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

  • B Talwar (a1), R Donnelly (a2), R Skelly (a3) and M Donaldson (a4)
Abstract
Abstract

Nutritional 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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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Address for correspondence: Bella Talwar, Head and Neck Centre, University College London Hospital NHS Foundation Trust, London, UK E-mail: bella.talwar@uclh.nhs.uk
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3 CG Gourin , ME Couch , JT. Johnson Effect of weight loss on short-term outcomes and costs of care after head and neck cancer surgery. Ann Otol Rhinol Laryngol 2014;123:101–10

5 A Weimann , M Braga , L Harsanyi , A Laviano , O Ljungqvist , P Soeters . ESPEN Guidelines on Enteral Nutrition: surgery including organ transplantation. Clin Nutr 2006;25:224–44

7 HM Mehanna , J Moledina , J. Travis Refeeding syndrome: what it is, and how to prevent and treat it. BMJ 2008;336:1495–98

8 P Ravasco , I Monteiro-Grillo , P Marques Vidal , ME. Camilo Impact of nutrition on outcome: a prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head Neck 2005;27:659–68

11 J Wang , M Liu , C Liu , Y Ye , G. Huang Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for patients with head and neck cancer: a systematic review. J Radiat Res 2014;55:559–67

13 C Orphanidou , K Biggs , ME Johnston , JR Wright , A Bowman , SJ Hotte Prophylactic feeding tubes for patients with locally advanced head-and-neck cancer undergoing combined chemotherapy and radiotherapy-systematic review and recommendations for clinical practice. Curr Oncol 2011;18:e191201

14 S Garg , J Yoo , E. Winquist Nutritional support for head and neck cancer patients receiving radiotherapy: a systematic review. Support Care Cancer 2010;18:667–77

15 G Sanguineti , N Rao , B Gunn , F Ricchetti , C. Fiorino Predictors of PEG dependence after IMRT+/-chemotherapy for oropharyngeal cancer. Radiother Oncol 2013;107:300–4

16 WD Stableforth , S Thomas , SJ. Lewis A systematic review of the role of immunonutrition in patients undergoing surgery for head and neck cancer. Int J Oral Maxillofac Surg 2009;38:103–10

19 J Arends , G Bodoky , F Bozzetti ESPEN Guidelines on Enteral Nutrition: non-surgical oncology. Clin Nutr 2006;25:245–59

21 T Brown , L Ross , L Jones , B Hughes , M. Banks Nutrition outcomes following implementation of validated swallowing and nutrition guidelines for patients with head and neck cancer. Support Care Cancer 2014;22:2381–91

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The Journal of Laryngology & Otology
  • ISSN: 0022-2151
  • EISSN: 1748-5460
  • URL: /core/journals/journal-of-laryngology-and-otology
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