Q25. What are the patient groups that may require long term nutrition support and monitoring?

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Q25. What are the patient groups that may require long term nutrition support and monitoring?

Summary

Although there are many studies which document the predictive factors for long term tube feeding such as tumour sites, stage and treatment modality, there are no agreed definitions of long term gastrostomy dependency. Prolonged feeding tube use can be influenced by several other clinical factors such as past medical history or other co-morbidities, radiotherapy treatment fields and dose, surgical resection and techniques, psychosocial factors, poor nutritional status requiring long term nutrition support, time and effort with eating, loss of enjoyment of eating and patient adherence to rehabilitation programs. These other variables are often not considered in the papers which report on frequency of gastrostomy dependency at various time points post treatment. There is also limited information on who makes the decision for feeding tube insertion and removal, the organisation of tube feeding services and specialist support from gastroenterology and radiology, and the impact of dietetic intervention has not been evaluated. As a confounding factor, it also should be noted that gastrostomy tubes are designed for longer term nutrition support. Swallowing outcome studies reported in the literature use gastrostomy tubes as a proxy measure of swallowing but fail to report on nutrition measures to enable accurate evaluation of tube outcomes and therefore understanding in definition of dependency.

One level II positive quality study compared prophylactic gastrostomy with clinical praxis (enteral feeding when deemed necessary), finding that the study group commenced enteral nutrition earlier and continued for significantly longer than controls[1]. The rate of severe dysphagia (nil by mouth) was lower in the prophylactic gastrostomy group at one year post treatment[1]. Another study on the same cohort (level II, neutral quality) found energy and protein intakes in both groups only met estimated requirements from six months post treatment, with weight loss ceasing after this time. Eating difficulties were highest at two and three months post treatment, with enteral nutrition providing the main source of nutrition at these time points in both groups[2]. The level II neutral quality study, which compared gastrostomy and nasogastric tubes, found that gastrostomy tubes remained in situ for longer than nasogastric tubes [3].

There is one level III-2 positive quality study [4], five level III-2 neutral quality studies [5][6][7][8][9], one level III-3 positive quality study [10], five level III-3 neutral quality studies [11][12][13][14][15], one level IV positive quality study [16], thirteen level IV neutral quality studies [17][18][19][20][21][22][23][24][25][26][27][28][29], and three level IV negative quality studies [30][31][32].

One level III-2 study confirmed the findings of Corry that gastrostomy tubes remained in situ for longer than nasogastric tubes [4]. Another reported high rates of gastrostomy dependency of 62-65% at 6/12, and 26-32% at 12 and 18 months, following either accelerated or hyper fractionated chemoradiotherapy with no difference found between types of treatment [5]. The third level III-2 study found patients who received a prophylactic gastrostomy were more likely to have high grade dysphagia and strictures compared to those who did not have a tube placed before treatment [6]. A further two level III-2 studies utilised surrogate markers for dysphagia (patient-reported swallowing outcome, change in mean diet level, and/or percentage weight loss) and found that those patients who received a prophylactic gastrostomy had worse long-term swallowing outcome than those who didn’t [7][8]. Conversely, another level III-2 study found no significant difference in gastrostomy dependence rates in those with tubes placed prophylactically versus reactively and that gastrostomy dependence was found to be associated with older age on multivariate analysis[9].

One level III-3 study identified the use of prophylactic gastrostomy to be associated with increased duration of enteral feeding compared with tube feeding as required [10]. Other factors reported to be associated with increased gastrostomy dependence by level III-3 studies include: primary site of larynx, pharyngeal wall, base of tongue [11], and hypopharynx [11][15]; T stage; baseline dysphagia [11]; higher doses to and volumes treated of larynx and inferior pharynx constrictor muscles [11][13]; neck dissection; pre treatment weight loss; being of older age [12]; being without a partner; treatment with radiation therapy; and tracheostomy placement for longer than 30 days [14].

The level IV studies report the following non tumour or treatment factors to be associated with long term gastrostomy feeding: heavy alcohol intake, ethnicity (African American), older age, smoking and pre treatment aspiration on thin fluids, and loss of >15% body weight. There are conflicting results for age as some studies show no difference. Various types of treatment regimens, tumour staging and sites are also considered to be factors in requirements for dependency on long term tube feeding, as per the criteria discussed when considering prophylactic feeding tube placement selection (See Q15).

There is one level IV positive quality study [16], seven level IV neutral quality studies [21][22][26][20][29][28][27], and one level IV negative quality study [30] pertaining to swallow outcomes. Three studies showed poorer swallowing outcomes with adjuvant radiotherapy [21][22][26]. Another study demonstrated increased dysphagia, increased risk of malnutrition and worse quality of life with co adjuvant treatment [30]. The latter finding was supported by one further study which identified reduced quality of life with adjuvant radiotherapy compared to those with surgery alone in the domains of burden, eating duration, eating desire, symptom frequency and food selection [20]. Other factors associated with poor swallowing outcomes and higher subsequent rate of enteral feeding were rural living, ex heavy alcohol intake, hypopharynx tumour site, and radiotherapy technique [16]. Chapuy et al. further identified higher tumour stage to be associated with greater dysphagia at 12 months and subsequent gastrostomy dependence at 12 and 24 months post chemo-radiotherapy [29]. Another study demonstrated that while patients reported several reasons for tube dependency, timely dietetic management assisted in tube weaning with more confidence [28]. Ames further demonstrated the benefits of maintaining oral intake during treatment in reducing duration of gastrostomy tube use and improving survival outcomes [27].

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Recommendation Grade
Patients who receive adjuvant radiotherapy are a high nutrition risk group and should be monitored closely for nutrition impact symptoms e.g. dysphagia, time and effort with meals, appetite, and long term side effects of treatment such as dysgeusia and xerostomia.
C
Predictors of long term feeding are well documented in terms of tumour site, stage, and treatment. However, other contributing factors, which may impact on long term gastrostomy dependency are not yet well explored. Reasons that should be considered during assessment may include: clinical aspects such as treatment-related toxicities, swallowing problems and need to improve nutritional status; patient factors such as social circumstances and adherence; or even service limitations such as inadequate access to essential allied health services during and post treatment. In addition, the MDT should be accountable for providing co-ordinated feeding tube management services (assessment for suitability of insertion, ongoing support for patients with tubes in place and removal of feeding tubes when no longer required).
D
As many patients may require tube feeding during or post treatment, follow up with a dietitian and speech pathologist is recommended for rehabilitation. Patients should be able to maintain their nutritional status with safe swallowing prior to tube removal.
D

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References

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