Q1. What is the impact of a diagnosis of malnutrition at baseline on a patient’s treatment outcomes?

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Q1. What is the impact of a diagnosis of malnutrition at baseline on a patient’s treatment outcomes?

Summary

Due to the high prevalence of malnutrition in patients with head and neck cancer, it is important firstly to understand the consequences and impact of malnutrition on a patient’s outcomes. This provides the rationale for addressing malnutrition in this patient group and why these guidelines are required. The subsequent questions in the guidelines provide more specific recommendations for practical management including how to identify malnutrition risk, how to assess a patient’s nutritional status and how to provide optimal intervention.

Of the 24 studies identified, 22 showed an association between malnutrition and various patient outcomes. There are five level III-2 neutral quality studies (total n=1597) [1][2][3][4][5], four level III-3 neutral quality studies (total n=397) [6][7][4][8], and fifteen level IV studies; 2 positive quality (total n= 125) [9][10] and thirteen neutral quality (total n= 1626) [11][12][13][14][15][16][17][18][19][20][21][22][23].

From the level III-2 studies, malnourished patients had an increased risk of developing non thyroidal illness post surgery [1]; reduced survival if greater weight loss at baseline [2][5]; lower Human Leukocyte Antigen-DR (HLA-DR) expression on monocytes, which is used as a measure of immune status and may explain increased risk of infections [3]; and reduced immune function, increased surgical complications and increased length of stay [24].

From the level III-3 studies, C-reactive protein and albumin levels impacted on survival and response to treatment [6], increased complications and length of stay [7], increased length of stay and readmissions [4] and patients below their ideal body weight pre treatment have increased risk of locoregional failure [8].

The two level IV positive quality studies demonstrated malnourished patients had reduced quality of life [9] and that patients who were malnourished at baseline had no impact on survival [10]. Only one other level IV neutral study found that malnutrition at baseline had no impact on survival outcomes [18]. The other level IV neutral studies showed malnourished patients had poorer outcomes such as: reduced quality of life [11][9][15], reduced survival [12][20][21][22][23], increased length of stay [14][19], and increased complications including infections, admissions and treatment interruptions [12][13][14][15][17][19][22].

While there have been several studies to address this question, there are some limitations to the interpretation of the results due to the methodology and study design and the chosen measures of nutritional status. There are limitations with the validity of single parameters such as C-reactive protein, albumin and weight loss in identifying malnutrition in patients with head and neck cancer. Nutritional assessment tools with at least two parameters are recommended as they have higher sensitivity and specificity of predicting nutritional status (see Q4 for further information on appropriate methods to assess nutritional status using validated tools).

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Recommendation Grade
Malnutrition in this patient group can have a significant adverse impact on clinical, cost and patient centred outcomes such as complications (infections), treatment response, treatment interruptions, unplanned admissions, length of stay and quality of life.
B
Malnutrition may reduce overall survival in this group
C

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References

  1. 1.0 1.1 Siroen MP, van Bokhorst-de van der Schueren MA, Richir MC, Sauerwein HP, Leemans CR, Quak JJ, et al. The prognostic value of severe malnutrition in the development of nonthyroidal illness in head and neck cancer patients. JPEN J Parenter Enteral Nutr 2006;30(5):415-20 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16931610.
  2. 2.0 2.1 van Bokhorst-de van der Schuer, von Blomberg-van der Flier BM, Kuik DJ, Scholten PE, Siroen MP, Snow GB, et al. Survival of malnourished head and neck cancer patients can be predicted by human leukocyte antigen-DR expression and interleukin-6/tumor necrosis factor-alpha response of the monocyte. JPEN J Parenter Enteral Nutr 2000;24(6):329-36 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11071592.
  3. 3.0 3.1 van Bokhorst-De van der Schuer MA, von Blomberg-van der Flier BM, Riezebos RK, Scholten PE, Quak JJ, Snow GB, et al. Differences in immune status between well-nourished and malnourished head and neck cancer patients. Clin Nutr 1998 Jun;17(3):107-11 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10205326.
  4. 4.0 4.1 4.2 Linn BS, Robinson DS. The possible impact of DRGs on nutritional status of patients having surgery for cancer of the head and neck. JAMA 1988 Jul;260(4):514-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/3133497.
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  17. 17.0 17.1 van Bokhorst-de van der Schueren MA, van Leeuwen PA, Sauerwein HP, Kuik DJ, Snow GB, Quak JJ. Assessment of malnutrition parameters in head and neck cancer and their relation to postoperative complications. Head Neck 1997 Aug;19(5):419-25 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9243270.
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  23. 23.0 23.1 Kubrak C, Olson K, Jha N, Jensen L, McCargar L, Seikaly H, 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 Mar;32(3):290-300 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19626639.
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