Q23. What frequency and duration of nutrition follow up should patients receive pre, peri and post treatment?
There are three level II positive quality studies which support weekly follow up during radiotherapy and minimum of fortnightly follow up post radiotherapy . There was one level III-1 neutral quality study  and two level III-3 neutral quality studies  further supporting the need for frequent dietetic contact. One study supported commencing dietetic intervention pre chemoradiotherapy , while another advocated continuing weekly follow up post radiotherapy . Similar to the level II studies, Kiss et al. supported weekly dietetic follow up during treatment and a minimum of two to four consultations in the first eight weeks post radiotherapy .
There is one level III-2 positive quality study , three level III-2 neutral quality studies , four level III-3 neutral quality studies , three level IV positive quality studies , twenty six level IV neutral quality studies , and two level IV negative quality studies . One study  reported on the incidence of late toxicity events at six months post treatment. Forty three percent of patients experienced a late toxicity event of either chronic grade 3-4 pharyngeal/laryngeal toxicity, requirement of a feeding tube, or a treatment related death. Due to the incidence of chronic toxicities at this stage post treatment, dietitian review for at least six months is recommended. Another study  reported no difference in gastrostomy tube feeding rates between patients who received hyper fractionated chemoradiotherapy compared to those receiving accelerated chemoradiotherapy, and that feeding rates post treatment were high with a mean of; 64% at six months, 31% at twelve months and 29% at eighteen months. McRackan et al.  reported gastrostomy dependency of mean 13 months. Another paper  describes positive outcomes in terms of less weight loss following increased dietetic intervention throughout the continuum of patient care, with 16% of patients still requiring gastrostomy feeds at 1 year post treatment.
A substantial number of lower level studies report on the incidence of dysphagia, weight loss and tube feeding post treatment, such as 10-24% requiring tube feeding at six months post treatment, 3-37% requiring tube feeding at twelve months post treatment and 6-16.2% requiring a feeding tube at 24 months post treatment.
One level IV positive quality study  found that patients receiving altered fractionation radiotherapy with concomitant boost for orpharyngeal cancer had reduced swallowing and nutritional status at 4-6 weeks post treatment, and this improved at 6 months post treatment. However weight and BMI did not improve to pre-treatment levels. Two level IV neutral quality studies also found that the nadir of weight loss occurred at 6 months post radiotherapy . Another level IV neutral quality qualitative paper  also supports the need to prepare patients for the post treatment phase and the slow recovery from side effects. The significance of eating problems needs to be acknowledged and the impact this has physically, emotionally and socially.
|Patient should receive minimum fortnightly follow up by a dietitian for at least 6 weeks post treatment.||A|
|Patients should be reviewed by a dietitian as required for up to 6 months post treatment, and then for as long they require management of chronic toxicities, weight loss or tube feeding.||C|
|Patient should be seen weekly by a dietitian during radiotherapy.||A|
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