1. “Oropharyngeal Squamous Cell Carcinoma”
A Case Study and Literature Review
By: Dietetic Intern Cameron Segura

2.  Review current literature on nutrition care in Head and Neck Cancer.
 Background
 Pathophysiology “Oropharayngeal Squamous Cell Carcinoma”
 Diagnosis
 Treatment
 Nutritional Care
 Case Study Comparison
 Literature Review on Cancer Research
 Quiz

3.  What is it ? Cancer that affects certain
regions in the body.
 H & N can affect a single region or
entire area of oral cavity.
 3-5% of all Cancers in the U.S
 55,070 people (40,220 men & 14,850
women)
 12,000 Deaths will occur (8,600 men
3,400 women)
 Oropharyngeal (oral & pharyngeal)

4.  6th most common cancer in the world
 90% of all Head & Neck Cancers
 Low survival rates in advanced stages
 > 5 years 60%
 Prognosis worsens as the depth of the tumor
increases

5.  Oropharyngeal cancer forms in the tissues of the
oropharynx.
 Back of the mouth, including soft palate, base of the
tongue, & tonsils.

6.  Oral Cavity & Oropharynx
composed of several cells.
 Different cancers can form in
different cell locations.
 Cancers that form in the oral cavity
and oropharynx.
1. Benign or non-cancerous growths
2. Pre-cancerous conditions
3. Squamous Cell carcinoma

7. Anatomy and physiology
• Begins in the squamous cells
• Thin flat cells that form the outer layer of the skin, hollow organs of the
body, and lining of the respiratory tract
• Cancer is formed from the reserved cells
• Carcinoma in Situ

9.  Tobacco/Alcohol use
 Poor oral hygiene
 Human papillomavirus infections (HPV)
 Obesity
 Mate’ tea
 Poor diet/low fruits & vegetables/preserved & processed foods
 Occupational exposure
 Radiation exposure
 Epstein-BarrVirus infection
 Ancestry

10. Tobacco/ETOH
75%
HPV,other risk
factors 25%
Main risk factors in developing Squamous Cell Carcinoma

11.  Combined ETOH and tobacco synergistic
 50 or more grams a day 2x risk
 Mechanism
 7 % people in the US have HPV (1% have
oropharyngeal cancer)

12. ETOH Acetalaldhyde
Carcinogen,
damages DNA,
protein
synthesis

13. ETOH
ROS  & estrogen
blood levels 
Damages DNA, lipids,
protein synthesis/
impairs body’s ability
to break down
nutrients

14. HPV Cancer
HPV invades skin
cells
DNA from HPV
enters skin cells
HPV causes infected
skin cells to multiply
and form warts
Virus sheds setting it
free to infect normal
tissues

15.  Signs & symptoms
 Physical Examination
 Diagnostic tests
 Imaging
 Lab tests/lab markers

16.  Red orWhite patch's in the mouth
 Lump, bump, or mass
 Persistent sore throat
 Swelling
 Hoarseness
 Foul mouth odor
 Unexplained weight loss
 Ear and jaw pain
 Painful, difficulty chewing, swallowing,
moving jaws

17.  Inspection of head
and neck area using a
light and mirror
 Dr. detects for present
lumps in neck, gums,
cheeks.

19.  Endoscopy (thin lighted flexible
tube)
- Laryngoscope
- Esophagoscope
- Nasopharyngoscope
 Biopsy (removal of a small amount
of tissue for examination
 MRI
 Pet Scan
 X-rays/barium swallow
 CT scan

21.  Complete blood count
 Tumor marker tests
 CRP
 ZINC
 Calcium
 BUN
 Cr
 Neutrophils/Lymphocytes/Macrophages

22.  American Joint Committee (AJCC)
designated staging to define oropharayngeal
cancer.
 TNM staging classification
 Stage grouping

23.  T: size of the primary tumor, and which; if any
tissues of the oral cavity or oropharynx it has
spread to.
 N: extent of spread to nearby (regional
lymph nodes).
 M: Indicates if the cancer has metastized to
other organs/tissues of the body.

24.  OnceT,N,M categories established
 Stages:
O
I
III IV
II
VI

25.  (T1, No, Mo) Stage 1 : The tumor is 2 cm (3/4”) across or smaller (T1) and has not
grown into nearby structures, lymph nodes (N0), or distant sites (M0).
 Stage IVA: can be 1 or 2
1) T4a, N0, or N1, M0: The tumor is growing into nearby structures (T4a). Size can vary (small-large).The
tumor has either not spread to the lymph nodes (N0) or has spread to one lymph node on the same side of
the head or neck, which is not larger than 3 cm (N1).The cancer hasn’t spread to distant sites (m0).
2) T1-T4, N2, M0: The tumor is any size and may or may not grow into nearby structures (T1-T4a). It has
not spread to distant sites (M0). It has spread to one of the following:
- One lymph node on the same side of the head and neck that is between 3-6 cm across (N2a).
- One lymph node on the opposite side of the head and neck that is no larger than 6 cm across (N2b).
- 2 or more lymph nodes, all of which are no more than 6 cm across.The lymph nodes can be on any side of
the neck (N2c).

26. Treatment Factors
1. The stage of cancer
2. The number of lymph nodes with cancer
3. Whether the patient has HPV infection of
the oropharynx
4. Whether the patient has a history of
smoking for more than ten years.

28.  Surgery
 Chemotherapy
 RadiationTherapy
 CAMTherapy (Gerson)
 New treatments
 $$$

29.  Surgery ( life threatening cases )
- removal of tumor
- may also receive chemo and radiation
- Adjuvant therapy (secondary treatment)

30.  Treatment that uses drugs to stop
the growth of cancer cells, either by
killing the cells via apoptosis, or by
stopping the cells from dividing .
 Mouth or injected into vein or
muscle.
 Systemic chemotherapy (distant)
 Regional therapy (local)

31.  Methodtrexate
 Fluorouracil
 Bleomycin
 Cetuixmab (1.9 Billion)
 Cisplatin
 Docetaxel
 Efudex
 Erbitux
 Erbitux
 Flurouracil
 Folex
 PFS
 Methotrexate-AQ
 Platinol
 Platinol-AQ
 Docetaxel

32.  High energy X-rays to kill cancer cells & keep
them from growing.
 TwoTypes
1. External radiation therapy: uses a machine
outside the body to send radiation toward
the cancer.
2. Internal radiation therapy: uses a radioactive
substance sealed in needles, seeds, wires, or
catheters placed directly into or near cancer.

33.  Complimentary medicine: used together with
conventional medicine & shown to be effective.
 Alternative medicine: used in placed of conventional
medicine, also shown to benefits.
 4/10 diagnosed with cancer used CAM
 Meta analysis study showed > 50% of all cancer patients
worldwide use CAM

34.  Prayer and spiritual practice
 Relaxation: yoga, meditation, religious acts .
 Nutritional supplements and vitamins (40%)

36.  Dr Max Gerson
 American Physician
 Developed Gerson therapy in 1930’s
 Dietary therapy claimed to cure cancer
 Fresh organic juice, coffee enemas
 15-20lbs of organically grown fruits and
vegetables daily.
 One glass every hour, 13X/day
 Supplementation
 Detox

37.  Journal of Clinical Oncology: head to head test of Gerson vs
chemotherapy agent gencitabine.
 55 patients pancreatic cancer
 23 elected chemotherapy, 32 elected enzyme treatment (raw
foods).
 Study stopped early due to excessive deaths in Gerson patients
 Conclusion: those who chose gencitabine-based chemotherapy
survived more than three times as long (14 months) and had better
quality of life.
 Dozen study’s published & reviewed by the Lancet Journal
concluded “ there is little scientific evidence to support Gerson
therapy use, and may be completely useless, expensive and
dangerous”.

38.  Estimates indicate 50% of head and neck cancer
patients present malnutrition at time of diagnosis.
 Cancer and its therapies place great stress on patients
nutritional status.
 Increase risk
- severe depletion of lean muscle
- weight loss
- body composition
- morbidity/mortality
- ineffective treatment/ treatment toxicity
- malnourishment

39. Severe Side Effects
 Dysphagia -87% of patients, 49% 3 months, 22% 6 months
 Anoreixa - >50%
 Decreased oral intake >50 %
 Odynophagia (painful swallowing)
 Mucositis - 76% of patients experience
 Esophagitis
 Xerostomia (dry mouth)
 Taste changes
 Dental carries
 Fatigue

40.  Maintains body weight, strength,
body tissues, and fights infection.
 Patients who are well nourished
have a better prognosis and
quality of life.
  risk of cancer cacheixa and
anorexia.
  risk of treatment related
toxicities

41. 1. To achieve and/or maintain optimal nutrition
status and body weight.
2. To maximize benefits of therapy/reduce
symptoms secondary to therapy.
3. To prevent or reverse a compromise in
visceral protein status.
4. To prevent or reverse immunosuppressant
5. To improve quality of life.

42. Management of side effects
• small frequent meals
• liquids/supplements between meals
• pleasant meal time atmosphere
• adding etc kcal’s w/ fats
• offering the patient their favorite foods
• avoid strong odors
• soft moist foods (mechanical soft, pureed)
• thickened liquids
• use plastic flatware & glass cups/plates

43.  H & N cancer patients maintain functional gut.
 Enteral Feeding vs. Parenteral
 Enteral feeding
- reduced weight loss
- hospitalizations
- dehydration
- malnutrition
- treatment interruptions
- improvements in anthropometrics &
lab values.
 10% H/N cancer patients require permanent EN
(dysphagai 4)

44. Methods
- severe malnutrition : 15-20kcals/kg to avoid
refeeding syndrome.
- Adjust nutrition needs in relation to progression.
  Enteral Nutrition
 weight loss
 poor wound healing
 activity levels
  Enteral Nutrition
 N/V
 uncomfortable fullness
 excessive weight gain

45. Route
 PEG placement most common
 Long term
 NG tube <3 weeks
 ND & NJ
 Complications:
- Infection
- Site leakage
- Skin breakdown

46. Determining Needs: surgery, therapy, stage,
activity level, nutritional status.
 Energy needs
- 25-35 kcals/kg (40kcals/kg H & N)
- 1500-2500 kcals/day adequate
 Protein
- 1-1.5 g/kg (normal weight)
- 1.5-2.5 g/kg (malnourished

47. Formula
- Standard polymeric formula well
tolerated
- High protein
- 1.5-2.0 kcals/mL preferred for long term
use.
- Arginine-enhanced controversial

48.  Bolus feeds 1-2
cans/cartons per day
 Convenient
 Minimal cost
 Oncology Dietitian

49.  62 year old Christian Caucasian Male
 Husband/Father to a 23YO daughter.
 Retired Air Force
 Hobbies: climbing 14r’s /hiking,
racquetball
 Very positive happy man
 “ God is in control of my life”

50.  Non-smoker
 Non-drinker
 Diet
- Enjoys his apple pie
- Fruit juice
- Soups/stews
- Doesn’t like vegetables to much
- Fast food every so often maybe
once a week

51.  Hypertension
 Arthritis
 Depression
 Anxiety
 Squamous cell
carcinoma on the
bridge of nose excised
13 years ago.

52. Oct, 2014 Noticed swelling
Evaluation by primary care physician
Nov, 2014 Ultrasound of left neck
Dec, 2014 MRI of neck
Dec, 2014 Biopsies taken from left and right
tongue base.

53.  Squamous cell carcinoma on left & right tongue base
(oropharynx region) (carcinoma in situ)
 P16 positive (HPV)
 No malignancy of other biopsies
 MRI scan shows no evidence of distant metastasis.
 Oropharyngeal cancer:T1 N2 a MO stage IVA
 (tumor is 2 cm (3/4”) or smaller, the cancer has spread to one
lymph node on the same side as primary tumor, the lymph node is
larger than 3 cm across but no larger than 6 cm across, no distant
spread has occurred.

54.  Chemo-radiation
 Salvage surgery if needed
 Radiation 6 weeks
 Cisplatin 40mg weekly during radiation.
 PICC line placement
 Side effects: infection, fatigue, myelosupression,
nausea, vomiting, renal injury, and ototoxicity.

55. Peg
placement
1/14
90%
nutrition
via tube
Outpatient
advice for
oral intake

57. 152
154
156
158
160
162
164
166
168
170
January 6th Febuary 18th April 23rd May 2nd
pounds(lbs)
Dates 2015
Mr. M weight trends
169 lbs
165 lbs
158 lbs
163lbs

58.  Main goals provided to Mr. M
 Early EN administration
 PEG placement
 Bolus Feeds
 AdjustedTF due to weight loss
 Received recommendations by oncology
dietitian

59.  PEG removed
 90-95% nutrition via oral intake
 Cancer is residing
 Will continue ongoing treatment
 Successful

60.  2 servings of nuts/week may protect against pancreatic cancer-British journal of cancer, 2013
 Which nuts fights cancer better? Walnuts, Pecans, & peanuts- decreased human liver cancer &
colon cancer cell proliferation – British Journal of cancer, 2013
 A follow up of the nurses health study involving the daughters (the growing up study) showed
that those who consumed peanut butter, nuts, lentils, corn found to have a fraction of the risk for
fibrocystic breast disease (increases risk of breast cancer) Breast Cancer ResearchTreatment,
2013
 Those eating one or more apples a day had less colon, breast, oral, larynx, kidney, & ovarian
cancer. – Planta medicine review, 2008.
 Curcumin found to sensitize tumor necrosis factors and up regulate death receptors of cancer
cells. – Carcinogenesis journal, 2005.
 Higher intake of soluble fiber, was associated with a significantly reduced risk of breast cancer, 62
% lower chance. – European journal of nutrition, 2012.
 Positive association between breast cancer risk and saturated fat intake in postmenopausal
women. – Journal of the National Cancer Institute, 1990.
 25 men with prostate cancer awaiting prostatectomy were given 3 tablespoons of flaxseed/day 1
month before surgery, researchers found lower proliferation rates and higher rates of cancer cell
death. Urology, 2004.
 Meta-analysis showed that those who have the highest consumption of coffee compared with
those who drink no coffee had a 50% reduction in liver cancer risk. – Gastroenterology, 2013
 Compounds found in broccoli have inhibitory effects on several types of cancer cells growth,
including leukemia, prostate, breast, cervical, lung and colorectal cancer, and shown to decrease
metastasis. – BMC Cancer, 2010