Q15. Which patients should be identified for prophylactic enteral feeding?
It is important to distinguish between the different types of tube feeding, approaches (proactive versus reactive) and timing. Tube feeding can be provided via a nasogastric tube or a gastrostomy tube (which may be placed endoscopically, radiologically or surgically). A proactive approach to nutritional management is a feeding tube placed prior to treatment or surgery either in anticipation of its need (prophylactic gastrostomy) or due to significant nutritional compromise or dysphagia at diagnosis (therapeutic gastrostomy). A reactive approach to nutritional management is a feeding tube placed post operatively to manage post operative dysphagia or during treatment only when it becomes clinically indicated due to significant nutritional compromise or dysphagia. In these cases this is a reactive feeding tube, and may be either a nasogastric tube or gastrostomy. Prophylactic enteral feeding is used in the anticipation they will require nutrition support for a prolonged period of time both during treatment and recovery. The National Institute of Clinical Excellence (NICE), nutrition support guidelines recommend considering a gastrostomy over a nasogastric tube if feeding is required for longer than a period of 4 weeks. In patients with head and neck cancer, this is most commonly achieved via placement of a prophylactic gastrostomy, as these devices are designed for longer term tube use. A number of prognosis studies have looked at which patient groups are more likely to require a gastrostomy, as placement prophylactically avoids the difficulties of undergoing a gastrostomy placement procedure once acute toxicities of treatment are present e.g. mucositis, oesophagitis and neutropenia. It should also be acknowledged that some patients may be unsuitable for a gastrostomy or may refuse this more invasive procedure, and so they will require the use of a nasogastric tube. See Q16 and Q19 for more details on how to select the most appropriate type of enteral feeding device.
In clinical practice, predicting which patients may benefit from prophylactic enteral feeding according to their treatment plan (surgery, adjuvant radiotherapy or definitive radiotherapy/chemoradiotherapy) would be considered useful. However, the study designs frequently result in recruitment of mixed treatment populations, limiting capacity to stratify data meaningfully into groups with adequate patient numbers. It may also ignore the significant patient-related factors that should be considered.
There are two level III-2 neutral quality studies in patients receiving chemoradiotherapy which conclude that other factors are associated with the use of tube feeding and include: age, tumour size (T3/T4), tumour site (larynx, hypopharynx) ; and T4 tumours and tumours of the hypopharynx, oral cavity and oropharynx . There is one level III-3 positive quality study  which predicts pectoralis major myocutaneous flap, preoperative radiotherapy, oropharynx and stage III-IV cancers to be associated with gastrostomy use. There are four level III-3 neutral quality studies concluding; increasing radiation dose to the pharyngeal constrictor muscles, T3, T4 , normal or low body mass index (BMI <25) , stage IV cancer, combined therapies, preoperative weight loss >4.5kg (10lbs) , and tumours of the pharynx  are also associated with tube feeding.
One level III-3 neutral quality study examined predictive factors for gastrostomy placement in surgically treated patients and identified low body mass index, size and localisation of tumour (posterior mouth floor or base of tongue), lymph node affection, resection of the root of the tongue or oropharynx region, and neck dissection as decisive .
These lower level studies also support findings from the previous higher level studies for the following factors to be associated with the use of tube feeding: advanced stage of tumour (stage 3/4) , chemoradiotherapy , and tumours of the hypopharynx  or oral cavity/oropharynx .
Some studies have also found the following other factors to be associated with the use of tube feeding: treatment field length >82mm for “boost” phase radiotherapy ; multimodality treatments ; bone resection and flap surgeries ; and tumour resection with adjuvant radiotherapy . Jack et al. further demonstrated pre-operative dietary texture to be associated with tube feeding. Specifically, those managing only tube feeds, fluids or soft diets pre-operatively were significantly more likely to require percutaneous gastrostomy tube insertion than those on normal or near normal diet textures .
In addition, factors associated with more severe weight loss were cancers of the nasopharynx and base of tongue , oropharynx , all sites except the larynx, higher body weight pre treatment, dysphagia/odynophagia pre treatment, lower functional status, stage II disease  and tumour stage. One level IV neutral study  has found that when using the PG-SGA, patients who had pre treatment symptoms of anorexia, dysphagia and mouth sores, were predictors of reduced dietary intake and weight loss, and these patients were more likely to start losing weight earlier during treatment. Pre treatment weight loss was associated with more severe weight loss during treatment  and a higher need for tube feeding during treatment . One systematic review on mucositis and outcomes indicated in the sub-analysis that grade III-IV mucositis was significantly associated with requirement for a feeding tube .
There has been one questionnaire disseminated to centres across the UK which reviewed opinions of the multidisciplinary team on decision making for gastrostomy insertion. This study concluded that there was no national consensus in the UK, but the most common factors which influenced decisions were pre treatment swallowing function, pre treatment weight loss, low BMI and patient choice. Another study reported that 11/23 patients in their case series with a prophylactic gastrostomy did not use their tube, however nutrition outcomes and dietetic intervention were not reported. There were no criteria for gastrostomy insertion and use was not found to be correlated with diagnosis, stage or treatment.
A level IV study described swallowing and nutrition guidelines developed from a literature review, which aimed to identify high-risk patients for proactive gastrostomy. Sensitivity of the guidelines to predict the need for proactive gastrostomy was 54%, specificity 93%, positive predictive value 82%, and negative predictive value 77%. This is the first set of guidelines to be validated for ability to predict the need for a gastrostomy and assist the multidisciplinary team in decision making on the appropriateness and timing of tube feeding in patients with head and neck cancer.
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.
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