Nutritional management in head and neck cancer: United Kingdom National Multidisciplinary Guidelines

Abstract

Nutritional support and intervention is an integral component of head and neck cancer management. Patients can be malnourished at presentation, and the majority of patients undergoing treatment for head and neck cancer will need nutritional support. This paper summarises aspects of nutritional considerations for this patient group and provides recommendations for the practising clinician.Recommendations• A specialist dietitian should be part of the multidisciplinary team for treating head and neck cancer patients throughout the continuum of care as frequent dietetic contact has been shown to have enhanced outcomes. (R)• Patients with head and neck cancer should be nutritionally screened using a validated screening tool at diagnosis and then repeated at intervals through each stage of treatment. (R)• Patients at high risk should be referred to the dietitian for early intervention. (R)• Offer treatment for malnutrition and appropriate nutrition support without delay given the adverse impact on clinical, patient reported and financial outcomes. (R)• Use a validated nutrition assessment tool (e.g. scored Patient Generated–Subjective Global Assessment or Subjective Global Assessment) to assess nutritional status. (R)• Offer pre-treatment assessment prior to any treatment as intervention aims to improve, maintain or reduce decline in nutritional status of head and neck cancer patients who have malnutrition or are at risk of malnutrition. (G)• Patients identified as well-nourished at baseline but whose treatment may impact on their future nutritional status should receive dietetic assessment and intervention at any stage of the pathway. (G)• Aim for energy intakes of at least 30 kcal/kg/day. As energy requirements may be elevated post-operatively, monitor weight and adjust intake as required. (R)• Aim for energy and protein intakes of at least 30 kcal/kg/day and 1.2 g protein/kg/day in patients receiving radiotherapy or chemoradiotherapy. Patients should have their weight and nutritional intake monitored regularly to determine whether their energy requirements are being met. (R)• Perform nutritional assessment of cancer patients frequently. (G)• Initiate nutritional intervention early when deficits are detected. (G)• Integrate measures to modulate cancer cachexia changes into the nutritional management. (G)• Start nutritional therapy if undernutrition already exists or if it is anticipated that the patient will be unable to eat for more than 7 days. Enteral nutrition should also be started if an inadequate food intake (60 per cent of estimated energy expenditure) is anticipated for more than 10 days. (R)• Use standard polymeric feed. (G)• Consider gastrostomy insertion if long-term tube feeding is necessary (greater than four weeks). (R)• Monitor nutritional parameters regularly throughout the patient's cancer journey. (G)• Pre-operative:○ Patients with severe nutritional risk should receive nutrition support for 10–14 days prior to major surgery even if surgery has to be delayed. (R)○ Consider carbohydrate loading in p...

Gastrostomy in the era of minimally invasive head and neck cancer surgery

“…Evidence‐based guidelines to predict the need for gastrostomy exist, but high‐quality evidence to support specific timing and screening criteria for tube feeds is lacking . It is generally accepted that demographics, tumor site and staging, nutritional status, and the presence of dysphagia play a role in risk stratification.…”

Malnutrition evaluation in head and neck cancer patients: Practice patterns among otolaryngologists and radiation oncologists

“…This has been shown to reduce both infectious and noninfectious complications in surgical patients and improve quality of life and tolerance of radiation therapy in nonsurgical patients . Other authors have recommended at least 10‐14 days of preoperative supplementation …”

Optimising nutrition support in patients with head and neck cancer

“…Many studies frequently classify severity of weight loss outcomes using the accepted definition of clinically significant weight loss >10% (National Centre for Classification in Health, 2010), however poorer survival outcomes have been shown with weight loss <10% (Langius et al, 2013b;Martin et al, 2015). Therefore it is also important to recognise patients who may be well-nourished at diagnosis but are at future risk of nutritional deterioration, and provide appropriate timely intervention and education (Talwar, Donnelly, Skelly, & Donaldson, 2016).…”

“…Since this review, the UK guidelines have been updated although again no clear recommendations are made regarding feeding tube choice, other than consideration of gastrostomy if tube feeding is anticipated for greater than four weeks and that prophylactic feeding can be offered as part of locally agreed guidelines (Talwar et al, 2016).…”

“…Nutrition support and intervention is considered an integral component of HNSCC management and includes regular nutrition screening and assessment, dietary counselling and tube feeding interventions, including consideration to prophylactic gastrostomy placement (Talwar et al, 2016). However despite these intensive recommended nutrition interventions, significant weight loss still occurs (Brown et al, 2014a;Silander et al, 2010).…”