Q1. What is the impact of a diagnosis of malnutrition at baseline on a patient’s treatment outcomes?
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) , four level III-3 neutral quality studies (total n=397) , and fifteen level IV studies; 2 positive quality (total n= 125)  and thirteen neutral quality (total n= 1626) .
From the level III-2 studies, malnourished patients had an increased risk of developing non thyroidal illness post surgery ; reduced survival if greater weight loss at baseline ; 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 ; and reduced immune function, increased surgical complications and increased length of stay .
From the level III-3 studies, C-reactive protein and albumin levels impacted on survival and response to treatment , increased complications and length of stay , increased length of stay and readmissions  and patients below their ideal body weight pre treatment have increased risk of locoregional failure .
The two level IV positive quality studies demonstrated malnourished patients had reduced quality of life  and that patients who were malnourished at baseline had no impact on survival . Only one other level IV neutral study found that malnutrition at baseline had no impact on survival outcomes . The other level IV neutral studies showed malnourished patients had poorer outcomes such as: reduced quality of life , reduced survival , increased length of stay , and increased complications including infections, admissions and treatment interruptions .
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).
|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|
- 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.
- 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.
- 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.
- 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.
- Langius JA, Bakker S, Rietveld DH, Kruizenga HM, Langendijk JA, Weijs PJ, et al. Critical weight loss is a major prognostic indicator for disease-specific survival in patients with head and neck cancer receiving radiotherapy. Br J Cancer 2013 Sep 3;109(5):1093-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23928661.
- Salas S, Deville JL, Giorgi R, Pignon T, Bagarry D, Barrau K, et al. Nutritional factors as predictors of response to radio-chemotherapy and survival in unresectable squamous head and neck carcinoma. Radiother Oncol 2008 May;87(2):195-200 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18342966.
- Guo CB, Zhang W, Ma DQ, Zhang KH, Huang JQ. Hand grip strength: an indicator of nutritional state and the mix of postoperative complications in patients with oral and maxillofacial cancers. Br J Oral Maxillofac Surg 1996 Aug;34(4):325-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8866070.
- Platek ME, Reid ME, Wilding GE, Jaggernauth W, Rigual NR, Hicks WL Jr, et al. Pretreatment nutritional status and locoregional failure of patients with head and neck cancer undergoing definitive concurrent chemoradiation therapy. Head Neck 2010 Dec 15 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21162055.
- Capuano G, Gentile PC, Bianciardi F, Tosti M, Palladino A, Di Palma M. Prevalence and influence of malnutrition on quality of life and performance status in patients with locally advanced head and neck cancer before treatment. Support Care Cancer 2010 Apr;18(4):433-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19562384.
- van Bokhorst-de van der Schuer, van Leeuwen PA, Kuik DJ, Klop WM, Sauerwein HP, Snow GB, et al. The impact of nutritional status on the prognoses of patients with advanced head and neck cancer. Cancer 1999 Aug 1;86(3):519-27 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10430262.
- van den Berg MG, Rasmussen-Conrad EL, van Nispen L, van Binsbergen JJ, Merkx MA. A prospective study on malnutrition and quality of life in patients with head and neck cancer. Oral Oncol 2008 Sep;44(9):830-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18243771.
- Capuano G, Grosso A, Gentile PC, Battista M, Bianciardi F, Di Palma A, et al. Influence of weight loss on outcomes in patients with head and neck cancer undergoing concomitant chemoradiotherapy. Head Neck 2008 Apr;30(4):503-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18098310.
- Guo CB, Ma DQ, Zhang KH, Hu XH. Relation between nutritional state and postoperative complications in patients with oral and maxillofacial malignancy. Br J Oral Maxillofac Surg 2007 Sep;45(6):467-70 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17254677.
- Shirodkar M, Mohandas KM. Subjective global assessment: a simple and reliable screening tool for malnutrition among Indians. Indian J Gastroenterol 2005;24(6):246-50 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16424621.
- Ravasco P, Monteiro-Grillo I, Vidal PM, Camilo ME. Cancer: disease and nutrition are key determinants of patients' quality of life. Support Care Cancer 2004 Apr;12(4):246-52 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/14997369.
- Doerr TD, Marks SC, Shamsa FH, Mathog RH, Prasad AS. Effects of zinc and nutritional status on clinical outcomes in head and neck cancer. Nutrition 1998 Jun;14(6):489-95 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9646288.
- 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.
- Matthews TW, Lampe HB, Dragosz K. Nutritional status in head and neck cancer patients. J Otolaryngol 1995 Apr;24(2):87-91 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7602677.
- Guo CB, Ma DQ, Zhang KH. Applicability of the general nutritional status score to patients with oral and maxillofacial malignancies. Int J Oral Maxillofac Surg 1994 Jun;23(3):167-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7930772.
- Mick R, Vokes EE, Weichselbaum RR, Panje WR. Prognostic factors in advanced head and neck cancer patients undergoing multimodality therapy. Otolaryngol Head Neck Surg 1991 Jul;105(1):62-73 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1909010.
- Brookes GB. Nutritional status--a prognostic indicator in head and neck cancer. Otolaryngol Head Neck Surg 1985 Feb;93(1):69-74 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/3920627.
- Goodwin WJ Jr, Torres J. The value of the prognostic nutritional index in the management of patients with advanced carcinoma of the head and neck. Head Neck Surg 1984;6(5):932-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/6427139.
- 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.
- Linn BS, Robinson DS, Klimas NG. Effects of age and nutritional status on surgical outcomes in head and neck cancer. Ann Surg 1988 Mar;207(3):267-73 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/3125799.