Nutritional Challenges in Head and Neck Cancer

Liz PriceMacmillan Specialist Head and Neck DietitianNutritional Challenges in Head and Neck Cancer1Setting the ScenePoor nutritional status can negatively affect cancer prognosis by decreasing response to therapy and increasing complications and toxicities to treatment. (Kim et al 2004, Andreyev et al 1998)Total weight loss reduction of 20% or more significantly correlates with treatment interruption, infection, hospital readmission, and early mortality (Ravasco et al2003, Van Den Berg et al 2008, Akst et al 2004, Capuano et al 2008)2EvidenceMalnutrition in head and neck cancer patients was significantly correlated with an increased risk of infections in patients undergoing surgery and the occurrence of major postoperative complications. (Colsanto et al 2005, Villares 2003)

Unintended weight loss was found to be associated with a higher rate of recurrence and second primary tumours of the oral cavity and oropharynx after radiotherapy(Beaver et at 2001)3EvidenceSeveral studies suggested that early and intensive nutritional intervention during radiotherapy may be beneficial in terms of decreasing the impact of side effects, decreasing unintended weight loss, and improving dietary intake, quality of life and treatment tolerance(Ravasco et al 2005, Rabinovitch et al 2006 Isenring et al 2007)4ChallengesAlcohol intakeObesityDiabetesRenal FailureDisordered eating

5Case Study 1 - AlcoholBert is a 56 year old man who lives alone. He is a heavy smoker and drinker. He has just been diagnosed T2N0 Vocal Cord TumourWeight 70kg, HT1.82m BMI 21.1He requires 2500kcal, 88g Prt, 2118ml Fluid day.Treatment is 4/52 RTHe drinks 12-14 cans of Carlsberg Export daily

2646kcal from Carlsberg6Case Study 1 - AlcoholHow many calories daily is he taking from Alcohol?

What do we need to be thinking about nutritionally for this patient?

7Case Study 1 - Alcohol - OutcomeHe continued to smoke and drink alcohol during RT.Refused help from alcohol cessation and smoking cessation.WT = 67.3KgReducing supplement drinks encouraging oral diet and regular meals.8Case Study 2 - ObesityJane is a 49 year old lady with a Nasopharynx tumour T1N2M0 Scc. She is married with children. Smoked 20 d until 10 years ago and drinks 30-40 units alcohol week.She is having induction chemo, followed by CHRTWt 136kg Ht = 1.62m BMI = 51.9Kg/M2Requires 2800kcal 165gPRT, 2800ml Fluid9Case Study 2 - ObesityDoes this patient need a PEG to get through treatment?

What will happen with her weight during treatment?

What will be the nutritional challenges post treatment?Neutropenic post chemo. Advised doctor to note weight as obese and chemo calculated on surface areaLost +++ post chemo due to nausea antiemetics commenced. Antacids commenced for heartburn.Had PEG inserted between chemos. Had infection post insertion treated by Nut nursesSuffered from constipation laxatives startedAdmitted due to neutropenia10Case Study 2 - ObesityHad PEG out 3/12 months post CHRTWT 113Kg BMI = 43.1Kg/m2Oral supplements stoppedEncouraged long term regular eating patternBack swimmingHealthy eating11

Case Study 3 - RenalJohn is a 70 year old with a T4aN2bM0 BOTHe lives alone. Works as gardener.Dialysis 3 times week at local unitFluid restriction of 500ml +P.D.U.OWt = 87Kg, HT =1.8m BMI= 26.8Kg/m2 Low K+ NAS dietRequires 2600kcal/dFor CHRT

Liaision with St Helier

12Case Study 3 - RenalShould this patient have a Feeding tube?

What are the main nutritional considerations?

How will his dialysis affect tolerance to treatment?

Fluid with medicationsFeed volume13Case Study 3 - RenalFelt exhausted after treatmentWt dropped to 80kg now improving 84kg 3/12Tube out, soft moist diet (within fluid restriction) Dry mouth management

Discussed with St Helier likely to need more calories with diaylsis and CHRT difficulty is getting adequate fluid and nourishment into small volume 7 x 125ml fsc 875ml with 20ml flushes (1000ml daily)14Case Study 4 - DiabetesPeter is 93yrs old. Lives alone in sheltered accommodationEx-smoker, occasional alcoholDiabetic on Metformin 1g bd T3N0M0 Supraglottic tumour Surgical Debulking followed by RT Pt StridousWT= 75Kg HT= 1.60M, BMI = 29.2Kg/m2

Does not monitor BMs BMs running high due to steriods sliding scale insulin.15Case Study 4 - DiabetesWhat action should be taken about diabetes?

What concerns would you have with this patient undergoing RT?

16Case Study 4 - DiabetesSeen #2 on RTUnable to weigh too unsteadyNot coping getting to RT?oral intake?BMs?ASPIRATINGSeen with Alice and Joe17Case Study 4 - DiabetesRIG finally placedRemains unsafe swallowBMs controlled with insulinNursing home care18Case Study 5 - Disordered EatingPamela is a 47 year old with T2N2a BOT SCCHeavy SmokerWt = 57.4Kg Ht = 1.73m BMI =19.1Aerobics instructor. Lives with partner and his children.Requires 1900kcal, 71g Prt, 1710ml fluid/dWorried about putting toxins into bodyLow fat, juicing diet followed

Refused Feeding tubeWhat are the potential consequences of this?Tube under GABloated on codeine.Laxatives commenced, antibiotics,By week 4 of tx really struggling with oral intake, 5 feeds via PEG ? Compliance Wt = 56kg

19Case Study 5 - Disordered EatingShould this patient have a feeding tube?20Case Study 5 - Disordered EatingBy Week 5Struggling with pain, thick phlegm, fatigueConverted to pump feedsStopped chemoDNAd MPC 3/12 Wt 51.3kg BMI = 17Kg/m2Friend provided powdered supplement at 150.00 tubNot back at workMinimal oral intakePeg to remain insitu until adequate intakeErractic eating patternCame to clinic on own? Support network.

21SummarySeeing more complex patientsGood dietary assessment prior to treatment commencing helpsRegular reviewsMultidisciplinary Care

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