NUTRITION

H E A D and N E C K C A N C ER
MELLANIE B. VICTORIA

H E A D and N E C K C A N C E R

H E A D and N E C K C A N C E R
3-5% new cancers (developed countries) 6th most common cause of CA and cause of CA mortality Nasal cavity, sinuses, lips, oral cavity, salivary glands, pharynx, larynx, esophagus, neck Squamous Cell Carcinoma (90%) 5 year survival rate: 52%

H E A D and N E C K C A N C E R
Major risk factors: Alcohol abuse & Smoking
Gender: Men 2-3xs > than women Race: African Americans at greatest risk Age: >40 years Sun Exposure Poor Oral Hygiene

Poorly Fitting Dentures

Poor Nutrition (low in vitamins A & B) Environmental/Occupational Hazards Epstein-Barr Virus, HPV 16 Exposure to Secondhand Smoke!!!!!

WHY NUTRITION IS IMPORTANT?

WHY NUTRITION IS IMPORTANT?

Estimated that over 50% of H&N cancer patients are malnourished
Many present at a very advanced stage of the disease Patients with advanced disease at risk of developing Cancer Anorexia Cachexia Syndrome (CACS) Suspect if involuntary wt loss of >5% of premorbid weight within 6 month period

Tumor obstruction of food passage

Significant weight loss Malnutrition

MALNUTRITION

MALNUTRITION
Malnutrition has significant impact on morbidity, mortality and quality of life for cancer patients

Head & neck cancer patients shown to have a significant decrease in survival at 2 years if malnourished (57.5% vs. 7.5%) (Brookes, et al).
Causes:
Diminished nutrient intake Increased nutrient demand not matched by intake Tumor-induced derangements

C A U S E S OF M A L N U T R I T I

C A U S E S OF M A L N U T R I T I
Diminished nutrient intake
Alcohol & Tobacco Poor dentition Partial or complete obstruction of aerodigestive tract Trismus Post-surgical functional and anatomic impairments of chewing and swallowing Post-XRT mucositis, dysgeusia, xerostomia Chemotherapy-induced nausea, vomiting

Increased nutrient losses

Vomiting Diarrhea

C A U S E S OF M A L N U T R I T I
Increased nutrient demand
Cancer Anorexia Cachexia Syndrome (CACS) Metabolic stress caused by surgery, Radiotherapy and/or Chemotherapy (dependent on intensity and duration of treatment)

Tumor-induced Metabolic abnormalities

Abnormal metabolism of carbohydrates, lipids, and protein Abnormal levels of neurotransmitters leading to anorexia Increased basal metabolic rate Cytokines appear to mediate these abnormalities Tumor necrosis factor, IL-1, IL-6

E F F E C T S OF T R E A T M E N

E F F E C T S OF T R E A T M E N
SURGERY
Side effects Oropharyngeal dysfunction Dysphagia Postoperative complications Infection Orocutaneous fistulas Wound dehiscence

CHEMORADIATION
Side effects Chewing / swallowing difficulties Nausea Altered taste sensation Xerostomia Changes in saliva viscosity Stomatitis Mucositis Anorexia

NUTRITIONAL MGT STRATEGIES FO

Problems Anorexia Strategies Eat 5 or 6 small meals instead of 3 larger meals. If allowed, use an appetite stimulant. Provide a relaxed, pleasant atmosphere for meals. Make meals more enjoyable. Respond to hunger even if it is not at conventional meal times. Keep snacks handy to eat when hungry: hard cooked eggs, peanut butter, cheese, ice cream, crackers, pretzels, nutritional drinks. Eat high-calorie, high protein foods at meals and snack time. Experiment with new foods. Modify foods to a soft consistency; avoid rough-textured foods. Drink 6-8 cups of fluid daily Use liquid nutritional supplements if patient cannot eat enough food Add sauces, gravies, and juices Use thickening products like gelatin, flour, commercial thickeners, pureed vegetables, instant potatoes, baby rice cereal to adjust consistency of foods for ease in swallowing.

Chewing and swallowing difficulty

NUTRITIONAL MGT STRATEGIES FO

Problems Strategies Mouth Avoid tart, acidic or salty beverages and foods. Avoid rough-textured foods sore such as dry toast, crackers and raw fruits and vegetables. Adjust food temp for tolerance; choose cool or lukewarm foods. Skip irritating spices such as chili powder, curry, hot sauces, nutmeg, and pepper. Season with herbs instead. Eat soft, bland, creamy foods such as cream soups, cheese, yogurt, mashed potatoes, milk shakes, and commercial liquid supplements Blend and moisten dry or solid foods. Puree or liquefy foods in a blender to make them easier to swallow Drink liquid with meals; through a straw to bypass mouth sores. Eat high protein, high-calorie foods to speed healing. Rinse mouth often with baking soda to remove food and germs.

NUTRITIONAL MGT STRATEGIES FO

Problems Strategies Mouth Drink 8-12 cups of liquid daily to loosen mucus. Dryness Drink liquid through a straw. or Eat soft bland foods cold or at room temperature, try blenderized thick fruits and vegetables; soft cooked chicken and fish; saliva well-thinned cereals; popsicles and slushies Moisten foods with broth, soup, sauce, gravy, butter, or margarine. Suck on sour lemon drops, popsicles or ice chips but avoid chewing ice cubes which can damage the teeth. Keep mouth clean with soft-bristle toothbrush; rinse mouth before and after eating with water or mild mouth rinse and floss regularly. Avoid commercial mouthwashes, alcohol and acidic beverages, and tobacco. Limit caffeinated drinks and foods that have a diuretic effect: coffee, tea, cola, chocolate.

NUTRITIONAL MGT STRATEGIES FO

Problems Taste alterations and Aversions Strategies Provide cold or room temperature foods Avoid foods with strong odors or tastes Experiment with seasonings and flavorings. Season foods with tart flavors (lemon, calamansi, other citrus fruit vinegar) or sweet flavors (sugar, honey, syrup) depending on the taste problem Chew lemon drops, mints, or gum to remove lingering taste, avoid sugarless gum if patient has diarrhea. If a food tastes too sweet, add salt or a sour taste to counteract the sweetness. If a food is too sour, adding sugar may help If meats are poorly tolerated, try alternative sources of protein such as peanut butter, cheese, tofu, or cooked eggs. Rinse mouth with tea, saline or water with baking soda before eating to clear taste buds. Rinse mouth and brush teeth frequently to relieve bad taste in the mouth

NUTRITIONAL SUPPORT

NUTRITIONAL SUPPORT
In relation to surgery:
Many have enteral tubes placed prophylactically before undergoing surgery

Percutaneuos endoscopic gastrostomies for tube feeding

Enteral feeding immediately post-op allows healing of operative wounds and improvement of swallowing With risk of chronic aspiration, the tip of tube is placed in the small bowel instead of stomach and nutrients are supplied via slow drip

NUTRITIONAL SUPPORT
Depending on the degree of dysphagia Mild to moderate dysphagia Foods with pleasant aroma Foods with high caloric Significant dysphagia Endoscopic gastrostomy tubes for feeding 3-4x/day

I M P A C T OF N U T R I T I O N A L

I M P A C T OF N U T R I T I O N A L
Patients who were given 7-10 days of preoperative enteral nutrition had a 10% reduction in morbidity and improved quality of life (Bertrand, et al, and Van Bokhorst-de
Van der Schuer et al)

PEG placement before XRT resulted in prevention of weight loss, treatment interruption, and hospitalization for hydration.(Scolapio, et al)