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Case Study: Nutritional

Management of Head and Neck


Cancer
Priscilla E. Bloom
Dietetic Intern
ARAMARK Healthcare
Distance Learning Dietetic Internship
Blessing Hospital
March 9, 2014

Abstract
Nutritional management of head and neck cancer can be extremely complicated for all
health care professionals. Cancer affects every patient differently making a standardized
nutrition prescription nearly impossible. The evidence-based literature suggests enteral nutrition
is a typical recommendation for those patients suffering from head and neck cancer. Tube
feeding is recommended to prevent weight loss as weight loss plays a big influence on quality of
life and increases risk of malnutrition. Research indicates that although enteral nutrition is
standard for most head and neck cancer patients it may not prevent weight loss as efficiently as
most health care professionals assume. Continued research needs to be done to provide further
insight on the best way to better support head and neck cancer patients.
This clinical report follows a 54-year-old Caucasian male with hypopharyngeal cancer.
The patient has history of smoking and alcohol use. Upon admission the patient had difficulty
swallowing, preventing him from consuming sufficient nutrients. During his stay at the hospital
the patient had a PEG tube placed and was provided with tube feeding recommendations to
provide adequate calories and protein. The support of the health care staff and the constant
nutrition monitoring form the dietitians involved allowed the patients nutrition status to greatly
improve.
Disease Description
Hypopharyngeal cancer occurs when malignant cancer cells are found on the tissues of
the hypopharynx
1
. The pharynx can be subdivided into three categories: the nasopharynx,
oropharynx, and hypopharynx. The pharynx begins behind the nasal canal and extends to the
top of the trachea and esophagus; both air and food pass through the pharynx. The chances of
developing hypopharyngeal cancer increase with the use of tobacco products, alcohol, an
unbalanced diet, and having Plummer-Vinson syndrome, a disorder resulting in iron deficiency
and web-like growth of membranes in the throat. Upper hypopharyngeal cancer is most closely
associated with heavy drinking and smoking while lower hypopharyngeal cancer is more closely
related to nutritional deficiencies.
To determine the best method of treatment and estimate the patients outcome,
hypopharyngeal cancer can be divided into the following stages
1
:
Stage 0 (Carinoma in Situ): abnormal cells are found in the lining of the hypopharynx,
which can become cancerous or metastasize.
Stage 1: cancer has formed in the hypopharynx and/or tumor size is two centimeters or
smaller
Stage 2: in this stage the tumor is either between two and four centimeter large and has
not spread to the larynx or the tumor is found in more than area of the hypopharynx
Stage 3: the tumor is larger than 4 centimeter and/or has metastasized to the larynx,
esophagus, or nearby tissues of the hypopharynx
Stage 4:
o Tumor has spread to cartilage around the thyroid, trachea, or nearby tissue.
o Timor has spread to one or more surrounding lymph nodes
Common signs and symptoms of hypopharyngeal cancer include a persistent sore throat, ear
pain, lump in the neck, pain or difficulty swallowing, or a change in voice. There are many tests
that can help detect the presence of hypopharyngeal cancer such as a physical exam of the
throat, CT and PET scan, MRI, endoscopy, and biopsy. These tests can help determine the
stage of the cancer, if the cancer has metastasized, and as a result the best method of
treatment for the patient.
Evidence-Based Nutrition Recommendations
The Evidence Analysis Library provided by the Academy of Nutrition and Dietetics
provides recommendations for patients with head and neck cancer. One of the
recommendations provided recommended the use of enteral nutrition
8
:
Use enteral nutrition (EN) to increase calorie and protein intake for outpatients with stage
III or IV head and neck cancer undergoing intensive radiation treatment. Maintenance of
nutritional status by EN during radiation therapy may improve tolerance of therapy to
promote better outcomes.
Weight loss is a common symptom for most patients with head and neck cancer. Enteral
nutrition provides adequate nutrition to help prevent any further weight loss and muscle wasting.
Weight maintenance has been proven to improve the patients quality of life during a very
emotionally and physically stressful time in their lives
In the Role of nutritional status in predicting quality of life outcomes in cancer- a systemic
review of the epidemiological literature, by Gupta and Lammersfeld et al, researchers set out to
find the role of nutrition status in predicting quality of life
7
. Researchers compiled available
literature on the topic of nutrition and quality of life; a total of twenty-six articles were chosen. Six
of those articles investigated the correlation in patients with head and neck cancer. All six
articles concluded that better nutritional status positively correlated with quality of life, three of
which showed a relationship between weight loss and swallowing function. Although there are
many limitations to this study, such as some of the articles using small sample sizes or potential
bias, the study shows the strong relationship between nutrition and quality of life of patients with
cancer. Head and neck cancer and the treatments for such cancer can result in decreased
appetite, changes in taste, and unintentional weight loss. Many patients with head and neck
cancer typically get a PEG tube placed to provide adequate calories and protein using nutrition
supplements. It is the intent of these nutrition supplements to prevent any major weight loss
associated with their condition.
Ehrsson and Langius-Eklof et al completed a retrospective single-institution cohort study
on Nutritional Surveillance and Weight Loss in Head and Neck Cancer Patients. This 2-year
study evaluated if therapeutic approach, tumor site, tumor stage, BMI, gender, age, and civil
status predicted body weight loss
6
. This research found that the strongest predictor for weight
loss was tumor stage (p < 0.001). Additionally this study found that the mean maximum weight
loss for patients receiving EN and per oral feeding was 13% and 6% respectively (p <0.001). Of
the participants in the study, those receiving EN showed significantly more weight loss than
those participants that could eat orally. Many professionals in the past who work with patients
receiving treatment for head and neck cancer show an inclination towards inserting a PEG tube
prior or at the initiation of treatment. As research shows a strong correlation between weight
loss, malnutrition and poor quality of life, many professionals want to curtail this by initiating EN
immediately. The research provided in this study, however, supports a wait-and-see approach
to PEG insertion. A weight loss of more than 5% was seen in EN patients receiving both
radiation and combined treatments, providing evidence of the importance of encouraging
patients to consume food orally. As the researchers in this study delved more into this topic they
found further research to support their findings, finding Nguyen et al reporting that 98% of head
and neck cancer patients in their study receiving PEG before chemoradiation therapy lost weight
despite being started on EN immediately. The limitation of this study is the study design
preventing an adequate power analysis restricting generalization. Acknowledging the limitation
the study supports nutritional surveillance of patients with head and neck cancer, closely
monitoring those with advance tumor stage, however, it suggests further research needs to be
done to identify more effective ways of preventing weight loss.
Case Presentation
A 52-year old Caucasian male who had a scheduled follow up with his physician. Upon
arrival the patient presented with severe hyperglycemia with a blood sugar of 712. The patient
was also found to be hyponatremic with sodium of 120 and a creatinine level of 2.4 with a GFR
of 30. Patient was recently diagnosed with moderately differntiated squamous cell carcinoma of
the hypopharynx and was receiving chemotherapy and radiation treatment.
Nutrition Care Process: Assessment
Client History
The patient is married and lives at home with his wife. The patient has a significant
history of alcohol use and had a 30-50 pack year history of smoking, although, he stated that he
quit six months ago. Family history shows that cancer is prevalent in this patients family with his
father passing away from cancer at the age of 69 and his mother passing away at the age of 68
from liver and bone cancer. The patients medial history is remarkable for diabetes and
compensated liver cirrhosis of unknown etiology and hypopharyngeal cancer.
Food/Nutrition-Related History
Several factors affected the patients food choices but the patient did not report a specific
diet or the use of supplements. The medication the patient took coincided with the medical
treatment for his cancer. Medical record indicates the patient was taking the following
medications: Hydrochlorothiazide 12.5 mg one table by mouth daily, Lisonopril 20 mg one table
by mouth daily, Metoprolol 100 mg one table by mouth, Compazine 10 mg one tablet by mouth
every 6 hours as needed for nausea and vomiting. Common side effects from these medications
include diarrhea, constipation, dry mouth, nausea, and decreased appetite
(2,3,4,5,6,)
. The patient
was previously on Glipizide 5 mg by mouth twice a day, and was previously on Metformin 1000
mg one table by mouth twice a day. Glipizde and Metformin were both on hold at the time of
admission.
Nutrition-Focused Physical Findings
The side effects of the cancer combined with the radiation therapy caused severe
swallowing difficulties. The patient also had his teeth removed in preparation for dentures, which
prevented him from eating solid foods. The swallowing difficulties and tooth lose combined with
the present taste alterations reported by the patient decreased his overall p.o. intake. Due to the
many things affecting p.o. intake and the subsequent weight loss the patient reported to drink
around three Glucerna Shakes a day to provide additional calories and protein, and mentioned
that the shakes served as a pick me up during the day. During admission the patient was
placed on an 1800 calories ADA diet to help control his blood sugars and provide adequate
calories and protein.
Anthropometric Measurements
At the time of admission the patients height was 5 feet 9 inches and weighed 240#. BMI
was 35.4 indicating obesity. Prior to admission the patient was being followed by the RD at the
Blessing Hospital outpatient Cancer Center; the RD reported a weight loss of 13# after five
weeks of treatment.
Biochemical Data, Medical Tests, and Procedures
Relevant laboratory data upon admission can be found on Table 1 in the appendix.
The lab values provided in this table are nutrition related lab values reviewed for every patient
upon assessment. Although the patient was admitted with hyperglycemia and uncontrolled
diabetes it was during this hospital stay that the physician decided to insert a PEG tube and to
begin tube feeding.
Nutrient Needs
Daily macronutrient requirements were as follows: 2181 kcal,109 g protein and 2181mL
fluid. Estimated needs were based on patients current cancer condition, and ideal body weight
as actual body weight was greater than 125% IBW. Estimated needs are based on the
guidelines provided by the Nutrition Care Manual. Calculations can be found in the appendix
under table 2.
ARAMARK Nutrition Status Classifications
Utilizing the ARAMARK Nutrition Status Classification Worksheet, the patient was
found to be at moderate nutrition risk (8-11 points) for the following:
Fair appetite (75% of needs for > 2 weeks) (2 points)
BMI Range >35-39 (3 points)
Albumin 3.0-3.4/Prealbumin 10-15 (2 points)
Uncontrolled Diabetes (3 points)
ARAMARK Healthcare. Assessment and education policy #2: Nutrition Care Priority
Points: Adults. New RD Training Manual. Updated May 2013.
Malnutrition Identification
The Academy and A.S.P.E.N collaboration to standardize the diagnosis of adult
malnutrition provides a tool to determine if this patient suffers or shows evidence of
malnutrition
9
. This tool provides six major characteristics were identified that suggests
malnutrition; a patient that has 2 or more of these characteristics is more likely to be diagnosed
with malnutrition. The characteristics include:
Insufficient energy intake
Weight loss
Loss of muscle mass
Loss of subcutaneous fat
Localized or generalized fluid accumulation that may sometimes mask weight loss
Diminished functional status as measured by handgrip strength.
At the time of admission the patient only showed signs of one of the characteristics, that being
insufficient energy intake. The patient reported fair appetite, 75% of needs, prior to admission.
Information on the patients chart did not show any weight loss, muscle mass, fluid accumulation,
etc. Although the patient did not show signs of malnutrition at the time of admission, follow up
visits at the Blessing Hospital Cancer center showed evidence of weight loss post admission
qualifying him for the diagnosis of chronic disease - related malnutrition.
Nutrition Care Process: Nutrition Diagnosis
Upon assessing the patient the most relevant diagnosis is as follows:
Swallowing difficulty (NC-1.1) RT mechanical causes AEB pt's comments, decreased estimated
food intake, reports of drinking Ensure TID prior to admission.
Nutrition Care Process: Intervention
Appropriate interventions were evaluated in order to determine the best method of
treatment for the patient:
1. Carbohydrate-modified diet (ND-1.2): Continue with 1800 ADA diet, as tolerated by patient, to
meet caloric needs and aid with glucose control.
2. Commercial beverage (ND-3.1.1): Will send Glucerna TID per pt's request. Glucerna TID will
provide additional 660 kcal and 29.7 g protein 432mL water if consumed.
3. Enteral Nutrition (2.1): See recommendations above for continuous and bolus feedings with
Glucerna shakes TID.
Nutritional goals
1. Patient will drink 100% supplement
2. Tolerance to enteral nutrition
3. Maintain skin integrity
4. Maintain current weight
5. Nutrition labs within normal limits
Nutrition Care Process: Monitoring and Evaluation
In order to monitor the patients nutritional status and indicate whether the interventions
were appropriate the following was monitored:
Nutrition-Focused Physical Findings (PD): skin (1.1.8)
Anthropometric Measurements: weight/weight change (1.1)
Biochemical Data, Medical Tests and Procedures (BD): glucose (1.5),
Food/Nutrition-Related History (FH): Enteral nutrition (1.3), nutritional supplements (1.2.1)
The dietitian at the Cancer Center continued to monitor the patient providing more details about
the patient post admission. The dietitian determined a 13-pound (6%) weight loss over the
course of five weeks. Directly post admission patient continued to lose weight and blood sugars
remained high. The RD following the patient decided to change the tube feeding
recommendations due to the availability of the product for the patient. New recommendations
were as follows: Glucerna 1.2 with 2,000ml/day (2-1,000 bags available currently at Denmans)
in bolus feeds of 500ml four times/day to provide 2400 kcals and 120 g PRO.

Conclusion
Patients with head and neck cancer suffer from many symptoms that increase their risk
for malnutrition. Nutritional interventions are typically surrounded on enteral nutrition. As a result
of the treatment and the cancer site many patients have difficulty swallowing preventing them
from consuming sufficient nutrients. Enteral nutrition as been found to aid with weight loss
associated with swallowing difficulties, however, research has provided evidence that oral intake
should still be the preferred method of nutrient intake.
Intern was allowed to sit in on the last follow up visit with the patient who reported a 14
pound weight gain and better swallowing function. The patient did report some taste alterations
but overall the patient and his wife seemed to be very excited over the patients improvement.













APPENDIX
Table 1
Measurement Value Normal
Glucose 349 65-100 MG/DL
BUN 12.3 7.0-24.0 MG/DL
Creatinine 1 0.6-1.2 MG/DL
GFR 86 >99 ML/MIN/1.73M*M
GOT/AST 16 10-40 U/L
GPT/ALT 13 10-47 U/L
Albumin 3.1 4.1-5.3 GM/DL
Sodium 125 136-144 MMOL/L
Potassium 3.4 3.4-4.8 MMOL/L
Table 2
Anthropometrics
Height Weight IBW BMI
69 inches 240# (108.8 kg) 159.85 35.4
Macronutrient Needs
REE Protein
30 kcals x 72.7 kg IBW =
2181 kcal/day
1.5 g x 72.7 kg IBW=
109 g/day
Resources
1.Hypopharyngeal Cancer Treatment (PDQ). National Cancer Institute at the National institutes
of Health.
http://www.cancer.gov/cancertopics/pdq/treatment/hypopharyngeal/HealthProfessional Updated
on February 28, 2014. Accessed on March 2, 2014.
2. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682571.html#side-effects
3. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a692051.html#side-effects
4. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682864.html#side-effects
5. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682116.html#side-effects
6. Ehrrson Y, Langius-Eklof A, Laurell G. Nutritional surveillance and weight loss in head and
neck cancer patients. Support Care Cancer. 2012; 20: 757-756.
7. Lis C, Gupta D, Lammerfeld C, Markman M, Vashi M. Role of nutritional status in predicting
quality of life outcomes in cancer- a systemic review of the epidemiological literature. Lis et al,
Nutrition Journal. 2012; 11(27): 1-18.
8. Oncology (Onc) Head and Neck Cancer: Radiation and Use of Enteral Nutrition (EN).
Evidence Analysis Library.
http://andevidencelibrary.com/template.cfm?template=guide_summary&key=1754&highlight=Ra
diation%20and%20Use%20of%20Enteral%20Nutrition&home=1. Accessed on March 6, 2014.
9. White J, Guenter P, Jensen G, et al. Consensus Statement: Academy of Nutrition and
Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics
Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition).
Journal of Parenteral and Enteral Nutrition. 2012; 36: 275-283.