Q7. Does nutrition intervention improve outcomes? - Radiotherapy and chemotherapy

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Q7. Does nutrition intervention improve outcomes? - Radiotherapy and chemotherapy

Summary

There are two level I positive quality studies [1][2], both systematic reviews of nutrition intervention for patients receiving radiotherapy and chemotherapy. The first study reported on results for 10 randomised controlled trials (RCT’s). The majority of these studies were radiotherapy alone, compared to concurrent chemoradiotherapy. Nutritional status was maintained/improved with dietary counselling (5 RCT's), and prophylactic tube feeding (1 RCT). The second study (10 RCT’s) included patients receiving a mixture of radiotherapy alone or in combination with chemotherapy[2]. Dietary counseling was found to convey benefit to nutritional status and quality of life (4 RCT’s), while nasogastric tube feeding was of greater benefit to nutritional status than oral intake alone (1 RCT) but less effective than gastrostomy (1 RCT). Prophylactic gastrostomy was not found to be superior to tube feeding as required (2 RCT’s).

There are three level II positive quality studies [3][4][5] and two level II neutral quality studies [6][7] looking at the impact of dietary counselling. Improvements were seen with nutritional intake/nutritional status [5][3][4] and quality of life [3][4]. There are also two level II neutral quality studies looking at tube feeding compared to oral diet [8][9], which found the tube fed group had increased energy and protein intakes and less weight loss, but no impact on treatment response or survival. There were two level II papers, one positive and one neutral quality, which examined that impact of prophylactic gastrostomy use. The positive quality paper reported improved quality of life at six months post treatment in the prophylactic gastrostomy group, and a trend toward reduced malnutrition prevalence (not significant)[10]. The neutral quality paper found no significant difference in energy and protein intakes between groups, although the prophylactic gastrostomy group tended to be higher[11]. There is one level III-1 neutral quality study which demonstrates improvements in weight and nutritional status following dietetic counselling footnote[12].

There are four level III-2 studies: one positive quality [13], one negative quality [14] and two neutral quality [15][16]. The first study found that prophylactic gastrostomy was associated with fewer unplanned inpatient days, but not reduced weight loss [13]. The negative quality study demonstrated that presence of a gastrostomy resulted in less weight loss and conveyed a reduction in set up variation in daily treatment [14]. Another neutral quality study supported that tube feeding results in higher energy and protein intakes than oral diet and/or supplements [15]. The final neutral quality study reported that prophylactic gastrostomy resulted in reduced hospital admissions[16].

There is one level III-3 positive quality study [17] and seven level III-3 neutral quality studies [18][19][20][21][22][23][24]. Two of these examined the effect of nutrition intervention incorporating supplement provision with reductions noted in both weight loss [19][22] and the number of gastrostomy insertions [19]. Increased intensity of dietetic supervision was evaluated in three studies with improved outcomes including: less weight loss [21][18], fewer treatment interruptions and unplanned admissions [18], less nutrition-related admissions and unplanned nasogastric tube insertions, improved transition to oral diet post-radiotherapy, and reduced need for medical follow-up during the immediate post-treatment period [23]. One study describing a set of nutritional guidelines also found that there was less weight loss and fewer admissions [20]. Two studies examined prophylactic tube feeding which was found to convey reduced hospital admissions and/or LOS [17][24], fewer treatment interruptions, and improved maintenance of baseline nutritional status [24]. No difference was observed regarding survival or tumour recurrence rates [24].

There are five level IV positive quality studies [25][26][27][28][29], and fourteen level IV neutral quality studies [29][30][31][32][33][34][35][36][37][38][39][40][41][42] looking at various patient tumour/treatment groups and different outcomes. One study found no survival difference between those that received nasogastric tube feeding and those that didn't [40]. A post hoc analysis of an RCT [43] (level IV neutral quality), demonstrated positive outcomes in terms of less weight loss and less mucositis, however patients that received baseline nutrition support were also more likely to have reduced loco-regional control and survival. Limitations of this study are that it was not designed to measure outcomes of nutrition support interventions, and it could be argued that patients who received baseline nutrition support were those who required it due to more severe weight loss/dysphagia as a consequence of more advanced disease, and were therefore more likely to have poorer clinical outcomes. Another study showed a non significant reduction in the rate of severe oral mucositis was reduced in patients whose adherence with an oral immune modulating formula was high (≥75% consumed) compared to lower adherence [41]. Similarly, a study examining the impact of prophylactic gastrostomy showed that patients with weak adherence exhibited a significant reduction in weight during chemoradiotherapy, while there was no significant weight change and higher completion rate of concurrent chemotherapy (70% versus 44%) in those with high adherence [42].  

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Recommendation Grade
Nutrition intervention (dietary counselling and/or supplements and/or tube feeding) improves/maintains nutritional status.
A
Nutrition intervention (dietary counselling and/or supplements and/or tube feeding) improves patient-centred outcomes (quality of life, physical function and patient satisfaction).
B
Tube feeding can improve protein and energy intake when oral intake is inadequate.
B
Tube feeding may reduce unplanned hospital admissions and reduced disruptions to treatment compared to oral intake alone.
C

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References

  1. Garg S, Yoo J, Winquist E. Nutritional support for head and neck cancer patients receiving radiotherapy: a systematic review. Support Care Cancer 2010 Jun;18(6):667-77 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19582484.
  2. 2.0 2.1 Langius JA, Zandbergen MC, Eerenstein SE, van Tulder MW, Leemans CR, Kramer MH, et al. Effect of nutritional interventions on nutritional status, quality of life and mortality in patients with head and neck cancer receiving (chemo)radiotherapy: a systematic review. Clin Nutr 2013 Oct;32(5):671-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23845384.
  3. 3.0 3.1 3.2 Isenring EA, Capra S, Bauer JD. Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area. Br J Cancer 2004 Aug 2;91(3):447-52 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15226773.
  4. 4.0 4.1 4.2 Ravasco P, Monteiro-Grillo I, Marques Vidal P, Camilo ME. Impact of nutrition on outcome: a prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head Neck 2005 Aug;27(8):659-68 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15920748.
  5. 5.0 5.1 Isenring EA, Bauer JD, Capra S. Nutrition support using the American Dietetic Association medical nutrition therapy protocol for radiation oncology patients improves dietary intake compared with standard practice. J Am Diet Assoc 2007 Mar;107(3):404-12 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17324657.
  6. Nayel H, el-Ghoneimy E, el-Haddad S. Impact of nutritional supplementation on treatment delay and morbidity in patients with head and neck tumors treated with irradiation. Nutrition 1992;8(1):13-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1562782.
  7. Arnold C, Richter MP. The effect of oral nutritional supplements on head and neck cancer. Int J Radiat Oncol Biol Phys 1989 Jun;16(6):1595-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/2656603.
  8. Daly JM, Hearne B, Dunaj J, LePorte B, Vikram B, Strong E, et al. Nutritional rehabilitation in patients with advanced head and neck cancer receiving radiation therapy. Am J Surg 1984 Oct;148(4):514-20 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/6385745.
  9. Hearne BE, Dunaj JM, Daly JM, Strong EW, Vikram B, LePorte BJ, et al. Enteral nutrition support in head and neck cancer: tube vs. oral feeding during radiation therapy. J Am Diet Assoc 1985 Jun;85(6):669-74, 677 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/3923081.
  10. Silander E, Nyman J, Bove M, Johansson L, Larsson S, Hammerlid E. Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer: a randomized study. Head Neck 2012 Jan;34(1):1-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21374756.
  11. Silander E, Jacobsson I, Bertéus-Forslund H, Hammerlid E. Energy intake and sources of nutritional support in patients with head and neck cancer--a randomised longitudinal study. Eur J Clin Nutr 2013 Jan;67(1):47-52 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23169469.
  12. van den Berg MG, Rasmussen-Conrad EL, Wei KH, Lintz-Luidens H, Kaanders JH, Merkx MA. Comparison of the effect of individual dietary counselling and of standard nutritional care on weight loss in patients with head and neck cancer undergoing radiotherapy. Br J Nutr 2010 Sep;104(6):872-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20441684.
  13. 13.0 13.1 Williams GF, Teo MT, Sen M, Dyker KE, Coyle C, Prestwich RJ. Enteral feeding outcomes after chemoradiotherapy for oropharynx cancer: a role for a prophylactic gastrostomy? Oral Oncol 2012 May;48(5):434-40 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22209648.
  14. 14.0 14.1 Mercuri A, Lim Joon D, Wada M, Rolfo A, Khoo V. The effect of an intensive nutritional program on daily set-up variations and radiotherapy planning margins of head and neck cancer patients. J Med Imaging Radiat Oncol 2009 Oct;53(5):500-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19788487.
  15. 15.0 15.1 Gonçalves Dias MC, de Fátima Nunes Marucci M, Nadalin W, Waitzberg DL. Nutritional intervention improves the caloric and proteic ingestion of head and neck cancer patients under radiotherapy. Nutr Hosp 2005;20(5):320-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16229399.
  16. 16.0 16.1 Baschnagel AM, Yadav S, Marina O, Parzuchowski A, Lanni TB Jr, Warner JN, et al. Toxicities and costs of placing prophylactic and reactive percutaneous gastrostomy tubes in patients with locally advanced head and neck cancers treated with chemoradiotherapy. Head Neck 2014 Aug;36(8):1155-61 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23852670.
  17. 17.0 17.1 Hughes BG, Jain VK, Brown T, Spurgin AL, Hartnett G, Keller J, et al. Decreased hospital stay and significant cost savings after routine use of prophylactic gastrostomy for high-risk patients with head and neck cancer receiving chemoradiotherapy at a tertiary cancer institution. Head Neck 2013 Mar;35(3):436-42 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22605643.
  18. 18.0 18.1 18.2 Paccagnella A, Morello M, Da Mosto MC, Baruffi C, Marcon ML, Gava A, et al. Early nutritional intervention improves treatment tolerance and outcomes in head and neck cancer patients undergoing concurrent chemoradiotherapy. Support Care Cancer 2010 Jul;18(7):837-45 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19727846.
  19. 19.0 19.1 19.2 Lee H, Havrila C, Bravo V, Shantz K, Diaz K, Larner J, et al. Effect of oral nutritional supplementation on weight loss and percutaneous endoscopic gastrostomy tube rates in patients treated with radiotherapy for oropharyngeal carcinoma. Support Care Cancer 2008 Mar;16(3):285-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17680281.
  20. 20.0 20.1 Wood K. Audit of nutritional guidelines for head and neck cancer patients undergoing radiotherapy. J Hum Nutr Diet 2005 Oct;18(5):343-51 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16150130.
  21. 21.0 21.1 Dawson ER, Morley SE, Robertson AG, Soutar DS. Increasing dietary supervision can reduce weight loss in oral cancer patients. Nutr Cancer 2001;41(1-2):70-4 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12094631.
  22. 22.0 22.1 Wallner PE, Endersbe LA, Marlin RL. Nutritional supplementation in two high-risk cancer populations. Curr Ther Res Clin E 1990;47:924-32.
  23. 23.0 23.1 Kiss NK, Krishnasamy M, Loeliger J, Granados A, Dutu G, Corry J. A dietitian-led clinic for patients receiving (chemo)radiotherapy for head and neck cancer. Support Care Cancer 2012 Sep;20(9):2111-20 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22086406.
  24. 24.0 24.1 24.2 24.3 Assenat E, Thezenas S, Flori N, Pere-Charlier N, Garrel R, Serre A, et al. Prophylactic percutaneous endoscopic gastrostomy in patients with advanced head and neck tumors treated by combined chemoradiotherapy. J Pain Symptom Manage 2011 Oct;42(4):548-56 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21477980.
  25. Oates JE, Clark JR, Read J, Reeves N, Gao K, Jackson M, et al. Prospective evaluation of quality of life and nutrition before and after treatment for nasopharyngeal carcinoma. Arch Otolaryngol Head Neck Surg 2007 Jun;133(6):533-40 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17576902.
  26. Bahl M, Siu LL, Pond GR, Kim J, Tannock IF, Bayley A, et al. Tolerability of the Intergroup 0099 (INT 0099) regimen in locally advanced nasopharyngeal cancer with a focus on patients' nutritional status. Int J Radiat Oncol Biol Phys 2004 Nov 15;60(4):1127-36 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15519784.
  27. Ng K, Leung SF, Johnson PJ, Woo J. Nutritional consequences of radiotherapy in nasopharynx cancer patients. Nutr Cancer 2004;49(2):156-61 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15489208.
  28. Zogbaum AT, Fitz P, Duffy VB.. Tube feeding may improve adherence to radiation treatment schedule in head and neck cancer: an outcomes study. Topics in Clinical Nutrition 2004;19:95-106. Abstract available at http://journals.lww.com/topicsinclinicalnutrition/Abstract/2004/04000/Tube_Feeding_May_Improve_Adherence_to_Radiation.3.aspx.
  29. 29.0 29.1 Nugent B, Parker MJ, McIntyre IA. Nasogastric tube feeding and percutaneous endoscopic gastrostomy tube feeding in patients with head and neck cancer. J Hum Nutr Diet 2010 Jun;23(3):277-84 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20337841.
  30. Raykher A, Correa L, Russo L, Brown P, Lee N, Pfister D, et al. The role of pretreatment percutaneous endoscopic gastrostomy in facilitating therapy of head and neck cancer and optimizing the body mass index of the obese patient. JPEN J Parenter Enteral Nutr 2009;33(4):404-10 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19520799.
  31. Morton RP, Crowder VL, Mawdsley R, Ong E, Izzard M. Elective gastrostomy, nutritional status and quality of life in advanced head and neck cancer patients receiving chemoradiotherapy. ANZ J Surg 2009 Oct;79(10):713-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19878166.
  32. 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.
  33. Wiggenraad RG, Flierman L, Goossens A, Brand R, Verschuur HP, Croll GA, et al. Prophylactic gastrostomy placement and early tube feeding may limit loss of weight during chemoradiotherapy for advanced head and neck cancer, a preliminary study. Clin Otolaryngol 2007 Oct;32(5):384-90 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17883560.
  34. Nguyen NP, North D, Smith HJ, Dutta S, Alfieri A, Karlsson U, et al. Safety and effectiveness of prophylactic gastrostomy tubes for head and neck cancer patients undergoing chemoradiation. Surg Oncol 2006 Dec;15(4):199-203 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17280829.
  35. Goguen LA, Posner MR, Norris CM, Tishler RB, Wirth LJ, Annino DJ, et al. Dysphagia after sequential chemoradiation therapy for advanced head and neck cancer. Otolaryngol Head Neck Surg 2006 Jun;134(6):916-22 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16730530.
  36. Ravasco P, Monteiro-Grillo I, Camilo ME. Does nutrition influence quality of life in cancer patients undergoing radiotherapy? Radiother Oncol 2003 May;67(2):213-20 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12812853.
  37. Beaver ME, Matheny KE, Roberts DB, Myers JN. Predictors of weight loss during radiation therapy. Otolaryngol Head Neck Surg 2001 Dec;125(6):645-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11743469.
  38. Marcy PY, Magné N, Bensadoun RJ, Bleuse A, Falewee MN, Viot M, et al. Systematic percutaneous fluoroscopic gastrostomy for concomitant radiochemotherapy of advanced head and neck cancer: optimization of therapy. Support Care Cancer 2000 Sep;8(5):410-3 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10975691.
  39. Chencharick JD, Mossman KL. Nutritional consequences of the radiotherapy of head and neck cancer. Cancer 1983 Mar 1;51(5):811-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/6821847.
  40. 40.0 40.1 Clavel S, Fortin B, Després P, Donath D, Soulières D, Khaouam N, et al. Enteral feeding during chemoradiotherapy for advanced head-and-neck cancer: a single-institution experience using a reactive approach. Int J Radiat Oncol Biol Phys 2011 Mar 1;79(3):763-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20510546.
  41. 41.0 41.1 Assenat E, Latournerie M, Thézenas S, Gaillet S, Janiszewski C, Flori N, et al. A prospective phase II study evaluating the efficacy of oral immune modulating formulae on acute oral mucositis during radiochemotherapy in head and neck neoplasms. E Spen Eur E J Clin Nutr Metab 2011 Aug;6(4):e171-e7 Abstract available at http://www.journals.elsevierhealth.com/periodicals/yeclnm/article/PIIS1751499111000266/abstract.
  42. 42.0 42.1 Atasoy BM, Yonal O, Demirel B, Dane F, Yilmaz Y, Kalayci C, et al. The impact of early percutaneous endoscopic gastrostomy placement on treatment completeness and nutritional status in locally advanced head and neck cancer patients receiving chemoradiotherapy. Eur Arch Otorhinolaryngol 2012 Jan;269(1):275-82 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21472468.
  43. Rabinovitch R, Grant B, Berkey BA, Raben D, Ang KK, Fu KK, et al. Impact of nutrition support on treatment outcome in patients with locally advanced head and neck squamous cell cancer treated with definitive radiotherapy: a secondary analysis of RTOG trial 90-03. Head Neck 2006 Apr;28(4):287-96 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16287132.

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