Weight loss among patients with Head and Neck cancer at St Vincent’s Hospital (SVH): Preliminary Findings

15/10/15

Amanda Duffy

Senior Oncology Dietitian

Masters of Applied Sc (Research) Candidate

E: Amanda.Duffy@svha.org.au

Abstract co-authors: Professor Vicki Flood, Dr Mark Halaki, Dr Stephen Cooper, Professor Allan Spigelman, A/Professor Richard Gallagher (Director of Cancer Services)

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Aim

To investigate the efficacy of nutrition interventions on the health outcomes of patients receiving multimodal curative intent treatment for SCC (squamous cell carcinoma) of the Head and Neck at SVH.

Health outcomes to be investigated:

• Nutritional decline- Weight changes, Body Mass Index (BMI)

• Feeding tube complications, including patient mortality

• Unplanned hospital admissions

15/10/15[1] Evidence based practice guidelines for the nutritional management of adult patients with Head and Neck cancer, Clinical Oncology

Society of Australia http://wiki.cancer.org.au/australia/COSA:Head_and_neck_cancer_nutrition_guidelines, 2014 Page 4

BackgroundMalnutrition- Morbidity in HNC

• 30-50% malnourished at diagnosis. Consequences [1]:

o Higher mortality (20-40% deaths in advanced cancer directly linked to cachexia)

o Poor immunity

o Poorer treatment response

o Increased no. Hospital admissions/ LOS

o Poorer QOL

15/10/15[2] Langius, J. et al. Critical weight loss is a major prognostic indicator for disease-specific survival in patients with head and neck cancer receiving radiotherapy. British journal of cancer 109, 1093–1099 (2013). Page 5

≥5% weight loss during Tx significantly associated with decreased survival

BackgroundMalnutrition- Morbidity in HNC [2]

15/10/2015 [3-6] Barker et al 2013, Bando et al 2013, Lee et al 2008, Hansen et al 2006). Page 6

Background: Weight Loss and Inaccurate RTx Dosimetry

• Weight loss may cause spatial changes between RTx targets and surrounding healthy tissue, especially in IMRT. [3-6]

• Weight loss highly correlated to medial displacement of parotid glands. Result: Higher RTx dose to parotid compared to original plan [4]

Figure 1: 50 y.o male with T2 N2b Base of Tongue SCC. Increased dose to spinal cord after 12% weight loss during Tx. Source: [6] Hansen et al 2006

Prophylactic PEG: Oral and bilateral chemoRTx/ Midline oropharyngeal/nasopharyngeal/pharyngeal dx + chemoRTx OR dysphagia OR severe malnutrition at presentation

Protocol also used by • Royal

Darwin Hospital- try to avoid reactive NG’s due to Indigenous population (shame re NG visibility)

• Lismore Hospital

15/10/15[7] Brown, T. E. et al. Validated swallowing and nutrition guidelines for patients with head and neck cancer: Identification of high-risk patients for proactive gastrostomy. Head & neck 35, 1385–1391 (2013). Page 7

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Study Protocol

• Study Type: Retrospective cohort study of patient data and outcomes

• Location: SVH and Genesis Cancer centre, St Vincent’s Clinic (SVC)

• Data sources: SVH and SVC medical records 2010 - June 2014 for

study population

Inclusion: SCC Head and Neck (HN), upper aerodigestive tract.

Exclusion criteria: Palliative Tx, tumour of the ear or skin, patient’s

receiving only single modality Tx

• Potential confounding variables: Data will be adjusted for age, sex,

medical co-morbidities, smoking status, alcoholism, tumour site and

stage, HPV status and treatment modality

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Study Protocol:

Primary health outcomes (up to 12 months post treatment):• Patient weight (kg) and percentage weight changes

• Number of hospital admissions

• Hospital length of stay

• Complications associated with each nutrition intervention (EN- G

tube/NG tube, ONS, TPN) , including mortality

Secondary health outcomes:• Number of treatment breaks and treatment re-planning incidences

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Results: Patient characteristics at presentation (n=54)

Mean Age 60 (SD=11)

Sex 76% male

Ex or current smoker 80%

ETOH >40g/day 52%

Self-reported weight loss 30%

Day/Month/Year Footnote to go here Page 11

Level One - SubheadingLevel Two – Body

• Level Three – Bullet 1– Level Four – Bullet 2

• Level Five – Bullet 3

Results: Weight loss (First presentation to end of therapy, n=30)

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Results: % Weight Loss vs BMI (First presentation to end of therapy, n= 25)

10.0 15.0 20.0 25.0 30.0 35.0 40.0

-10.0%

-5.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

% Weight Loss v BMI%Weight Loss Box BMI Normal

BMI Beginning Treatment

%W

eigh

t Los

s P

re to

End

Tre

atm

ent

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Results: Weight Loss by Tumour Subsite (n=30)

Tumour Subsite AverageStandard deviation n Minimum Maximum

Hypopharynx 5% 9% 3 -7% 15%Larynx 17% 0% 1 17% 17%Nasopharnx 14% 4% 2 10% 18%Oral Cavity 10% 9% 5 2% 24%Oropharynx 9% 5% 17 1% 17%Other 6% 1% 2 6% 7%

Total (All Subsites) 9% 6% 30 -7% 24%

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Conclusion

• At presentation, patients with SCC HN have high rates of smoking

and alcohol abuse. These factors have been associated with poor

nutrition status in previous studies

• Mean patient weight loss in HNC patients in this study is significant

(9%)

• HNC patients lose a significant amount of weight pre, during and

post treatment, irrespective of their BMI

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Future Directions

Develop a patient protocol that achieves the following:

•Appropriate malnutrition screening at presentation

•Sceening and correct use of nutrition interventions (prophylactic G tube vs reactive feeding tube vs oral nutrition support)

•Prevent unnecessary hospital admissions related to malnutrition and/or feeding tube complications

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References

[1] Findlay, M, Baeur, J, Brown, T & HNSC Evidence-based practice guidelines for the nutritional management of adult patients with head and neck cancer. (2014).at <http://wiki.cancer.org.au/australiawiki/index.php?oldid=76062s>

[2] Langius, J. et al. Critical weight loss is a major prognostic indicator for disease-specific survival in patients with head and neck cancer receiving radiotherapy. British journal of cancer 109, 1093–1099 (2013).

[3] Bando, R. et al. Changes of tumor and normal structures of the neck during radiation therapy for head and neck cancer requires adaptive strategy. The Journal of Medical Investigation 60, 46–51 (2013).

[4] Barker, J. L. et al. Quantification of volumetric and geometric changes occurring during fractionated radiotherapy for head-and-neck cancer using an integrated CT/linear accelerator system. International Journal of Radiation Oncology* Biology* Physics 59, 960–970 (2004).

[5] Lee C, L. W. Langen KM Assessment of parotid gland dose changes during head and neck cancer radiotherapy using daily megavoltage computed tomography and deformable image registration (2008)

[6] Hansen EK, X. P. Bucci MK Quivey JM Weinberg V Repeat CT imaging and replanning during the course of IMRT for head-and-neck cancer (abstract only). (2006).

[7] Brown, T. E. et al. Validated swallowing and nutrition guidelines for patients with head and neck cancer: Identification of high-risk patients for proactive gastrostomy. Head & neck 35, 1385–1391 (2013).