The changing landscape of head and neck cancer radiotherapy patients: is high‐risk, prolonged feeding tube use indicative of on‐treatment weight loss?

Abstract

IntroductionPrecision radiotherapy relies heavily on optimal weight management. Our group previously developed a risk stratification model for patients at risk of prolonged feeding tube (FT) intervention. The study objective was to assess on‐treatment weight loss according to stratified risk of prolonged FT use.MethodsOne hundred and one (n = 101) definitive head and neck radiotherapy patients were included in this study. Patients were stratified into high risk (HRi: T‐classification ≥ 3 with level 2 Nodal disease), high‐intermediate risk (HIRi: T‐classification ≥ 3 without level 2 Nodes) and low‐intermediate risk (LIRi: T‐classification < 3 with level 2 Nodes) of prolonged FT use. Demographic variables and on‐treatment weight loss were evaluated according to risk status.ResultsOropharyngeal carcinoma (OPC) was present in a larger proportion in the LIRi cohort (HRi: 71%, HIRi: 52%, LIRi: 81%, P = 0.008). LIRi patients were more likely to have human papilloma virus (HPV)‐associated disease (88%, P = 0.001). Never/minimal smoking (P = 0.003), good performance status (P < 0.001), healthy BMI (P = 0.050) and no pre‐existing dysphagia (P < 0.001) were predominant within the LIRi prognostic group. LIRi patients lost significantly more weight in total (HRi = 4.8% vs. LIRi = 8.2%, P = 0.002; HIRi = 5.2% vs. LIRi = 8.2%, P = 0.006) and when using a FT (HRi = 4.6% vs. LIRi = 8.8%, P < 0.001; HIRi = 5.3% vs. LIRi = 8.8%, P = 0.002).ConclusionsPatients identified as low‐intermediate risk of prolonged, ≥25% FT use report significantly increased weight loss compared with patients at higher risk of FT use. This cohort is typical of the increasing number of patients presenting with HPV‐associated OPC. Results of this study suggest we should closely observe such patients throughout treatment, to ensure optimal weight maintenance, facilitating precision radiotherapy.

Nutritional Support in Head and Neck Radiotherapy Patients Considering HPV Status

“…The authors concluded that T classification ≥ three and level two lymphadenopathy could potentially stratify patients into four risk groups for developing severe dysphagia requiring feeding tube use. The following risk groups of prolonged FT use were stratified: 1 In the next study, Anderson et al [63] analyzed 101 OPC patients undergoing RT. Patients were divided into high risk (HRi: T-classification ≥ three with level two Nodal disease), high-intermediate risk (HIRi: T-classification ≥ three without level two Nodes), and low-intermediate risk (LIRi: T-classification < three with level two Nodes) of prolonged feeding tube use.…”

“…In the next study, Anderson et al [ 63 ] analyzed 101 OPC patients undergoing RT. Patients were divided into high risk (HRi: T-classification ≥ three with level two Nodal disease), high-intermediate risk (HIRi: T-classification ≥ three without level two Nodes), and low-intermediate risk (LIRi: T-classification < three with level two Nodes) of prolonged feeding tube use.…”

“…So, in HPV-positive OPC patients, despite the low-intermediate risk (T < 3, N2), the feeding tube placement is observed more frequently, and there was no good adherence of the above-mentioned risk stratification to the prophylactic feeding tube recommendations in this patients group. In the authors’ opinion, the poor nutritional outcomes in HPV (+) OPC patients are associated with a lack of adherence to nutrition recommendations given, and thus suboptimal feeding tube utilization in this patient group [ 63 , 64 ].…”

The Impact of Human Papillomavirus (HPV) Associated Oropharyngeal Squamous Cell Carcinoma (OPSCC) on Nutritional Outcomes

“…Patients with HPV-positive OPSCC are known to have better nutritional status at diagnosis than people with HPV-negative OPSCC [ 13 , 14 , 15 ]. Studies comparing the prevalence of malnutrition in HPV-positive and negative patients after treatment report similar, if not worse, nutritional outcomes for people who are HPV-positive compared to those who are HPV-negative [ 13 , 14 ].…”

“…This suggests that people who are HPV-positive are susceptible to a greater decline in nutritional status and potentially at greater risk of treatment-related malnutrition than people who are HPV-negative. Some studies attribute the comparatively worse nutritional outcomes in HPV-positive patients to lack of adherence to nutritional guidelines which leads to delayed feeding tube insertion and initiation of feeding [ 13 , 15 ]. Other studies suggest that patients with HPV-positive status are at greater risk of a decline in nutritional status due to experiencing worse treatment toxicities [ 14 ].…”