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

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

Summary

There are three level II positive quality studies which support weekly follow up during radiotherapy and minimum of fortnightly follow up post radiotherapy [1][2][3]. There was one level III-1 neutral quality study [4] and two level III-3 neutral quality studies [5][6] further supporting the need for frequent dietetic contact. One study supported commencing dietetic intervention pre chemoradiotherapy [5], while another advocated continuing weekly follow up post radiotherapy [4]. 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 [6].

There is one level III-2 positive quality study [7], three level III-2 neutral quality studies [8][9][10], four level III-3 neutral quality studies [11][12][13][14], three level IV positive quality studies [15][16][17], twenty six level IV neutral quality studies [18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43], and two level IV negative quality studies [44][45]. One study [9] 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 [8] 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. [11] reported gastrostomy dependency of mean 13 months. Another paper [12] 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 [46] 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 [47][48]. Another level IV neutral quality qualitative paper [49] 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.

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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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References

  1. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15226773.
  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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15920748.
  3. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17324657.
  4. 4.0 4.1 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20441684.
  5. 5.0 5.1 .
  6. 6.0 6.1 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22086406.
  7. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22209648.
  8. 8.0 8.1 .
  9. 9.0 9.1 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18559875.
  10. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21850606.
  11. 11.0 11.1 .
  12. 12.0 12.1 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12094631.
  13. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22518330.
  14. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22505332.
  15. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15577796.
  16. Ng K, Leung SF, Johnson PJ, Woo J. Nutritional consequences of radiotherapy in nasopharynx cancer patients. Nutr Cancer 2004;49(2):156-61 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15489208.
  17. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20421546.
  18. .
  19. 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 Available from: http://www.e-spenjournal.org/article/S1751-4991(10)00024-7/abstract.
  20. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19563935.
  21. .
  22. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17999111.
  23. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19041505.
  24. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18283161.
  25. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17585279.
  26. .
  27. .
  28. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17185036.
  29. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16601440.
  30. .
  31. .
  32. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16500444.
  33. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16544094.
  34. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16330963.
  35. .
  36. .
  37. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12784234.
  38. .
  39. .
  40. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/2044067.
  41. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19536858.
  42. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21472468.
  43. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21477980.
  44. .
  45. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22137826.
  46. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21344190.
  47. Ehrsson YT, Langius-Eklöf A, Laurell G. Nutritional surveillance and weight loss in head and neck cancer patients. Support Care Cancer 2011 Apr 19 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21503674.
  48. Chapuy CI, Annino DJ, Snavely A, Li Y, Tishler RB, Norris CM, et al. Swallowing function following postchemoradiotherapy neck dissection: review of findings and analysis of contributing factors. Otolaryngol Head Neck Surg 2011 Sep;145(3):428-34 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21493276.
  49. 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20864401.

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