MAIN ARTICLE
The Journal of Laryngology & Otology (2014), 128, 263–267. © JLO (1984) Limited, 2014 doi:10.1017/S0022215113002582
Factors affecting duration of gastrostomy tube retention in survivors following treatment for head and neck cancer H BLANCHFORD1, D HAMILTON1, I BOWE1, S WELCH2, R KUMAR1, J W MOOR3, A R WELCH1, V PALERI1 1
Department of Otolaryngology Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK, Department of Anaesthesia, North Tyneside General Hospital, North Shields, UK, and 3Department of Otolaryngology-Head and Neck Surgery, Sunderland Royal Hospital, Sunderland, UK
2
Abstract Background: Many patients treated for head and neck cancer require nutritional support, which is often delivered using a gastrostomy tube. It is difficult to predict which patients will retain their gastrostomy tube in the long term. This study aimed to identify the factors which affect the duration of gastrostomy tube retention. Method: In this retrospective study, 151 consecutive patients from one centre were audited. All patients had a mucosal tumour of the head and neck, and underwent gastrostomy tube insertion between 2003 and 2007. Results: There were near-complete data sets for 132 patients. The gastrostomy tube was retained in survivors (n = 66) for a mean of 21.3 months and in non-survivors (n = 66) for 11.9 months. Univariate analysis showed that co-morbidity was the only factor which significantly increased duration of gastrostomy tube retention in survivors ( p = 0.041). Conclusion: Co-morbidity alone was associated with a significant increase in gastrostomy tube retention. It is suggested that co-morbidity be included as a variable in future relevant research. Co-morbidity should also be considered when counselling patients about their long-term function following cancer treatment. Gastrostomy tube retention is likely to be affected by many factors, with few single variables having importance independently. Key words: Head And Neck Cancer; Gastrostomy; Comorbidity; Nutritional Support
Introduction Gastrostomy is commonly used as an enteral feeding route to supplement nutrition in patients with head and neck cancer. Gastrostomy tube use has increased since the publication of several systematic reviews demonstrating its safety.1,2 However, the indications for its use remain poorly defined, and variable practices are employed across head and neck centres.3 Several studies have examined the role of different clinical and patient factors that predict the need for gastrostomy tube placement.4–7 However, there are no published data on factors affecting the duration of gastrostomy tube retention. Interviews of disease-free patients who retain their gastrostomy tube for over 12 months have identified several clinical, social and personal factors,8 many of which are difficult to quantify. This single-centre, retrospective study aimed to analyse the quantifiable patient-, tumour- and treatment-related factors that may influence the duration of gastrostomy tube retention in patients who are disease-free after treatment for head and neck cancer.
Accepted for publication 20 May 2013
Materials and methods Study population Patients with mucosal tumours of the upper aerodigestive tract who underwent gastrostomy tube placement between January 2003 and December 2007 were identified via the dietetic service and included in this retrospective study. Patients who underwent gastrostomy tube placement for supportive care alone or for disease recurrence were excluded, as were those for whom data were insufficient. Clinical variables The clinical indices recorded were: tumour–node– metastasis (TNM) stage, tumour stage, co-morbidity grade, tumour site, treatment modality and deprivation score. The only data collected from the notes were those aspects pertaining to the duration of gastrostomy tube retention. All other patient demographic and clinical data were identified from a local head and neck oncology database.
First published online 11 March 2014
264
The demographic data collected for this study included postcode and age. The primary outcome measure was the duration of gastrostomy tube retention (in days). The sixth edition of the TNM Classification of Malignant Tumours was used for staging purposes.9 The treatment modalities were categorised into unimodality (surgery only or radiation only) or multimodality (surgery and radiotherapy, or concurrent chemoradiation). Patients were divided into deprivation quintiles on the basis of their postcode, according to their Townsend score.10,11 The Townsend index is based on four variables from the 2001 Census: unemployment, overcrowding, non-home ownership and noncar ownership. The score is derived from the sum of standardised scores for each variable, and an increased score represents increased deprivation. The Townsend score is categorised into quintiles: 1 represents the most affluent and 5 represents the most deprived. Co-morbidities are diseases that coexist with the patient’s head and neck cancer. The burden of co-morbidity was estimated using the Adult Comorbidity Evaluation 27-item index (ACE-27). This index, which has been validated in head and neck cancer, categorises co-morbidity into grades of severity: none (0), mild (1), moderate (2) and severe (3).12 Statistical analysis Univariate analyses of gastrostomy tube retention were restricted to disease-free survivors in order to eliminate competing variables in those patients with uncontrolled disease. Clinical variables were dichotomised for statistical comparison: (1) co-morbidity grade, none or mild versus moderate or severe; (2) TNM stage, stages I–III versus stage IV; (3) tumour stage, stages T0–2 versus stages T3–4; (4) tumour location, oral cavity and larynx versus pharynx and unknown primary; (5) treatment modality, multimodality versus single modality; and (6) Townsend deprivation quintile, 5 versus 1–4. All analyses were performed using the Statistical Package for the Social Sciences software, version 17 (SPSS; Chicago, Illinois, USA). The categorisation of tumour location into two groups for analysis was considered pragmatic. This is in line with the treatment policy at our centre: the treatment fields for tumours of the pharynx and unknown primary sites are wider, and these patients tend to have greater swallowing-related morbidity. Given the numbers of patients with higher deprivation (quintile group 5) in this cohort, Townsend quintile groups 1–4 were grouped into one category.
Results Of 151 patients who underwent gastrostomy tube placement between January 2003 and December 2007, we identified 132 whose clinical records were considered to have sufficient data for inclusion in this
H BLANCHFORD, D HAMILTON, I BOWE et al.
TABLE I PATIENTS’ DEMOGRAPHIC AND CLINICAL CHARACTERISTICS Parameter
Patients n
Total Age (years) – 65 TNM stage –I – II – III – IV – Unknown Tumour stage – T0 – T1 – T2 – T3 – T4 – Unknown Primary site – Oral cavity – Larynx – Pharynx – Unknown primary – Unknown Co-morbidity burden – 0 None – 1 Mild – 2 Moderate – 3 Severe – Unknown Treatment modality – Chemoradiation – Combined treatment – Radiation only – Surgery only – Unknown Townsend quintile of deprivation –1 –2 –3 –4 –5 – Unknown
132
% 100
12 68 52
9.1 51.5 39.4
1 6 16 95 14
0.8 4.5 12.1 72.0 10.6
4 7 17 28 62 14
3.0 5.3 12.9 21.2 47.0 10.6
23 39 60 4 6
17.4 29.5 45.5 3.0 4.5
42 29 32 24 5
31.8 22.0 24.2 18.2 3.8
38 48 21 10 15
28.8 36.4 15.9 7.6 11.4
4 3 8 28 85 4
3.0 2.3 6.1 21.2 64.4 3.0
TNM = tumour–node–metastasis
study. The demographic and clinical characteristics are shown in Table I. The mean patient age was 63 years (standard deviation = 10.97, range of 27 to 89 years). The mean duration of gastrostomy tube retention in all 132 patients was 16.75 months (standard error of the mean (SEM) ± 1.36, median = 12.63). The duration of gastrostomy tube retention was longer in the 66 survivors (mean = 21.26 months, SEM ± 2.22, median = 15.9). The 66 patients with uncontrolled disease and those who died had a lower mean duration of 11.89 months (SEM ± 1.46, median = 8.25). The gastrostomy tube retention data were analysed further in survivors. Univariate analysis was performed using the independent samples t-test and adjusted for unequal standard deviations. This revealed that patients with a co-morbidity grade of 2 or 3 retained their
GASTROSTOMY TUBE RETENTION IN HEAD AND NECK CANCER PATIENTS
TABLE II CLINICAL PARAMETERS AND GASTROSTOMY TUBE RETENTION Parameter Co-morbidity grade – 0–1 – 2–3 TNM stage – I–III – IV Tumour stage – T0–2 – T3–4 Primary site – Oral cavity & larynx – Pharynx & unknown primary Treatment modality – Single modality – Multimodality Deprivation quintile – 5 (deprived) – 1–4 (less deprived)
Pts† (n)
GT retention (mean; mth)
43 23
18.1 29.7
0.041
14 44
21.6 24.0
0.697
15 41
17.1 25.2
0.156
23 42
20.0 23.7
0.462
16 43
32.4 20.9
0.123
39 26
24.5 18.5
0.180
p∗
∗ Independent samples t-test, two-tailed. †Survivors only. Pts = patients; GT = gastrostomy tube; mth = months; TNM = tumour–node–metastasis
gastrostomy tubes for significantly longer (mean duration of 29.7 months); those with a co-morbidity grade of 0 or 1 had a mean duration of 18.1 months ( p = 0.041). The univariate analysis identified no other significant variable. The three most common categories of co-morbidity were: cardiovascular disease (52 per cent), chronic obstructive pulmonary disease (COPD) (26 per cent) and substance abuse (29 per cent) where alcohol was the only substance abused. Thirty-eight per cent of survivors (25 of 66) who underwent gastrostomy tube placement had a co-morbidity grade of 0. The durations of gastrostomy tube retention by group are shown in Table II. A significant proportion of our cohort came from the most deprived areas as defined by Townsend deprivation quintiles. Although the mean duration of gastrostomy tube retention was longer in patients living in the Townsend quintile 5 regions (24.5 months) compared with those living in less deprived areas (18.5 months), this difference was not statistically significant.
Discussion In our retrospective study of 132 head and neck cancer patients, a higher co-morbidity grade was significantly associated with a longer duration of gastrostomy tube retention in survivors. The data also demonstrated that patients living in areas of greater deprivation retained their gastrostomy tube for longer; however, this finding was not statistically significant. Enteral feeding by gastrostomy tube is widely used in the nutritional management of patients receiving treatment for upper aerodigestive tract tumours. While several studies have looked at the clinical and treatment factors that influence the decision to place a gastrostomy tube, this is the first study to analyse the impact of
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quantifiable demographic, patient, tumour and treatment factors on the duration of gastrostomy tube retention. The variables chosen for analysis were based on what we clinically judged may have an impact on the duration of gastrostomy tube retention. Given the cohort, we determined that if a multivariate analysis was required, the use of more than six variables would undermine the strength of any conclusions. Our results demonstrated that increased co-morbidity grade was the only independent prognostic factor for gastrostomy tube dependence. Given the high rate of smoking and alcohol use often seen in patients with head and neck cancer, it is not unexpected that cardiovascular disease, COPD and alcohol abuse were the most common co-morbidities in our cohort. These observations therefore support in part a study of head and neck cancer patients that found alcohol dependence to be significantly associated with long-term gastrostomy tube use.13 Our recent review confirmed the lack of consensus in using primary site alone as an indication for gastrostomy tube placement.3 Various other factors have also been implicated in the decision making for gastrostomy tube placement. A study investigating factors independently associated with feeding tube placement identified the following variables: oropharynx or hypopharynx tumour site, stage III or IV, disease flap reconstruction, current tracheostomy, chemotherapy, and increased age.14 Surgery to the tongue base and pharynx, and flap reconstruction,13 and radiation dose delivered to the inferior constrictors and the cricopharyngeal inlet,15 have also been cited as factors that predispose a patient to prolonged enteral support. Some of those factors were analysed in the current study; however, none were correlated with the duration of gastrostomy tube retention. It has been postulated that a lack of social support and a higher index of social deprivation may play a role in the duration of gastrostomy tube use. Our data showed an increase in gastrostomy tube retention in relation to deprivation index, but the difference was not statistically significant; however, this finding is limited by the lack of patients in our cohort from less deprived areas. None of the other factors analysed in this study were associated with duration of gastrostomy tube retention. Advanced tumour stages and prophylactic gastrostomy tube placement have both been associated with gastrostomy tube retention at 12 months.16,17 Our study found no significant relationship between gastrostomy tube retention and tumour stage. Of note, we employ a highly selective policy in offering patients gastrostomy tube placement, which may account for the longer mean duration of gastrostomy tube retention compared with other publications.18–20 The decision to offer gastrostomy tube placement is made by a multidisciplinary team, following nutritional and swallowing assessments. Factors such as patient preference, social support and expected treatment-related dysphagia are also taken into account.
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The presence of a feeding tube21 and gastrostomy tube retention at one year22 are significantly associated with a decreased quality of life (QoL). Importantly, pretreatment QoL and co-morbidity are also predictive of QoL at one year post-treatment.22 Given the significant negative associations between gastrostomy tube use, co-morbidity and QoL, it is vital that further prospective studies are conducted to examine the factors affecting gastrostomy tube retention. Gastrostomy tube retention is likely to be affected by many factors, but a clear understanding of these factors will provide valuable insight for treatment planning and information given to patients. • Head and neck cancer patients often require nutritional support via a gastrostomy tube • Patients remain gastrostomy tube fed for varying durations, the reasons for which are poorly understood • This is the first study to analyse the impact of quantifiable demographic, patient, tumour and treatment factors on the duration of gastrostomy tube retention • This study demonstrated a correlation between higher co-morbidity grade and longer duration of gastrostomy tube retention The findings of this study highlighted co-morbidity as an important factor which significantly affected the duration of gastrostomy tube retention. The study is, however, limited by the retrospective collection of data and the need to dichotomise data for analysis. Nevertheless, the association between co-morbidity and longer duration of gastrostomy tube dependence may be taken into account when planning treatment or counselling patients about their long-term function following cancer treatment. Co-morbidity should be considered as a variable in future prospective studies of gastrostomy tube use.
Conclusion In this study, TNM stage, tumour stage, primary site, treatment modality and deprivation were not independently predictive factors for the duration of gastrostomy tube retention in patients with upper aerodigestive tract tumours. However, increased co-morbidity grade was significantly associated with increased duration of gastrostomy tube retention. We postulate that gastrostomy tube retention is likely to be affected by many factors, with few single variables being independently important. The role of other factors influencing prolonged gastrostomy tube dependence remains speculative. Despite the limitations of this retrospective study, the findings add weight to the importance of acknowledging co-morbid disease when planning head and neck cancer treatment. We welcome future prospective clinical studies to verify co-morbidity as an independent predictive factor for gastrostomy tube retention.
H BLANCHFORD, D HAMILTON, I BOWE et al.
References 1 Grant DG, Bradley PT, Pothier DD, Bailey D, Caldera S, Baldwin DL et al. Complications following gastrostomy tube insertion in patients with head and neck cancer: a prospective multi-institution study, systematic review and meta-analysis. Clin Otolaryngol 2009;34:103–12 2 Wollman B, D’Agostino HB, Walus-Wigle JR, Easter DW, Beale A. Radiologic, endoscopic, and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature. Radiology 1995;197:699–704 3 Paleri V, Patterson J. Use of gastrostomy in head and neck cancer: a systematic review to identify areas for future research. Clin Otolaryngol 2010;35:177–89 4 Nugent B, Parker MJ, McIntyre IA. Nasogastric tube feeding and percutaneous endoscopic gastrostomy tube feeding in patients with head and neck cancer. J Hum Nutr Diet 2010;23: 277–84 5 Brown T, Spurgin A, Crombie J, Ross L, Tripcony L, Keller J et al. Improved sensitivity of swallowing and nutrition guidelines to predict which head and neck cancer patients will benefit from prophylactic gastrostomy placement. Asia Pac J Clin Oncol 2010;6(suppl 3):114 6 Zuercher BF, Grosjean P, Monnier P. Percutaneous endoscopic gastrostomy in head and neck cancer patients: indications, techniques, complications and results. Eur Arch Otorhinolaryngol 2011;268:623–9 7 Moor JW, Patterson J, Kelly C, Paleri V. Prophylactic gastrostomy before chemoradiation in advanced head and neck cancer: a multiprofessional web-based survey to identify current practice and to analyse decision making. Clin Oncol (R Coll Radiol) 2010;22:192–8 8 Owen S, Patterson J, Johnson K, Paleri V. Factors associated with long-term retention of gastrostomy in head and neck cancer patients. In: Abstracts of the 13th British Academic Conference in Otolaryngology and ENT Expo, July 8–10, 2009, Liverpool, UK. Clin Otolaryngol 2009;34(suppl 1): 69–70 9 Sobin LH, Wittekind C, eds. TNM Classification of Malignant Tumours, 6th edn. Hoboken, New Jersey: John Wiley & Sons, 2002 10 2001 Townsend scores. In: http://census.ukdataservice.ac.uk/ get-data/related/deprivation.aspx [6 February 2014] 11 Townsend P, Phillimore P, Beattie A. Health and Deprivation: Inequality and the North. London: Routledge, 1988 12 Piccirillo J, Costas I, Claybour P, Borah A, Grove L, Jeffe D. The measurement of comorbidity by cancer registries. J Registry Manag 2003;30:8–14 13 Schweinfurth JM, Boger GN, Feustel PJ. Preoperative risk assessment for gastrostomy tube placement in head and neck cancer patients. Head Neck 2001;23:376–82 14 Cheng SS, Terrell JE, Bradford CR, Ronis DL, Fowler KE, Prince ME et al. Variables associated with feeding tube placement in head and neck cancer. Arch Otolaryngol Head Neck Surg 2006;132:655–61 15 Li B, Li D, Lau DH, Farwell DG, Luu Q, Rocke DM et al. Clinical-dosimetric analysis of measures of dysphagia including gastrostomy-tube dependence among head and neck cancer patients treated definitively by intensity-modulated radiotherapy with concurrent chemotherapy. Radiat Oncol 2009;4:52 16 Chapuy CI, Annino DJ, Snavely A, Li Y, Tishler RB, Norris CM et al. Swallowing function following postchemoradiotherapy neck dissection: review of findings and analysis of contributing factors. Otolaryngol Head Neck Surg 2011;145:428–34 17 Chen AM, Li BQ, Lau DH, Farwell DG, Luu Q, Stuart K et al. Evaluating the role of prophylactic gastrostomy tube placement prior to definitive chemoradiotherapy for head and neck cancer. Int J Radiat Oncol Biol Phys 2010;78:1026–32 18 Oates JE, Clark JR, Read J, Reeves N, Gao K, Jackson M et al. Prospective evaluation of quality of life and nutrition before and after treatment for nasopharyngeal carcinoma. Arch Otolaryngol Head Neck Surg 2007;133:533–40 19 Nguyen NP, North D, Smith HJ, Dutta S, Alfieri A, Karlsson U et al. Safety and effectiveness of prophylactic gastrostomy tubes for head and neck cancer patients undergoing chemoradiation. Surg Oncol 2006;15:199–203 20 Wiggenraad RG, Flierman L, Goossens A, Brand R, Verschuur HP, Croll GA et al. Prophylactic gastrostomy
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placement and early tube feeding may limit loss of weight during chemoradiotherapy for advanced head and neck cancer, a preliminary study. Clin Otolaryngol 2007;32: 384–90 21 Terrell JE, Ronis DL, Fowler KE, Bradford CR, Chepeha DB, Prince ME et al. Clinical predictors of quality of life in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg 2004;130:401–8 22 El-Deiry MW, Futran ND, McDowell JA, Weymuller EA Jr, Yueh B. Influences and predictors of long-term quality of life in head and neck cancer survivors. Arch Otolaryngol Head Neck Surg 2009;135:380–4
Address for correspondence: Mr V Paleri, Department of Otolaryngology, Head and Neck Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK E-mail: [email protected] Mr V Paleri takes responsibility for the integrity of the content of the paper Competing interests: None declared
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The Journal of Laryngology & Otology (2014), 128, 263–267. © JLO (1984) Limited, 2014 doi:10.1017/S0022215113002582
Factors affecting duration of gastrostomy tube retention in survivors following treatment for head and neck cancer H BLANCHFORD1, D HAMILTON1, I BOWE1, S WELCH2, R KUMAR1, J W MOOR3, A R WELCH1, V PALERI1 1
Department of Otolaryngology Head and Neck Surgery, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK, Department of Anaesthesia, North Tyneside General Hospital, North Shields, UK, and 3Department of Otolaryngology-Head and Neck Surgery, Sunderland Royal Hospital, Sunderland, UK
2
Abstract Background: Many patients treated for head and neck cancer require nutritional support, which is often delivered using a gastrostomy tube. It is difficult to predict which patients will retain their gastrostomy tube in the long term. This study aimed to identify the factors which affect the duration of gastrostomy tube retention. Method: In this retrospective study, 151 consecutive patients from one centre were audited. All patients had a mucosal tumour of the head and neck, and underwent gastrostomy tube insertion between 2003 and 2007. Results: There were near-complete data sets for 132 patients. The gastrostomy tube was retained in survivors (n = 66) for a mean of 21.3 months and in non-survivors (n = 66) for 11.9 months. Univariate analysis showed that co-morbidity was the only factor which significantly increased duration of gastrostomy tube retention in survivors ( p = 0.041). Conclusion: Co-morbidity alone was associated with a significant increase in gastrostomy tube retention. It is suggested that co-morbidity be included as a variable in future relevant research. Co-morbidity should also be considered when counselling patients about their long-term function following cancer treatment. Gastrostomy tube retention is likely to be affected by many factors, with few single variables having importance independently. Key words: Head And Neck Cancer; Gastrostomy; Comorbidity; Nutritional Support
Introduction Gastrostomy is commonly used as an enteral feeding route to supplement nutrition in patients with head and neck cancer. Gastrostomy tube use has increased since the publication of several systematic reviews demonstrating its safety.1,2 However, the indications for its use remain poorly defined, and variable practices are employed across head and neck centres.3 Several studies have examined the role of different clinical and patient factors that predict the need for gastrostomy tube placement.4–7 However, there are no published data on factors affecting the duration of gastrostomy tube retention. Interviews of disease-free patients who retain their gastrostomy tube for over 12 months have identified several clinical, social and personal factors,8 many of which are difficult to quantify. This single-centre, retrospective study aimed to analyse the quantifiable patient-, tumour- and treatment-related factors that may influence the duration of gastrostomy tube retention in patients who are disease-free after treatment for head and neck cancer.
Accepted for publication 20 May 2013
Materials and methods Study population Patients with mucosal tumours of the upper aerodigestive tract who underwent gastrostomy tube placement between January 2003 and December 2007 were identified via the dietetic service and included in this retrospective study. Patients who underwent gastrostomy tube placement for supportive care alone or for disease recurrence were excluded, as were those for whom data were insufficient. Clinical variables The clinical indices recorded were: tumour–node– metastasis (TNM) stage, tumour stage, co-morbidity grade, tumour site, treatment modality and deprivation score. The only data collected from the notes were those aspects pertaining to the duration of gastrostomy tube retention. All other patient demographic and clinical data were identified from a local head and neck oncology database.
First published online 11 March 2014
264
The demographic data collected for this study included postcode and age. The primary outcome measure was the duration of gastrostomy tube retention (in days). The sixth edition of the TNM Classification of Malignant Tumours was used for staging purposes.9 The treatment modalities were categorised into unimodality (surgery only or radiation only) or multimodality (surgery and radiotherapy, or concurrent chemoradiation). Patients were divided into deprivation quintiles on the basis of their postcode, according to their Townsend score.10,11 The Townsend index is based on four variables from the 2001 Census: unemployment, overcrowding, non-home ownership and noncar ownership. The score is derived from the sum of standardised scores for each variable, and an increased score represents increased deprivation. The Townsend score is categorised into quintiles: 1 represents the most affluent and 5 represents the most deprived. Co-morbidities are diseases that coexist with the patient’s head and neck cancer. The burden of co-morbidity was estimated using the Adult Comorbidity Evaluation 27-item index (ACE-27). This index, which has been validated in head and neck cancer, categorises co-morbidity into grades of severity: none (0), mild (1), moderate (2) and severe (3).12 Statistical analysis Univariate analyses of gastrostomy tube retention were restricted to disease-free survivors in order to eliminate competing variables in those patients with uncontrolled disease. Clinical variables were dichotomised for statistical comparison: (1) co-morbidity grade, none or mild versus moderate or severe; (2) TNM stage, stages I–III versus stage IV; (3) tumour stage, stages T0–2 versus stages T3–4; (4) tumour location, oral cavity and larynx versus pharynx and unknown primary; (5) treatment modality, multimodality versus single modality; and (6) Townsend deprivation quintile, 5 versus 1–4. All analyses were performed using the Statistical Package for the Social Sciences software, version 17 (SPSS; Chicago, Illinois, USA). The categorisation of tumour location into two groups for analysis was considered pragmatic. This is in line with the treatment policy at our centre: the treatment fields for tumours of the pharynx and unknown primary sites are wider, and these patients tend to have greater swallowing-related morbidity. Given the numbers of patients with higher deprivation (quintile group 5) in this cohort, Townsend quintile groups 1–4 were grouped into one category.
Results Of 151 patients who underwent gastrostomy tube placement between January 2003 and December 2007, we identified 132 whose clinical records were considered to have sufficient data for inclusion in this
H BLANCHFORD, D HAMILTON, I BOWE et al.
TABLE I PATIENTS’ DEMOGRAPHIC AND CLINICAL CHARACTERISTICS Parameter
Patients n
Total Age (years) – 65 TNM stage –I – II – III – IV – Unknown Tumour stage – T0 – T1 – T2 – T3 – T4 – Unknown Primary site – Oral cavity – Larynx – Pharynx – Unknown primary – Unknown Co-morbidity burden – 0 None – 1 Mild – 2 Moderate – 3 Severe – Unknown Treatment modality – Chemoradiation – Combined treatment – Radiation only – Surgery only – Unknown Townsend quintile of deprivation –1 –2 –3 –4 –5 – Unknown
132
% 100
12 68 52
9.1 51.5 39.4
1 6 16 95 14
0.8 4.5 12.1 72.0 10.6
4 7 17 28 62 14
3.0 5.3 12.9 21.2 47.0 10.6
23 39 60 4 6
17.4 29.5 45.5 3.0 4.5
42 29 32 24 5
31.8 22.0 24.2 18.2 3.8
38 48 21 10 15
28.8 36.4 15.9 7.6 11.4
4 3 8 28 85 4
3.0 2.3 6.1 21.2 64.4 3.0
TNM = tumour–node–metastasis
study. The demographic and clinical characteristics are shown in Table I. The mean patient age was 63 years (standard deviation = 10.97, range of 27 to 89 years). The mean duration of gastrostomy tube retention in all 132 patients was 16.75 months (standard error of the mean (SEM) ± 1.36, median = 12.63). The duration of gastrostomy tube retention was longer in the 66 survivors (mean = 21.26 months, SEM ± 2.22, median = 15.9). The 66 patients with uncontrolled disease and those who died had a lower mean duration of 11.89 months (SEM ± 1.46, median = 8.25). The gastrostomy tube retention data were analysed further in survivors. Univariate analysis was performed using the independent samples t-test and adjusted for unequal standard deviations. This revealed that patients with a co-morbidity grade of 2 or 3 retained their
GASTROSTOMY TUBE RETENTION IN HEAD AND NECK CANCER PATIENTS
TABLE II CLINICAL PARAMETERS AND GASTROSTOMY TUBE RETENTION Parameter Co-morbidity grade – 0–1 – 2–3 TNM stage – I–III – IV Tumour stage – T0–2 – T3–4 Primary site – Oral cavity & larynx – Pharynx & unknown primary Treatment modality – Single modality – Multimodality Deprivation quintile – 5 (deprived) – 1–4 (less deprived)
Pts† (n)
GT retention (mean; mth)
43 23
18.1 29.7
0.041
14 44
21.6 24.0
0.697
15 41
17.1 25.2
0.156
23 42
20.0 23.7
0.462
16 43
32.4 20.9
0.123
39 26
24.5 18.5
0.180
p∗
∗ Independent samples t-test, two-tailed. †Survivors only. Pts = patients; GT = gastrostomy tube; mth = months; TNM = tumour–node–metastasis
gastrostomy tubes for significantly longer (mean duration of 29.7 months); those with a co-morbidity grade of 0 or 1 had a mean duration of 18.1 months ( p = 0.041). The univariate analysis identified no other significant variable. The three most common categories of co-morbidity were: cardiovascular disease (52 per cent), chronic obstructive pulmonary disease (COPD) (26 per cent) and substance abuse (29 per cent) where alcohol was the only substance abused. Thirty-eight per cent of survivors (25 of 66) who underwent gastrostomy tube placement had a co-morbidity grade of 0. The durations of gastrostomy tube retention by group are shown in Table II. A significant proportion of our cohort came from the most deprived areas as defined by Townsend deprivation quintiles. Although the mean duration of gastrostomy tube retention was longer in patients living in the Townsend quintile 5 regions (24.5 months) compared with those living in less deprived areas (18.5 months), this difference was not statistically significant.
Discussion In our retrospective study of 132 head and neck cancer patients, a higher co-morbidity grade was significantly associated with a longer duration of gastrostomy tube retention in survivors. The data also demonstrated that patients living in areas of greater deprivation retained their gastrostomy tube for longer; however, this finding was not statistically significant. Enteral feeding by gastrostomy tube is widely used in the nutritional management of patients receiving treatment for upper aerodigestive tract tumours. While several studies have looked at the clinical and treatment factors that influence the decision to place a gastrostomy tube, this is the first study to analyse the impact of
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quantifiable demographic, patient, tumour and treatment factors on the duration of gastrostomy tube retention. The variables chosen for analysis were based on what we clinically judged may have an impact on the duration of gastrostomy tube retention. Given the cohort, we determined that if a multivariate analysis was required, the use of more than six variables would undermine the strength of any conclusions. Our results demonstrated that increased co-morbidity grade was the only independent prognostic factor for gastrostomy tube dependence. Given the high rate of smoking and alcohol use often seen in patients with head and neck cancer, it is not unexpected that cardiovascular disease, COPD and alcohol abuse were the most common co-morbidities in our cohort. These observations therefore support in part a study of head and neck cancer patients that found alcohol dependence to be significantly associated with long-term gastrostomy tube use.13 Our recent review confirmed the lack of consensus in using primary site alone as an indication for gastrostomy tube placement.3 Various other factors have also been implicated in the decision making for gastrostomy tube placement. A study investigating factors independently associated with feeding tube placement identified the following variables: oropharynx or hypopharynx tumour site, stage III or IV, disease flap reconstruction, current tracheostomy, chemotherapy, and increased age.14 Surgery to the tongue base and pharynx, and flap reconstruction,13 and radiation dose delivered to the inferior constrictors and the cricopharyngeal inlet,15 have also been cited as factors that predispose a patient to prolonged enteral support. Some of those factors were analysed in the current study; however, none were correlated with the duration of gastrostomy tube retention. It has been postulated that a lack of social support and a higher index of social deprivation may play a role in the duration of gastrostomy tube use. Our data showed an increase in gastrostomy tube retention in relation to deprivation index, but the difference was not statistically significant; however, this finding is limited by the lack of patients in our cohort from less deprived areas. None of the other factors analysed in this study were associated with duration of gastrostomy tube retention. Advanced tumour stages and prophylactic gastrostomy tube placement have both been associated with gastrostomy tube retention at 12 months.16,17 Our study found no significant relationship between gastrostomy tube retention and tumour stage. Of note, we employ a highly selective policy in offering patients gastrostomy tube placement, which may account for the longer mean duration of gastrostomy tube retention compared with other publications.18–20 The decision to offer gastrostomy tube placement is made by a multidisciplinary team, following nutritional and swallowing assessments. Factors such as patient preference, social support and expected treatment-related dysphagia are also taken into account.
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The presence of a feeding tube21 and gastrostomy tube retention at one year22 are significantly associated with a decreased quality of life (QoL). Importantly, pretreatment QoL and co-morbidity are also predictive of QoL at one year post-treatment.22 Given the significant negative associations between gastrostomy tube use, co-morbidity and QoL, it is vital that further prospective studies are conducted to examine the factors affecting gastrostomy tube retention. Gastrostomy tube retention is likely to be affected by many factors, but a clear understanding of these factors will provide valuable insight for treatment planning and information given to patients. • Head and neck cancer patients often require nutritional support via a gastrostomy tube • Patients remain gastrostomy tube fed for varying durations, the reasons for which are poorly understood • This is the first study to analyse the impact of quantifiable demographic, patient, tumour and treatment factors on the duration of gastrostomy tube retention • This study demonstrated a correlation between higher co-morbidity grade and longer duration of gastrostomy tube retention The findings of this study highlighted co-morbidity as an important factor which significantly affected the duration of gastrostomy tube retention. The study is, however, limited by the retrospective collection of data and the need to dichotomise data for analysis. Nevertheless, the association between co-morbidity and longer duration of gastrostomy tube dependence may be taken into account when planning treatment or counselling patients about their long-term function following cancer treatment. Co-morbidity should be considered as a variable in future prospective studies of gastrostomy tube use.
Conclusion In this study, TNM stage, tumour stage, primary site, treatment modality and deprivation were not independently predictive factors for the duration of gastrostomy tube retention in patients with upper aerodigestive tract tumours. However, increased co-morbidity grade was significantly associated with increased duration of gastrostomy tube retention. We postulate that gastrostomy tube retention is likely to be affected by many factors, with few single variables being independently important. The role of other factors influencing prolonged gastrostomy tube dependence remains speculative. Despite the limitations of this retrospective study, the findings add weight to the importance of acknowledging co-morbid disease when planning head and neck cancer treatment. We welcome future prospective clinical studies to verify co-morbidity as an independent predictive factor for gastrostomy tube retention.
H BLANCHFORD, D HAMILTON, I BOWE et al.
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Address for correspondence: Mr V Paleri, Department of Otolaryngology, Head and Neck Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK E-mail: [email protected] Mr V Paleri takes responsibility for the integrity of the content of the paper Competing interests: None declared
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