Approximately 35% to 60% of all patients with head and neck cancer are malnourished at the time of their diagnosis because of tumor burden and obstruction of intake or the anorexia and cachexia associated with their cancer. The purpose of this presentation is to provide a contemporary review of the nutritional aspects of care for patients with head and neck cancer.

1. NUTRITION IN HEAD AND NECK
CANCER
Dr HIMANSHU SONI
Fellow in Head & Neck Surgical Oncology - FHNO
Fellow in CranioMaxilloFacial Trauma – AOMSI
MDS - Oral and Maxillofacial Surgeon

2. Annually, over 3,00,000 new cases of oral cancer are diagnosed all over the world where the
majority are diagnosed in the advanced stages III or IV. Such data make the oral cancer an
important public health matter which is responsible for 3% to 10% of cancer mortality
worldwide.

3. Introduction
• Nutritional support and intervention is an integral component of head
and neck cancer management.
• Patients can be malnourished at presentation
• The majority of patients undergoing treatment for head and neck
cancer will need nutritional support

4. Most patients of head and neck malignancyare
malnourished atdiagnosis.
 Mechanical obstruction
 Sensory impairment
 Odynophagia
 Trismus
 The co-existentalcohol abuse and long term tobacco
Carol Rees Parrish Nutritional Management for Head and Neck Cancer Patients.; Practical
Gastroenterology, September 2013; pp43-51

5. 1 Surgery
2 Radiotherapy
3. Chemotherapy
lead tochanges that further complicateand challenge oral intake
aggressive intervention and focus towardsthe nutritional status of thepatients.
Hunter KU, Jolly S. Clinical review of physical activity and functional considerationsin
head and neck cancer patients. Support Care Cancer 2013;21:1475-1479.

6.  Second most important factor in predicting longterm
prognosis.
 No comprehensive evidence based guidelines for the
nutritional management of this complex patient
population.
Brookes GB. Nutritional status--a prognostic indicator in head and neck cancer. Otolaryngol Head Neck
Surg 1985 Feb;93(1):69-74

7. Malnutrition in HNSCC

8. Types of Malnutrition
1) insufficient energy intake
2) weight loss
3) loss of muscle mass
4) loss of subcutaneous fat
5) localized or generalized fluid accumulation that may sometimes mask weight loss,
6) diminished functional status as measured by handgrip strength
There are 3 major categories:
•Simple starvation with no underlying inflammation
•Mild to moderate inflammation, which would include conditions such as cancer
cachexia, pancreatitis, and sarcopenic obesity
•Severe inflammation, including trauma and sepsis.
Because no single parameter defines adult malnutrition, the identification of 2 or more of the
following 6 characteristics is recommended for diagnosis:

10. Factors Contributing to Malnutrition
 Upon location of malignancy:
Anorexia
Nausea
Inadequate mastication
Xerostomia
Dysgeusia
Dysphagia orodynophagia.
 Diminished oral intake and avoidance of firmsolids
correlated with malnutrition

11. Treatment related complication
Surgery
• Negative nitrogen
balance
• Inability to chew
• Agluttion (inability to
swallow)
• Dysphagia
• Communication
impairment
• Aspiration
Radiotheray
• Mucositis
• Xerostomia ( dry
mouth)
• Odynophagia (
pain in
swallowing)
• Dysguesia ( loss
of taste)
• Dental caries
associated with
xerostomia
Chemotherapy
• Nausea
• Vomiting
• Diarrhea
• Cheilosis
• Glossitis
• Pharyngitis
• Esophagitis
• anorexia

12. Nutritional screening and
assessment

14. NUTRITIONAL ASSESSMENT

16. Impact of Malnutrition on Outcome
of Patient
Studies :correlations between malnutritionand
increased postoperative
1. Morbidity
2. Mortality
3. Length of hospitalization
4. Decreased survival at two years
Goodwin WJ Jr, Torres J. Thevalue of the prognostic nutritional index in the management of
patients with advanced carcinoma of the headand neck. Head Neck Surg 1984; 6:932-

17. Malnutrition associated morbidity

18. Recommendations
• Aim for energy intakes of at least 30 kcal/kg/ day. As energy
requirements may be elevated post-operatively, monitor weight and
adjust intake as required
• Aim for energy and protein intakes of at least 30kcal/kg/day and 1.2 g
protein/kg/day in patients receiving radiotherapy or
chemoradiotherapy
• Patients should have their weight and nutritional intake monitored
regularly to determine whether their energy requirements are being
met

19. Standards of care to be followed
 Early nutrition support.
 Total calorie intake should be restricted to 1500-2000
kcals/day.
 Main substrates providing calories should be
Carbohydrates and lipids.
 Protein intake determined by severity of catabolism.
 Enteral nutrition should be the choice.

20. Dietary Guidelines
 Macro nutrients:
Energy: 15-20 kcals/kg PBW/day to preventre-feeding
syndrome
25-35 kcals/kg PBWfor maintenance
39-50kcals/kg PBW/day. for weight gain:
Proteins: 1-1.5gm/kg PBW/day for maintenance
1.5-2.5gm/kg PBW/day for hyper metabolic, weight gain
patients.

21. Micronutrients
 1. Sodium: hyponatrimia due to
 Dehydration
 Drains

 2. Zinc:common deficiency, results in:
• decreased NKcell lytic activity and decreased proportion of CD4cells in the
peripheral blood.
• Zinc deficiency is associated with increased tumor size, overall stage of the cancer
and increased unplanned hospitalizations
• Zinc deficiency resulted in an imbalance of TH1 and TH2functions. AJCN (Vol. 17, No. 5, 409-418
(1998 )

22.  Water:30-40ml/kg PBW/day
2. Prevent dehydration
3. Prevent respiratory distress due to dryingof secretions.
 Arginine:(controversial)
 Shown to increases fistula and wound complications
 Glutamine:
9. Decreases the risk and severity ofstomatitis
10. Helpsin wound healing after surgery
11. Reduced the side effects of chemo drugslike doxorubicin etc.
Contraindicated:shown to stimulate growth of cancer cells.

23. Approach to Nutrition Suppor

24. Approach to Nutrition Support
PRETREATMENT-Nutrition
screening, History( weight loss),
Physical examination( BMI) ,
Lab studies(Serum albumin)
Malnourished
Is therapy
intensive
Oral supplements
NO
Moderately or severely
malnourished
Aggressive nutritional
support
Is GI tract
functional
Oral supp or
Enteral tube
feeding
Parenteral
nutrition
YES NO

25. 1. Oral
2. Enteral
3. Parenteral
Types of nutrition support

26. Oral nutrition support
 Thereareavarietyof oral nutritional supportproducts available.
 The choice will dependon
1. Presence of lesion
2. Type of surgery
3. current macro and micro nutrientintake
4. patientpreference

27. Enteral nutrition support
 Clinicalconsiderations should
include:
1. Site of tumour
2. Predicted durationof enteral
feeding
3. Patientchoice.

28.  The types of tubes availableare
 Nasogastric
 Nasojejunal
 orogastric
 tracheo–oesophageal fistulae tubes
 gastrostomy
 gastro-jejunostomy
 jejunostomy
Enteral feeding

29. Enteral nutrition
 The type and volume of enteral nutrition will
depend upon the patients’ symptomsand current
intakeand is likely tochange throughout and
following treatment.
 No data to suggest a role for cancer specific enteral
formulaeand standard polymeric feeds should be
used in this populationgroup.
 Thereare a range of nutritionally complete
feeds available.

30.  There are no nationally agreed selectioncriteria(time & method)
 NICE guidelines on enteral feeding suggest that if enteral feeding is expected to
be required forlonger than 4 weeks then gastrostomy insertion is recommended.
 Screening and assessment for suitability and method of gastrostomy insertion by
endoscopic, radiological or surgical approach is essential.
 Assessment of co-morbidities and contraindications should be undertaken in order
to prevent complications of tube insertion prior to oncological treatment
Gastrostomy

33. Immune enhanced nutrition
 Immunonutrition are feeds containing aminoacids,
nucleotides and lipids.
 may reduce post-operative infective
complications=>thispremise isyet to be proven.
 There is evidence that patientsgiven immunonutrition
experience a reduction in hospitalstay.

35. Nasogastric tube vs. percutaneous endoscopic
gastrostomy: advantages and disadvantages.

36. Cancer Cachexia
 Cachexia syndrome results in decreased appetite, weight
loss, metabolic alterations and an inflammatory state that
cannot be fully reversed by conventional nutritional support
and leads to progressive functional impairment.
William D. DeWys. Pathophysiology of Cancer Cachexia: Current Understanding andarea
for Future Research. Cancer Res1982;42:721s-725s.

37. “stateof maladaptation to the fasting statewith ongoing
mobilization of energyreserves”
 In normal subjects, a forced reduction in caloric intake
leads toa reduction in caloricexpenditure
 In cancerpatients, this normal adaptation may be
blunted orblocked
William D. DeWys. Pathophysiology of Cancer Cachexia: Current Understanding andarea
for Future Research. Cancer Res1982;42:721s-725s.

38.  Pro-inflammatory processes can lead to insulin resistance,
increased loss of body fat, muscle mass and production of
acute phase proteins.
 Cytokine-induced metabolic alterations can prevent
cachectic patients from regaining body cell mass during
nutritional support, and are not relieved by conventional
nutritional intervention.

39.  Toxohormones (tumor
derived factors):
1. Lipid Mobilising
Protein (LMP)
2. Proteolysis Inducing
Factor(PIF).
 These hormones further
mediate the lipolysisand
proteolysis

40. • Pathogenesis of cancer cachexia is not strictly a function of tumor burden, as
patients with small tumor volumes are often diagnosed with cachexia
• This syndrome may never develop in patients with enormous tumor burdens.
• Despite this, cachexia does appear frequently in patients with advanced stages
of cancer
Cancer cachexia
Robert L. Ferris. Cancer cachexia syndrome in head and neck cancer Patients: part i. Diagnosis,
impacton qualityof life and survival, and treatment. HEAD & NECK—DOI 10.1002/hed April
2007: 401 – 411.

41. A three-stage classification system of cancer cachexia was
proposed by Fearon et al., distinguishing between precachexia,
cachexia, and refractory cachexia

42.  The management approach should be multifactorial
and includes
• Assessment and on going monitoring with intensive
nutritional support,
• Anti-inflammatory treatment,
• Symptom control as well as oncological treatment
options to reduce the catabolic effect of the cancer

43. Treatment of cancer anorexia-
cachexia syndrome.
Treatment mode Dose MOA

44. Nutritional interventions and
pharmacological therapy for cachexia.

45. REFEEDING SYNDROME
 Potentially fatal shifts in fluids and electrolytes that may occur in
malnourished patients receiving feedingresulting in hormonal and
metabolic changes causing serious clinical complications.(Mehanna et al)
 It can occur irrespective of the feeding route.
 The main feature is hypophosphataemia but can feature abnormal
sodium and fluid balance;
 Changes in glucose, protein, and fat metabolism,thiamine deficiency,
hypokalaemia and hypomagnesaemia.

46. Refeeding
 Incidence of refeeding syndrome in head andneck cancer is
unknown.
 By defining refeeding syndrome as a reduction in serum phosphate to
below 0.4mmol/l, retrospective data from a regional cancer centre
found 37.5% of patients to be at risk as defined by NICE criteria with
an incidence rate of 9.5%

48. PHYSIOLOGIC CHANGES OCCUR DURING
REFEEDING
 Intracellular mineral depletion
Hypophosphatemia
hypomagnesemia
Hypokalemia
body fluid disturbances (―refeeding edema‖)
vitamin deficiencies (eg, thiamine)
 lifethreatening
cardiac arrythmias
respiratory arrest
Congestive heart failure

49. consequences of electrolyte abnormalities
Electrolytes Consequence
 PO4 Acute ventilatory failure Arrythmias
Confusion
Congesive heart failure Lethargy,
weakness Rhabdomyolysis
 K+
Arrythmias Cardiac arrest
Constipation / ileus
Polyuria / polydipsia Respiratory
depression Weakness
 Mg2+
Anorexia Arrythmias
Confusion
Diarrhoea / constipation Weakness

50. Management of re-feeding syndrome (Mehanna et
al., BMJ2008)
10kcal

51.  Severe malnourished :
 Body mass index ≤ 14 ora negligible intake for >two
weeks
 NICE guidelines :
1. Refeeding should startata maximumof 5 kcal/kg/24
hours
2. Cardiac monitoring owing to the riskof cardiac
arrhythmias.
3. Circulatory volumeshould also be replaced butcare
should be taken not to overloadpatients.
 Firstweek: dailyelectrolyte levelschecked
 Second week :threetimes
 Assessmentof urinaryelectrolytescan be helpful in assessing losses.

52. Nutritional management of chyle
leaks
Rare complication with an incidence of 1–4% in neck dissections.
 Central lymphatic system has been damaged during surgery.
 Fluid : milky appearance
The management
1. conservative: dietary manipulation
2. further surgery.

53.  A triglyceride level >110 mg/dl is diagnostic of a chyle leak.
 If the triglyceride level is <110 mg/dl, further analysis is required to
demonstrate the presence of chylomicrons.
 A triglyceride level <50 mg/dl usually rules out a diagnosis of a chyle leak
unless a patient is malnourished or has been fasted.
The principal aims of nutritional management:
1. Reduce the flow of chyle whilst maintaining nutritional status
2. Ensuring adequate fluid balance
3. Replacing electrolyte losses.

54. Chyle leaks
 The nutritional management is to use a fat free or high medium chain
triglyceride (MCT) product.
 MCT is recommended because it is directly absorbed into the portal system
resulting in less chyle production.
 In clinical practice fat free products are more accessible and practical than
MCT feeds.
 If dietary manipulation is unsuccessful parenteral nutrition may be
required.
 This should not be used as first line management except in extreme cases
eg: very high volume leaks (>1000mls).

55. NUTRITION CONSIDERATIONS DURING SURGICAL TREATMENT
 Preoperative nutrition
 Inadequate oral intake for more than 14 days is associated with a higher
mortality.
 Patients with severe nutritional risk should receive nutrition support for
10–14 days prior to major surgery even if surgery has to be delayed
 Carbohydrate loading is becoming standard practice in some centres for all
patients undergoing head and neck cancer surgery. It has been shown to be
safe and well tolerated in patients undergoing head and neck surgery.

56.  Enteral nutrition is indicated even in patients
without obvious undernutrition, if it is
anticipated that patients will be unable to eat
for more than 7 days peri-operatively

57.  Early post operative tube feeding (within 24 hours) is indicated
in patients in whom early oral nutrition cannot be initiated.
 Nutrition support, especially enteralnutrition, reduces
morbidity.
• Standard polymeric enteral feeds are suggested post-
operatively with currently very limited evidence to support the
use of immunonutrition
Postoperative nutrition

58. Nutritional considerations during curative radiotherapy ± chemotherapy
 Concomitant mucositis during radiotherapy ±chemotherapy results in weight loss,
which cannot be completely prevented by nutritional counselling alone.
 Prophylactic tube feeding compared to oral intake alone demonstrates reduced
weight loss in the short term and may improve QoL during and after treatment
 Intensity Modulated radiotherapy is now used for the treatment of head and neck
cancer. This treatment has not been found to reduce nutrition related toxicity and
patients should be managed in the sameway as conventional radiotherapy.
 Patients receiving biological agents such as cetuximab with radiotherapy should be
nutritionally managed in the sameway as those receiving chemoradiotherapy

59. • Vitamin E, at high doses of 400IU/d- reduced recurrent disease
• Selenium supplementation of 200ug/d taken daily during treatment - improve
immune function.
• Beta carotene (30mg/d) may reduce side effects, however care needs to be taken in
its use due to other demonstrated effects of reduced survival or recurrent disease in
other cancer patients
• Zinc at doses of 25mg tds taken during or post chemoradiotherapy has been linked
with survival benefits in patients with nasopharyngeal cancer
• Antioxidants should not be taken due to possible tumour protection and reduced
survival.
radiotherapy ± chemotherapy
Findlay M, Bauer J, Brown T, Committee HaNGS. Evidence- Based Practice Guidelines for the Nutritional Management of Adult
Patients with Head and Neck Cancer. Sydney: Cancer Council Australia, 2014

60. • Nutrition has an important role in the management of head and neck cancer
and its associated treatment modalities
• Nutritional interventions are varied and have an important role throughout
the course of the disease, from diagnosis through to terminal care
• Effective nutritional interventions should ultimately aim to improve QoL
and enhance the beneficial effects of treatment.
Conclusion

61. Thank you