Pathology
Nutritional Considerations for Head and Neck Cancer Patients: A Review of the Literature

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Purpose

Approximately 35% to 60% of all patients with head and neck cancer are malnourished at the time of their diagnosis because of tumor burden and obstruction of intake or the anorexia and cachexia associated with their cancer. The purpose of this article is to provide a contemporary review of the nutritional aspects of care for patients with head and neck cancer.

Materials and Methods

A literature search was performed in Medline, Cochrane, and other available databases from 1990 through 2012 for the clinical effectiveness of nutritional support, treatment modalities, and methods of delivery in relation to patients with head and neck malignancies. Human studies published in English and having nutritional status and head and neck cancer as a predictor variable were included. Randomized controlled trials, meta-analyses, prospective clinical studies, and systemic reviews were selected based on their relevance to the abovementioned subtitles. The resultant articles were analyzed and summarized into the definition, impact, assessment, treatment, and modes of administration of nutrition on the outcome of patients with head and neck cancer.

Results

Articles were reviewed that focused on the etiology and assessment of malnutrition and current nutritional treatments for cancer-induced anorexia and cachexia. Two hundred forty-eight articles were found: 2 clinical trials, 10 meta-analyses, 210 review studies, and 26 systematic reviews. Because of the lack of prospective data, a summative review of the conclusions of the studies is presented.

Conclusion

Nutritional interventions should be initiated before cancer treatment begins and these interventions need to be ongoing after completion of treatment to ensure optimal outcomes for patients. A nutritional assessment must be part of all comprehensive treatment plans for patients with head and neck cancer. Alternative medical interventions, such as immune-enhancing nutrients or anticytokine pharmaceutical agents, also may be effective as adjuvant therapies, but more research is needed to quantify their clinical effect.

Section snippets

Etiology and Types of Malnutrition

Formerly, the definition of malnutrition was based on population and individual patient anthropomorphic and laboratory values. The American Society of Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics have recently developed standardized definitions for malnutrition based on a patient's degree of inflammation.6 There are 3 major categories: simple starvation with no underlying inflammation; mild to moderate inflammation, which would include conditions such as cancer

Impact of Malnutrition

The impact of malnutrition on patients is profound and directly affects outcomes. Mick et al13 studied a group of patients with stage III and IV head and neck cancer treated with multiple modalities. The strongest independent predictor of survival was pretreatment weight loss. Bertrand et al14 showed that 7 to 10 days of preoperative nutrition resulted in a significant improvement in postoperative quality of life and led to a 10% decrease in postoperative infectious complications. Van

Nutritional Assessment

Because of the risks associated with malnutrition, it is important to be able to identify before treatment begins those patients with head and neck cancer most at risk for malnutrition. Multiple assessment tools for malnutrition have been proposed. A complete history and physical examination are probably the most commonly used and best methods of evaluating nutritional status. Components of the history that must be elicited include recent unintentional weight loss, loss of appetite, and changes

Treatment of Malnutrition

Patients with difficulty eating secondary to pain and anorexia are treated easily with simple medical interventions. Mucositis is common in patients receiving radiation therapy and chemotherapy. Treatment is generally with topical medications (analgesics, antifungals, coating agents, and antihistamines) and gentle local care. Dental care can address pain of dental origin and frequent sips of water, synthetic saliva, and pilocarpine can address problems of xerostomia. Patients with

Methods of Nutritional Administration

Feeding tubes are placed into the gastrointestinal system, effectively bypassing the most common areas of feeding difficulty for the patient with upper aerodigestive tract cancer. Dysphagia, odynophagia, and aspiration are usually not a concern once feeding is started through a nasogastric, gastrostomy, or jejunostomy tube. If a patient is cachectic or unable to satisfy maintenance caloric needs by oral intake, the patient is a candidate for supplemental tube feeds. Gastrostomy tube placement

Modalities of Nutritional Support

Patients who are judged at high risk and cannot eat by mouth should be provided enteral feedings. There are 2 main routes of nutritional support: enteral and parenteral nutrition. Enteral nutrition is well tolerated and effective. There are many enteral formulas available (Table 3). Osmolality affects the patient's ability to tolerate the formula.33 High osmolality (>1,000 mOsm/kg) refers to a hypertonic formula that should be infused into the stomach to take advantage of the dilutional effects

Looking to the Future

Dietary causes for cancers are being found in certain populations (oral cancer with betel nuts, esophageal cancer with smoked foods) and to prevent such cancers by altering the diet is one of the most exciting new oncologic concepts. Some researchers have investigated food-related substances to identify which foods might offer a protective value against head and neck cancer. Low serum levels of vitamin A or β-carotene have been associated with cancer of the head and neck and gastric cancer.50

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    Conflict of Interest Disclosures: None of the authors reported any disclosures.

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