June 2008 Issue
Enteral Nutrition for Patients With Head and Neck Cancer
By Theresa A. Fessler, MS, RD, CNSD
Today’s Dietitian
Vol. 10 No. 6 P. 46
Tube feeding may benefit patients with oral intake issues undergoing radiation and other treatments by improving nutritional status and tolerance to therapies. These patients have unique needs, but basic guidelines can help dietitians provide optimal nutrition support.
Howard*, age 63, was diagnosed with recurrent cancer of the tongue and floor of the mouth. Surgery included hemiglossectomy, mandibulectomy, partial floor of mouth excision, and neck dissection, with a tissue flap taken from his forearm to reconstruct part of his neck. His surgeon says that he will need enteral nutrition (EN) for approximately 12 weeks.
Tom was diagnosed with squamous cell cancer of the left tongue base with a metastatic left neck mass at the age of 56. He underwent chemotherapy and then concurrent chemotherapy and radiation therapy (chemoradiation therapy [CRT]). Several months later, he underwent left neck dissection surgery.
Sandra was diagnosed with mandibular cancer at the age of 67. She had a tracheostomy and mandible resection with a flap taken from her thigh to reconstruct the tissue. Her surgeon expects that she will be able to start advancing oral diet within six weeks. All of these patients had percutaneous endoscopic gastrostomy (PEG) tubes placed for EN either prior to cancer treatments or during surgery.
Head and neck cancer includes malignancies of the oral and nasal cavities, sinuses, salivary glands, pharynx, larynx, and lymph nodes in the neck. According to the American Cancer Society (ACS), 35,310 new cases of oral or pharyngeal cancer and 12,250 new cases of laryngeal cancer are expected this year alone in the United States. Head and neck cancer is more prevalent in men, with expected occurrence of oral and pharyngeal cancer more than 2.5 times higher and of laryngeal cancer more than 3.7 times higher, according to the ACS. The National Cancer Institute reports that 85% of head and neck cancers have been associated with tobacco use, and the use of both tobacco and alcohol increases the risk. Head and neck cancers are more common in adults over the age of 50.1
Malnutrition
Estimates indicate that up to 50% of patients with head and neck cancer present with malnutrition at the time of diagnosis for multiple reasons.2 First of all, many patients have decreased oral intake prior to treatment due to mouth or throat pain or difficulty swallowing. A history of excessive alcohol use and smoking can also contribute to poor nutritional status. The effects of cancer therapies further complicate problems with oral intake. Treatments for head and neck cancer include surgery, radiation, chemotherapy, or CRT. Side effects of surgery include dysphagia and odynophagia; side effects of chemotherapy and radiation therapies include dysphagia, mucositis, stomatitis, nausea, anorexia, and altered taste sensation. Diarrhea can also occur with chemotherapy. Xerostomia and sometimes esophageal strictures can occur after radiation therapy.1,3
Weight loss can occur not only because of poor food intake but also due to cancer cachexia syndrome. Cancer cachexia differs from starvation in that both skeletal muscle and fat tissue are lost, and metabolism is shifted to a state of increased proteolysis and lipolysis. A systemic inflammatory response is caused by cytokines secreted either by the tumor or the host, promoting muscle wasting and an increased production of acute phase proteins by the liver. Resting energy expenditure is increased in cancer cachexia, in contrast to the decreased resting energy expenditure of starvation. Along with unintentional weight loss and weakness, C-reactive protein can be elevated in cancer cachexia.3
Most patients with head and neck cancer have normal gastrointestinal (GI) function but severe problems with oral intake; thus, the enteral route is used for nutrition support. The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines state that EN is appropriate for patients receiving anticancer treatment who are malnourished and not expected to be able to take adequate nutrition for a prolonged time. The American Dietetic Association (ADA) oncology evidence-based nutrition practice guidelines state that evidence is strong for the use of EN in outpatients with head and neck cancer undergoing radiation treatment and maintenance of nutritional status may improve tolerance to therapy and outcomes. An estimated 10% of people who survive head and neck cancer require permanent EN because of dysphagia.4
Feeding Tubes
PEG or other gastrostomy (G) tubes are the most common feeding method for patients with head and neck cancer. Sometimes endoscopic placement cannot be done due to obstructing masses in the pharyngeal tract, in which case percutaneous fluoroscopic or surgical G tube placement can be done. Postpyloric feeding methods such as nasoduodenal (ND), nasojejunal (NJ), percutaneous jejunostomy, or PEG-jejunal tubes are used if gastric feedings are not tolerated or not possible. Nasogastric, ND, or NJ tubes are the least invasive; however, they are typically used only if needed for less than one month due to problems such as nasal and throat discomfort, the disruption of body image and daily activities, a greater likelihood of clogging due to the smaller diameter, and the risk of accidental dislodgement or removal.5
Another less common method of feeding for patients with laryngeal cancer is to use a feeding tube in the tracheoesophageal puncture (TEP). TEP, a surgical opening between the trachea and esophagus, is a method of voice rehabilitation used for patients who have had laryngectomy. A temporary feeding tube can be inserted in the esophagostomy and the end placed in the stomach.6,7
Prophylactic, or pretherapy, PEG placement is generally recommended for patients with head and neck cancer who will be receiving radiation or chemotherapy, as this can help prevent dehydration, limit weight loss, and help ensure the completion of therapies.8,9 A low percentage of weight loss and low complication rate were reported in a recent retrospective review of 50 patients with unresectable stage 3 and 4 head and neck cancer who were receiving CRT and had prophylactic PEG placement.10 In 2006, Nguyen and colleagues reported no serious PEG tube complications in a group of 104 patients with locally advanced head and neck cancer whose feeding tubes were placed prophylactically prior to CRT. Their 3% complication rate included one tube site infection and two tube replacements due to leakage.11
Complications of PEG tubes include wound infection, site leakage, skin breakdown, and erosion of the tract. Major complications such as peritonitis, necrotizing fasciitis, and fistula formation are rare. Patients should be taught to notify healthcare practitioners of any new pain, redness, or unusual drainage at tube sites. Stabilizing devices can be used to prevent side torsion and resultant tissue breakdown, and antibiotics can be prescribed for site infection. Compression and inflammation of the tissues between the interior and exterior bolsters can lead to ulceration or, in severe cases, erosion of the tract, known as buried bumper. In some cases of severe tissue breakdown, tube removal and replacement may be necessary.5,12
Some patients use EN for several weeks or months, while others may require it for years or the rest of their lives. The likelihood of a patient having a feeding tube in place one month after cancer treatment has been found to be significantly greater for those with tumors in the oropharynx or hypopharynx, tumor stage 3 to 4, flap reconstruction, tracheotomy, chemotherapy, and advanced age.13 In another recent study of 59 patients with head and neck cancer, after the completion of CRT, 63% of the patients had their G tubes removed at six months, which rose to 81% at 12 months and 90% at two years due to the ability to eat a soft diet.14 In a retrospective review of 39 long-term home EN-dependent head and neck cancer survivors, Schattner and colleagues reported that 85% achieved the goals of weight maintenance, gain, or gradual loss (for those who were obese).4
Nutritional Needs
Energy and protein needs depend on the extent of surgery and other therapies, the stage of the disease, body weight, age, gender, activity level, and nutritional status. In general, 25 to 30 kilocalories per kilogram body weight per day and 1 to 1.5 grams of protein per kilogram per day is appropriate for those of normal weight. For those who are hypermetabolic or need to gain weight, 30 to 35 kilocalories per kilogram or greater and 1.5 to 2.5 grams of protein per kilogram may be necessary.9 We generally use a range of 20 to 35 kilocalories per kilogram in our health system, but we have found the need for weight gain in head and neck cancer patients to be as high as 39 kilocalories per kilogram.15 Patients with severe malnutrition should be fed 15 to 20 kilocalories per kilogram for the first several days to prevent refeeding syndrome and then gradually advance to calorie goals. Water needs can be estimated at 30 to 40 milliliters per kilogram per day or 1 milliliter per kilocalorie, with instructions for the patient to increase water for thirst or if urine output is decreased or dark in color.9
A commonsense approach is to adjust nutrition as needed in relation to overall progress. EN calories are increased in situations of undesired weight loss, lack of weight gain when needed, poor wound healing, increased activity levels, or subjective fatigue or hunger. EN feedings are decreased in situations of uncomfortable fullness, nausea, or excessive weight gain. Sometimes we are surprised by patients who maintain weight and healing using less EN than was prescribed, or others who use an unexpectedly large amount of EN to maintain or gain weight.
Bolus feeding of one to two cans of EN formula at a time using a syringe is a common and convenient method of feeding with minimal cost. Ideally, tolerance to bolus feedings should be established prior to hospital discharge. Adjustments to the feeding schedule or methods may be needed. For nausea, vomiting, gastroesophageal reflux, or diarrhea, it may be helpful to decrease the feeding bolus volume, slow the feeding rate using a gravity bag, or control the rate using a pump, and anti-nausea medications may be necessary. A postpyloric or jejunal feeding tube and pump may be needed in cases of severe nausea and vomiting with gastric feeding. Multivitamin supplements can be added if deficiencies are suspected or if patients are using less than the volume of formula required to meet daily requirements.
Enteral Formulas
Standard polymeric formulas are commonly used and well tolerated. Immediately following surgery, high-protein formulas can be used to help ensure adequate healing. For long-term home use, formulas that provide 1.5 kilocalories per milliliter are preferred for convenience and ease of use. Protein powder supplements can be administered with water in the feeding tube if necessary. Patients who have higher calorie needs and are struggling with weight loss or those with uncomfortable GI fullness can use more concentrated formulas with 2 kilocalories per milliliter to get more nutrition with less volume. Fiber-containing formulas can be helpful for maintaining bowel regularity.
Over the past eight years, some study has been conducted using arginine-enhanced formulas for postsurgical head and neck cancer patients.16 The use of arginine-enriched formulas is controversial. The ADA oncology evidence-based practice guidelines state that there is not enough evidence to prove that these formulas are beneficial, and preoperative or postoperative use of arginine-enhanced formulas is not recommended for those with head and neck cancer. In a 2007 report, de Luis and colleagues concluded that an arginine-enhanced EN formula was associated with less fistula (wound complication) rates compared with a standard formula in 72 postsurgical head and neck cancer patients, but there were no differences in wound infection rates or length of hospital stay.16 More high-quality and longer term studies are needed before making recommendations about arginine-enhanced formulas.
Hospital Discharge and Home Follow-Up
In addition to the RD, several specialists help prepare patients for home EN and ensure nutrition therapy progresses according to goals in the following weeks or months. The patient and/or caregivers are the most important part of this team, as even the best plans will not work without compliance and cooperation. The surgeon or gastroenterologist can ensure proper feeding tube placement and should be consulted if tube- or site-related problems are identified. The nurse and RD can educate the patient and caregivers prior to discharge. At the discretion of the surgeon or oncologist, speech-swallow therapists can be consulted in the hospital, clinic, or home setting to help determine whether and when patients will be able to advance oral diet and choose appropriate consistency of oral foods and drinks. EN can be gradually decreased as oral intake improves and as weight goals are maintained.
Good communication with a social worker or discharge planner is essential so that home care can be appropriately set up and financial coverage determined. Patients should be informed at the onset what costs will and won’t be covered, as insurance companies differ. For example, some companies will not pay for EN formulas simply because they are considered to be food, yet they will cover feeding bags or pumps if necessary. Medicare has very specific guidelines for coverage (see sidebar). For patients who do not have insurance coverage for EN, costs can be contained by using less expensive brands of EN or oral supplement products, concentrated formulas (for a lower number of cans used per day), and even milk, juices, and blenderized foods to supplement intake. Syringe bolus feeds are the most economical, since feeding pump rental and gravity feeding bags are very expensive.
EN support is a critically important part of therapy for people with advanced head and neck cancer. RDs and other healthcare practitioners can help ensure successful outcomes with early nutrition assessment and feeding tube placement, careful attention to changing nutritional needs, ongoing monitoring, and adjustments to the feeding plan as needed throughout treatment.
* Names are fictitious.
— Theresa A. Fessler, MS, RD, CNSD, is a nutrition support specialist at the University of Virginia Health System in Charlottesville and a freelance writer.
Terminology and Definitions
Some Structures of the Head and Neck
Oral cavity: lips, tongue, gums, hard palate, buccal mucosa, floor of mouth
Mandible: the bone of the lower jaw forming the jaw and lower teeth
Paranasal sinuses: air-filled hollow spaces in the bone near the nasal cavity and lined with mucous membrane
Nasal cavity: the areas on either side of the nasal septum extending from the nares to the pharynx
Pharynx: the throat; the cavity behind the nasal cavity, mouth, and larynx
Oropharynx: the part of the pharynx between the soft palate and upper edge of the epiglottis
Nasopharynx: the part of the pharynx behind the nose and above the soft palate
Hypopharynx: the lower part of the pharynx that opens to the larynx and esophagus
Larynx: part of the respiratory tract between the pharynx and trachea that is made of cartilage and muscle lined with mucous membrane and contains the vocal cords
Lymph nodes: small oval or round structures that supply lymphocytes to the blood and trap bacteria and other foreign particles
Definitions
Dysphagia: difficulty swallowing or inability to swallow
Odynophagia: painful swallowing
Xerostomia: dry mouth as a result of diminished or a lack of salivary secretion
Mucositis: inflammation of the mucous membranes
Stomatitis: inflammation of the mucous lining of any part of the mouth
— Source: Adapted from The Free Dictionary (http://medical-dictionary.thefreedictionary.com)
Medicare Part B Coverage of Enteral Feeding
• There must be a disorder that prevents food from passing from the mouth to the small bowel for digestion and absorption, or there must be a disorder of the intestine preventing adequate nourishment from regular food intake.
• The need for enteral feeding must be anticipated to last for three months or longer.
• The formula must be taken via feeding tube.
• If a nonstandard or specialized enteral feeding product is used, there must be further medical documentation to justify the added cost for reimbursement.
• If a feeding pump is used, there must be medical documentation to justify the need for reimbursement.
— Source: Adapted from Centers for Medicare & Medicaid Services. LCD for enteral nutrition. Available at: http://www.medicarenhic.com/dme/medical_review/mr_lcds
/mr_lcd_current/enteral_nutrition_0308.htm
References
1. National Cancer Institute. Head and neck cancer: Questions and answers. Reviewed March 9, 2005. Available at: http://www.cancer.gov/cancertopics/factsheet/Sites-Types/head-and-neck. Accessed April 1, 2008.
2. Dixon SW. Nutrition care issues in the ambulatory (outpatient) head and neck cancer patient. Support Line. 2005;27(3):3-10.
3. Couch M, Lai V, Cannon T, et al. Cancer cachexia syndrome in head and neck cancer patients: Part I. Diagnosis, impact on quality of life and survival, and treatment. Head Neck. 2007;29:401-411.
4. Schattner MA, Willis HJ, Raykher A, et al. Long-term enteral nutrition facilitates optimization of body weight. JPEN J Parenter Enteral Nutr. 2005;29(3):198-203.
5. DeLegge MH. Enteral access in home care. JPEN J Parenter Enteral Nutr. 2006;30(1):S13-S20.
6. Karlen RG, Maisel RH. Does primary tracheoesophageal puncture reduce complications after laryngectomy and improve patient communication? Am J Otolaryngol. 2001;22(5):324-328.
7. Malik NW, Timon CI, Russel J. A unique complication of primary tracheoesophageal puncture: Knotting of the nasogastric tube. Otolaryngol Head Neck Surg. 1999;120(4):528-529.
8. DeLegge MH, and the HPEN working group. Consensus statements regarding optimal management of home enteral nutrition (HEN) access. JPEN J Parenter Enteral Nutr. 2006;30(1):S39-S40.
9. Roberts S, Mattox T. Cancer. In: The A.S.P.E.N. Nutrition Support Core Curriculum: A Case Based Approach, the Adult Patient. Silver Spring, Md.: American Society for Parenteral and Enteral Nutrition; 2007:649-675.
10. Wiggenraad RGJ, Flierman L, Goossens A, et al. Prophylactic gastrostomy placement and early tube feeding may limit loss of weight during chemoradiotherapy for advanced head and neck cancer, a preliminary study. Clin Otolaryngol. 2007;32(5):384-390.
11. Nguyen NP, North D, Smith HJ, et al. Safety and effectiveness of prophylactic gastrostomy tubes for head and neck cancer patients undergoing chemoradiation. Surg Oncol. 2006;15(4):199-203.
12. McClave SA, Neff RL. Care and long-term maintenance of percutaneous endoscopic gastrostomy tubes. JPEN J Parenter Enteral Nutr. 2006;30(1):S27-S38.
13. Cheng SS, Terrell JE, Bradford CR, et al. Variables associated with feeding tube placement in head and neck cancer. Arch Otolaryngol Head Neck Surg. 2006;132(6):655-661.
14. Goguen LA, Posner MR, Norris CM, et al. Dysphagia after sequential chemoradiation therapy for advanced head and neck cancer. Otolaryngol Head Neck Surg. 2006;134(6):916-922.
15. Pagano A, Parrish C, McCray S, Reibel J. A retrospective review of calorie needs of enterally fed head and neck cancer patients. Nutr Clin Pract. 2000;15:S19-S20.
16. 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):200-204.