Support Care Cancer DOI 10.1007/s00520-014-2180-9
ORIGINAL ARTICLE
Nutrition outcomes following implementation of validated swallowing and nutrition guidelines for patients with head and neck cancer Teresa Brown & Lynda Ross & Lee Jones & Brett Hughes & Merrilyn Banks
Received: 13 May 2013 / Accepted: 25 February 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose Head and neck cancer patients have a high risk of malnutrition and swallowing dysfunction. This study reports on adherence and nutrition outcomes with the use of local evidence-based guidelines for the nutrition management of patients with head and neck cancer, including placement of proactive gastrostomy tubes for high risk patients. Methods This study is a prospective observational audit in patients treated for head and neck cancer at a tertiary hospital from 2007 to 2008 (n=539). Nutrition outcomes (weight, nutritional status and type of nutrition support) were compared for each nutrition risk category. Primary outcome was 10 % or more weight loss at 3 months post-treatment (n=219). Results Overall adherence to the guideline tube feeding recommendations was 81 %. High risk patients had mean weight loss of 6 % on completion of treatment and 9 % at 3 months post-treatment, despite the majority having a proactive gastrostomy tube. Medium and low risk patients also lost weight over this time. Univariate analysis found that nonadherence to the guidelines was associated with weight loss at 3 months (p=0.013). Multivariate analysis found overweight patients had 1.82 greater odds, and obese patients had 3.49 greater odds of losing weight (p=0.021). Patients This research has been presented at the 8th International Conference for Head and Neck Cancer, Toronto, Canada, July 2012. T. Brown (*) : L. Ross : M. Banks Department of Nutrition & Dietetics, Royal Brisbane and Women’s Hospital, Level 2, James Mayne Building, Butterfield St, Herston, Brisbane, QLD 4029, Australia e-mail: [email protected] L. Jones Queensland Institute of Medical Research, Brisbane, QLD, Australia B. Hughes Department of Cancer Care Services, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
with significant weight loss at diagnosis had decreased odds of losing weight later (p=0.011). Conclusion Clinically significant weight loss was still prevalent in this population despite proactive interventions. Predictors of weight loss support the evidence-based guidelines’ risk categories, and adherence was important to improve outcomes. Further research is required to determine the impact of significant weight loss in patients with high body mass index (BMI). Keywords Head and neck cancer . Prophylactic gastrostomy . Enteral feeding . Nutritional status . Nutrition
Introduction Head and neck cancer patients have a high risk of malnutrition and swallowing dysfunction secondary to the cancer itself and/or the side effects of treatment. Enteral (tube) feeding is often used in response to dysphagia, odynophagia or other side effects of treatment that lead to dehydration and/or weight loss during or after cancer treatment. Although the optimal method of tube feeding remains unclear [1], a number of benefits have been demonstrated from prophylactic gastrostomy tube feeding (a feeding tube proactively inserted prior to treatment), including earlier commencement of nutrition support [2], reduced weight loss [3, 4], improved quality of life [5–7] and reduced admissions and healthcare costs [8–10]. Risks associated with gastrostomy placement should also be considered [11], as concerns that gastrostomy placement might result in gastrostomy dependency, with longer duration of tube usage and increased dysphagia posttreatment [12, 13]. In order to assist clinical decision making, a number of studies have attempted to retrospectively determine which patient groups would benefit most from early intervention.
Support Care Cancer
Risk factors that increase dysphagia and the need for tube feeding during cancer treatment may include: the type of cancer [14–16]; type of cancer treatment [14, 17]; and at initial diagnosis of the head and neck cancer, the presence of either dysphagia [18, 19] and/or malnutrition [3, 20]. In 2006, the “Swallowing and Nutrition Management Guidelines for Patients with Head & Neck Cancer” (H&N guidelines) were developed at the Royal Brisbane and Women’s Hospital to address the lack of standardised clinical practices for swallowing intervention and tube feeding before, during and after cancer treatment. At this time, there was no national consensus or published evidence-based clinical pathways, in the UK or Australia, to support the identification and management of dysphagia and malnutrition risk in head and neck cancer patients [21]. The aims of the H&N guidelines were to assist in the identification of patients at high risk of dysphagia and malnutrition who would benefit from proactive tube feeding. Our local H&N guidelines were based on a combination of evidence from the literature and expert consensus by the hospital’s Combined Head and Neck Clinic multidisciplinary team. High risk criteria descriptions were used to determine which patients should be referred for a proactive gastrostomy tube. This could be patients who would benefit from immediate nutrition support (therapeutic gastrostomy) as well as those who would benefit based on future treatment side effects (prophylactic gastrostomy) [10]. All other medium and low risk patients who were later identified to require tube feeding during treatment would have a nasogastric or gastrostomy tube placed (reactive tube feeding). The H&N guidelines have since been validated for clinical use [22] and have been shown to reduce unplanned hospital admissions and length of stay [10]. This study reports on adherence to the H&N guideline recommendations in our hospital and the impact on weight change during and after cancer treatment. Clinical and patient characteristics associated with increased risk of 10 % weight loss or more at 3 months post-treatment were also identified.
Materials and methods Patients who attended the Combined Head and Neck Clinic at a large metropolitan tertiary referral hospital for cancer treatment from January 2007 to December 2008 were consecutively enrolled into a prospective observational cohort study to coincide with the introduction of the H&N guidelines (Fig. 1) on 1 January 2007. The H&N guidelines consist of risk categories based on patients’ tumour characteristics, treatment plan and swallowing and nutritional status and were used to rate patients’ level of nutrition risk as high, medium or low. Each risk category provided a defined pathway to guide swallowing and nutrition management by the multidisciplinary team, outlined as follows: all high risk patients were
recommended for proactive gastrostomy tube insertion and were reviewed by the dietitian and speech pathologist pretreatment, and medium and low risk patients were reviewed by the dietitian and speech pathologist from the commencement of radiotherapy or on admission for surgery. Initiation of tube feeding for all patients was recommended if oral intake fell or was anticipated to fall below 60 % of estimated energy requirement for more than 10 days during cancer treatment (estimated from 24-h recalls conducted on each dietetic review). Adherences to the recommendations for tube feeding were monitored and data collected. Outpatients were seen on a weekly basis during treatment, and inpatients were seen daily to weekly as clinically indicated as part of standard care. All patients were referred to the local allied health service on completion of treatment. Recommended follow-up was fortnightly review for the first 6 weeks post-treatment and then as required. This aspect of the guidelines, frequency of dietetic and speech pathology review, was not monitored for adherence. Patients were included in the study if they had confirmed malignant disease, planned treatment with curative intent and were referred to the dietitian as part of standard care. Exclusion criteria for the study were nonmalignant disease; palliative care or palliative intent treatment; lymphoma; and thyroid or oesophageal cancer. A blanket referral to the dietitian and speech pathologist was standard for all patients with head and neck cancer on the surgical ward, oncology ward and in radiotherapy outpatients. Some patients who attended the Combined Head and Neck Clinic initially went on to have their treatment at another public or private hospital. Others not referred were those having simple surgical procedures which usually only required an overnight stay and therefore had minimal nutrition risk. The hospital’s human research ethics committee confirmed the project conformed to the National Health and Medical Research Council ethical principles of a quality assurance study. All participants were seen as part of standard clinical practice by the multidisciplinary team: surgical and oncological specialists; dentist; speech pathologist; dietitian; and nursing staff. Swallowing function was assessed by the speech pathologist on presentation and ongoing monitoring which occurred throughout treatment in conjunction with dietitian assessments. Validated tools were used to monitor swallowing outcomes at similar time points, and these data will be presented elsewhere. Cancer site was coded using the International Classification of Diseases version 10-Australian Modifications (ICD-10AM), and stages were determined using the Union for International Cancer Control (UICC) Tumour, Node and Metastasis (TNM) staging system. Radiotherapy was usually delivered using a highly conformal 3D approach at a dose of 2 Gy/ day, 5 days/week, to total doses of 70 Gy (definitive) or 60 Gy (adjuvant). Concomitant chemotherapy was usually in the form of high-dose cisplatin.
Support Care Cancer
Royal Brisbane & Women’s Hospital: Multi-Disciplinary Team Assessment:
HIGH RISK Oral + bilateral chemoradiotherapy Midline oropharyngeal/nasopharyngeal/ pharyngeal + chemoradiotherapy
Swallowing and Nutrition Management Guidelines for Patients with Head and Neck Cancer Combined Head & Neck Clinic assessment by SP & D
Referral to local SP & D for pretreatment management
Referral to gastroenterology
Insertion of prophylactic PEG – to remain insitu for minimum 3 months
Baseline MBS pre radiotherapy & commence swallow rehabilitation
OR
Weekly review by SP & D during treatment
Ongoing review by local SP & D for at least 12 months
Team consensus to remove PEG
Dysphagia at presentation or prior to radiotherapy/chemoradiotherapy OR
HIGH RISK
Severe malnutrition at presentation: • Unintentional weight loss > 10% in 6 months • BMI < 18.5 • BMI < 20 with unintentional weight loss 5-10% in 6 months • Dietitian assessment SGA C • Poor oral intake (minimal intake > 5days and/or unlikely to improve > 5days)
NGT if anticipated for < 4weeks PEG if anticipated for > 4weeks
MEDIUM RISK All other head and neck cancers which do not fit into high or low risk category OR
MEDIUM RISK
Moderate malnutrition at presentation:
Combined Head & Neck Clinic assessment by SP & D
Weekly review by SP & D during treatment
Referral to local D for pretreatment nutrition management
• Unintentional weight loss > 5% in 6 months • BMI < 20 with unintentional weight loss up to 5% in 6 months • Dietitian assessment SGA B
LOW RISK Surgery alone, no radiotherapy required Unilateral radiotherapy alone All salivary tumours All tumours of skin in temple region and above
March 2007 Developed by the Departments of Nutrition and Dietetics and Speech Pathology and endorsed by the Combined Head and Neck Clinic, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
LOW RISK
Combined Head & Neck Clinic assessment by SP & D
Key: SP Speech = Pathologist D = Dietitian BMI = Body Mass Index SGA = Subjective Global Assessment PEG = Percutaneous Endoscopic MBS = Modified Barium Swallow Gastrostomy NGT = Nasogastric Tube
Ongoing review by local SP & D for at least 12 months
Intake < 60% requirements for > 10days
Team consensus to remove PEG/NGT
FACTORS FOR CONSIDERATION
FACTORS FOR CONSIDERATION
During Treatment
Post-Treatment
Significant or multiple combinations of the following factors may push patients up the risk categories:
Significant or multiple combinations of the following factors may push patients up the risk categories:
• Odynophagia not controlled with medication • Severe mucositis • Severe mouth ulceration • Trismus • Presence of tracheostomy • Lack of social support to manage dysphagia • Inadequate dentition • Significantly reduced appetite/taste alterations
• • • • • • • • • •
Failure to stabilise weight Severe ongoing mucositis Xerostomia Trismus Fibrosis Osteoradionecrosis Lymphoedema Inadequate dentition Stricture formation Presence of tracheostomy HMMU March ‘07 sf 0031 Morton_ai
Fig. 1 The “RBWH swallowing and nutrition management guidelines for patients with head and neck cancer.” Original Source: Validated swallowing and nutrition guidelines for patients with head and neck
cancer: Identification of high risk patients for proactive gastrostomy. Brown, Spurgin, Ross et al. Head Neck. doi:10.1002/hed.23146. Copyright © 2012 Wiley Periodicals, Inc
The Malnutrition Screening Tool (MST) [23] was selfcompleted by participants and identified those at risk of malnutrition on presentation. The MST was chosen as a validated tool to assess nutrition risk and involved two questions relating to appetite and weight loss. A score of 2 or greater (range 0 to 5) identified the patient to be at risk of malnutrition, and further assessment by the dietitian was required. Nutritional status was assessed by the dietitian using the Patient-Generated Subjective Global Assessment (PG-SGA) [24]. This was chosen as a validated tool to assess a patient’s nutritional status and encompasses assessment of the patients’ weight history, dietary intake, nutrition impact symptoms, functional/activity levels and a physical assessment of fat and muscle stores. Following assessment of each of these domains, a global rating was given; well nourished (SGA A), moderate or suspected malnutrition (SGA B), or severe malnutrition (SGA C). A PG-SGA score was calculated to indicate nutrition risk, with a score >9 indicating a critical need for improved symptom management and/or nutrition intervention options.
Clinic nursing staff measured and recorded each patient’s height and body weight on presentation using standard scales and stadiometer, and body mass index (BMI) (kg/m2) was calculated. Nutrition requirements were calculated by the dietitian using the ratio method [25]. Energy requirements (125 kJ/kg/day) and protein requirements (1.2 g/kg/day) were based on actual body weight, unless the patient was overweight (BMI >25 kg/m2), and then adjusted body weight was used. Adjusted body weight was calculated using the following equation: (IBW+[(actual body weight–IBW)×25 %]), whereby ideal body weight (IBW) was the weight at BMI 25 kg/m2. At each dietetic review, weight was monitored, and energy and protein intakes were estimated using a 24-h recall method, whereby the dietitian estimated the actual intake against standard portion sizes. Nutrition requirements were adjusted as clinically indicated. The patients’ weight and nutritional status were remeasured by the dietitian at the end of cancer treatment and 3 and 6 months post-treatment. The primary categorical outcome was defined as percentage weight loss (10 % or greater) from diagnosis to 3 months
Support Care Cancer
after the completion of treatment. A percentage weight loss of greater than 10 % was considered clinically significant as this is acknowledged as an indicator of malnutrition (ICD-10AM). The primary outcome was referred to in this paper as the outcome of weight loss. The secondary outcomes were nutritional status (PG-SGA), adherence to the H&N guideline tube feeding recommendations and type and duration of nutrition support. A proactive gastrostomy was defined as insertion prior to or within the first 2 weeks of treatment—this would have been placed prophylactically in anticipation of future need or because it was required for therapeutic tube feeding. Reactive tube feeding was defined as either a gastrostomy placed greater than 2 weeks after the start of treatment or a nasogastric feeding tube (NGT). The data were collected prospectively by the clinical dietitian. Individual chart audits and the Cancer Care Services Clinical Administration System database were used to collect missing information. Participant characteristics were summarised using mean and standard deviation for continuous variables and analysed using Student’s t tests. Categorical variables were summarised using frequencies and percentages and analysed using chi-squared tests of association. Potential explanatory and confounding variables were identified through literature review and multidisciplinary consultation. Confounders included patient characteristics such as age, gender, BMI, tumour site, tumour stage, type of cancer treatment and whether any further treatment was required due to residual or recurrent disease. Candidate explanatory variables were nutrition risk (MST score), nutritional status (PG-SGA), H&N guideline nutrition risk rating, adherence to H&N guideline tube feeding recommendations and the type of nutrition support actually provided. The primary outcome (a weight loss of 10 % or more from diagnosis to 3 months post-cancer treatment) was examined using logistic regression where purposeful selection was used to create a multivariable model by including variables from the univariate analysis with a p value
ORIGINAL ARTICLE
Nutrition outcomes following implementation of validated swallowing and nutrition guidelines for patients with head and neck cancer Teresa Brown & Lynda Ross & Lee Jones & Brett Hughes & Merrilyn Banks
Received: 13 May 2013 / Accepted: 25 February 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose Head and neck cancer patients have a high risk of malnutrition and swallowing dysfunction. This study reports on adherence and nutrition outcomes with the use of local evidence-based guidelines for the nutrition management of patients with head and neck cancer, including placement of proactive gastrostomy tubes for high risk patients. Methods This study is a prospective observational audit in patients treated for head and neck cancer at a tertiary hospital from 2007 to 2008 (n=539). Nutrition outcomes (weight, nutritional status and type of nutrition support) were compared for each nutrition risk category. Primary outcome was 10 % or more weight loss at 3 months post-treatment (n=219). Results Overall adherence to the guideline tube feeding recommendations was 81 %. High risk patients had mean weight loss of 6 % on completion of treatment and 9 % at 3 months post-treatment, despite the majority having a proactive gastrostomy tube. Medium and low risk patients also lost weight over this time. Univariate analysis found that nonadherence to the guidelines was associated with weight loss at 3 months (p=0.013). Multivariate analysis found overweight patients had 1.82 greater odds, and obese patients had 3.49 greater odds of losing weight (p=0.021). Patients This research has been presented at the 8th International Conference for Head and Neck Cancer, Toronto, Canada, July 2012. T. Brown (*) : L. Ross : M. Banks Department of Nutrition & Dietetics, Royal Brisbane and Women’s Hospital, Level 2, James Mayne Building, Butterfield St, Herston, Brisbane, QLD 4029, Australia e-mail: [email protected] L. Jones Queensland Institute of Medical Research, Brisbane, QLD, Australia B. Hughes Department of Cancer Care Services, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
with significant weight loss at diagnosis had decreased odds of losing weight later (p=0.011). Conclusion Clinically significant weight loss was still prevalent in this population despite proactive interventions. Predictors of weight loss support the evidence-based guidelines’ risk categories, and adherence was important to improve outcomes. Further research is required to determine the impact of significant weight loss in patients with high body mass index (BMI). Keywords Head and neck cancer . Prophylactic gastrostomy . Enteral feeding . Nutritional status . Nutrition
Introduction Head and neck cancer patients have a high risk of malnutrition and swallowing dysfunction secondary to the cancer itself and/or the side effects of treatment. Enteral (tube) feeding is often used in response to dysphagia, odynophagia or other side effects of treatment that lead to dehydration and/or weight loss during or after cancer treatment. Although the optimal method of tube feeding remains unclear [1], a number of benefits have been demonstrated from prophylactic gastrostomy tube feeding (a feeding tube proactively inserted prior to treatment), including earlier commencement of nutrition support [2], reduced weight loss [3, 4], improved quality of life [5–7] and reduced admissions and healthcare costs [8–10]. Risks associated with gastrostomy placement should also be considered [11], as concerns that gastrostomy placement might result in gastrostomy dependency, with longer duration of tube usage and increased dysphagia posttreatment [12, 13]. In order to assist clinical decision making, a number of studies have attempted to retrospectively determine which patient groups would benefit most from early intervention.
Support Care Cancer
Risk factors that increase dysphagia and the need for tube feeding during cancer treatment may include: the type of cancer [14–16]; type of cancer treatment [14, 17]; and at initial diagnosis of the head and neck cancer, the presence of either dysphagia [18, 19] and/or malnutrition [3, 20]. In 2006, the “Swallowing and Nutrition Management Guidelines for Patients with Head & Neck Cancer” (H&N guidelines) were developed at the Royal Brisbane and Women’s Hospital to address the lack of standardised clinical practices for swallowing intervention and tube feeding before, during and after cancer treatment. At this time, there was no national consensus or published evidence-based clinical pathways, in the UK or Australia, to support the identification and management of dysphagia and malnutrition risk in head and neck cancer patients [21]. The aims of the H&N guidelines were to assist in the identification of patients at high risk of dysphagia and malnutrition who would benefit from proactive tube feeding. Our local H&N guidelines were based on a combination of evidence from the literature and expert consensus by the hospital’s Combined Head and Neck Clinic multidisciplinary team. High risk criteria descriptions were used to determine which patients should be referred for a proactive gastrostomy tube. This could be patients who would benefit from immediate nutrition support (therapeutic gastrostomy) as well as those who would benefit based on future treatment side effects (prophylactic gastrostomy) [10]. All other medium and low risk patients who were later identified to require tube feeding during treatment would have a nasogastric or gastrostomy tube placed (reactive tube feeding). The H&N guidelines have since been validated for clinical use [22] and have been shown to reduce unplanned hospital admissions and length of stay [10]. This study reports on adherence to the H&N guideline recommendations in our hospital and the impact on weight change during and after cancer treatment. Clinical and patient characteristics associated with increased risk of 10 % weight loss or more at 3 months post-treatment were also identified.
Materials and methods Patients who attended the Combined Head and Neck Clinic at a large metropolitan tertiary referral hospital for cancer treatment from January 2007 to December 2008 were consecutively enrolled into a prospective observational cohort study to coincide with the introduction of the H&N guidelines (Fig. 1) on 1 January 2007. The H&N guidelines consist of risk categories based on patients’ tumour characteristics, treatment plan and swallowing and nutritional status and were used to rate patients’ level of nutrition risk as high, medium or low. Each risk category provided a defined pathway to guide swallowing and nutrition management by the multidisciplinary team, outlined as follows: all high risk patients were
recommended for proactive gastrostomy tube insertion and were reviewed by the dietitian and speech pathologist pretreatment, and medium and low risk patients were reviewed by the dietitian and speech pathologist from the commencement of radiotherapy or on admission for surgery. Initiation of tube feeding for all patients was recommended if oral intake fell or was anticipated to fall below 60 % of estimated energy requirement for more than 10 days during cancer treatment (estimated from 24-h recalls conducted on each dietetic review). Adherences to the recommendations for tube feeding were monitored and data collected. Outpatients were seen on a weekly basis during treatment, and inpatients were seen daily to weekly as clinically indicated as part of standard care. All patients were referred to the local allied health service on completion of treatment. Recommended follow-up was fortnightly review for the first 6 weeks post-treatment and then as required. This aspect of the guidelines, frequency of dietetic and speech pathology review, was not monitored for adherence. Patients were included in the study if they had confirmed malignant disease, planned treatment with curative intent and were referred to the dietitian as part of standard care. Exclusion criteria for the study were nonmalignant disease; palliative care or palliative intent treatment; lymphoma; and thyroid or oesophageal cancer. A blanket referral to the dietitian and speech pathologist was standard for all patients with head and neck cancer on the surgical ward, oncology ward and in radiotherapy outpatients. Some patients who attended the Combined Head and Neck Clinic initially went on to have their treatment at another public or private hospital. Others not referred were those having simple surgical procedures which usually only required an overnight stay and therefore had minimal nutrition risk. The hospital’s human research ethics committee confirmed the project conformed to the National Health and Medical Research Council ethical principles of a quality assurance study. All participants were seen as part of standard clinical practice by the multidisciplinary team: surgical and oncological specialists; dentist; speech pathologist; dietitian; and nursing staff. Swallowing function was assessed by the speech pathologist on presentation and ongoing monitoring which occurred throughout treatment in conjunction with dietitian assessments. Validated tools were used to monitor swallowing outcomes at similar time points, and these data will be presented elsewhere. Cancer site was coded using the International Classification of Diseases version 10-Australian Modifications (ICD-10AM), and stages were determined using the Union for International Cancer Control (UICC) Tumour, Node and Metastasis (TNM) staging system. Radiotherapy was usually delivered using a highly conformal 3D approach at a dose of 2 Gy/ day, 5 days/week, to total doses of 70 Gy (definitive) or 60 Gy (adjuvant). Concomitant chemotherapy was usually in the form of high-dose cisplatin.
Support Care Cancer
Royal Brisbane & Women’s Hospital: Multi-Disciplinary Team Assessment:
HIGH RISK Oral + bilateral chemoradiotherapy Midline oropharyngeal/nasopharyngeal/ pharyngeal + chemoradiotherapy
Swallowing and Nutrition Management Guidelines for Patients with Head and Neck Cancer Combined Head & Neck Clinic assessment by SP & D
Referral to local SP & D for pretreatment management
Referral to gastroenterology
Insertion of prophylactic PEG – to remain insitu for minimum 3 months
Baseline MBS pre radiotherapy & commence swallow rehabilitation
OR
Weekly review by SP & D during treatment
Ongoing review by local SP & D for at least 12 months
Team consensus to remove PEG
Dysphagia at presentation or prior to radiotherapy/chemoradiotherapy OR
HIGH RISK
Severe malnutrition at presentation: • Unintentional weight loss > 10% in 6 months • BMI < 18.5 • BMI < 20 with unintentional weight loss 5-10% in 6 months • Dietitian assessment SGA C • Poor oral intake (minimal intake > 5days and/or unlikely to improve > 5days)
NGT if anticipated for < 4weeks PEG if anticipated for > 4weeks
MEDIUM RISK All other head and neck cancers which do not fit into high or low risk category OR
MEDIUM RISK
Moderate malnutrition at presentation:
Combined Head & Neck Clinic assessment by SP & D
Weekly review by SP & D during treatment
Referral to local D for pretreatment nutrition management
• Unintentional weight loss > 5% in 6 months • BMI < 20 with unintentional weight loss up to 5% in 6 months • Dietitian assessment SGA B
LOW RISK Surgery alone, no radiotherapy required Unilateral radiotherapy alone All salivary tumours All tumours of skin in temple region and above
March 2007 Developed by the Departments of Nutrition and Dietetics and Speech Pathology and endorsed by the Combined Head and Neck Clinic, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
LOW RISK
Combined Head & Neck Clinic assessment by SP & D
Key: SP Speech = Pathologist D = Dietitian BMI = Body Mass Index SGA = Subjective Global Assessment PEG = Percutaneous Endoscopic MBS = Modified Barium Swallow Gastrostomy NGT = Nasogastric Tube
Ongoing review by local SP & D for at least 12 months
Intake < 60% requirements for > 10days
Team consensus to remove PEG/NGT
FACTORS FOR CONSIDERATION
FACTORS FOR CONSIDERATION
During Treatment
Post-Treatment
Significant or multiple combinations of the following factors may push patients up the risk categories:
Significant or multiple combinations of the following factors may push patients up the risk categories:
• Odynophagia not controlled with medication • Severe mucositis • Severe mouth ulceration • Trismus • Presence of tracheostomy • Lack of social support to manage dysphagia • Inadequate dentition • Significantly reduced appetite/taste alterations
• • • • • • • • • •
Failure to stabilise weight Severe ongoing mucositis Xerostomia Trismus Fibrosis Osteoradionecrosis Lymphoedema Inadequate dentition Stricture formation Presence of tracheostomy HMMU March ‘07 sf 0031 Morton_ai
Fig. 1 The “RBWH swallowing and nutrition management guidelines for patients with head and neck cancer.” Original Source: Validated swallowing and nutrition guidelines for patients with head and neck
cancer: Identification of high risk patients for proactive gastrostomy. Brown, Spurgin, Ross et al. Head Neck. doi:10.1002/hed.23146. Copyright © 2012 Wiley Periodicals, Inc
The Malnutrition Screening Tool (MST) [23] was selfcompleted by participants and identified those at risk of malnutrition on presentation. The MST was chosen as a validated tool to assess nutrition risk and involved two questions relating to appetite and weight loss. A score of 2 or greater (range 0 to 5) identified the patient to be at risk of malnutrition, and further assessment by the dietitian was required. Nutritional status was assessed by the dietitian using the Patient-Generated Subjective Global Assessment (PG-SGA) [24]. This was chosen as a validated tool to assess a patient’s nutritional status and encompasses assessment of the patients’ weight history, dietary intake, nutrition impact symptoms, functional/activity levels and a physical assessment of fat and muscle stores. Following assessment of each of these domains, a global rating was given; well nourished (SGA A), moderate or suspected malnutrition (SGA B), or severe malnutrition (SGA C). A PG-SGA score was calculated to indicate nutrition risk, with a score >9 indicating a critical need for improved symptom management and/or nutrition intervention options.
Clinic nursing staff measured and recorded each patient’s height and body weight on presentation using standard scales and stadiometer, and body mass index (BMI) (kg/m2) was calculated. Nutrition requirements were calculated by the dietitian using the ratio method [25]. Energy requirements (125 kJ/kg/day) and protein requirements (1.2 g/kg/day) were based on actual body weight, unless the patient was overweight (BMI >25 kg/m2), and then adjusted body weight was used. Adjusted body weight was calculated using the following equation: (IBW+[(actual body weight–IBW)×25 %]), whereby ideal body weight (IBW) was the weight at BMI 25 kg/m2. At each dietetic review, weight was monitored, and energy and protein intakes were estimated using a 24-h recall method, whereby the dietitian estimated the actual intake against standard portion sizes. Nutrition requirements were adjusted as clinically indicated. The patients’ weight and nutritional status were remeasured by the dietitian at the end of cancer treatment and 3 and 6 months post-treatment. The primary categorical outcome was defined as percentage weight loss (10 % or greater) from diagnosis to 3 months
Support Care Cancer
after the completion of treatment. A percentage weight loss of greater than 10 % was considered clinically significant as this is acknowledged as an indicator of malnutrition (ICD-10AM). The primary outcome was referred to in this paper as the outcome of weight loss. The secondary outcomes were nutritional status (PG-SGA), adherence to the H&N guideline tube feeding recommendations and type and duration of nutrition support. A proactive gastrostomy was defined as insertion prior to or within the first 2 weeks of treatment—this would have been placed prophylactically in anticipation of future need or because it was required for therapeutic tube feeding. Reactive tube feeding was defined as either a gastrostomy placed greater than 2 weeks after the start of treatment or a nasogastric feeding tube (NGT). The data were collected prospectively by the clinical dietitian. Individual chart audits and the Cancer Care Services Clinical Administration System database were used to collect missing information. Participant characteristics were summarised using mean and standard deviation for continuous variables and analysed using Student’s t tests. Categorical variables were summarised using frequencies and percentages and analysed using chi-squared tests of association. Potential explanatory and confounding variables were identified through literature review and multidisciplinary consultation. Confounders included patient characteristics such as age, gender, BMI, tumour site, tumour stage, type of cancer treatment and whether any further treatment was required due to residual or recurrent disease. Candidate explanatory variables were nutrition risk (MST score), nutritional status (PG-SGA), H&N guideline nutrition risk rating, adherence to H&N guideline tube feeding recommendations and the type of nutrition support actually provided. The primary outcome (a weight loss of 10 % or more from diagnosis to 3 months post-cancer treatment) was examined using logistic regression where purposeful selection was used to create a multivariable model by including variables from the univariate analysis with a p value
