Q23. What frequency and duration of nutrition follow up should patients receive pre, peri and post treatment?
There are three level II positive quality studies which support weekly follow up during radiotherapy and minimum of fortnightly follow up post radiotherapy . There was one level III-1 neutral quality study  and two level III-3 neutral quality studies  further supporting the need for frequent dietetic contact. One study supported commencing dietetic intervention pre chemoradiotherapy , while another advocated continuing weekly follow up post radiotherapy . Similar to the level II studies, Kiss et al. supported weekly dietetic follow up during treatment and a minimum of two to four consultations in the first eight weeks post radiotherapy .
There is one level III-2 positive quality study , three level III-2 neutral quality studies , four level III-3 neutral quality studies , three level IV positive quality studies , twenty six level IV neutral quality studies , and two level IV negative quality studies . One study  reported on the incidence of late toxicity events at six months post treatment. Forty three percent of patients experienced a late toxicity event of either chronic grade 3-4 pharyngeal/laryngeal toxicity, requirement of a feeding tube, or a treatment related death. Due to the incidence of chronic toxicities at this stage post treatment, dietitian review for at least six months is recommended. Another study  reported no difference in gastrostomy tube feeding rates between patients who received hyper fractionated chemoradiotherapy compared to those receiving accelerated chemoradiotherapy, and that feeding rates post treatment were high with a mean of; 64% at six months, 31% at twelve months and 29% at eighteen months. McRackan et al.  reported gastrostomy dependency of mean 13 months. Another paper  describes positive outcomes in terms of less weight loss following increased dietetic intervention throughout the continuum of patient care, with 16% of patients still requiring gastrostomy feeds at 1 year post treatment.
A substantial number of lower level studies report on the incidence of dysphagia, weight loss and tube feeding post treatment, such as 10-24% requiring tube feeding at six months post treatment, 3-37% requiring tube feeding at twelve months post treatment and 6-16.2% requiring a feeding tube at 24 months post treatment.
One level IV positive quality study  found that patients receiving altered fractionation radiotherapy with concomitant boost for orpharyngeal cancer had reduced swallowing and nutritional status at 4-6 weeks post treatment, and this improved at 6 months post treatment. However weight and BMI did not improve to pre-treatment levels. Two level IV neutral quality studies also found that the nadir of weight loss occurred at 6 months post radiotherapy . Another level IV neutral quality qualitative paper  also supports the need to prepare patients for the post treatment phase and the slow recovery from side effects. The significance of eating problems needs to be acknowledged and the impact this has physically, emotionally and socially.
|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|
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Machtay M, Moughan J, Trotti A, Garden AS, Weber RS, Cooper JS, et al. Factors associated with severe late toxicity after concurrent chemoradiation for locally advanced head and neck cancer: an RTOG analysis. J Clin Oncol 2008 Jul 20;26(21):3582-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18559875.
- 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.
- McRackan TR, Watkins JM, Herrin AE, Garrett-Mayer EM, Sharma AK, Day TA, et al. Effect of body mass index on chemoradiation outcomes in head and neck cancer. Laryngoscope 2008 Jul;118(7):1180-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18475213.
- 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.
- 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.
- 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.
- Akst LM, Chan J, Elson P, Saxton J, Strome M, Adelstein D. Functional outcomes following chemoradiotherapy for head and neck cancer. Otolaryngol Head Neck Surg 2004 Dec;131(6):950-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15577796.
- 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.
- Feng FY, Kim HM, Lyden TH, Haxer MJ, Worden FP, Feng M, et al. Intensity-modulated chemoradiotherapy aiming to reduce dysphagia in patients with oropharyngeal cancer: clinical and functional results. J Clin Oncol 2010 Jun 1;28(16):2732-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20421546.
- McLaughlin BT, Gokhale AS, Shuai Y, Diacopoulos J, Carrau R, Heron DE, et al. Management of patients treated with chemoradiotherapy for head and neck cancer without prophylactic feeding tubes: the University of Pittsburgh experience. Laryngoscope 2010 Jan;120(1):71-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19877245.
- Silander E, Nymanb J, Bovec M, Johanssond L, Larssone S, Hammerlida E.. The use of prophylactic percutaneous endoscopic gastrostomy and early enteral feeding in pateitns with advanced head and neck cancer - a prospective longitudinal study. The european e-journal of clinical nutrition and metabolism 2010 Aug;5(4):e166-e172 Abstract available at http://www.e-spenjournal.org/article/S1751-4991(10)00024-7/abstract.
- 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.
- 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.
- 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.
- 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.
- Allen AM, Elshaikh M, Worden FP, Bradford CR, Teknos TN, Chepeha DB, et al. Acceleration of hyperfractionated chemoradiation regimen for advanced head and neck cancer. Head Neck 2007 Feb;29(2):137-42 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17111432.
- Bleier BS, Levine MS, Mick R, Rubesin SE, Sack SZ, McKinney K, et al. Dysphagia after chemoradiation: analysis by modified barium swallow. Ann Otol Rhinol Laryngol 2007 Nov;116(11):837-41 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18074669.
- Larsson M, Hedelin B, Athlin E. A supportive nursing care clinic: conceptions of patients with head and neck cancer. Eur J Oncol Nurs 2007 Feb;11(1):49-59 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17185036.
- Unsal D, Mentes B, Akmansu M, Uner A, Oguz M, Pak Y. Evaluation of nutritional status in cancer patients receiving radiotherapy: a prospective study. Am J Clin Oncol 2006 Apr;29(2):183-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16601440.
- Pauloski BR, Rademaker AW, Logemann JA, Newman L, MacCracken E, Gaziano J, et al. Relationship between swallow motility disorders on videofluorography and oral intake in patients treated for head and neck cancer with radiotherapy with or without chemotherapy. Head Neck 2006 Dec;28(12):1069-76 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16823874.
- 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.
- Shiley SG, Hargunani CA, Skoner JM, Holland JM, Wax MK. Swallowing function after chemoradiation for advanced stage oropharyngeal cancer. Otolaryngol Head Neck Surg 2006 Mar;134(3):455-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16500444.
- Dworkin JP, Hill SL, Stachler RJ, Meleca RJ, Kewson D. Swallowing function outcomes following nonsurgical therapy for advanced-stage laryngeal carcinoma. Dysphagia 2006 Jan;21(1):66-74 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16544094.
- Larsson M, Hedelin B, Johansson I, Athlin E. Eating problems and weight loss for patients with head and neck cancer: a chart review from diagnosis until one year after treatment. Cancer Nurs 2005;28(6):425-35 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16330963.
- Nguyen NP, Moltz CC, Frank C, Vos P, Smith HJ, Karlsson U, et al. Dysphagia following chemoradiation for locally advanced head and neck cancer. Ann Oncol 2004 Mar;15(3):383-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/14998839.
- Rademaker AW, Vonesh EF, Logemann JA, Pauloski BR, Liu D, Lazarus CL, et al. Eating ability in head and neck cancer patients after treatment with chemoradiation: a 12-month follow-up study accounting for dropout. Head Neck 2003 Dec;25(12):1034-41 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/14648862.
- Logemann JA, Pauloski BR, Rademaker AW, Lazarus CL, Mittal B, Gaziano J, et al. Xerostomia: 12-month changes in saliva production and its relationship to perception and performance of swallow function, oral intake, and diet after chemoradiation. Head Neck 2003 Jun;25(6):432-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12784234.
- Connor NP, Cohen SB, Kammer RE, Sullivan PA, Brewer KA, Hong TS, et al. Impact of conventional radiotherapy on health-related quality of life and critical functions of the head and neck. Int J Radiat Oncol Biol Phys 2006 Jul 15;65(4):1051-62 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16682129.
- Newman LA, Vieira F, Schwiezer V, Samant S, Murry T, Woodson G, et al. Eating and weight changes following chemoradiation therapy for advanced head and neck cancer. Arch Otolaryngol Head Neck Surg 1998 May;124(5):589-92 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9604988.
- Wilson PR, Herman J, Chubon SJ. Eating strategies used by persons with head and neck cancer during and after radiotherapy. Cancer Nurs 1991 Apr;14(2):98-104 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/2044067.
- Chen AM, Li BQ, Jennelle RL, Lau DH, Yang CC, Courquin J, et al. Late esophageal toxicity after radiation therapy for head and neck cancer. Head Neck 2010 Feb;32(2):178-83 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19536858.
- 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.
- 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.
- 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.
- 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.
- Cartmill B, Cornwell P, Ward E, Davidson W, Porceddu S. A Prospective Investigation of Swallowing, Nutrition, and Patient-rated Functional Impact Following Altered Fractionation Radiotherapy with Concomitant Boost for Oropharyngeal Cancer. Dysphagia 2011 Feb 23 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21344190.
- Ehrsson YT, Langius-Eklöf A, Laurell G. Nutritional surveillance and weight loss in head and neck cancer patients. Support Care Cancer 2011 Apr 19 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21503674.
- McQuestion M, Fitch M, Howell D. The changed meaning of food: Physical, social and emotional loss for patients having received radiation treatment for head and neck cancer. Eur J Oncol Nurs 2011 Apr;15(2):145-51 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20864401.