Q25. What are the patient groups that may require long term nutrition support and monitoring?
Although there are many studies which document the predictive factors for long term tube feeding such as tumour sites, stage and treatment modality, there are no agreed definitions of long term gastrostomy dependency. Prolonged feeding tube use can be influenced by several other clinical factors such as past medical history or other co-morbidities, radiotherapy treatment fields and dose, surgical resection and techniques, psychosocial factors, poor nutritional status requiring long term nutrition support, time and effort with eating, loss of enjoyment of eating and patient adherence to rehabilitation programs. These other variables are often not considered in the papers which report on frequency of gastrostomy dependency at various time points post treatment. There is also limited information on who makes the decision for feeding tube insertion and removal, the organisation of tube feeding services and specialist support from gastroenterology and radiology, and the impact of dietetic intervention has not been evaluated. As a confounding factor, it also should be noted that gastrostomy tubes are designed for longer term nutrition support. Swallowing outcome studies reported in the literature use gastrostomy tubes as a proxy measure of swallowing but fail to report on nutrition measures to enable accurate evaluation of tube outcomes and therefore understanding in definition of dependency.
One level II positive quality study compared prophylactic gastrostomy with clinical praxis (enteral feeding when deemed necessary), finding that the study group commenced enteral nutrition earlier and continued for significantly longer than controls. The rate of severe dysphagia (nil by mouth) was lower in the prophylactic gastrostomy group at one year post treatment. Another study on the same cohort (level II, neutral quality) found energy and protein intakes in both groups only met estimated requirements from six months post treatment, with weight loss ceasing after this time. Eating difficulties were highest at two and three months post treatment, with enteral nutrition providing the main source of nutrition at these time points in both groups. The level II neutral quality study, which compared gastrostomy and nasogastric tubes, found that gastrostomy tubes remained in situ for longer than nasogastric tubes .
There is one level III-2 positive quality study , five level III-2 neutral quality studies , one level III-3 positive quality study , five level III-3 neutral quality studies , one level IV positive quality study , thirteen level IV neutral quality studies , and three level IV negative quality studies .
One level III-2 study confirmed the findings of Corry that gastrostomy tubes remained in situ for longer than nasogastric tubes . Another reported high rates of gastrostomy dependency of 62-65% at 6/12, and 26-32% at 12 and 18 months, following either accelerated or hyper fractionated chemoradiotherapy with no difference found between types of treatment . The third level III-2 study found patients who received a prophylactic gastrostomy were more likely to have high grade dysphagia and strictures compared to those who did not have a tube placed before treatment . A further two level III-2 studies utilised surrogate markers for dysphagia (patient-reported swallowing outcome, change in mean diet level, and/or percentage weight loss) and found that those patients who received a prophylactic gastrostomy had worse long-term swallowing outcome than those who didn’t . Conversely, another level III-2 study found no significant difference in gastrostomy dependence rates in those with tubes placed prophylactically versus reactively and that gastrostomy dependence was found to be associated with older age on multivariate analysis.
One level III-3 study identified the use of prophylactic gastrostomy to be associated with increased duration of enteral feeding compared with tube feeding as required . Other factors reported to be associated with increased gastrostomy dependence by level III-3 studies include: primary site of larynx, pharyngeal wall, base of tongue , and hypopharynx ; T stage; baseline dysphagia ; higher doses to and volumes treated of larynx and inferior pharynx constrictor muscles ; neck dissection; pre treatment weight loss; being of older age ; being without a partner; treatment with radiation therapy; and tracheostomy placement for longer than 30 days .
The level IV studies report the following non tumour or treatment factors to be associated with long term gastrostomy feeding: heavy alcohol intake, ethnicity (African American), older age, smoking and pre treatment aspiration on thin fluids, and loss of >15% body weight. There are conflicting results for age as some studies show no difference. Various types of treatment regimens, tumour staging and sites are also considered to be factors in requirements for dependency on long term tube feeding, as per the criteria discussed when considering prophylactic feeding tube placement selection (See Q15).
There is one level IV positive quality study , seven level IV neutral quality studies , and one level IV negative quality study  pertaining to swallow outcomes. Three studies showed poorer swallowing outcomes with adjuvant radiotherapy . Another study demonstrated increased dysphagia, increased risk of malnutrition and worse quality of life with co adjuvant treatment . The latter finding was supported by one further study which identified reduced quality of life with adjuvant radiotherapy compared to those with surgery alone in the domains of burden, eating duration, eating desire, symptom frequency and food selection . Other factors associated with poor swallowing outcomes and higher subsequent rate of enteral feeding were rural living, ex heavy alcohol intake, hypopharynx tumour site, and radiotherapy technique . Chapuy et al. further identified higher tumour stage to be associated with greater dysphagia at 12 months and subsequent gastrostomy dependence at 12 and 24 months post chemo-radiotherapy . Another study demonstrated that while patients reported several reasons for tube dependency, timely dietetic management assisted in tube weaning with more confidence . Ames further demonstrated the benefits of maintaining oral intake during treatment in reducing duration of gastrostomy tube use and improving survival outcomes .
|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|
- 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.
- 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.
- Corry J, Poon W, McPhee N, Milner AD, Cruickshank D, Porceddu SV, et al. Randomized study of percutaneous endoscopic gastrostomy versus nasogastric tubes for enteral feeding in head and neck cancer patients treated with (chemo)radiation. J Med Imaging Radiat Oncol 2008 Oct;52(5):503-10 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19032398.
- 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.
- Hatoum GF, Abitbol A, Elattar I, Lewin A, Troner M, Kronberg F, et al. Radiation technique influence on percutaneous endoscopic gastrostomy tube dependence: Comparison between two radiation schemes. Head Neck 2009 Jul;31(7):944-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19309724.
- Chen AM, Li BQ, Lau DH, Farwell DG, Luu Q, Stuart K, et al. Evaluating the role of prophylactic gastrostomy tube placement prior to definitive chemoradiotherapy for head and neck cancer. Int J Radiat Oncol Biol Phys 2010 Nov 15;78(4):1026-32 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20231073.
- Oozeer NB, Corsar K, Glore RJ, Penney S, Patterson J, Paleri V. The impact of enteral feeding route on patient-reported long term swallowing outcome after chemoradiation for head and neck cancer. Oral Oncol 2011 Oct;47(10):980-3 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21856212.
- Langmore S, Krisciunas GP, Miloro KV, Evans SR, Cheng DM. Does PEG use cause dysphagia in head and neck cancer patients? Dysphagia 2012 Jun;27(2):251-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21850606.
- 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.
- 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.
- Caudell JJ, Schaner PE, Desmond RA, Meredith RF, Spencer SA, Bonner JA. Dosimetric factors associated with long-term dysphagia after definitive radiotherapy for squamous cell carcinoma of the head and neck. Int J Radiat Oncol Biol Phys 2010 Feb 1;76(2):403-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19467801.
- Lango MN, Egleston B, Ende K, Feigenberg S, D'Ambrosio DJ, Cohen RB, et al. Impact of neck dissection on long-term feeding tube dependence in patients with head and neck cancer treated with primary radiation or chemoradiation. Head Neck 2010 Mar;32(3):341-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19693946.
- Sanguineti G, Gunn GB, Parker BC, Endres EJ, Zeng J, Fiorino C. Weekly dose-volume parameters of mucosa and constrictor muscles predict the use of percutaneous endoscopic gastrostomy during exclusive intensity-modulated radiotherapy for oropharyngeal cancer. Int J Radiat Oncol Biol Phys 2011 Jan 1;79(1):52-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20418027.
- Magnuson JS, Durst J, Rosenthal EL, Carroll WR, Ritchie CS, Kilgore ML, et al. Increased likelihood of long-term gastrostomy tube dependence in head and neck cancer survivors without partners. Head Neck 2013 Mar;35(3):420-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22505332.
- Ishiki H, Onozawa Y, Kojima T, Hironaka S, Fukutomi A, Yasui H, et al. Nutrition support for head and neck squamous cell carcinoma patients treated with chemoradiotherapy: how often and how long? ISRN Oncol 2012;2012:274739 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22518330.
- Frowen J, Cotton S, Corry J, Perry A. Impact of demographics, tumor characteristics, and treatment factors on swallowing after (chemo)radiotherapy for head and neck cancer. Head Neck 2010 Apr;32(4):513-28 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19691115.
- Lawson JD, Gaultney J, Saba N, Grist W, Davis L, Johnstone PA. Percutaneous feeding tubes in patients with head and neck cancer: rethinking prophylactic placement for patients undergoing chemoradiation. Am J Otolaryngol 2009;30(4):244-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19563935.
- Li B, Li D, Lau DH, Farwell DG, Luu Q, Rocke DM, et al. Clinical-dosimetric analysis of measures of dysphagia including gastrostomy-tube dependence among head and neck cancer patients treated definitively by intensity-modulated radiotherapy with concurrent chemotherapy. Radiat Oncol 2009 Nov 12;4:52 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19909531.
- Hutcheson KA, Barringer DA, Rosenthal DI, May AH, Roberts DB, Lewin JS. Swallowing outcomes after radiotherapy for laryngeal carcinoma. Arch Otolaryngol Head Neck Surg 2008 Feb;134(2):178-83 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18283161.
- Costa Bandeira AK, Azevedo EH, Vartanian JG, Nishimoto IN, Kowalski LP, Carrara-de Angelis E. Quality of life related to swallowing after tongue cancer treatment. Dysphagia 2008 Jun;23(2):183-92 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17999111.
- de Casso C, Slevin NJ, Homer JJ. The impact of radiotherapy on swallowing and speech in patients who undergo total laryngectomy. Otolaryngol Head Neck Surg 2008 Dec;139(6):792-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19041505.
- Fujimoto Y, Hasegawa Y, Yamada H, Ando A, Nakashima T. Swallowing function following extensive resection of oral or oropharyngeal cancer with laryngeal suspension and cricopharyngeal myotomy. Laryngoscope 2007 Aug;117(8):1343-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17585279.
- Tsao AS, Garden AS, Kies MS, Morrison W, Feng L, Lee JJ, et al. Phase I/II study of docetaxel, cisplatin, and concomitant boost radiation for locally advanced squamous cell cancer of the head and neck. J Clin Oncol 2006 Sep 1;24(25):4163-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16943532.
- Kornguth DG, Garden AS, Zheng Y, Dahlstrom KR, Wei Q, Sturgis EM. Gastrostomy in oropharyngeal cancer patients with ERCC4 (XPF) germline variants. Int J Radiat Oncol Biol Phys 2005 Jul 1;62(3):665-71 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15936543.
- Schweinfurth JM, Boger GN, Feustel PJ. Preoperative risk assessment for gastrostomy tube placement in head and neck cancer patients. Head Neck 2001 May;23(5):376-82 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11295811.
- Finlay PM, Dawson F, Robertson AG, Soutar DS. An evaluation of functional outcome after surgery and radiotherapy for intraoral cancer. Br J Oral Maxillofac Surg 1992 Feb;30(1):14-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1550799.
- Ames JA, Karnell LH, Gupta AK, Coleman TC, Karnell MP, Van Daele DJ, et al. Outcomes after the use of gastrostomy tubes in patients whose head and neck cancer was managed with radiation therapy. Head Neck 2011 May;33(5):638-44 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21077186.
- Mayre-Chilton KM, Talwar BP, Goff LM. Different experiences and perspectives between head and neck cancer patients and their care-givers on their daily impact of a gastrostomy tube. J Hum Nutr Diet 2011 Jun 8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21649745.
- García-Peris P, Parón L, Velasco C, de la Cuerda C, Camblor M, Bretón I, et al. Long-term prevalence of oropharyngeal dysphagia in head and neck cancer patients: Impact on quality of life. Clin Nutr 2007 Dec;26(6):710-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17954003.
- Shike M, Berner YN, Gerdes H, Gerold FP, Bloch A, Sessions R, et al. Percutaneous endoscopic gastrostomy and jejunostomy for long-term feeding in patients with cancer of the head and neck. Otolaryngol Head Neck Surg 1989 Nov;101(5):549-54 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/2512533.
- Jack DR, Dawson FR, Reilly JE, Shoaib T. Guideline for prophylactic feeding tube insertion in patients undergoing resection of head and neck cancers. J Plast Reconstr Aesthet Surg 2012 May;65(5):610-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22137826.