostomy: indications, technique, complications and management. World J Gastroenterol. 2014;20(24):7739-51.
  6. Kurien M, Mcalindon ME, Westaby D, Sanders DS. Percutaneous endoscopic gastrostomy (PEG) feeding. BMJ. 2010;340:c2414.

Rehabilitation

Learning Objectives 
  1. Understand pertinent rehabilitative issues as they relate to nutrition supplementation and swallowing, and the roles of:
    • Speech pathology
    • Swallow therapy
    • Dentistry for dentition treatment and possible prosthedontics
  2. Understand the different phases of head and neck cancer survivorship, and the physical and mental morbidities experienced during recovery.
References 
  1. van Bokhorst-de, MA, van der Schueren, van Leeuwen AP, et al. The Impact of Nutritional Status on the Prognosis of Patients with Advanced Head and Neck Cancer. Cancer. 1999;89(3): 519-27.
  2. Ravasco P, Monteiro-Grillo I, Vidal PM, Camilo ME. Nutritional deterioration in cancer:  the role of disease and diet. Clin Oncol. 2003:15(8):443-50.
  3. Logemann JA, Pauloski BR, Rademaker AW, Lazarus CL, Mittal B, Gaziano J, Stachowiak L, MacCracken E, Newman LA.  Xerostomia: 12-month changes in salvia production and its relationship to perception and performance of swallow function, oral intake, and diet after chemoradiation. Head Neck. 2003;25:432-437.
  4. Chainai-Wu, N. Diet and oral, pharyngeal, and esophageal cancer. Nutr Cancer. 2002;44(2):104-26.
  5. Malloy KM, Pou AM. Survivorship: Morbidity, Mortality, Malignancy. Otolaryngol Clin North Am. 2017;50(4):853-866.

Case Studies

  1. A 67 year old white female presents with a T3N2cM0 squamous cell carcinoma of the oral cavity. She noticed a mass on the right side of her tongue about 6 months ago. It is painful to eat and she attributes that pain as the cause of a 45 pound weight loss over the past 3 months. Her past medical history is significant for alcoholism, tobacco abuse (50 pack years), and hypertension. Does this patient have malnutrition or cancer anorexia-cachexia syndrome? How would you evaluate her nutritional status? How would you potentially address her nutritional needs?
  2. A 77 year old male with unresectable laryngeal cancer is able to swallow liquids but is losing weight at a rapid rate. He has lost over 50 pounds since completing his chemoradiation therapy. The muscles in his arms and legs are reduced in size. The recent CT scans document a large tumor burden both at the primary site and in both necks. He is taking pain medicine and fluids and is comfortable. Should a percutaneous endoscopic feeding tube be offered to the patient to increase his caloric intake?

Complications

Learning Objectives 
  • Understand re-feeding syndrome as a complication of nutritional intervention
  • Recognize potential complications associated with specific feeding modalities, including those seen with:
  • Nasogastric tubes
  • PEG tubes
  • TPN therapy
References 
  1. Boateng AA, Sriram K, Meguid MM, Crook M. Refeeding syndrome: treatment considerations based on collective analysis of literature case reports. Nutrition. 2010;26(2):156-67.
  2. Brousseau VJ, Kost KM. A rare but serious entity: nasogastric tube syndrome. Otolaryngol Head Neck Surg. 2006;135(5):677-9.
  3. Tucker AT, Gourin CG, Ghegan MD, Porubsky ES, Martindale RG, Terris DJ. 'Push' versus 'pull' percutaneous endoscopic gastrostomy tube placement in patients with advanced head and neck cancer. Laryngoscope. 2003;113(11):1898-902.
  4. Rahnemai-azar AA, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT. Percutaneous endoscopic gastrostomy: indications, technique, complications and management. World J Gastroenterol. 2014;20(24):7739-51.
  5. Alshadwi A, Nadershah M, Carlson ER, Young LS, Burke PA, Daley BJ. Nutritional considerations for head and neck cancer patients: a review of the literature. J Oral Maxillofac Surg. 2013;71(11):1853-60.

Review

Review Questions 
  1. What are the cytokines and pathways involved in the cancer anorexia-cachexia syndrome?
  2. What are some of the agents that can be used to treat it?
  3. What is the definition of cancer anorexia-cachexia syndrome?
  4. What risk factors do many of the head and neck cancer patients have for malnutrition?
  5. What evidence supports providing nutritional counseling and nutritional supplementation during radiation therapy for head and neck cancer?
  6. What are some of the potential complications of percutaneous endoscopic feeding tubes?
  7. What are the options for providing nutritional supplementation to patients with head and neck cancer?
Resources 

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  1. Annual Meeting Webcast (AMW):