Nutritional follow-up of patients with head and neck cancer

Head and neck (H&N) cancer constitutes approximately 5.1% of all cancers worldwide and 2.2% in Sweden. It is a heterogeneous group of malignant tumours with differences in natural history and prognosis. The treatment is often multiple, where the main treatment modalities are external beam radiotherapy (RT) and surgery. For many patients with H&N cancer, nutritional problems are an immense and complex range of challenges. If the patient cannot swallow and the gastrointestinal tract is functioning normally, nutritional support is mainly given with enteral nutrition. The most common way to administer enteral feeding is via a polyurethane nasogastric feeding tube (NGT) or via a percutaneous endoscopic gastrostomy (PEG) tube. In this thesis different cohorts of patients with H&N cancer have been studied with the ultimate goal to identify patients in need of nutritional support and to improve nutritional surveillance. Study I The predictive value of systematic inflammatory and metabolic markers was prospectively studied in 27 patients with H&N cancer undergoing RT. All patients lost body weight with the greatest loss at the end of RT. Highly sensitive C-reactive protein (hsCRP) increased during RT. None of the systemic inflammatory and metabolic markers was significantly associated with body weight loss. Study II A retrospective study of consecutive patients who received a PEG tube is presented. Of the 171 patients planned for PEG, 156 were successfully carried out, while the attempt failed in 15 patients. The duration of PEG tube usage varied considerably. Complications were seen in 42% (n=65) of the patients. Seven patients (5%) had fatal complications related directly or indirectly to the PEG tube placement, 33 patients (21%) had severe complications and 25 patients (16%) had minor complications. Study III Consecutive patients (n=157) with H&N cancer who were seen for nutritional control at a nurse-led outpatient clinic were evaluated for factors known to contribute to body weight loss. Nadir of body weight was observed at 6 months after RT. In total, 92 patients (59%) with no evidence of residual tumour after treatment received enteral nutrition. Patients that maintained oral feeding did not lose as much body weight as patients who received enteral nutrition. Tumour stage was the only independent predictive factor of maximum body weight loss. Body weight loss was not found to be associated with post-operative infections or mortality. Study IV Using a descriptive, prospective design, semi-structured interviews about what in life is influenced by disease and feeding (oral feeding, NGT or PEG) were conducted in 41 patients with H&N cancer. More than 50% of the patients manifested eating-related problems. No significant differences in life areas (e.g., fatigue, pain, nutrition and social and family life) influenced by disease were observed over time between oral feeding and enteral nutrition. Furthermore, no differences were noted between patients having NGT or PEG, except that patients with NGT expressed negative views regarding social limitations and patients with PEG felt confined by the tube. The conclusions of this thesis are that body weight and CRP are valuable variables to follow-up. The risk for complications because of PEG ought to be considered when deciding on an enteral nutrition method of feeding. NGT should be regarded as the first choice of enteral nutrition in patients with an expected limited time of tube feeding, whereas in patients in which prolonged treatment is needed PEG could be the choice for most patients. The extended body weight loss after treatment indicates that a nutritional surveillance programme (e.g. managed by a nurse-led outpatient clinic) is important before, during but not in the least after treatment

Factors that affect quality of life for older people with head and neck cancer: A systematic review

Purpose: Quality of life is a critical aspect in the management of older head and neck cancer patients. It needs to be considered alongside survival benefit, treatment burden, and longer-term outcomes. The purpose was to undertake a systematic review of empirical peer-reviewed studies with a primary focus on factors impacting quality of life for older head and neck cancer patients. Methods: A systematic review, searching 5 electronic databases (PsychoINFO, MEDLINE, CINHAL, Embase, and Scopus) using PRISMA methodology was conducted. Data was appraised using the Newcastle-Ottawa scale and a narrative synthesis performed. Results: Only 10 papers fulfilled the inclusion criteria. Two main themes emerged: 1) Impact of head and neck cancer on quality of life domains and 2) quality of life in treatment decision-making. Conclusions: In an era of progressive personalised care, there is an evident need for more qualitative and quantitative studies focusing on quality of life for older head and neck cancer patients. However, older head and neck cancer patients experience notable differences, especially with poorer physical functioning and greater eating and drinking challenges. Quality of life impacts older patients decision-making, treatment planning and intensifies post-treatment support

Variations in concerns reported on the Patient Concerns Inventory (PCI) in head and neck cancer patients from different health settings across the world

Background: The aim was to collate and contrast patient concerns from a range of different head and neck cancer follow-up clinics around the world. Also, we sought to explore the relationship, if any, between responses to the patient concerns inventory (PCI) and overall quality of life (QOL). Methods: Nineteen units participated with intention of including 100 patients per site as close to a consecutive series as possible in order to minimize selection bias. Results: There were 2136 patients with a median total number of PCI items selected of 5 (2-10). “Fear of the cancer returning” (39%) and “dry mouth” (37%) were most common. Twenty-five percent (524) reported less than good QOL. Conclusion: There was considerable variation between units in the number of items selected and in overall QOL, even after allowing for case-mix variables. There was a strong progressive association between the number of PCI items and QOL

Mapping Health-Related Quality of Life, Anxiety, and Depression in Patients with Head and Neck Cancer Diagnosed with Malnutrition Defined by GLIM

Patients with cancer deal with problems related to physical, psychological, social, and emotional functions. The aim was to investigate malnutrition defined by the Global Leadership Initiative on Malnutrition (GLIM) criteria in relation to health-related quality of life, anxiety, and depression in patients with head and neck cancer. This was a prospective observational research study with 273 patients followed at the start of treatment, seven weeks, and one year. Data collection included nutritional status and support, and the questionnaires: European Organization for Research and Treatment of Cancer Head and neck cancer module (EORTC QLQ-H&N35) and the Hospital Anxiety and Depression Scale (HADS). Malnutrition was defined using the GLIM criteria. The study showed that patients with malnutrition had significantly greater deterioration in their health-related quality of life at seven weeks. On a group level, health-related quality of life was most severe at this time point and some scores still implied problems at one year. Significantly, more patients reported anxiety at the start of treatment whereas significantly more patients reported depression at seven weeks. Over the trajectory of care, the need for support often varies. Psychosocial support is imperative and at the end of treatment extra focus should be put on nutritional interventions and managing treatment-related symptoms to improve nutritional status and health-related quality of life. In the long-term, head and neck cancer survivors need help to find strategies to cope with the remaining sequel

An explorative study on energy balance in patients with head and neck cancer

Background: Involuntary body weight loss in head and neck cancer is common. Fundamental for weight loss is an energy imbalance where total energy expenditure exceeds energy intake. Aim: To map energy intake and parameters of energy expenditure at the start of and after radiotherapy, and their relation to weight change, body mass index, and immune markers in patients with head and neck cancer. Materials and Methods: Data from 20 patients on energy intake (24-hour dietary intake recalls), total energy expenditure (SenseWear Armband Pro3), resting energy expenditure (indirect calorimetry), body weight, body mass index, and immune markers in serum (C-reactive protein and Interleukin-6) were collected at the start of and after radiotherapy (median 8 mo, range 5–13). Results: No statistical significance was shown between the two measurement points for energy intake or for the different parameters of energy expenditure. Median values for energy balance were 0.93 and 0.96 for the start of treatment and follow-up, respectively. Twelve and 13 patients had a negative energy balance at the start of radiotherapy and at follow-up, respectively. Conclusion: A negative energy balance was seen for the majority of patients, which stresses the importance of nutritional treatment at the start of and after radiotherapy

Mapping the impact of malnutrition as defined by the Global Leadership Initiative on Malnutrition and nutrition impact symptoms on the possibility of returning to work after treatment for head and neck cancer

Purpose: This study aimed to investigate whether malnutrition or nutrition impact symptoms (NIS) affect the possibility of returning to work after treatment for head and neck cancer. Methods: Patients of working age with head and neck cancer were followed up from treatment initiation to 3 months (n = 238), 1 year (n = 182), and 2 years (n = 130) after treatment completion. The observed decrease in the number of patients over time was due to retirement, lack of follow-up, or death. Returning to work was dichotomised as yes or no. Malnutrition was diagnosed 7 weeks after treatment initiation using the Global Leadership Initiative on Malnutrition (GLIM) criteria. This time-point corresponds to the end of chemoradiotherapy or radiotherapy (with or without prior surgery), except for patients who underwent exclusive surgery. NIS were scored on a Likert scale (1-5) at each follow-up using the Head and Neck Patient Symptom Checklist (c) (HNSC (c)). Nonparametric tests were used to analyse the ability of patients with/without malnutrition and high/low NIS scores to return to work. Results: At 3 months, 1 year, and 2 years after treatment completion, 135/238 (56.7%), 49/182 (26.9%), and 23/130 (17.7%) patients had not returned to work. Patients with malnutrition at 7 weeks after treatment initiation were more likely to not return to work at 3 months than those without malnutrition, 70.5% compared to 47.1% (p < 0.001). At all three follow-up time-points, patients reporting high scores for a number of NIS had more often not returned to work, with this pattern being most distinct at 2 years. Conclusion: Malnutrition according to the GLIM criteria at 7 weeks after treatment initiation and NIS assessed by the HNSC (c) at subsequent follow-ups were predictors of the return-to-work process after treatment for up to 2 years

Higher Risk of Recurrence in Patients Treated for Head and Neck Cancer with Low BMI and Elevated Levels of C-Reactive Protein

Simple Summary Head and neck cancer (HNC) treatment poses several challenges in clinical practice, and treatment side effects can be debilitating due to the close proximity of important anatomical structures. Cancer recurrence post-treatment presents some of the most challenging HNC management issues. This prospective study identifies high-risk groups for recurrence of head and neck cancer, based on commonly accessible clinical parameters. In this study with 272 HNC patients, elevated pre- and post-treatment CRP levels, low BMI and advanced stage at admission indicate higher risk for recurrence of disease. Using these parameters, a risk model is proposed which may be useful for estimating the probability of cancer recurrence and allow the identification of high and low-risk patients. This prospective study identifies high-risk groups for recurrence of head and neck cancer by BMI and circulating inflammatory response markers. Head and neck cancer patients from three Swedish hospitals were included (n = 272). Leukocyte and thrombocyte counts, CRP levels, and BMI were measured pre-treatment and post-treatment. Associations between the four factors and treatment failure (residual tumor, loco-regional failure, general failure/distant metastasis) were assessed using a Cox proportional hazards model adjusted for sex, age at the initial visit, smoking status, cancer stage, and hemoglobin count. CRP level was the only significant single variable, with an average increase in risk of recurrence of 74% (p = 0.018) for every doubling. The predictive power of a combined model using all variables was highest during the initial months after treatment, with AUC under the ROC curve 0.75 at the 0-3 month timepoints. Patients with elevated pre- and post-treatment CRP levels are at higher risk for recurrence of disease. Male patients with low post-treatment BMI, advanced stage, and high CRP at any time post treatment are at high risk for recurrence. The combined model may be useful for stratifying post-treatment patients into low and high-risk groups, to enable more detailed follow-up or additional treatment regimens

Predicting Return to Work after Head and Neck Cancer Treatment Is Challenging Due to Factors That Affect Work Ability

Striving to return to work is of great importance to many cancer survivors. The purpose of the study is to prospectively investigate the factors that hinder and facilitate return to work (RTW) at 3 and 12 months after the end of treatment in head and neck cancer (HNC) survivors and whether these factors influence the ability to continue working after treatment. Participants (n = 227) aged ≤ 65 years at diagnosis with HNC were included. Data were collected before the start of treatment and at 3 and 12 months after the end of treatment. The Rubin causal model was used for statistical analysis. Within the 3-month follow-up period, 92 participants had RTW and 30 had retired. At the 12-month follow-up, 80 of these participants were still working, another 51 participants had RTW, and five participants working still suffered from cancer. The hindrance to RTW within 3 months was advanced tumour stage (stage III and IV) (p = 0.0038). Hindrances to RTW at the 12-month follow-up were oral cancer (p = 0.0210) and larynx cancer (p = 0.0041), and facilitators were living in a relationship (p = 0.0445) and a white-collar job (p = 0.00267). Participants with early tumour stage (stage I and II) (p = 0.0019) and a white-collar job (p = 0.0185) had earlier RTW. The conclusion is that disease factors were the most important hindrances to RTW, and type of work and living with a spouse or partner were nonclinical factors influencing RTW

Sexual and contraceptive behavior among female university students in Sweden : repeated surveys over a 25-year period

ObjectiveTo study female students' sexual and contraceptive behavior and compare these results with earlier surveys. DesignComparative, repeated cross-sectional surveys, started in 1989 and repeated every fifth year. SettingContraceptive counseling delivered at a Student Health Center in Sweden. PopulationFemale university students (n=359). MethodsMultiple-choice waiting-room questionnaire. Main outcome measuresSexual and contraceptive behavior. ResultsIn 1989, age at first intercourse was 17.6years vs. 16.7years in 2014, number of lifetime sexual partners was 4.0 vs. 12.1 in 2014, and number of sexual partners during the previous 12months was 1.0 vs. 2.8 in 2014. Condom use during first intercourse with the latest partner decreased from 49% to 41% (n=172 in 2009 vs. n=148 in 2014: p&lt;0.001), and experience of anal sex increased from 39% to 46% (n=136 in 2009 vs. n=165 in 2014: p=0.038), and 25% (n=41 in 2014) always used a condom during anal sex. A total of 70% (n=251) made use of pornography, and 48% (n=121) considered their sexual behavior affected by pornography. Eighty-nine percent (n=291) wanted two to three children and 9% (n=33) had thought about freezing eggs for the future. The female students' knowledge about increasing age being correlated with decreased fertility varied. ConclusionsSexual behavior among female university students has gradually changed during the last 25years and behavior appears more risky today. As this may have consequences on future reproductive health, it is vital to inform women about consistent and correct condom use and about the limitations of the fertile window.Christina Stenhammar och Ylva Tiblom Ehrsson delar förstaförfattarskapet.</p