Summary of recommendations

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Summary of recommendations

This page summarises all the recommendations for each clinical question of the Evidence Based Guidelines for Nutritional Management of Patients with Head and Neck Cancer. You can click on the heading for a question to navigate to the full content. Clicking on the grade of recommendation will navigate to an explanation of the grading systems used in the development of these guidelines.

Appropriate access to care - Nutrition screening and assessment

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

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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Q2. When should patients be screened and referred to the dietitian?

Recommendation Grade
Malnutrition screening should be undertaken on all patients at diagnosis to identify those at nutritional risk and then repeated at intervals through each stage of treatment (e.g. surgery, radiotherapy/chemotherapy, and post treatment). If identified at high risk refer to the dietitian for early intervention. B
All patients receiving radiation therapy to the head and neck area should be referred to the dietitian for nutrition support. A
Patients who are not malnourished at baseline, but are identified as having future high nutritional risk, should be referred to the dietitian prior to the commencement of treatment for assessment and consideration of appropriate nutrition support. C

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Q3. How should patients be screened and referred to the dietitian?

Recommendation Grade
Use a validated nutrition screening tool (e.g. Malnutrition Screening Tool) for identifying malnutrition risk in cancer patients. B

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Q4. How should nutritional status be assessed?

Recommendation Grade
Use a validated nutrition assessment tool (e.g. scored Patient Generated–Subjective Global Assessment or Subjective Global Assessment) to assess nutritional status. B

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Quality nutrition care - Nutrition intervention

Q5. What is the impact of the dietitian providing nutrition intervention as part of a multidisciplinary team?

Recommendation Grade
A dietitian should be part of the multidisciplinary team for treating patients with head and neck cancer throughout the continuum of care, as frequent dietitian contact has been shown to improve nutrition outcomes and quality of life. A

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Q6. Does nutrition intervention improve outcomes? - Surgery

Recommendation Grade
Tube feeding using standard formula can be used to minimise weight loss in the acute post operative period. C
Pre operative nutrition intervention in malnourished patients may lead to improved outcomes such as quality of life and reduce adverse related consequences of malnutrition. B
Pre operative immunonutrition has no additional benefits compared to standard nutrition support for patients undergoing surgery for head and neck cancer. C
Post operative immunonutrition may be considered to reduce length of stay, although the mechanism is unclear, as other clinical benefits such as reduced complications and infections were not demonstrated. B
Peri operative n-3 fatty acid enriched nutrition support may improve nutritional outcomes such as weight, lean body mass and fat mass. C

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

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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Q8. Does nutrition intervention improve outcomes? - Post treatment

Recommendation Grade
Nutrition intervention (dietary counselling and/or supplements) for 3 months post treatment improves/maintains nutritional status. A
Nutrition intervention (dietary counselling and/or supplements) for 3 months post treatment improves/maintains quality of life. A

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Quality nutrition care - Establishing goals

Q9. What are the goals of nutrition intervention - Pre treatment?

Recommendation Grade
Aim to maintain/prevent a decline/improve nutritional status and associated outcomes in adults with malnutrition or at risk of malnutrition. A

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Q10. What are the goals of nutrition intervention? - Surgery

Recommendation Grade
Aim to maintain/prevent a decline/improve nutritional status and associated outcomes in adults with malnutrition or at risk of malnutrition. A

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Q11. What are the goals of nutrition intervention? - Radiotherapy and chemotherapy

Recommendation Grade
Aim to minimise a decline in nutritional status/weight and to maintain quality of life and symptom management in patients receiving radiotherapy/chemotherapy. A

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Quality nutrition care - Nutrition prescription

Q12. What is the nutrition prescription to meet these goals? - Surgery

Recommendation Grade
Standard polymeric fibre feed should be used post operatively. B
If immunonutrition is to be used post operatively, this should be given for a minimum of 7 days. C
Aim for energy intakes of at least 125kJ/kg/day (30kcal/kg/day). As energy requirements may be elevated post operatively, monitor weight and adjust intake as required. C

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Q13. What is the nutrition prescription to meet these goals? - Radiotherapy and chemotherapy

Recommendation Grade
Aim for energy and protein intakes of at least 125kJ/kg/day (30kcal/kg/day) and 1.2g protein/kg/day in patients receiving radiotherapy or chemoradiotherapy. Patients should have their weight and nutritional intake monitored regularly to determine whether their energy requirements are being met. C

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Q14. What is the nutrition prescription to meet these goals? - Post treatment

Recommendation Grade
Energy and protein requirements remain elevated post treatment and weight should continue to be monitored and intervention adjusted as appropriate. C

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Nutrition implementation - Pre treatment

Q15. Which patients should be identified for prophylactic enteral feeding?

Recommendation Grade
Prophylactic enteral feeding should be considered to improve nutritional status, cost and patient outcomes for patients who have T4 or hypopharyngeal tumours undergoing concurrent chemoradiotherapy.


Other patient groups should be considered by the multidisciplinary team on an individual basis dependent on other clinical factors such as tumour site, staging, effect of multi-modality treatments, radiotherapy treatment fields and dose, type of surgical procedure, nutritional status, dysphagia and social support.

C

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Q16. What are the complications from gastrostomy tube placement and is there a preferred method of placement?

Recommendation Grade
Procedure and associated choice of feeding tube should consider gastrostomy complications vary according to the tube type, insertion method and skill/expertise of those undertaking the procedure, as well as variations in the definitions of major and minor complications. Overall, there is a low procedure mortality rate (mean approx 1%). C

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Nutrition implementation - Surgery

Q17. When or how should post operative tube feeding commence?

Recommendation Grade
Post operative tube feeding should commence within 24 hours in patients in whom oral feeding cannot be established, with individual consideration to patients depending on surgical procedures in collaboration with the multidisciplinary team. A

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Q18. When or how should oral intake resume post total laryngectomy?

Recommendation Grade
Early oral feeding post primary total laryngectomy (from as early as 1 day post op to 7 days) should be considered to reduce length of stay as there has been no difference in fistula rates compared to delayed oral feeding from >7 days.


However, there may be different variables of the patient and surgery that need to be considered by the team in this decision making, therefore collaboration with the multidisciplinary team including the surgeons and speech pathologist on how and when oral intake should be resumed and progressed is advised.

B

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Nutrition implementation - Radiotherapy and chemotherapy

Q19. What are the effective methods of implementation to ensure positive outcomes?

Recommendation Grade
Reactive tube feeding: Nasogastric versus Gastrostomy

Reactive tube feeding (nasogastric or gastrostomy) results in similar nutritional and clinical outcomes and although no difference in global quality of life, there are differences in domains of quality of life and tube complications which should be discussed with the patient.

B
Prophylactic gastrostomy feeding versus Reactive tube feeding (either Nasogastric or Gastrostomy)

Prophylactic tube feeding compared to reactive tube feeding demonstrates improves nutrition outcomes (weight loss), quality of life and clinical outcomes (reduced hospital admissions, LOS and treatment interruptions) during the treatment phase.

B
Dietary counselling and/or Nutritional supplements

Dietary counselling and/or supplements are effective methods of nutrition intervention, and weekly dietitian contact improves outcomes in patients receiving radiotherapy.

A
Prophylactic gastrostomy feeding versus Reactive tube feeding (either Nasogastric or Gastrostomy)

Prophylactic tube feeding compared to reactive tube feeding does not improve nutrition outcomes (weight loss/BMI) in long-term post-treatment phase (6 months post treatment and beyond).

B
Prophylactic tube feeding (Nasogastric and Gastrostomy) versus Oral intake alone

For patients not tolerating adequate intake orally, tube feeding should be used to improve nutritional intake and minimise weight loss.

B
Prophylactic gastrostomy feeding versus Reactive tube feeding (either Nasogastric or Gastrostomy)

Prophylactic tube feeding compared to a reactive tube feeding approach may improve quality of life in long-term post-treatment phase (>6 months post treatment).

B
Prophylactic tube feeding (Nasogastric and Gastrostomy) versus Oral intake alone

Prophylactic tube feeding compared to oral intake alone demonstrates improved nutrition outcomes with less weight loss.

B
Psychosocial considerations with tube feeding

Patients who are unable to eat and are reliant on tube feeding should be screened for distress and provided with psychosocial supports to assist with quality of life.

C
Prophylactic tube feeding (Nasogastric and Gastrostomy) versus Oral intake alone

Practice Point The optimal method of tube feeding (nasogastric vs gastrostomy) remains unclear due to a lack of comparative studies therefore, the risks and benefits of both proactive and reactive approaches should be discussed with the patient to ensure individualised nutritional care at the point of diagnosis .

B

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Q20. What are the impacts of new developing treatment regimens on nutritional status and outcomes?

Recommendation Grade
Targeted therapy treatments (e.g. Cetuximab) have high rates of weight loss, mucositis and need for tube feeding. Patient should be managed in the same way as for conventional chemoradiotherapy. C
The impact of neoadjuvant chemotherapy on nutritional status and nutrition impact symptoms is varied with limited studies available. Patients should be monitored for symptoms to prevent decline in nutritional status. D
IMRT has not been found to reduce toxicity significantly, with still a high rate of weight loss, mucositis and need for tube feeding. Patients should be managed in the same way as for conventional radiotherapy. C


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Q21. What is the effect or benefit of vitamins or minerals during or post radiotherapy treatment?

Recommendation Grade
Zinc at doses of 25mg tds taken during or post (chemo) radiotherapy has been linked with survival benefits in patients with nasopharyngeal cancer, however care needs to be taken in its use due to potential and unknown interactions with chemotherapy and radiotherapy. C
Zinc at doses of 25mg tds taken during or post (chemo) radiotherapy may reduce side effects (mucositis, taste changes), however care needs to be taken in its use due to potential and unknown interactions with chemotherapy and radiotherapy. C
Vitamin E, at high doses of 400IU/d, may be associated with reduced survival or recurrent disease. A
Selenium supplementation of 200ug/d taken daily during treatment may improve immune function, but has not been shown to have any impact on clinical symptoms. C
Antioxidants should not be taken during chemotherapy or radiotherapy due to possible tumour protection and reduced survival. B
Beta carotene (30mg/d) may reduce side effects, however care needs to be taken in its use due to other demonstrated effects of reduced survival or recurrent disease in other cancer patients. B
Vitamin A, at high doses of 200 000IU/week, has no benefits and may have an adverse effect on survival and disease outcomes. B

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Nutrition implementation - Palliative care

Q22. What is the role for the dietitian in the management of patients with head and neck cancer requiring palliative care?

Recommendation Grade
The dietitian is an important member of the palliative care team due to the high incidence of weight loss, dysphagia and tube feeding in this patient population. Liaise with the speech pathologist for the expected nature of any dysphagia and likely progression, to determine level of nutrition intervention required. C
The goals and outcomes of nutrition intervention will be dependent on the prognosis of the patient. For patients with end stage disease the desired outcome is to maximise patient comfort and quality of life, and the dietitian should liaise with patient, family or carers and the palliative care team for the appropriate level of intervention required. C

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Nutrition monitoring and evaluation

Q23. What frequency and duration of nutrition follow up should patients receive pre, peri and post treatment?

Recommendation Grade
Patient should be seen weekly by a dietitian during radiotherapy. A
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

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Q24. What nutritional parameters need to be monitored?

Recommendation Grade
Monitor weight, intake and nutritional status during and post (chemo) radiotherapy. A

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

Recommendation Grade
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
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

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Q26. What is the impact of patient adherence with dietary advice to their outcomes?

Recommendation Grade
Patient adherence with dietary advice and nutrition support recommendations are essential to achieve positive outcomes through nutrition intervention. Therefore, the role of the multidisciplinary team is essential to ensure management of treatment side effects (e.g. pain, dysphagia, and mucositis) and other psychosocial factors are addressed to enable patients to follow dietary advice. B

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Q27. How should patients be nutritionally assisted in the transition to survivorship?

Recommendation Grade
Adjust dietary advice to cancer prevention diet and physical activity guidelines where appropriate depending on patient’s disease status and presence of late side effects post treatment. D


Practice point
To achieve long term oral health and reduce the risk of dental complications and osteoradionecrosis, it is important to seek the advice of a dentist who is experienced in the management of post radiation therapy patients. Any dietary changes should be considered in the context of the patient’s nutritional status and presence of prolonged or late side effects post treatment.

Practice points – No systematic review conducted but rather a guidance point important to clinicians.

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