Current Gastroenterology Reports

, Volume 14, Issue 4, pp 349–355 | Cite as

Nutrition Support and Therapy in Patients with Head and Neck Squamous Cell Carcinomas

  • Arvin C. Gee
  • Laszlo Kiraly
  • Mary S. McCarthy
  • Robert Martindale
Nutrition and Obesity (S McClave, Section Editor)

Abstract

Head and neck squamous cell carcinomas (HNSCC) present a unique set of challenges in both the treatment of the disease and in support of the patient afflicted with the cancer. A major challenge is the nutritional support of these patients. Often, patients with HNSCC are malnourished at baseline due to an underlying dysphagia. Many others develop dysphagia as a result of their surgical resection and external beam radiation therapy. This dysphagia further exacerbates the chronic dehydration and malnutrition. This article will review strategies to provide nutritional support to HNSCC patients and also to review nutritional strategies that may decrease the morbidity and mortality associated with HNSCC treatment.

Keywords

Head and neck squamous cell carcinomas Nutrition support Nutrition in head and neck cancer 

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Society AC. Cancer Facts & Figures 2012. Atlanta: American Cancer Society; 2012.Google Scholar
  2. 2.
    Scully C. Oral cancer aetiopathogenesis; past, present and future aspects. Med Oral, Patol Oral Y Cir Bucal. 2011;16(3):e306–11.CrossRefGoogle Scholar
  3. 3.
    Einstein MH, Schiller JT, Viscidi RP, Strickler HD, Coursaget P, Tan T, et al. Clinician’s guide to human papillomavirus immunology: knowns and unknowns. Lancet Infect Dis. 2009;9(6):347–56. doi:10.1016/S1473-3099(09)70108-2.PubMedCrossRefGoogle Scholar
  4. 4.
    Li G, Sturgis EM. The role of human papillomavirus in squamous carcinoma of the head and neck. Curr Oncol Rep. 2006;8(2):130–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Gillison ML, Broutian T, Pickard RK, Tong ZY, Xiao W, Kahle L, et al. Prevalence of oral HPV infection in the United States, 2009-2010. JAMA. 2012;307(7):693–703. doi:10.1001/jama.2012.101.PubMedCrossRefGoogle Scholar
  6. 6.
    Cerchietti LC, Navigante AH, Lutteral MA, Castro MA, Kirchuk R, Bonomi M, et al. Double-blinded, placebo-controlled trial on intravenous L-alanyl-L-glutamine in the incidence of oral mucositis following chemoradiotherapy in patients with head-and-neck cancer. Int J Radiat Oncol Biol Phys. 2006;65(5):1330–7. doi:10.1016/j.ijrobp.2006.03.042.PubMedCrossRefGoogle Scholar
  7. 7.
    Capuano G, Grosso A, Gentile PC, Battista M, Bianciardi F, Di Palma A, et al. Influence of weight loss on outcomes in patients with head and neck cancer undergoing concomitant chemoradiotherapy. Head Neck. 2008;30(4):503–8. doi:10.1002/hed.20737.PubMedCrossRefGoogle Scholar
  8. 8.
    van Bokhorst-de van der S, van Leeuwen PA, Kuik DJ, Klop WM, Sauerwein HP, Snow GB, et al. The impact of nutritional status on the prognoses of patients with advanced head and neck cancer. Cancer. 1999;86(3):519–27. doi:10.1002/(SICI)1097-0142(19990801)86:3<519::AID-CNCR22>3.0.CO;2-S.CrossRefGoogle Scholar
  9. 9.
    Colasanto JM, Prasad P, Nash MA, Decker RH, Wilson LD. Nutritional support of patients undergoing radiation therapy for head and neck cancer. Oncology (Williston Park). 2005;19(3):371–9. discussion 80-2, 87.Google Scholar
  10. 10.
    Cox JD, Pajak TF, Marcial VA, Coia L, Mohiuddin M, Fu KK, et al. Interruptions adversely affect local control and survival with hyperfractionated radiation therapy of carcinomas of the upper respiratory and digestive tracts. New evidence for accelerated proliferation from Radiation Therapy Oncology Group Protocol 8313. Cancer. 1992;69(11):2744–8.PubMedCrossRefGoogle Scholar
  11. 11.
    •• Paccagnella A, Morello M, Da Mosto MC, Baruffi C, Marcon ML, Gava A, et al. Early nutritional intervention improves treatment tolerance and outcomes in head and neck cancer patients undergoing concurrent chemoradiotherapy. Support Care Cancer. 2010;18(7):837–45. doi:10.1007/s00520-009-0717-0. This study demonstrated that initiation of pre‐therapy nutritional support lead to a decreased weight loss and the number of unplanned hospitalizations. Additionally, the study demonstrated increased tolerance to external beam radiation therapy. PubMedCrossRefGoogle Scholar
  12. 12.
    Rabinovitch R, Grant B, Berkey BA, Raben D, Ang KK, Fu KK, et al. Impact of nutrition support on treatment outcome in patients with locally advanced head and neck squamous cell cancer treated with definitive radiotherapy: a secondary analysis of RTOG trial 90-03. Head Neck. 2006;28(4):287–96. doi:10.1002/hed.20335.PubMedCrossRefGoogle Scholar
  13. 13.
    Ravasco P, Monteiro-Grillo I, Marques Vidal P, Camilo ME. Impact of nutrition on outcome: a prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head Neck. 2005;27(8):659–68. doi:10.1002/hed.20221.PubMedCrossRefGoogle Scholar
  14. 14.
    Scully C, Epstein J, Sonis S. Oral mucositis: a challenging complication of radiotherapy, chemotherapy, and radiochemotherapy: part 1, pathogenesis and prophylaxis of mucositis. Head Neck. 2003;25(12):1057–70. doi:10.1002/hed.10318.PubMedCrossRefGoogle Scholar
  15. 15.
    Stokman MA, Spijkervet FK, Boezen HM, Schouten JP, Roodenburg JL, de Vries EG. Preventive intervention possibilities in radiotherapy- and chemotherapy-induced oral mucositis: results of meta-analyses. J Dent Res. 2006;85(8):690–700PubMedCrossRefGoogle Scholar
  16. 16.
    Kubota A, Meguid MM, Hitch DC. Amino acid profiles correlate diagnostically with organ site in three kinds of malignant tumors. Cancer. 1992;69(9):2343–8.PubMedCrossRefGoogle Scholar
  17. 17.
    • Garcia-Peris P, Paron L, Velasco C, de la Cuerda C, Camblor M, Breton I, et al. Long-term prevalence of oropharyngeal dysphagia in head and neck cancer patients: impact on quality of life. Clin Nutr. 2007;26(6):710–7. doi:10.1016/j.clnu.2007.08.006. Retrospective study of patients who have undergone treatment for HNSCC. The authors are able to detail the effects of HNSCC treatment on dysphagia and quality of life.PubMedCrossRefGoogle Scholar
  18. 18.
    • Lango MN, Egleston B, Ende K, Feigenberg S, D’Ambrosio DJ, Cohen RB, et al. Impact of neck dissection on long-term feeding tube dependence in patients with head and neck cancer treated with primary radiation or chemoradiation. Head Neck. 2010;32(3):341–7. doi:10.1002/hed.21188. This is a retrospective study in which up to 75% of HNSCC patients who underwent a major surgical resection remained dependent on a feeding tube for nutritional support at 2 years after completion of therapy.PubMedGoogle Scholar
  19. 19.
    Chang JH, Gosling T, Larsen J, Powell S, Scanlon R, Chander S. Prophylactic gastrostomy tubes for patients receiving radical radiotherapy for head and neck cancers: a retrospective review. J Med Imaging Radiat Oncol. 2009;53(5):494–9. doi:10.1111/j.1754-9485.2009.02103.x.PubMedCrossRefGoogle Scholar
  20. 20.
    Loser C, Aschl G, Hebuterne X, Mathus-Vliegen EM, Muscaritoli M, Niv Y, et al. ESPEN guidelines on artificial enteral nutrition–percutaneous endoscopic gastrostomy (PEG). Clin Nutr. 2005;24(5):848–61.PubMedCrossRefGoogle Scholar
  21. 21.
    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(3):192–8. doi:10.1016/j.clon.2010.01.008.CrossRefGoogle Scholar
  22. 22.
    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(3):177–89. doi:10.1111/j.1749-4486.2010.02128.x.PubMedCrossRefGoogle Scholar
  23. 23.
    Cruz I, Mamel JJ, Brady PG, Cass-Garcia M. Incidence of abdominal wall metastasis complicating PEG tube placement in untreated head and neck cancer. Gastrointest Endosc. 2005;62(5):708–11. doi:10.1016/j.gie.2005.06.041. quiz 52, 53.PubMedCrossRefGoogle Scholar
  24. 24.
    Patterson J, Wilson JA. The clinical value of dysphagia preassessment in the management of head and neck cancer patients. Curr Opin Otolaryngol Head Neck Surg. 2011;19(3):177–81. doi:10.1097/MOO.0b013e328345aeb0.PubMedCrossRefGoogle Scholar
  25. 25.
    Corry J, Poon W, McPhee N, Milner AD, Cruickshank D, Porceddu SV, et al. Prospective study of percutaneous endoscopic gastrostomy tubes versus nasogastric tubes for enteral feeding in patients with head and neck cancer undergoing (chemo)radiation. Head Neck. 2009;31(7):867–76. doi:10.1002/hed.21044.PubMedCrossRefGoogle Scholar
  26. 26.
    •• Madhoun MF, Blankenship MM, Blankenship DM, Krempl GA, Tierney WM. Prophylactic PEG placement in head and neck cancer: how many feeding tubes are unused (and unnecessary)? World J Gastroenterol. 2011;17(8):1004–8. doi:10.3748/wjg.v17.i8.1004. This prospective study compared patients who received a prophylactic PEG tube to those who were treated with a nasogastric tube. The authors found that while a PEG tube lead to a decreased amount of post‐therapy weight loss, patients who received a prophylactic tube had a longer time of dependence on tube feeds and were also more likely to develop long‐term dysphagia. PubMedCrossRefGoogle Scholar
  27. 27.
    •• Nourissat A, Bairati I, Samson E, Fortin A, Gelinas M, Nabid A, et al. Predictors of weight loss during radiotherapy in patients with stage I or II head and neck cancer. Cancer. 2010;116(9):2275–83. doi:10.1002/cncr.25041. The authors in this study were able to determine that nearly 50% of patients who underwent the prophylactic placement of a PEG tube either did not use the tube or used it for less than 2 weeks. The authors strongly argue against routine placement of a PEG tube prior to HNSCC therapy.PubMedGoogle Scholar
  28. 28.
    Nugent B, Lewis S, O’Sullivan JM. Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy. Cochrane Database Syst Rev. 2010(3):CD007904. doi:10.1002/14651858.CD007904.pub2.
  29. 29.
    Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr. 1987;11(1):8–13.PubMedCrossRefGoogle Scholar
  30. 30.
    O’Neill JP, Shaha AR. Nutrition management of patients with malignancies of the head and neck. Surg Clin North Am. 2011;91(3):631–9. doi:10.1016/j.suc.2011.02.005.PubMedCrossRefGoogle Scholar
  31. 31.
    van Bokhorst-de van der Schueren MA, van Leeuwen PA, Sauerwein HP, Kuik DJ, Snow GB, Quak JJ. Assessment of malnutrition parameters in head and neck cancer and their relation to postoperative complications. Head Neck. 1997;19(5):419–25. doi:10.1002/(SICI)1097-0347(199708)19:5<419::AID-HED9>3.0.CO;2-2.PubMedCrossRefGoogle Scholar
  32. 32.
    • Boger RH. The pharmacodynamics of L-arginine. J Nutr. 2007;137(6 Suppl 2):1650S–5S. A prospective study that show that pre‐operative malnutrition was common in HNSCC patients, and that this chronic malnutrition lead to an increased risk of post‐operative complications. PubMedGoogle Scholar
  33. 33.
    Zhou M, Martindale RG. Arginine in the critical care setting. J Nutr. 2007;137(6 Suppl 2):1687S–92S.PubMedGoogle Scholar
  34. 34.
    de Luis DA, Izaola O, Cuellar L, Terroba MC, Martin T, Aller R. Clinical and biochemical outcomes after a randomized trial with a high dose of enteral arginine formula in postsurgical head and neck cancer patients. Eur J Clin Nutr. 2007;61(2):200–4. doi:10.1038/sj.ejcn.1602515.PubMedCrossRefGoogle Scholar
  35. 35.
    •• De Luis DA, Izaola O, Cuellar L, Terroba MC, Martin T, Aller R. High dose of arginine enhanced enteral nutrition in postsurgical head and neck cancer patients. A randomized clinical trial. Eur Rev Med Pharmacol Sci. 2009;13(4):279–83. This is a small randomized control trial that demonstrated benefit to arginine supplementation. These researchers noted a significant decrease in the rate of fistula formation after surgical resection of oral and laryngeal cancer.PubMedGoogle Scholar
  36. 36.
    De Luis DA, Izaola O, Cuellar L, Terroba MC, Martin T, Ventosa M. A randomized double-blind clinical trial with two different doses of arginine enhanced enteral nutrition in postsurgical cancer patients. Eur Rev Med Pharmacol Sci. 2010;14(11):941–5.PubMedGoogle Scholar
  37. 37.
    van Bokhorst-De Van Der Schueren MA, Quak JJ, von Blomberg-van der Flier BM, Kuik DJ, Langendoen SI, Snow GB, et al. Effect of perioperative nutrition, with and without arginine supplementation, on nutritional status, immune function, postoperative morbidity, and survival in severely malnourished head and neck cancer patients. Am J Clin Nutr. 2001;73(2):323–32.PubMedGoogle Scholar
  38. 38.
    Buijs N, Langius JA, Leemans CR, Kuik DJ, Vermeulen MA, et al. Perioperative arginine-supplemented nutrition in malnourished patients with head and neck cancer improves long-term survival. Am J Clin Nutr. 2010;92(5):1151–6. doi:10.3945/ajcn.2010.29532.PubMedCrossRefGoogle Scholar
  39. 39.
    •• Pribis JP, Zhu X, Vodovotz Y, Ochoa JB. Systemic arginine depletion after a murine model of surgery or trauma. JPEN J Parenter Enteral Nutr. 2012;36(1):53–9. doi:10.1177/0148607111414579. The authors of this randomized control trial were able to show that arginine supplementation, in addition to standard nutritional support, in chronically malnourished patients undergoing HNSCC treatment had improved survival and locoregional disease control. All of the patients in this study received enteral nutrition via a nasogastric tube for 7‐10 days prior to onset of therapy and those in the arginine arm, did not receive arginine supplementation for more than 10 days in the post‐operative period.PubMedCrossRefGoogle Scholar
  40. 40.
    Sippel TR, White J, Nag K, Tsvankin V, Klaassen M, Kleinschmidt-DeMasters BK, et al. Neutrophil degranulation and immunosuppression in patients with GBM: restoration of cellular immune function by targeting arginase I. Clin Cancer Res. 2011;17(22):6992–7002. doi:10.1158/1078-0432.CCR-11-1107.PubMedCrossRefGoogle Scholar
  41. 41.
    Stechmiller JK, Childress B, Porter T. Arginine immunonutrition in critically ill patients: a clinical dilemma. Am J Crit Care: an official publication, American Association of Critical-Care Nurses. 2004;13(1):17–23.Google Scholar
  42. 42.
    Kim H. Glutamine as an immunonutrient. Yonsei Med J. 2011;52(6):892–7. doi:10.3349/ymj.2011.52.6.892.PubMedCrossRefGoogle Scholar
  43. 43.
    Ryan AM, Reynolds JV, Healy L, Byrne M, Moore J, Brannelly N, et al. Enteral nutrition enriched with eicosapentaenoic acid (EPA) preserves lean body mass following esophageal cancer surgery: results of a double-blinded randomized controlled trial. Ann Surg. 2009;249(3):355–63. doi:10.1097/SLA.0b013e31819a4789.PubMedCrossRefGoogle Scholar
  44. 44.
    Senkal M, Geier B, Hannemann M, Deska T, Linseisen J, Wolfram G, et al. Supplementation of omega-3 fatty acids in parenteral nutrition beneficially alters phospholipid fatty acid pattern. JPEN J Parenter Enteral Nutr. 2007;31(1):12–7.PubMedCrossRefGoogle Scholar
  45. 45.
    Tsekos E, Reuter C, Stehle P, Boeden G. Perioperative administration of parenteral fish oil supplements in a routine clinical setting improves patient outcome after major abdominal surgery. Clin Nutr. 2004;23(3):325–30. doi:10.1016/j.clnu.2003.07.008.PubMedCrossRefGoogle Scholar
  46. 46.
    Wichmann MW, Thul P, Czarnetzki HD, Morlion BJ, Kemen M, Jauch KW. Evaluation of clinical safety and beneficial effects of a fish oil containing lipid emulsion (Lipoplus, MLF541): data from a prospective, randomized, multicenter trial. Crit Care Med. 2007;35(3):700–6. doi:10.1097/01.CCM.0000257465.60287.AC.PubMedCrossRefGoogle Scholar
  47. 47.
    Weed HG, Ferguson ML, Gaff RL, Hustead DS, Nelson JL, Voss AC. Lean body mass gain in patients with head and neck squamous cell cancer treated perioperatively with a protein- and energy-dense nutritional supplement containing eicosapentaenoic acid. Head Neck. 2011;33(7):1027–33. doi:10.1002/hed.21580.PubMedCrossRefGoogle Scholar
  48. 48.
    De Stefani E, Oreggia F, Boffetta P, Deneo-Pellegrini H, Ronco A, Mendilaharsu M. Tomatoes, tomato-rich foods, lycopene and cancer of the upper aerodigestive tract: a case-control in Uruguay. Oral Oncol. 2000;36(1):47–53.PubMedCrossRefGoogle Scholar
  49. 49.
    Andic F, Garipagaoglu M, Yurdakonar E, Tuncel N, Kucuk O. Lycopene in the prevention of gastrointestinal toxicity of radiotherapy. Nutr Cancer. 2009;61(6):784–8. doi:10.1080/01635580903285171.PubMedCrossRefGoogle Scholar
  50. 50.
    Marik PE, Zaloga GP. Immunonutrition in high-risk surgical patients: a systematic review and analysis of the literature. JPEN J Parenter Enteral Nutr. 2010;34(4):378–86. doi:10.1177/0148607110362692.PubMedCrossRefGoogle Scholar
  51. 51.
    Casas-Rodera P, Gomez-Candela C, Benitez S, Mateo R, Armero M, Castillo R, et al. Immunoenhanced enteral nutrition formulas in head and neck cancer surgery: a prospective, randomized clinical trial. Nutr Hosp. 2008;23(2):105–10.PubMedGoogle Scholar
  52. 52.
    • Felekis D, Eleftheriadou A, Papadakos G, Bosinakou I, Ferekidou E, Kandiloros D, et al. Effect of perioperative immuno-enhanced enteral nutrition on inflammatory response, nutritional status, and outcomes in head and neck cancer patients undergoing major surgery. Nutr Cancer. 2010;62(8):1105–12. doi:10.1080/01635581.2010.494336. This study found that an “immune‐enhancing” formula and an arginine supplemented formula were equivalent in their ability to reduce the risk of HNSCC patients developing post‐operative complications and infections as compared to a “standard” formula. The study was not able to identify any differences in biochemical markers used for nutritional status or for inflammation.PubMedCrossRefGoogle Scholar
  53. 53.
    • Sorensen D, McCarthy M, Baumgartner B, Demars S. Perioperative immunonutrition in head and neck cancer. Laryngoscope. 2009;119(7):1358–64. doi:10.1002/lary.20494. This study also supports the use of “immune‐enhancing” formulas in the peri‐operative period for HNSCC patients. The authors of this study also were unable to detect any changes in biochemical markers of patients in the study group as compared to the control group.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Arvin C. Gee
    • 1
  • Laszlo Kiraly
    • 2
  • Mary S. McCarthy
    • 3
  • Robert Martindale
    • 2
  1. 1.Legacy Emanuel Trauma ServicesLegacy Emanuel Medical CenterPortlandUSA
  2. 2.Oregon Health and Science UniversityPortlandUSA
  3. 3.Madigan Healthcare SystemTacomaUSA

Personalised recommendations