Elsevier

Nutrition

Volume 69, January 2020, 110548
Nutrition

Review
Nutrition and swallowing therapy strategies for patients with head and neck cancer

https://doi.org/10.1016/j.nut.2019.06.028Get rights and content

Highlights

  • Patients with head and neck cancer are at high risk of swallowing and nutritional problems.

  • Pre-habilitation exercises overseen by a speech pathologist can help maintain swallowing function.

  • Multidisciplinary screening, assessment and intervention can improve intake, nutritional status and quality of life.

  • Telehealth is a useful model for supporting patients with head and neck cancer from pre-habilitation through to post treatment supportive care.

Abstract

Patients with head and neck cancer experience many problems with eating which make them at high risk of malnutrition. Pre-habilitation swallowing exercises as overseen by a speech pathologist can improve swallowing function. A multidisciplinary approach to care, including effective nutritional screening, assessment and intervention has demonstrated improved outcomes in terms of meet nutritional requirements, improved nutritional status and quality of life. Nutritional recommendations are 1.2-1.5 g protein per kilogram per day and 125kJ/kg body weight per day but as these are guides close monitoring of intake and weight is important. Multidisciplinary teams and telehealth have shown better outcomes for nutrition and swallowing status for head and neck cancer patients and ongoing support is required for best patient care.

Introduction

Patients with head and neck cancer (HNC) are one of the most vulnerable groups in terms of cancer-related malnutrition and development of nutrition impact symptoms (NIS) before, during, and after cancer treatment [1], [2]. Globally, ∼900 000 individuals are diagnosed with HNC every year [3]. The incidence has increased during recent years partly due to an increase in the numbers caused by oncogenic viruses such as human papillomavirus (HPV) and Epstein-Barr virus [4]. In the same period, the overall survival of the patient group has improved [5], [6], and thus the population of survivors of HNC is increasing.

Dysphagia, or difficulty swallowing, is one of the most common and debilitating side effects related to HNC and its treatment. Dysphagia affects ≤30% of patients with HNC pretreatment, with long-term dysphagia affecting 38% to 46%, despite improvements in treatment [7], [8]. The sequelae of dysphagia include avoidance of eating or drinking, poor dietary intake, aspiration leading to pneumonia, reduced psychosocial functioning, and poor social engagement and quality of life (QoL) [9], [10], [11]. Long-term swallowing function is strongly related to the ability to swallow before treatment in the population with HNC [12], [13], [14]. For this reason, optimizing swallowing function before and during treatment is important. Historically, for those patients undergoing radiotherapy with or without chemotherapy treatment, dysphagia has been managed with a reactive approach—waiting for signs and symptoms of difficulty managing oral intake to develop before assessment or intervention being recommended.

As such, many patients with HNC may present with involuntary weight loss at the time of diagnosis [15], and body composition and function may be affected despite only a modest weight loss. In a population of 65 patients with newly diagnosed HNC, Orell-Kotikankas et al. investigated the prevalence of malnutrition, cachexia, and sarcopenia defined by different assessment criteria [16]. They categorized 34% of participants as malnourished according to the Patient-Generated Subjective Global Assessment (PG-SGA), 31% were categorized as cachectic (defined as low handgrip strength and low midarm muscle area) and 46% were categorized as sarcopenic (defined as low midarm muscle area) [16]. As the assessment criteria were overlapping, participants could be categorized in more than one category. In an exploratory study, Jager-Wittenaar et al. found a cachexia prevalence of 46% among 26 patients with newly diagnosed HNC before treatment was initiated [17]. In this study, cachexia was defined by Fearon's cancer-specific framework [18].

The treatment modalities in HNC include surgery, radiation therapy, chemotherapy, and targeted therapy. Often combinations of treatment modalities are used. Frequent side effects to these regimens include development of NIS such as dysphagia, xerostomia, dysgeusia, anorexia, and pain on swallowing [19], resulting in decreased dietary intake and malnutrition. Critical weight loss (≥5%) during treatment affects ≤66% of patients with HNC [20], [21], and weight loss may occur regardless of nutritional status at diagnosis [22]. Patients with HNC receiving concurrent chemotherapy and radiation therapy are particularly at risk for involuntary weight loss and development of malnutrition during treatment [20], [22]. Malnutrition in patients with HNC is a concern, as it is associated with increased treatment toxicity and interruptions in treatment, increased mortality and morbidity [15], [16], increased number of admissions, and increased health care costs [23]. Furthermore, malnutrition in HNC is associated with depression [24] and reduced QoL [22], [25]. The nutritional challenges in HNC often continue beyond the treatment phase. NIS may persist or occur years after completion of treatment and, in the worst case, become chronic [19]. NIS may lead to social isolation and have great consequences for everyday life [26], [27], [28], [29].

Historically, the major risk factors for development of HNC have been alcohol and tobacco use [30]. The proportion of high-risk alcohol- and tobacco-related cases has decreased, and demographic characteristics have changed toward a younger population due to early onset of HPV-related HNC [30], [31]. However, this change in demographic characteristics has not eliminated the problems of NIS and malnutrition. Conversely, Vangelov et al. found that the incidence of critical weight loss during treatment was higher in patients with HPV-positive oropharyngeal carcinoma than in HPV-negative patients, although a larger proportion of the latter group presented with critical weight loss at diagnosis [31].

Newer treatment modalities such as intensity-modulated radiation therapy have reduced the severity of certain NIS in patients with HNC, but still has not offset the development of these side effects [32]. Hence, nutritional care in patients with HNC remains as important as ever, and interventions to maintain adequate nutritional status, swallowing function, and dietary intake are vital throughout the trajectory of care. This review will address nutrition and swallowing therapy strategies in patients with HNC from the time of diagnosis to rehabilitation and survivorship.

Section snippets

Aims of nutritional interventions

Nutrition interventions in patients with HNC should aim to maintain or improve dietary intake and nutritional status, including maintenance or build-up of skeletal muscle mass [33]. The adverse effects of malnutrition on physical performance, QoL and cancer treatment tolerance and effect should be minimized by appropriate nutrition interventions. Preferably, nutrition interventions should be initiated before malnutrition manifests, as the condition is difficult to reverse in metabolically

Assessment and screening

To provide early and appropriate nutrition intervention, patients undergoing cancer treatment should have early and regular screening for malnutrition [34]. Validated nutrition screening tools for patients with HNC include the PG-SGA Short Form [35], the Malnutrition Screening Tool, and the Malnutrition Universal Screening Tool [36]. Patients identified as being at nutritional risk should be referred to a nutrition expert (e.g., registered dietitian) for full nutrition assessment and early

Swallowing prehabilitation

The past decade has seen a shift in clinical priorities, driven by research that investigates a prophylactic approach to swallowing management. Swallowing “prehabilitation” or prophylactic swallowing exercise programs are delivered before the onset of dysphagia. Prehabilitation aims to minimize the effect of dysphagia through the maintenance of muscle mass, strength, range of motion, coordination, and function, specifically targeting structures of the oral cavity, jaw, tongue base, pharynx, and

Nutritional interventions during treatment

Nutritional expertise provided by a dietitian as part of the multidisciplinary team for treating patients with HNC has been shown to improve nutrition outcomes and QoL [37]. Nutrition counseling is a dedicated and repeated professional communication process aimed at providing patients with a thorough understanding of nutritional issues leading to lasting changes in eating habits and should be part of first-line nutrition therapy [33].

Nutritional recommendations for patients with HNC should aim

Survivorship and post-treatment nutritional interventions

Eating problems and NIS often persist beyond completion of cancer treatment [19] with negative consequences for the survivor's dietary intake and enjoyment of food and eating [27], [28], [29]. The early post-treatment phase is particularly challenging as the severity of NIS often peaks within the first weeks after completion of treatment [56], [57]. A number of qualitative and mixed-methods studies have reported that survivors of HNC have felt unprepared to deal with these ongoing challenges

Multidisciplinary modal of care

Nutrition and swallowing therapy in HNC is primarily managed by clinical dietitians and speech pathologists (or occupational therapists in certain countries). However, given the complexity of nutrition and swallowing problems in HNC, a close collaboration with other health professionals is recommended [65]. Furthermore, supportive care needs during and after treatment for HNC are multifaceted and go far beyond nutrition and swallowing therapy. Required supportive care to cope with acute or

Technology in HNC management

Management of swallowing and nutritional sequelae of HNC are predominantly centralized in metropolitan cancer centers and delivered by a specialist multidisciplinary team, as is best practice. However, there are barriers to patients accessing accurate information and timely, specialist services including a lack of available and skilled workforce, costs associated with advances in medical and technological services, and a geographic spread of patients [74]. The use of technology to optimize

Conclusion

Despite the increase in incidence of HNC owing to oncogenic viruses rather than heavy alcohol and smoking usage, patients with HNC often still experience NIS requiring nutrition support. Valid screening tools, including electronic triage systems, exist to detect nutrition risk but it also can be argued that patients with HNC should be automatically assessed by a registered dietitian and should receive appropriate nutrition intervention. Prehabilitation swallowing exercises have demonstrated

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