- Email: [email protected]
Predictors of weight loss during radiation therapy
Predictors of weight loss during radiation therapy MARY ES BEAVER, MD, KEITH E. MATHENY,
MD,
DIANNA B. ROBERTS, PHD, and JEFFREY N. MYERS, MD, PHD, Houston, Texas,
and Nashville, Tennessee
OBJECTIVE: To define risk factors for weight loss or dehydration during radiation therapy (RT). STUDY DESIGN AND SETTING: Retrospective chart review, academic tertiary care center. RESULTS: The incidence of severe weight loss during RT was 32.7%, the incidence of dehydration was 10.9%, and the rate of prophylactic feeding gastrostomy tube placement was 32%. The patients most likely to suffer severe weight loss included patients with tumor sites of nasopharynx and base of tongue, those treated with chemoradiation, and patients with severe pretreatment weight loss. Prophylactic feeding gastrostomy tube placement before RT significantly reduced the incidence of severe weight loss and hospitalization during RT. CONCLUSION: Severe weight loss and dehydration during RT for head and neck cancer is common. Prophylactic feeding gastrostomy tubes significantly reduce the incidence of severe weight loss and hospitalization for dehydration during RT when placed before onset of RT. Patients at risk for severe weight loss include those with severe pretreatment weight loss, tumors of the nasopharynx and base of tongue, or treatment with chemoradiation. (Otolaryngol Head Neck Surg 2001;125:645-8.)
Head and neck cancer patients are at high risk of malnutrition due to their disease process and the treatment of their disease.1,2 Specifically, radiation therapy delivered to the head and neck region confers a predictable morbidity on the patient with incidences of severe weight loss during treatment up to 58%.3 Prophylactic gastrostomy tubes (PFGs) placed before the onset of radiation treatments have been shown to decrease the From the Texas Voice Center (Dr Beaver); Department of Otolaryngology (Dr Matheny), Vanderbilt University Medical Center; and The University of Texas M.D. Anderson Cancer Center (Dr Roberts and Myers). Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, September 1998, New Orleans LA. Reprint requests: Jeffrey N. Myers, MD, PhD, Department of Head and Neck Surgery, The U.T. M.D. Anderson Cancer Center, 1515 Holcombe, Houston, TX, 77030; e-mail, [email protected] Copyright © 2001 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/2001/$35.00 + 0 23/1/120428 doi:10.1067/mhn.2001.120428
incidence of weight loss and dehydration during treatment.4 PFGs have also been shown to be a safe and effective way of delivering enteral supplementation during radiotherapy.5 The goal of this study was to determine if specific risk factors were identifiable in the head and neck cancer patient undergoing radiation therapy (RT) that could predict weight loss or dehydration during treatment. The ultimate aim was to identify those at greatest risk of developing significant weight loss who would benefit from prophylactic PFG placement. The secondary goal of this study was to confirm that pretreatment feeding tube placement reduced the incidence of severe weight loss during radiotherapy and hospitalization due to dehydration during treatment. MATERIALS AND METHODS The medical records and nutritional records of 249 head and neck cancer patients at M. D. Anderson Cancer Center (MDACC) from 1985 to 1996 were retrospectively reviewed to determine risk factors for weight loss or dehydration during RT. All patients receiving RT were evaluated by the nutrition service before treatment and received counseling on weight loss and oral supplementation. Some patients received gastrostomy tubes (GT) or nasogastric tubes (NGT) prior to RT. The decision to place a GT or NGT was made on an individual basis by each of the 10 head and neck surgeons for each case using clinical criteria. Inclusion criteria for the review were a diagnosis of squamous carcinoma of the nasopharynx, oral cavity/oropharynx, hypopharynx, or supraglottic larynx; definitive or postoperative RT, entire treatment performed at MDACC, and a completed nutritional flow sheet during treatment. Exclusion criteria included the following: incomplete nutritional records, incomplete treatment, palliative or shortcourse treatment, and death during treatment. Variables measured were: patient age, patient race, patient sex, history of alcoholism and smoking, tumor site, tumor size (T stage), severe weight loss before primary medical evaluation (PME), history of surgery within 6 weeks before RT, dose of radiation, RT hyperfractionation, and concomitant chemoradiation. Outcomes measured included tube placement rate, timing of tube placement, incidence of hospitalization during RT for dehydration, incidence of emergency room (ER) visits during RT for dehydration, and incidence of severe weight loss during RT. Severe weight loss before PME was defined as >10% of usual body weight (UBW) lost in 6 months, 5% of UBW lost in 1 month, 2% of UBW lost in 1 week, or > 7% of body mass index (BMI) lost in 6 months. 645
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Table 1. Weight loss during RT according to tumor site Tumor site
Nasopharynx Oral cavity/oropharynx Hypopharynx Supraglottic larynx
Severe weight loss N (%)
No severe weight loss N (%)
22 (46)* 27 (35)* 15 (28) 16 (27)
48 (54) 77 (65) 53 (72) 59 (73)
Table 3. Timing of tube placement and weight loss during RT Timing of tube placement
No tube placed Tube placed before onset of RT Tube placed during or after RT
Table 2. Severe weight loss during RT for oral cavity/oropharynx Subsite
Tongue BOT Tonsil RMT Buccal
88 (75) 29 (86) 45 (40)
No severe weight loss N (%)
5 (22) 17 (49)* 4 (25) 1 (20) —
17 (74) 18 (51) 12 (75) 3 (80) 3 (100)
Table 4. Other factors affecting weight loss during RT
Severe weight No severe loss during weight loss RT N (%) during RT N (%)
32 (25) 4 (14)* 27 (60)*
Severe weight loss N (%)
Factor
Surgery before RT 7% Decrease in BMI before PME No decrease in BMI before PME
Severe weight loss N (%)
9 (14)* 70 (59) 9 (8)*
No severe weight loss N (%)
65 (86) 49 (41) 116 (92)
*P < 0.05.
Patient variables and outcomes were compared in all combinations to determine significant associations. Differences in proportions of patients in the various experimental groups with the outcomes listed above were tested by means of the 2 test with the Yates correction factor if the groups to be compared had fewer than 10 but at least 6 patients in them. If there were < 5 patients in a group, the 2-tailed Fisher exact test was used. All statistical tests were performed with the assistance of the Statistica statistical software application (StatSoft, Inc, Tulsa, OK). RESULTS
The results of 249 sequential patients were reviewed. The mean age was 57.6 years, with 75% males and 25% females; 78.6% of the patients were white, 10.1% were Hispanic, 6% were African American, 1.6% were Asian, and 3.6% were of other racial descent. There was an overall incidence of severe weight loss during radiation therapy of 32.7%. There was a 10.9% rate of admission into the hospital for dehydration and emergency room visits for dehydration. Thirty-two percent of the patients had feeding tubes placed at some time during their evaluation or treatment. Of the tubes placed, 38% were placed before treatment, 50% were placed during treatment, and 12% were placed after completion of treatment. Severe Weight Loss During RT
There was no statistically significant difference in incidence of severe weight loss during RT in patients
with respect to differences in age, sex, race, alcoholism, smoking, T stage, N stage, dose of RT, or fractionation schedule of RT. With respect to site and subsite of the primary tumor, the patients with a tumor site of the nasopharynx had significantly more severe weight loss during RT when compared with patients with tumors at other sites (Table 1). Patients with a tumor site of base of tongue had significantly more severe weight loss when compared with other oral cavity/oropharynx sites (Table 2). The patients who received a feeding tube before the onset of RT had a significantly lower incidence of severe weight loss when compared with those patients who received only nutritional counseling and oral supplementation or those patients who received feeding tubes during or after RT (Table 3). The patients who underwent surgery and postoperative RT had a significantly lower incidence of severe weight loss during RT when compared with those patients who received therapeutic RT alone. Finally, patients who had lost >7% of their BMI before PME had a significantly higher incidence of severe weight loss during RT (Table 4). Hospitalization for Dehydration During Treatment
Patients who had tumors located in the nasopharynx had a significantly higher rate of admission to the hospital for dehydration during RT when compared with patients with tumors in other sites. In addition, patients
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Table 5. Hospitalizations during RT for dehydration Variable
Hospitalized during RT N (%)
Not hospitalized NN (%)
Table 6. Tube placement rate according to tumor site Tumor site
Nasopharynx Oral cavity/oropharynx Hypopharynx Supraglottic larynx Surgery before RT ChemoRT Severe weight loss during RT
12 (24)* 2 (2)* 6 (11) 6 (10) 3 (5)* 3 (33)* 16 (21)
38 (76) 79 (98) 44 (88) 48 (90) 54 (95) 6 (67) 59 (79)
*P < 0.05.
with tumors in the oral cavity/oropharynx had a significantly lower rate of hospitalization when compared with patients with tumors at other sites. Those patients who underwent surgery and postoperative RT had a lower rate of hospitalization during RT than those patients who underwent definitive RT alone. The patients who received concomitant chemotherapy-RT had a significantly higher rate of hospitalization. In addition, if a patient received a tube during or after RT rather than before RT, they were more likely to be admitted to the hospital during RT (Table 5). Emergency Room Visits During Treatment
Patients with tumors of the nasopharynx had significantly more ER visits during treatment than patients with tumors at other sites. If a patient had severe weight loss during RT, they were more likely to have visited the ER during their treatment for dehydration. And if a patient had a feeding tube placed during or after treatment rather than before treatment, they had significantly more ER visits during RT. Need for Tube Placement
Thirty-two percent of the patients received feeding tubes at some point in their treatment; 12% of the patients had feeding tubes placed before RT; 16% had tubes placed during RT; and 4% had tubes placed after completion of treatment. Patients with tumors of the nasopharynx had significantly fewer tubes placed overall, and patients with tumors of the oral cavity/oropharynx had significantly more tubes placed overall (Table 6). Patients with larger tumors (T3-4) had more tubes placed than those patients with smaller tumors (T1-2). Patients who had severe weight loss before PME had more tubes placed. Patients who received surgery also received more tubes than patients receiving RT alone. Patients who visited the ER or were admitted to the hospital during treatment for dehydration received more tubes than patients that did not visit the ER.
647
Nasopharynx Oral cavity/oropharynx Hypopharynx Supraglottic larynx
Tube placed N (%)
9 (18) 35 (43) 19 (35) 16 (27)
No tube placed N (%)
39 (82) 36 (57) 33 (65) 43 (73)
DISCUSSION
There were no standard criteria for placing PFGs in this study population or for timing of tube placement. This study attempted to analyze negative outcomes of severe weight loss during RT and hospitalization due to dehydration during RT, as well as find associations between patient variables and negative outcomes in order to determine whether existing clinical criteria for tube placement were sufficient and what modifications to those criteria needed to be made. There were 32.7% of patients who had severe weight loss during RT and 10.9% who were hospitalized for dehydration during RT despite pretreatment nutritional counseling, oral supplementation, and PFG placement on clinical criteria alone. These numbers suggest that more patients could benefit from PFG placement than were detected by clinical criteria alone. Fewer than half of the feeding tubes placed in this study were placed before the onset of therapy. According to the results of this study, the patients who received PFGs before the onset of RT had a significantly lower incidence of severe weight loss when compared with those patients who received only nutritional counseling and oral supplementation, and tube placement during therapy was associated with severe weight loss during therapy and with hospitalization for dehydration. Clearly it is of benefit to the patient to provide PFGs, and to provide them before therapy begins. It is neither cost-effective nor appropriate to perform PFGs on every patient who is scheduled for RT. Therefore, this study targeted several groups recommended to receive pretreatment PFGs. Patients with a tumor site of nasopharynx or subsite of base of tongue had more severe weight loss and dehydration than patients with other tumor sites. This outcome could be due to the fact that fewer patients with a tumor site of nasopharynx received PFGs; patients who received more PFGs (site of oral cavity/oropharynx, surgery patients) had less weight loss and less hospitalizations for dehydration than patients who received fewer PFGs. The other group that received more PFGs, the surgery/RT group, also had a lower incidence of severe weight loss during RT.
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648 BEAVER et al
Although the patients with tumor site of oral cavity/oropharynx as a group had less weight loss during RT and less hospitalization overall, within that group the subset of base of tongue had a significantly higher rate of severe weight loss. Tumor size, N stage, and radiation dose did not appear to be factors associated with severe weight loss. Patients with severe pretreatment weight loss, though they received more PFGs, still had a higher incidence of hospitalization for dehydration, and those that lost >7% of their BMI before evaluation had a significantly higher incidence of severe weight loss during RT. This study indicates that the risk of weight loss and dehydration from RT is high and that PFGs should be used frequently. The recommendations from this study are that the patients at most risk for severe weight loss include those who have lost significant weight before PME, those with a tumor site of nasopharynx or base of tongue, and those patients undergoing concomitant chemoradiation therapy. Patients with other tumor sites in the head and neck are still at risk for weight loss and should be evaluated on an individual basis using clinical nutritional criteria. The data also suggest
that some patients who have had severe weight loss before PME may continue to lose weight during RT or have a higher incidence of dehydration during RT despite PFG placement. In these cases, severe nutritional deficits may not be able to be reversed even with aggressive enteral supplementation. This subset of patients needs appropriate counseling and would benefit from further study. REFERENCES 1. Donaldson SS, Lenon RA. Alterations of nutritional status: impact of chemotherapy and radiation therapy. Cancer 1979;43(5 Suppl):2036-52. 2. Sobol SM, Conoyer JM, Zill R, et al. Nutritional concepts in the management of the head and neck cancer patient. I. basic concepts. Laryngoscope 1979;89:794-803. 3. Nayel H, el-Ghoreimy E, el-Haddad S. Impact of nutritional supplementation on treatment delay and morbidity in patients with head and neck tumors treated with irradiation. Nutrition 1992; 8:13-8. 4. Lee JH, Machtay M, Unger LD, et al. Prophylactic gastrostomy tubes in patients undergoing intensive irradiation for cancer of the head and neck. Arch Oto HNS 1998;124:871-5. 5. Bell SD, Carmody EA, Yeung EY. Percutaneous gastrostomy and gastrojejunostomy: additional experience in 519 procedures. Radiology 1995;194:817-20.
MD,
DIANNA B. ROBERTS, PHD, and JEFFREY N. MYERS, MD, PHD, Houston, Texas,
and Nashville, Tennessee
OBJECTIVE: To define risk factors for weight loss or dehydration during radiation therapy (RT). STUDY DESIGN AND SETTING: Retrospective chart review, academic tertiary care center. RESULTS: The incidence of severe weight loss during RT was 32.7%, the incidence of dehydration was 10.9%, and the rate of prophylactic feeding gastrostomy tube placement was 32%. The patients most likely to suffer severe weight loss included patients with tumor sites of nasopharynx and base of tongue, those treated with chemoradiation, and patients with severe pretreatment weight loss. Prophylactic feeding gastrostomy tube placement before RT significantly reduced the incidence of severe weight loss and hospitalization during RT. CONCLUSION: Severe weight loss and dehydration during RT for head and neck cancer is common. Prophylactic feeding gastrostomy tubes significantly reduce the incidence of severe weight loss and hospitalization for dehydration during RT when placed before onset of RT. Patients at risk for severe weight loss include those with severe pretreatment weight loss, tumors of the nasopharynx and base of tongue, or treatment with chemoradiation. (Otolaryngol Head Neck Surg 2001;125:645-8.)
Head and neck cancer patients are at high risk of malnutrition due to their disease process and the treatment of their disease.1,2 Specifically, radiation therapy delivered to the head and neck region confers a predictable morbidity on the patient with incidences of severe weight loss during treatment up to 58%.3 Prophylactic gastrostomy tubes (PFGs) placed before the onset of radiation treatments have been shown to decrease the From the Texas Voice Center (Dr Beaver); Department of Otolaryngology (Dr Matheny), Vanderbilt University Medical Center; and The University of Texas M.D. Anderson Cancer Center (Dr Roberts and Myers). Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, September 1998, New Orleans LA. Reprint requests: Jeffrey N. Myers, MD, PhD, Department of Head and Neck Surgery, The U.T. M.D. Anderson Cancer Center, 1515 Holcombe, Houston, TX, 77030; e-mail, [email protected] Copyright © 2001 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/2001/$35.00 + 0 23/1/120428 doi:10.1067/mhn.2001.120428
incidence of weight loss and dehydration during treatment.4 PFGs have also been shown to be a safe and effective way of delivering enteral supplementation during radiotherapy.5 The goal of this study was to determine if specific risk factors were identifiable in the head and neck cancer patient undergoing radiation therapy (RT) that could predict weight loss or dehydration during treatment. The ultimate aim was to identify those at greatest risk of developing significant weight loss who would benefit from prophylactic PFG placement. The secondary goal of this study was to confirm that pretreatment feeding tube placement reduced the incidence of severe weight loss during radiotherapy and hospitalization due to dehydration during treatment. MATERIALS AND METHODS The medical records and nutritional records of 249 head and neck cancer patients at M. D. Anderson Cancer Center (MDACC) from 1985 to 1996 were retrospectively reviewed to determine risk factors for weight loss or dehydration during RT. All patients receiving RT were evaluated by the nutrition service before treatment and received counseling on weight loss and oral supplementation. Some patients received gastrostomy tubes (GT) or nasogastric tubes (NGT) prior to RT. The decision to place a GT or NGT was made on an individual basis by each of the 10 head and neck surgeons for each case using clinical criteria. Inclusion criteria for the review were a diagnosis of squamous carcinoma of the nasopharynx, oral cavity/oropharynx, hypopharynx, or supraglottic larynx; definitive or postoperative RT, entire treatment performed at MDACC, and a completed nutritional flow sheet during treatment. Exclusion criteria included the following: incomplete nutritional records, incomplete treatment, palliative or shortcourse treatment, and death during treatment. Variables measured were: patient age, patient race, patient sex, history of alcoholism and smoking, tumor site, tumor size (T stage), severe weight loss before primary medical evaluation (PME), history of surgery within 6 weeks before RT, dose of radiation, RT hyperfractionation, and concomitant chemoradiation. Outcomes measured included tube placement rate, timing of tube placement, incidence of hospitalization during RT for dehydration, incidence of emergency room (ER) visits during RT for dehydration, and incidence of severe weight loss during RT. Severe weight loss before PME was defined as >10% of usual body weight (UBW) lost in 6 months, 5% of UBW lost in 1 month, 2% of UBW lost in 1 week, or > 7% of body mass index (BMI) lost in 6 months. 645
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646 BEAVER et al
Table 1. Weight loss during RT according to tumor site Tumor site
Nasopharynx Oral cavity/oropharynx Hypopharynx Supraglottic larynx
Severe weight loss N (%)
No severe weight loss N (%)
22 (46)* 27 (35)* 15 (28) 16 (27)
48 (54) 77 (65) 53 (72) 59 (73)
Table 3. Timing of tube placement and weight loss during RT Timing of tube placement
No tube placed Tube placed before onset of RT Tube placed during or after RT
Table 2. Severe weight loss during RT for oral cavity/oropharynx Subsite
Tongue BOT Tonsil RMT Buccal
88 (75) 29 (86) 45 (40)
No severe weight loss N (%)
5 (22) 17 (49)* 4 (25) 1 (20) —
17 (74) 18 (51) 12 (75) 3 (80) 3 (100)
Table 4. Other factors affecting weight loss during RT
Severe weight No severe loss during weight loss RT N (%) during RT N (%)
32 (25) 4 (14)* 27 (60)*
Severe weight loss N (%)
Factor
Surgery before RT 7% Decrease in BMI before PME No decrease in BMI before PME
Severe weight loss N (%)
9 (14)* 70 (59) 9 (8)*
No severe weight loss N (%)
65 (86) 49 (41) 116 (92)
*P < 0.05.
Patient variables and outcomes were compared in all combinations to determine significant associations. Differences in proportions of patients in the various experimental groups with the outcomes listed above were tested by means of the 2 test with the Yates correction factor if the groups to be compared had fewer than 10 but at least 6 patients in them. If there were < 5 patients in a group, the 2-tailed Fisher exact test was used. All statistical tests were performed with the assistance of the Statistica statistical software application (StatSoft, Inc, Tulsa, OK). RESULTS
The results of 249 sequential patients were reviewed. The mean age was 57.6 years, with 75% males and 25% females; 78.6% of the patients were white, 10.1% were Hispanic, 6% were African American, 1.6% were Asian, and 3.6% were of other racial descent. There was an overall incidence of severe weight loss during radiation therapy of 32.7%. There was a 10.9% rate of admission into the hospital for dehydration and emergency room visits for dehydration. Thirty-two percent of the patients had feeding tubes placed at some time during their evaluation or treatment. Of the tubes placed, 38% were placed before treatment, 50% were placed during treatment, and 12% were placed after completion of treatment. Severe Weight Loss During RT
There was no statistically significant difference in incidence of severe weight loss during RT in patients
with respect to differences in age, sex, race, alcoholism, smoking, T stage, N stage, dose of RT, or fractionation schedule of RT. With respect to site and subsite of the primary tumor, the patients with a tumor site of the nasopharynx had significantly more severe weight loss during RT when compared with patients with tumors at other sites (Table 1). Patients with a tumor site of base of tongue had significantly more severe weight loss when compared with other oral cavity/oropharynx sites (Table 2). The patients who received a feeding tube before the onset of RT had a significantly lower incidence of severe weight loss when compared with those patients who received only nutritional counseling and oral supplementation or those patients who received feeding tubes during or after RT (Table 3). The patients who underwent surgery and postoperative RT had a significantly lower incidence of severe weight loss during RT when compared with those patients who received therapeutic RT alone. Finally, patients who had lost >7% of their BMI before PME had a significantly higher incidence of severe weight loss during RT (Table 4). Hospitalization for Dehydration During Treatment
Patients who had tumors located in the nasopharynx had a significantly higher rate of admission to the hospital for dehydration during RT when compared with patients with tumors in other sites. In addition, patients
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Table 5. Hospitalizations during RT for dehydration Variable
Hospitalized during RT N (%)
Not hospitalized NN (%)
Table 6. Tube placement rate according to tumor site Tumor site
Nasopharynx Oral cavity/oropharynx Hypopharynx Supraglottic larynx Surgery before RT ChemoRT Severe weight loss during RT
12 (24)* 2 (2)* 6 (11) 6 (10) 3 (5)* 3 (33)* 16 (21)
38 (76) 79 (98) 44 (88) 48 (90) 54 (95) 6 (67) 59 (79)
*P < 0.05.
with tumors in the oral cavity/oropharynx had a significantly lower rate of hospitalization when compared with patients with tumors at other sites. Those patients who underwent surgery and postoperative RT had a lower rate of hospitalization during RT than those patients who underwent definitive RT alone. The patients who received concomitant chemotherapy-RT had a significantly higher rate of hospitalization. In addition, if a patient received a tube during or after RT rather than before RT, they were more likely to be admitted to the hospital during RT (Table 5). Emergency Room Visits During Treatment
Patients with tumors of the nasopharynx had significantly more ER visits during treatment than patients with tumors at other sites. If a patient had severe weight loss during RT, they were more likely to have visited the ER during their treatment for dehydration. And if a patient had a feeding tube placed during or after treatment rather than before treatment, they had significantly more ER visits during RT. Need for Tube Placement
Thirty-two percent of the patients received feeding tubes at some point in their treatment; 12% of the patients had feeding tubes placed before RT; 16% had tubes placed during RT; and 4% had tubes placed after completion of treatment. Patients with tumors of the nasopharynx had significantly fewer tubes placed overall, and patients with tumors of the oral cavity/oropharynx had significantly more tubes placed overall (Table 6). Patients with larger tumors (T3-4) had more tubes placed than those patients with smaller tumors (T1-2). Patients who had severe weight loss before PME had more tubes placed. Patients who received surgery also received more tubes than patients receiving RT alone. Patients who visited the ER or were admitted to the hospital during treatment for dehydration received more tubes than patients that did not visit the ER.
647
Nasopharynx Oral cavity/oropharynx Hypopharynx Supraglottic larynx
Tube placed N (%)
9 (18) 35 (43) 19 (35) 16 (27)
No tube placed N (%)
39 (82) 36 (57) 33 (65) 43 (73)
DISCUSSION
There were no standard criteria for placing PFGs in this study population or for timing of tube placement. This study attempted to analyze negative outcomes of severe weight loss during RT and hospitalization due to dehydration during RT, as well as find associations between patient variables and negative outcomes in order to determine whether existing clinical criteria for tube placement were sufficient and what modifications to those criteria needed to be made. There were 32.7% of patients who had severe weight loss during RT and 10.9% who were hospitalized for dehydration during RT despite pretreatment nutritional counseling, oral supplementation, and PFG placement on clinical criteria alone. These numbers suggest that more patients could benefit from PFG placement than were detected by clinical criteria alone. Fewer than half of the feeding tubes placed in this study were placed before the onset of therapy. According to the results of this study, the patients who received PFGs before the onset of RT had a significantly lower incidence of severe weight loss when compared with those patients who received only nutritional counseling and oral supplementation, and tube placement during therapy was associated with severe weight loss during therapy and with hospitalization for dehydration. Clearly it is of benefit to the patient to provide PFGs, and to provide them before therapy begins. It is neither cost-effective nor appropriate to perform PFGs on every patient who is scheduled for RT. Therefore, this study targeted several groups recommended to receive pretreatment PFGs. Patients with a tumor site of nasopharynx or subsite of base of tongue had more severe weight loss and dehydration than patients with other tumor sites. This outcome could be due to the fact that fewer patients with a tumor site of nasopharynx received PFGs; patients who received more PFGs (site of oral cavity/oropharynx, surgery patients) had less weight loss and less hospitalizations for dehydration than patients who received fewer PFGs. The other group that received more PFGs, the surgery/RT group, also had a lower incidence of severe weight loss during RT.
Otolaryngology– Head and Neck Surgery December 2001
648 BEAVER et al
Although the patients with tumor site of oral cavity/oropharynx as a group had less weight loss during RT and less hospitalization overall, within that group the subset of base of tongue had a significantly higher rate of severe weight loss. Tumor size, N stage, and radiation dose did not appear to be factors associated with severe weight loss. Patients with severe pretreatment weight loss, though they received more PFGs, still had a higher incidence of hospitalization for dehydration, and those that lost >7% of their BMI before evaluation had a significantly higher incidence of severe weight loss during RT. This study indicates that the risk of weight loss and dehydration from RT is high and that PFGs should be used frequently. The recommendations from this study are that the patients at most risk for severe weight loss include those who have lost significant weight before PME, those with a tumor site of nasopharynx or base of tongue, and those patients undergoing concomitant chemoradiation therapy. Patients with other tumor sites in the head and neck are still at risk for weight loss and should be evaluated on an individual basis using clinical nutritional criteria. The data also suggest
that some patients who have had severe weight loss before PME may continue to lose weight during RT or have a higher incidence of dehydration during RT despite PFG placement. In these cases, severe nutritional deficits may not be able to be reversed even with aggressive enteral supplementation. This subset of patients needs appropriate counseling and would benefit from further study. REFERENCES 1. Donaldson SS, Lenon RA. Alterations of nutritional status: impact of chemotherapy and radiation therapy. Cancer 1979;43(5 Suppl):2036-52. 2. Sobol SM, Conoyer JM, Zill R, et al. Nutritional concepts in the management of the head and neck cancer patient. I. basic concepts. Laryngoscope 1979;89:794-803. 3. Nayel H, el-Ghoreimy E, el-Haddad S. Impact of nutritional supplementation on treatment delay and morbidity in patients with head and neck tumors treated with irradiation. Nutrition 1992; 8:13-8. 4. Lee JH, Machtay M, Unger LD, et al. Prophylactic gastrostomy tubes in patients undergoing intensive irradiation for cancer of the head and neck. Arch Oto HNS 1998;124:871-5. 5. Bell SD, Carmody EA, Yeung EY. Percutaneous gastrostomy and gastrojejunostomy: additional experience in 519 procedures. Radiology 1995;194:817-20.