Commentary (Ensley): Nutritional Support of Patients Undergoing Radiation Therapy for Head and Neck Cancer

Perhaps no other group of malignancies is more severely affected by the problems patients have with establishing or maintaining good nutrition than those of the upper aerodigestive tract. Nutrition, or malnutrition, is a critical consideration during all phases of the diagnosis, treatment, and long-term management of patients with head and neck malignan cies, even following curative therapy.

This central consideration in the management of these patients is well reviewed by Colasanto et al in this issue of ONCOLOGY. Although the title suggests that the focus is only on patients undergoing radiation therapy, the review actually encompasses a broader discussion of the head and the impact of cytotoxic therapy on nutrition. The impact of surgery on nutrition is mentioned in the introduction, but the profound and lasting effects that surgical interventions can and do have in this group of patients is not extensively explored in the review. Also, the long-term effect of the tumor and its treatment, which may persist for a lifetime, is not discussed.

Head and Neck Cancer Patients

Indeed, malnutrition is one of comorbidities that many patients with head and neck cancer present with at the time of diagnosis.[1] The causes for this common state in this patient group are multifactorial, including social habits that preclude good nutritional habits (smoking, excess alcohol consumption, poor oral hygiene and dental care) and other disease states such as chronic lung disease; gastrointestinal diseases such as gastritis, alcoholic bowel, liver, and pancreatic disease; as well as diabetes mellitus. Head and neck cancers, by definition, involve structures critical to mastication, taste, and deglutition. Therefore, the acquisition of these tumors is often accompanied by trismus, dysphasia and odynophagia, which add significantly to malnutrition, in conjunction with the common problems of anorexia and cachexia seen in patients with carcinomas in general.

Treatment of Head and Neck Cancer

Treatment modalities-surgery, radiotherapy, and chemotherapy-individually and collectively add to the problem of malnutrition. Increasingly, the regimens that have been shown to produce survival advantages or are successful in organ preservation produce increased acute and long-term toxicities, many of which have an impact on the patient's nutritional status. In addition to the trials reviewed in this article, standards for advancedstage, unresectable tumors,[2] organ preservation for advanced-stage laryngeal cancer,[3] and postoperative adjuvant treatment regimens[4] using concurrent radiotherapy and highdose cisplatinum have been recently reported from large-scale, randomized Intergroup phase III trials. These intense regimens can have profound effects on the patient's ability to chew, salivate, taste, swallow, aliment, and maintain nutrition.

Long-Term Sequelae

The head and neck cancer patient's lifestyle, damage from the tumor, and treatment all culminate in long-term sequelae that often affect nutritional status for a lifetime. In this review, the short-term strategies to correct malnutrition are discussed in depth. Long term strategies that include pharyngeal-esophageal dilatation, myomectomy,[ 5] intensive swallowing rehabilitation, and experimental approaches such as botulism toxin injections and salivary gland transposition[ 6] are often employed with inconsistent results. Indeed, some of the short-term solutions such as gastric and jejunal tubes become permanent, and the patient becomes "feeding tube-dependent."[7]

Following intensive swallowing rehabilitation, other patients may find ways to feed themselves without relying on alimentation tubes; however, they may never again gain pleasure from eating nor regain all the social ramifications that normal eating encompasses. While these patients may survive their tumors, their lives and quality of life are altered irrevocably. Concomitant with therapeutic advances that increase survival and organ preservation for patients with these tumors, the development of strategies for improved nutritional function and support is paramount.

Financial Disclosure:The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

1. Kucuk O, Prasad A: Nutrients, phytocemicals and squamous cell carcinomas of the head and neck, in Ensley JF, Lippman S, Jacobs JR, et al (eds): Head and Neck Cancer: Emerging Perspectives. San Diego, Academic Press, 2002.
2. Adelstein DJ, Li Y, Adams G, et al: An Intergroup phase III comparison of standard radiation therapy (RT) and two schedules of concurrent chemoradiotherapy in patients with unresectable squamous cell head and neck cancer (SCHNC). J Clin Oncol 21:92-98. 2003.
3. Forastiere AA, Goepfert H, Maor M, et al: Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 349:2091-2098, 2003.
4. Cooper JS, Pajak TF, Forastiere A, et al: Postoperative concurrent radiochemotherapy in high-risk squamous cell carcinoma of the head and neck: Initial report of RTOG 9501/Intergroup phase III trial. N Engl J Med 350:1937- 1944, 2004.
5. Jacobs JR, Logemann J, Pajak TF, et al: Failure of cricopharyngeal myotomy to improve dysphagia following head and neck cancer surgery. Arch Otolaryngol Head Neck Surg 125:942-946, 1999.
6. Jha N, Seikaly H, Harris J, et al: Prevention of radiation induced xerostomia by surgical transfer of submandibular salivary gland into the submental space. Radiother Oncol 66:283- 289, 2003.
7. Al-Othman MO, Amdur RJ, Morris CG, et al: Does feeding tube placement predict for long-term swallowing disability after radiotherapy for head and neck cancer? Head Neck 25:741-747, 2003.