Q1. What is the impact of a diagnosis of malnutrition at baseline on a patient’s treatment outcomes?
Due to the high prevalence of malnutrition in patients with head and neck cancer, it is important firstly to understand the consequences and impact of malnutrition on a patient’s outcomes. This provides the rationale for addressing malnutrition in this patient group and why these guidelines are required. The subsequent questions in the guidelines provide more specific recommendations for practical management including how to identify malnutrition risk, how to assess a patient’s nutritional status and how to provide optimal intervention.
Of the 24 studies identified, 22 showed an association between malnutrition and various patient outcomes. There are five level III-2 neutral quality studies (total n=1597) , four level III-3 neutral quality studies (total n=397) , and fifteen level IV studies; 2 positive quality (total n= 125)  and thirteen neutral quality (total n= 1626) .
From the level III-2 studies, malnourished patients had an increased risk of developing non thyroidal illness post surgery ; reduced survival if greater weight loss at baseline ; lower Human Leukocyte Antigen-DR (HLA-DR) expression on monocytes, which is used as a measure of immune status and may explain increased risk of infections ; and reduced immune function, increased surgical complications and increased length of stay .
From the level III-3 studies, C-reactive protein and albumin levels impacted on survival and response to treatment , increased complications and length of stay , increased length of stay and readmissions  and patients below their ideal body weight pre treatment have increased risk of locoregional failure .
The two level IV positive quality studies demonstrated malnourished patients had reduced quality of life  and that patients who were malnourished at baseline had no impact on survival . Only one other level IV neutral study found that malnutrition at baseline had no impact on survival outcomes . The other level IV neutral studies showed malnourished patients had poorer outcomes such as: reduced quality of life , reduced survival , increased length of stay , and increased complications including infections, admissions and treatment interruptions .
While there have been several studies to address this question, there are some limitations to the interpretation of the results due to the methodology and study design and the chosen measures of nutritional status. There are limitations with the validity of single parameters such as C-reactive protein, albumin and weight loss in identifying malnutrition in patients with head and neck cancer. Nutritional assessment tools with at least two parameters are recommended as they have higher sensitivity and specificity of predicting nutritional status (see Q4 for further information on appropriate methods to assess nutritional status using validated tools).
|Malnutrition may reduce overall survival in this group||C|
|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|
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