Since April was the Head and Neck Awareness cancer month, we are acknowledging the cancers of the head and neck, which account for 4 % of all cancers diagnosed in the United States with a 5 year survival rate [i]. Concomitant chemo-radiotherapy (CCRT) with/without surgery is the most common form of treatment for head and neck cancer patients (HNCPs) [ii]. One of the issues with CCRT is the detrimental effect it often has on quality of life [ii]. Evidence suggests that at least 90% of HNC patients develop acute nutrition impact symptoms (NIS). NIS are defined as barriers to oral intake which include difficulty swallowing, dry mouth and inflammation of mucous membranes, lockjaw, pain, dental problems, and sensory and taste alterations [iii]. In addition, prior to the start of treatment, patients may already present with some of these symptoms due to the tumor disrupting normal body structure and function [ii]. The study below from the Cancer Survivorship Journal identifies these main NIS in post CCRT among head and neck cancer survivors.
Study 1
Journal: Cancer Survivorship
The purpose of this study was to address the long-term outcome of NIS on nutrition and quality of life in head and neck cancer patients. Fifteen studies were reviewed comprising a total of 849 HNC survivors. The most common NIS reported throughout these studies was difficulty swallowing (73%) followed by dry mouth (36%), lockjaw (36%), salivary issues (36%), inflammation of mucous membranes (13%), and oral pain (13%).
Other main findings:
- In a cross-sectional study, roughly one third of 52 survivors relied on a soft or pureed diet 6 months to 5 years after treatment to meet caloric needs [iv].
- In a prospective cohort study of 67 chemoradiotherapy survivors, the severity of xerostomia was found to be a significant predictor of 5-year survival (p <0.001) [v].
- Long-term (> 5 years) survivors report improvements in quality of life yet continue to suffer from eating challenges.
- 4 out of 5 studies that tracked survivors for ≥ 5 years reported a reduced quality of life in those unable to consume a normal diet
In conclusion the authors stated that” functional problems associated with eating can remain for years following treatment“and that “alleviating the substantial NIS burden experienced by HNC survivors is essential”. Nutritional interventions are a crucial component in alleviating NIS, and yet currently, there are no universal standards of after-treatment care for the HNC population [vi]. This review highlights the need for establishing standard protocols to manage NIS in HNC patients over the long-term to ensure quality of life and nutritional status remain stable beyond the completion of treatment.
FOR THE PATIENT AND CAREGIVER
Eating a healthy diet can be a challenge during head and neck cancer treatment but it is crucial as a poor diet can delay healing. Be sure to ask your health care team, especially the Registered Dietitian on staff for lists of foods and recipes that you can tolerate during the different phases of treatment. Some general rules of thumb to maintain weight and adequate nutrient intake:
- Eat small, frequent meals – 5 to 6 times per day
- Make every bite and sip count by eating calorie-dense foods
- Carry food with you at all times to snack on while waiting for treatment, in the car, waiting to see the physician, etc.
- Transition to soft foods and liquids as side effects make chewing and swallowing more difficult (smoothies can be a high source of calories and can be created in a variety of flavor combinations)
- Enlist friends and family to prepare meals that are appropriate for each treatment phase
- It may be helpful to think of “food as medicine”
FOR THE HEALTHCARE TEAM
The most common challenge among HNCP’s is to maintain nutrition status with adequate oral intake. As these patients move along the trajectory of diagnosis, treatment, and recovery, their ability to cope with ever changing symptoms and side effects depends greatly on their support system. According to a recent study which interviewed HNCP’s throughout their various treatment phases, the ability to swallow, eat, and maintain a healthy weight was associated with signs of progress toward healing and recovery [vii]. Other points to keep in mind:
- Provide nutrition counseling that is tailored to the patient and initiate early in the treatment process
- Provide specific and achievable nutrition goals
- Discuss rehabilitation at the start of treatment and coordinate with the healthcare team to provide continuing support once treatment is completed
- Encourage and discuss “real food” over oral nutrition supplements
- Include family members throughout the process and educate them regarding symptom management and food preparation
- There is a need to establish a standard protocol for managing NIS in HNC patients for better quality of life post treatment
References
[i] Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA: A Cancer Journal for Clinicians. 2017; 67(1):7-30.
[ii] Crowder SL; Douglas KG; Pepino MY; Sarma KP; Arthur AE. Nutrition impact symptoms and associated outcomes in post-chemoradiotherapy head and neck cancer survivors: a systematic review. Journal of Cancer Survivorship. 2018.
[iii] Retel, V.P., van der Molen, L., Hilgers, F.J., Rasch, C.R., L’ortye, A.A., Steuten, L.M. et al. A cost-effectiveness analysis of a preventive exercise program for patients with advanced head and neck cancer treated with concomitant chemo-radiotherapy. BMC Cancer. 2011; 11: 475
[iv] Rinkel RN, Verdonck-de Leeuw IM, Doornaert P, Buter J, de Bree R, Langendijk JA, et al. Prevalence of swallowing and speech problems in daily life after chemoradiation for head and neck cancer based on cut-off scores of the patient-reported outcome measures SWAL-QOL and SHI. Eur Arch Otorhinolaryngol. 2016;273(7): 1849–55.
[v] Nordgren M, Hammerlid E, Bjordal K, Ahlner-Elmqvist M, Boysen M, Jannert M. Quality of life in oral carcinoma: a 5-year prospective study. Head Neck. 2008;30(4):461–70.
[vi] Kawecki A, Krajewski R. Follow-up in patients treated for head and neck cancer. Memo. 2014;7(2):87–91
[vii] Cathy Alberda, MSc, RD; Tatjana Alvadj-Korenic; Maria Mayan, PhD; Leah Gramlich, MD, FRCP. Nutrition care in patients with head and neck or esophageal cancer: patient perspectives. Nutrition in Clinical Practice. (2017) (32)
