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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 3  |  Page : 54-58

Assessment and results of early active nutritional interventions during radiotherapy with or without chemotherapy of head-and-neck cancer


Department of Radiation Oncology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication27-Dec-2019

Correspondence Address:
Dr. Rohini Khurana
Department of Radiation Oncology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/oji.oji_29_19

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  Abstract 


Background: Patients of head-and-neck cancer (HANC) undergoing chemoradiotherapy (CRT) are at high risk of malnutrition due to acute effects of radiotherapy (RT). This study was intended to assess weight loss and change in body mass index (BMI) during CRT with active diet counseling and nutritional supplementation. Aims and Objective: The primary end point was to assess loss of weight and BMI during treatment. The secondary end point is assessment of compliance to stipulated treatment time, frequency of nasogastric tube feeding, intravenous support, and duration of hospital admission. Materials and Methods: This was a prospective observational study performed in Radiation Oncology department of a tertiary care center. Consecutive patients of HANC requiring definitive or adjuvant RT (±chemotherapy) were included. Nutritional status assessment and diet counseling were done before start of RT, and further weekly assessment of body weight and BMI was done. Results: Between December 2017 and December 2018, 128 patients were included in this study. Sitewise distribution were oral cavity, oropharynx, hypopharynx, and larynx in 69, 33, 9, and 17 patients, respectively. Weight loss and BMI comparison were done at the start and end of RT (mean weight: 53.86 kg; 95% confidence interval [CI]: ± 1.71, mean BMI: 21.52; 95% CI: ± 0.95 [at the start of RT] and mean weight: 48.30 kg; 95% CI: ± 1.58, mean BMI: 19.18; 95% CI: ± 0.88 [at the end of RT]).There was a significant reduction in weight (P < 0.0001, S) and BMI (P = 0.00034, S), respectively. During the treatment, a total of 14 patients were put on nasogastric tube feeding, and 23 patients were admitted for parenteral nutrition with median hospital stay of 3 days (range: 1–5 days). Conclusions: There is a significant weight loss and change in BMI during CRT in HANC patients. Regular assessment and active nutritional intervention are required in all patients to improve compliance.

Keywords: Body mass index, chemoradiotherapy, head-and-neck cancer, nutrition


How to cite this article:
Singh HB, Khurana R, Rastogi M, Nanda SS, Rath S, Mishra A. Assessment and results of early active nutritional interventions during radiotherapy with or without chemotherapy of head-and-neck cancer. Oncol J India 2019;3:54-8

How to cite this URL:
Singh HB, Khurana R, Rastogi M, Nanda SS, Rath S, Mishra A. Assessment and results of early active nutritional interventions during radiotherapy with or without chemotherapy of head-and-neck cancer. Oncol J India [serial online] 2019 [cited 2020 Jun 4];3:54-8. Available from: http://www.ojionline.org/text.asp?2019/3/3/54/274094




  Introduction Top


Head-and-neck cancer (HANC) is the sixth leading cancer by incidence worldwide and the eighth by mortality, in which radiotherapy (RT) is the integral component of treatment.[1] Patients with head-and-neck squamous cell carcinoma undergoing concurrent chemo-RT (CRT) are at high risk of malnutrition, which is related to acute and late toxicity.[2] Diet intake may be significantly compromised in these patients due to dysphagia and odynophagia associated with tumor site, poor dietary habits, tumor-related inflammation, and anticancer treatments side effects.[3],[4],[5] Nutritional problems, such as reduced protein–calorie intake before and/or during RT, cause weight loss, reduce body mass index (BMI), and thus are associated with worse prognosis (locoregional treatment failure and reduced survival). Further, it impairs quality of life (QoL) and enhances RT-related toxicity and mostly mucositis.[4],[5],[6],[7] Weight loss in patients with cancer is seldom recognized and assessed or managed actively. The predominant symptoms are progressive emaciation, weight loss, or edema due to hypoalbuminemia.[8] The malnutrition prevalence rate of HANC patients may be as high as 74.2%.[9] The toxic effect of RT and concurrent chemotherapy on normal tissue contributes to nausea, vomiting, dysgeusia, anorexia, dysphagia, oral mucositis, and oropharyngeal pain. These symptoms influence the patient's interest in food and reduce feeding capacity.

Early nutritional intervention with high protein–calorie intakes has been found to result in better nutritional status and QoL as well as in improved treatment tolerance. Nutritional counseling (individually tailored dietary advices, meal plans, and recipe suggestions associated with continuous monitoring), with or without the use of oral nutritional supplements (ONS), is also becoming the important component of treatment.[10] However, strength of the evidence in favor of using ONS in HANC patients has been questioned.[10]

The purpose of this study is to assess the loss of body weight and change in BMI in patients of HANC receiving CRT along with active nutritional counseling and ONS. Secondarily, we intend to evaluate the compliance to stipulated treatment time, frequency of nasogastric tube feeding, intravenous support, and duration of hospital admission and correlate it with weight loss and BMI.


  Materials and Methods Top


The study was a single-institution prospective observational study conducted in the department of radiation oncology of a tertiary care center. HANC patients who fulfilled the inclusion criteria were selected for the study after obtaining informed consent. Patients with histologically proven squamous cell carcinoma of oral cavity, pharynx, and larynx, aged 18–80 years, and with Karnofsky Performance Status ≥70 who received definitive or adjuvant CRT were included in the study. Patients requiring total parenteral nutrition or unable to take food orally and patients with cardiac, renal, hepatic, or other systemic diseases were excluded. Patients with premalignant lesions and lymphoma of head and neck were also excluded. Baseline patient's characteristics are innumerated in [Table 1].
Table 1: Baseline patients' characteristics

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The nutritional status of the patients was assessed from history, physical examination, anthropomorphic measurements, and laboratory tests. The anthropomorphic parameters considered in the study were body weight and BMI. The percentage of body weight loss was calculated as initial weight − current weight/initial weight × 100. The diet taken by the patients during the study was according to a specific diet chart depicted in [Table 2]. The diet chart was prepared based on optimal daily requirement of protein, calorie, and fat appropriate for HANC patients receiving CRT with specific emphasis on local food habits [Table 2]. This diet was administered during the entire treatment period of chemotherapy and/or RT. All the nutritional parameters were measured at the initiation of treatment, thereafter weekly till the end of treatment. Food items which were locally available, economical, and easier to swallow were included preferably. All patients were treated on 6-MV linear accelerators (ELEKTA, Infinity and Synergy) immobilized in the supine position by the use of thermoplastic cast. All patients were treated with curative intent using conventional 3-dimensional conformal RT technique. Based on the histopathological features and staging, post-operative adjuvant radiotherapy dose of 60–66 Gy at 2 Gy per fraction 5 day per week with or without concurrent chemotherapy platinum based (35–40 mg/m2 weekly) was delivered in 6–6.5 weeks. Patients of inoperable oral cavity and pharyngeal and laryngeal cancers, who merit definitive CRT, were treated with 66–70 Gy at 2 Gy per fraction in 6.5–7 weeks with concurrent chemotherapy.
Table 2: Diet chart

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From the start of RT, patients received dietary counseling to achieve individual nutritional requirements. If required, protein-rich high-calorie ONS and/or enteral tube feeding by nasogastric tube or percutaneous endoscopic gastrostomy were prescribed. Since there is no consensus definition or diagnostic criteria of weight loss or BMI specific for cancer patients, National Cancer Institute-Common Toxicity Criteria Adverse Events Versions 5. (Published in November 2017 and became effective in April 2018, accessed electronically) Available from: https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/CTCAE_v5_Quick_Reference_8.5x11.pdf was used to define weight loss [Table 2]. Paired t-test was used to compare weight loss and BMI between the start of RT and at the end of RT. We also compared weight and BMI site wise and during the course of treatment ( first 3 weeks vs. last 3 weeks). A two tailed P ≤ 0.05 was considered statistically significant.


  Results Top


In our study, a total of 128 patients were recruited between December 2017 and December 2018. The baseline characteristics of enrolled patients are depicted in [Table 1]. Majority of patients were male (78%). The median age was 48.5 years (range: 20–80 years). Oral cavity was the most predominant (54%) subsite. Stagewise distribution was 9.4%, 26.6%, 37.5%, and 26.5% for Stage I, II, III, and IV, respectively. About 71.8% of patients were treated with combined modality CRT treatment. About 23 patients received neoadjuvant chemotherapy, 92 patients received concurrent CRT, and 36 patients received adjuvant RT [Table 3]. Weight loss was calculated using equation (initial weight − current weight/initial weight × 100) and categorized using CTCAE version 5 and is depicted in [Table 4].
Table 3: Treatment details

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Table 4: Weight loss definition: Common terminology criteria for adverse events Version 5

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Weekly assessment of weight and BMI is given in [Table 5]. The mean body weight for first 7 weeks was 53.85, 52.57, 52.11, 51.75, 51.42, 50.1, and 48.29 kg, respectively. The mean percentage loss of body weight for these 7 weeks was 0.81%, 3.16%, 4.01%, 4.67%, 5.28%, 7.71%, and 11%, respectively [Table 6].
Table 5: Weight and body mass index

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Table 6: Mean body weight loss and body mass index

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Weight and BMI at the time of start of RT was (mean weight 53.86 kg ± 1.71 and mean BMI 21.52 ± 0.95) compared with at the end of RT (mean weight 48.30 ± 1.58 and mean BMI 19.18 ± 0.88). The difference was found to be significant for both weight (P< 0.0001) and BMI (P = 0.00034) [Table 7] and [Table 8].
Table 7: Weight comparison

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Table 8: Body mass index comparison

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Further, we compared the mean BMI in postoperative patients receiving adjuvant CRT vis-a-vis patients receiving definitive CRT. For postoperative patients, the mean BMI was 20.37 ± 0.52 compared to patients of definitive CRT 20.83 ± 0.50, and the difference was nonsignificant (P = 0.14) [Table 9]. Similarly, the mean BMI of the first 3 weeks was compared to the mean BMI for last 3 weeks. The mean BMI for first 3 weeks was 20.97 ± 0.84 versus 20.28 ± 0.89 for the last 3 weeks. Their difference was not statistically significant with P = 0.07 [Table 10].
Table 9: Body mass index comparison in postoperated oral cavity cancer and pharyngeal cancers

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Table 10: Body mass index comparison early 3 weeks versus last 3 weeks of radiotherapy

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All patients completed RT within planned treatment time (intention was to complete treatment in stipulated time). Maximum Grade 3 or higher oral mucositis was observed in 45% of patients. A total of 21 patients required nasogastric tube feeding, and 23 patients were admitted for intravenous fluid support (median hospital stay for supportive treatment was 3 days) [Table 11].
Table 11: Outcomes of treatment tolerance for nutritional intervention

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CTCAE version 5 grade for percentage weight loss from baseline is given in [Table 12]. At the end of RT, 8 patients had Grade 3 toxicity, 62 patients had Grade 2 toxicity, and 44 patients had Grade 1 toxicity.
Table 12: Common terminology criteria for adverse events Versions 5 grade for percentage weight loss from baseline

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  Discussion Top


Nutritional aspect of treatment remains a vital determinant in optimal outcome in malignancy. Its importance is even more pronounced in HANCs where both disease process and RT-related toxicities adversely influence the dietary intake.

This study aimed at examining the impact of an early intensive nutritional intervention on nutritional status and clinical outcomes in patients receiving CRT for HANC. Investigators frequently have reported 10% or greater weight loss of initial body weight during treatment with CRT.[11],[12],[13] This loss cannot be completely prevented by nutritional counseling.[14] Most of the studies assessing acute and late toxicity during RT do not account for weight loss, which is a predominant factor for treatment tolerance, disease control, and QoL.

Ravasco et al.[5] demonstrated that concurrent individualized dietary counseling, based on regular diet with appropriate manipulation, is the most effective way of improving patients nutritional intake, status, and QoL, thereby lessening RT-induced morbidity, in HANC patients undergoing RT. However, patients in that study had sequential and not concomitant chemotherapy. Concurrent CRT has demonstrated improved rates of tumor control for locally advanced HANC,[15],[16],[17] but it is associated with increased acute toxicity, higher prevalence of weight loss during therapy,[14],[18] and more severe oral mucositis[19] compared to RT alone. However, a randomized study performed in oncology outpatients receiving RT for head and neck or gastrointestinal areas demonstrated that an early, individualized, and intensive nutritional intervention resulted beneficial in terms of minimizing weight loss, deterioration in nutritional status, global QoL, and physical functions.[20] This might suggest that weight maintenance, rather than weight gain, may be a more appropriate aim of nutritional intervention in these patients.

Langius et al.[7] investigated the association between weight loss before or during RT and disease-specific survival (DSS) in HANC patients. They found that ≥10% weight loss before RT remained significantly associated with a worse overall survival (OS) (hazard ratio [HR]: 1.7; 95% CI: 1.2–2.5; P = 0.002) and DSS (HR: 2.1; 95% CI: 1.2–3.5; P = 0.007). The 5-year OS and DSS rates for patients with critical weight loss during RT were 62% and 82% compared with 70% and 89% for patients without critical weight loss (P = 0.01; P = 0.001). After adjustment, critical weight loss during RT remained significantly associated with a worse DSS (HR: 1.7; 95% CI: 1.2–2.4; P = 0.004).

Ottosson et al.[21] compared weight loss during and after two different RT schedules. It was seen that weight loss was multifactorial, and significant predictive factors for weight loss were primary site, obesity, and lack of tube feeding during whole course of RT. It was also observed that maximum weight loss was at 5 months after RT completion. There were more patients requiring tube feeding in accelerated fractionation as compared to conventional standard fractionations.

Comparing with previous different randomized and retrospective studies, we have used conventional fractionation schedule in all patients. Our aim is to focus on active nutritional counseling during the whole course treatment to improve general condition so that patients could tolerate and complete the treatment within stipulated time. Qualified dietician of cancer support group at the RT department provided an individualized diet chart to every patients with optimal calories and protein. However, weight loss and reduction in BMI were found significant. Estimated average percentage loss of body weight is 11% at the end of RT. There was no significant difference in weight loss in different sub-sites. While comparing the first 3 weeks and last 3 weeks of course of treatment, no significant difference was found in mean weight and BMI. Hence, it was concluded that there is no specific point of time to give attention to nutritional status during RT. Intensive active nutritional counseling is required during the whole course of RT. In this study, we used CTCAE version 5.0 to grade weight loss as acute toxicity which has been seldom reported before. We found Grade I, Grade II, and Grade III toxicity in 34.4%, 48.4%, and 6.25% of patients, respectively. A limitation of our study is that it is a single-arm study with no comparative cohort group. Locoregional control, disease-free survival, OS, and QoL after the treatment for HANC depend on several factors, of which maintenance of nutrition during treatment may be an important one. Further studies with more number of patients and longer follow-up periods are required to correlate outcomes with nutritional status.


  Conclusions Top


There is a significant weight loss and change in BMI during CRT in HANC patients despite active nutritional intervention. Regular assessment and active nutritional intervention is required in all patients to improve compliance and to complete planned RT treatment within stipulated time. Active nutritional counseling and individualized diet chart as proposed in this study may be used as template for dietary advice in HNCA patients. Further adequately powered, prospective, randomized studies with longer follow-up are needed to correlate active nutritional supplement in patients treated for head-and-neck malignancy with locoregional control, disease-free survival, OS, and QoL.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]



 

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