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1、Nutrition in Head&Neck Cancer,Glen T.Porter,MDAnna M.Pou,MDDepartment of OtolaryngologyHead&Neck SurgeryGalveston,Texas March 2003,An“At Risk”Population,Alcohol use/abuseTobacco useUp to 40%of newly diagnosed head and neck cancer patients are malnourished.Malnutrition has significant impact on morbi
2、dity,mortality and quality of life for cancer patientsPhysicians often do not address this issue,Causes of Malnutrition,Diminished nutrient intakeIncreased nutrient demand not matched by intakeTumor-induced derangements,Diminished Nutrient Intake,Alcohol&TobaccoPoor dentitionPartial or complete obst
3、ruction of aerodigestive tractTrismusPost-surgical functional and anatomic impairments of chewing and swallowingPost-XRT mucositis,dysgeusia,xerostomiaChemotherapy-induced nausea,vomiting,Increased Nutrient Losses,VomitingDiarrhea,Increased Nutrient Demand,Acute metabolic stresses caused by surgery,
4、XRT,chemotherapyDuration and intensity of stresses depend on intensity and duration of treatment as well as complications,Tumor-induced Metabolic Abnormalities,Abnormal metabolism of carbohydrates,lipids,and proteinAbnormal levels of neurotransmitters leading to anorexiaIncreased basal metabolic rat
5、eCytokines appear to mediate these abnormalities Tumor necrosis factor,IL-1,IL-6,Impact of Malnutrition,Stage III/IV head&neck cancer treated with multiple modalitiesthe strongest independent predictor of survival was pretreatment weight loss(Mick,et al).Head&neck cancer patients shown to have a sig
6、nificant decrease in survival at 2 years if malnourished(57.5%vs.7.5%)(Brookes,et al).Postoperative morbidity and quality of life significantly influenced by preoperative nutrition(Bertrand,et al,Van Bokhorst-de Van der Shuer,et al),Impact of Malnutrition,ImmunocompetenceDecreased cell-mediated immu
7、nity(anergy)Depressed T-cell proliferation,NKC cytotoxicity,macrophage cytotoxicityInability to tolerate antineoplastic treatmentsToxicities more severetreatment delays,higher costsPostoperative complicationsWound infection,healingquality of life,cost,Surgical Insult on Malnourished Cancer Patients,
8、Initiates complex series of metabolic events as response to surgery.Energy demands increase with coextant pneumonia/wound infection/sepsisIncreased metabolic needs when oral intake is greatly diminishedwell tolerated by healthy with glucose,fluid,and electrolyte repletionGlycogen depleted in 24 hour
9、s followed by catabolism of protein(muscle and visceral)Fat energy is not available in acute phase(vs.starvation),Assessment of Nutritional Status,History&physical examAnthropomorphic measurementsSkin testingLaboratory valuesWeight loss as percentage of baseline weight Dietitian referral,Laboratory
10、Values,Serum Albuminlevels fall only after significant protein depletion has occurred.Half-life is 20 days.Serum Transferrinmore sensitive marker of marginal protein depletion.Half-life is 8 days.Can also evaluate prealbumin,retinol-binding protein,SymptomaticTreatments,MucositisTopical medications(
11、analgesics,antifungals,etc.)Baking soda and saline rinsesDental careXerostomiaNausea/VomitingOndansetron,GranisetronAnorexiaMegestrol(80-160mg qid),THCOdynophagia,Nutritional Counseling,Appropriate for patients with mild to moderate malnutrition who tolerate PO(need 40 kcal/kg/D)High-calorie,high-pr
12、otein foodsButter,whole milk,instant breakfast,ice cream,cream,meats,legumes,mayonnaise,eggsHigh fluid intakeFoods high in Vitamins A,C,EXRT/Chemo diet modificationBland,avoid red meat&fruits,soft consistency,Oral Supplementation of Diet,Appropriate for patients who are unable to meet their caloric
13、needs through food choices.Expense,intolerance over timeCommercially-available enteral formulasIntact proteins,complex carbohydrates,fats,vitamins,trace elements(caloric density usually 1 to 2 kcal/cc)Lactose-freeUsually chosen based on palatabilitySpecialized formulasFiber-added,hepatic,renal,diabe
14、tic,immunodeficient,Enteral nutrition,Nasogastric feeding tube Gastrostomy feeding tubeOpen,endoscopic,flouroscopic,“push”vs.“pull”Jejunostomy feeding tubeOpen,endoscopic,flouroscopic,Nasogastric Feeding Tubes,Appropriate for patients who are unable to ingest sufficient calories despite supplementat
15、ion and who will need enteral nutrition for less than 30 daysMay bolus feed,but less aspiration with continuousNeed replacement when narrow lumen clogs(about every 10-15 days)Patient tolerance/pressure necrosisReflux,depressed cough reflex,GI dysfunction,Gastrostomy or Jejunostomy,Appropriate for pa
16、tients who will need longer-term enteral feeds(at least 2 weeks)Fewer complications than NGT feeding(aspiration,dumping syndrome,tube obstruction,nasal damage)Can be easily maintained and used in outpatient setting,less cosmetic impactIdeal for bolus feeds(Gastrostomy)Complications:leak,infection,dy
17、sfunction,pain,Jejunostomy,Indicated for patients who need prolonged enteral feeds and who have had previous gastric surgery,severe GERD,gastric outlet obstructionDecreased aspiration shown in intensive care patients when compared to gastrostomyDoes not permit bolus feeds,though continuous rate can
18、reach as high as 250ml/hr.,NGT vs.Gastrostomy,Gibson,et al studied NGT vs.Gastrostomy one day before surgery for patients with Stage III/IV SCCA of larynx,tongue,OC,tonsilGastrostomy group had significantly shorter hospital stay(60+%reduction for tonsil and laryngeal cancers)Saunders,et al showed pa
19、tients tolerated gastrostomy long-term with high patient satisfaction and no nutritional rehospitalization,Parenteral Nutrition,Appropriate for patients who are severely malnourished or have contraindications to enteral feeding”If the gut works,use it”Composition-amino acids,dextrose,fat emulsions,v
20、itamins,trace elements,electrolytes.May add medications(insulin,antihypertensives,etc.)Requires central venous line and daily laboratory evaluation and composition adjustments Complications:secondary to central venous access,infection and sepsis,metabolic complications,Parenteral nutrition,Transitio
21、n from parenteral to enteral should be gradual with monitoring for hypoglycemia.Should attempt to wean before general anesthesia(inadvertent hypo/hyperglycemia,hypotension)Clinical experience indicates pretherapeutic treatment has more impact on course,though both pre and post-therapeutic TPN showed
22、 good results.(Dudrick,et al),Impact of Nutritional Support,Bertrand,et al,and Van Bokhorst-de Van der Schuer et al showed that patients who were given 7-10 days of preoperative enteral nutrition had a 10%reduction in morbidity and improved quality of lifeScolapio,et al showed that PEG placement bef
23、ore XRT resulted in prevention of weight loss,treatment interruption,and hospitalization for hydration.,Frontiers,Schantz,et al showed increased risk of head and neck cancer in patients with cryptoxanthin,lycopene,and Vitamins C&E-deficient diets(free radical scavengers)Immune-enhancing enteral formulas,
