Point/Counter

Do the benefits of a feeding tube outweigh the risks for a malnourished patient with cancer treated with curative intent?

Click here to read the Cover Story, “Malnutrition ‘almost epidemic’ among patients with advanced cancer.”

POINT

Nutrition intervention should be considered a critical supportive measure in the overall oncology strategy.

Malnutrition — suspected to occur in 40% to 80% of patients with cancer — can negatively affect response to treatment; increase treatment-related toxicity; interrupt treatment plan schedules; extend hospital stays; impair muscle function; and decrease performance status, immune function, quality of life and OS.

Kathryn K. Hamilton, MA, RDN, CSO, CDN, FAND
Kathryn K. Hamilton

Patients’ physiological response to the cancer and the effects of treatment can lead to malnutrition. Other circumstances include reduced food intake, alterations in normal digestion, absorption and utilization of nutrients, and increased metabolic needs. Cancers — particularly those involving the alimentary canal — can place stress on the body due to impaired organ function, increased nutrient losses, and treatment-related toxicities that impact nutritional status.

There are no definitive guidelines for starting nutrition support; however, the decision to use enteral nutrition support (ENS) is relatively simple for a malnourished patient who is undergoing treatment for curative disease but unable to meet nutrition needs orally for 7 or more days.

Consistent with National Comprehensive Cancer Network Guidelines, clinicians should consider nutrition support for a patient with life expectancy of months or years. Guidelines and recommendations from the European Society for Parenteral and Enteral Nutrition, Academy of Nutrition and Dietetics, American Society of Parenteral and Enteral Nutrition, and the Dietitians of Australia also recommend initiation of nutrition intervention for malnourished patients or those expected to experience difficulties with eating.

Methods of nutrition support depend on the presence or absence of a functioning gut, treatment plans, nutritional deficits, quality of life and prognosis. If a patient is unable to meet nutritional needs through oral intake and the gut is functional, clinicians should consider using a gastrostomy or jejunostomy tube. For short-term support of 3 weeks or less, clinicians can place a nasogastric, -duodenal or -jejunal tube after consideration of patient discomfort, possible mucosal erosion and concern for the tube in the treatment field. Also, patients with esophageal cancer who receive neoadjuvant treatment and need nutrition support may require placement of a nasojejunal feeding tube to prevent disruption or compromise of the future surgical site.

Barriers may include lack of expertise in ENS management, patient dissatisfaction, concern for long-term tube feeding dependency and swallowing dysfunction after treatment. Enlisting the services of an interprofessional team that includes a registered dietitian nutritionist and speech language pathologist can help overcome management challenges and improve nutritional outcomes.

ENS is not only a viable option for management of malnutrition in patients being treated for curable cancer, it can significantly benefit aspects of quality of life during a difficult process.

Kathryn K. Hamilton, MA, RDN, CSO, CDN, FAND, is an oncology dietician at Carol G. Simon Cancer Center. She can be reached at kathryn.hamilton@atlantichealth.org. Hamilton reports no relevant financial disclosures.

COUNTER

Feeding tubes can lead to poor quality of life, especially for patients with head and neck cancer.

Feeding tubes play a critical role in maintaining positive nitrogen balance during cancer therapy. Most oncologists agree that placing them to optimize nutrition is a critical step in successful cancer therapy. However, placement of a percutaneous endoscopic gastrostomy (PEG) tube is a surgical procedure and, as such, carries inherent risk. A large meta-analysis showed a procedure-related morbidity of 9.4% and mortality of 0.53%. Most series report morbidity rates ranging from 9% to 17%, although major complications occur in only 1% to 3% of cases.

Ted Teknos, MD
Ted Teknos

Weighing the benefits and risks of enteral nutrition support is crucial for patients with head and neck cancer, because the treatments we administer — particularly the combinations of chemotherapy and radiation therapy — result in significant mucositis and swallowing-related difficulties. It has been a debate in our field for many years as to how beneficial it is to give patients a feeding tube to maintain their weight compared with encouraging them to continue to swallow during treatment.

There has been literature supporting both sides of the argument. However, we have learned that — in head and neck cancer in particular, and possibly in other malignancies — the continued exercise of the pharyngeal musculature and tongue musculature during therapy results in better swallowing outcomes after treatment. High doses of radiation therapy to the head and neck damage the muscles of the throat and weaken a patient’s ability to recover. We have taken the approach of having a feeding tube there as a safety valve, but doing very aggressive speech and swallowing therapy during treatment and after treatment to maintain optimal swallowing after therapy.

The biggest source of debate is that there is well-documented evidence that if patients are malnourished during their treatment, their treatment is less effective. Losing too much weight during therapy may affect a patient’s ability to recover from treatment. There is some implication that the immune system also is compromised due to malnutrition, which limits the ability to “beat” cancer. There is overwhelming evidence that malnutrition is correlated with poorer cancer outcomes. The balancing act is maintaining a patient’s weight while still dealing with the significant side effects from the tumor, which are long-lasting and can negatively affect quality of life.

In head and neck cancer, quality-of-life surveys after treatment show the number one predictor of a poor quality of life is a feeding tube — even more than a tracheotomy and more than fear of cancer coming back. It is not a small deal to have a feeding tube long term, so we try to make sure the patient is nourished, while also ensuring they will be able to swallow well after treatment is complete so they have optimal quality of life.

Ted Teknos, MD, is chair of otolaryngology at The Ohio State University Wexner Medical Center. He can be reached at ted.teknos@osumc.edu. Disclosure: Teknos reports no relevant financial disclosures.

Click here to read the Cover Story, “Malnutrition ‘almost epidemic’ among patients with advanced cancer.”

POINT

Nutrition intervention should be considered a critical supportive measure in the overall oncology strategy.

Malnutrition — suspected to occur in 40% to 80% of patients with cancer — can negatively affect response to treatment; increase treatment-related toxicity; interrupt treatment plan schedules; extend hospital stays; impair muscle function; and decrease performance status, immune function, quality of life and OS.

Kathryn K. Hamilton, MA, RDN, CSO, CDN, FAND
Kathryn K. Hamilton

Patients’ physiological response to the cancer and the effects of treatment can lead to malnutrition. Other circumstances include reduced food intake, alterations in normal digestion, absorption and utilization of nutrients, and increased metabolic needs. Cancers — particularly those involving the alimentary canal — can place stress on the body due to impaired organ function, increased nutrient losses, and treatment-related toxicities that impact nutritional status.

There are no definitive guidelines for starting nutrition support; however, the decision to use enteral nutrition support (ENS) is relatively simple for a malnourished patient who is undergoing treatment for curative disease but unable to meet nutrition needs orally for 7 or more days.

Consistent with National Comprehensive Cancer Network Guidelines, clinicians should consider nutrition support for a patient with life expectancy of months or years. Guidelines and recommendations from the European Society for Parenteral and Enteral Nutrition, Academy of Nutrition and Dietetics, American Society of Parenteral and Enteral Nutrition, and the Dietitians of Australia also recommend initiation of nutrition intervention for malnourished patients or those expected to experience difficulties with eating.

Methods of nutrition support depend on the presence or absence of a functioning gut, treatment plans, nutritional deficits, quality of life and prognosis. If a patient is unable to meet nutritional needs through oral intake and the gut is functional, clinicians should consider using a gastrostomy or jejunostomy tube. For short-term support of 3 weeks or less, clinicians can place a nasogastric, -duodenal or -jejunal tube after consideration of patient discomfort, possible mucosal erosion and concern for the tube in the treatment field. Also, patients with esophageal cancer who receive neoadjuvant treatment and need nutrition support may require placement of a nasojejunal feeding tube to prevent disruption or compromise of the future surgical site.

Barriers may include lack of expertise in ENS management, patient dissatisfaction, concern for long-term tube feeding dependency and swallowing dysfunction after treatment. Enlisting the services of an interprofessional team that includes a registered dietitian nutritionist and speech language pathologist can help overcome management challenges and improve nutritional outcomes.

PAGE BREAK

ENS is not only a viable option for management of malnutrition in patients being treated for curable cancer, it can significantly benefit aspects of quality of life during a difficult process.

Kathryn K. Hamilton, MA, RDN, CSO, CDN, FAND, is an oncology dietician at Carol G. Simon Cancer Center. She can be reached at kathryn.hamilton@atlantichealth.org. Hamilton reports no relevant financial disclosures.

COUNTER

Feeding tubes can lead to poor quality of life, especially for patients with head and neck cancer.

Feeding tubes play a critical role in maintaining positive nitrogen balance during cancer therapy. Most oncologists agree that placing them to optimize nutrition is a critical step in successful cancer therapy. However, placement of a percutaneous endoscopic gastrostomy (PEG) tube is a surgical procedure and, as such, carries inherent risk. A large meta-analysis showed a procedure-related morbidity of 9.4% and mortality of 0.53%. Most series report morbidity rates ranging from 9% to 17%, although major complications occur in only 1% to 3% of cases.

Ted Teknos, MD
Ted Teknos

Weighing the benefits and risks of enteral nutrition support is crucial for patients with head and neck cancer, because the treatments we administer — particularly the combinations of chemotherapy and radiation therapy — result in significant mucositis and swallowing-related difficulties. It has been a debate in our field for many years as to how beneficial it is to give patients a feeding tube to maintain their weight compared with encouraging them to continue to swallow during treatment.

There has been literature supporting both sides of the argument. However, we have learned that — in head and neck cancer in particular, and possibly in other malignancies — the continued exercise of the pharyngeal musculature and tongue musculature during therapy results in better swallowing outcomes after treatment. High doses of radiation therapy to the head and neck damage the muscles of the throat and weaken a patient’s ability to recover. We have taken the approach of having a feeding tube there as a safety valve, but doing very aggressive speech and swallowing therapy during treatment and after treatment to maintain optimal swallowing after therapy.

The biggest source of debate is that there is well-documented evidence that if patients are malnourished during their treatment, their treatment is less effective. Losing too much weight during therapy may affect a patient’s ability to recover from treatment. There is some implication that the immune system also is compromised due to malnutrition, which limits the ability to “beat” cancer. There is overwhelming evidence that malnutrition is correlated with poorer cancer outcomes. The balancing act is maintaining a patient’s weight while still dealing with the significant side effects from the tumor, which are long-lasting and can negatively affect quality of life.

PAGE BREAK

In head and neck cancer, quality-of-life surveys after treatment show the number one predictor of a poor quality of life is a feeding tube — even more than a tracheotomy and more than fear of cancer coming back. It is not a small deal to have a feeding tube long term, so we try to make sure the patient is nourished, while also ensuring they will be able to swallow well after treatment is complete so they have optimal quality of life.

Ted Teknos, MD, is chair of otolaryngology at The Ohio State University Wexner Medical Center. He can be reached at ted.teknos@osumc.edu. Disclosure: Teknos reports no relevant financial disclosures.