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Nutrition Support Options in Patients with Head and Neck Cancer

  By Rachel Sipaul RD    
 

While we know cancer can have an adverse effect on nutritional status, patients with head and neck cancer are at a particularly high risk of malnutrition. This is not only because of the disease itself and the invasive treatment options, but because it directly impacts the very area of the mouth and throat that are used for eating and swallowing. Ensuring that patients diagnosed with head and neck cancer have tailored nutrition support at every stage of their treatment is critical to their overall well-being.

Guidelines

UK guidelines by Talwar et al in 2016 are a useful reference as they offer 24 recommendations for the nutritional management of patients with head and neck cancer.

“Patients can be malnourished at presentation, and the majority of patients undergoing treatment for head and neck cancer will need nutritional support”.

They recommend patients with head and neck cancer to be managed by a multi-disciplinary team including a specialist dietitian. Patients should be screened for the risk of malnutrition at pre-treatment assessment and those at risk of malnutrition should be referred to a dietitian for early intervention.

Nutritional Interventions

Nutritional intervention will vary depending on each patient’s needs. Some may be malnourished on first presentation of their illness and require nutritional support prior to receiving treatment, for example, if a patient is severely malnourished and requires surgery, they should ideally receive pre-operative nutrition support for 1-2 weeks (Talwar, 2016). Typically oral nutrition support needs to be intensive, dietary counselling and food fortification can be used, but if treatment options make it insufficient, oral nutritional supplements that replete both macro- and micro-nutrients should be considered.

Enteral nutrition will also need to be initiated for different treatment options, particularly if the tumour site is likely to obstruct with swallowing and/or the treatment options such as radiotherapy to the area will cause prolonged mucositis, again interfering with swallowing.  While there is no doubt of the benefits of enteral tube feeding in this patient group, the exact route (e.g. nasogastric, trachea-oesophageal fistulae tubes, gastrostomy) and timing  (prophylactic feeding or reactive feeding) is dependent on the clinical condition of each patient and local guidelines.

The choice of enteral feed and how much to feed is also of interest. The volume will depend on patient requirements, goals suggested include: intakes of at least 30kcal/kg/day energy and 1.2g/kg /day protein, to be adjusted in line with changes in body weight (Talwar,  2016);  ESPEN recommend energy intakes of 25-30kcal/kg/day and protein of 1.2-1.5g/kg/day as a target to help maintain weight (ESPEN, 2017). While standard polymeric formulas are recommended, immune-enhanced feeds that contain essential amino acids, nucleotides or fish oils (long chain omega-3) have also shown promising results and may impart additional benefit (ESPEN, 2017). This is an area of ongoing research, such as a study by Chao et al in 2020 investigating an immune-modulating enteral feed in patients with head and neck cancer.

Refeeding Syndrome

Refeeding syndrome is not specific to head and neck cancer, but always something to be aware of in this group of patients who can be severely malnourished over an extended period of time. Of interest is a recent review by de Silva (Dec 2019) revisiting the clinical presentation and providing up to date guidance for the practical management of refeeding syndrome.  

ERAS Protocols

Enhanced recovery after surgery (ERAS) protocols in head and neck cancer surgery have also been implemented in some UK centres.  Commercially available preoperative carbohydrate loading products have been rigorously tested to ensure they are a safe component of the ERAS protocol. In 2016 the UK ERAS Society published a guideline for major head and neck surgery and more studies are likely to become available as ERAS protocols are adopted.

 

For patients with head and neck cancer there is a wide spectrum of nutrition support interventions that should be considered, and different options will be appropriate at different stages of the treatment pathway. A dietitian is an essential member of the medical team, ensuring that the patient receives the most appropriate nutrition support throughout their treatment and recovery.