Nutrition plays a vital role during all phases of treatment for many cancer types, but it is particularly important for individuals with head and neck cancer.
An estimated 30% to 50% of patients with head and neck cancer experience malnutrition before treatment begins. Even those who are not malnourished at the time of diagnosis remain highly susceptible to malnutrition.
Significant weight loss in 75% to 80% of those with head and neck cancer has been widely reported.
Malnutrition and poor food intake are associated with more frequent and severe radiation therapy–induced toxicities, more frequent and longer radiation therapy interruptions, greater hospital readmission rates, impaired quality of life and increased mortality. Many studies showed malnourished patients experience worse physical functioning and fatigue than well-nourished patients.
Therefore, nutritional needs — often elevated among those with cancer due to hypermetabolism and increased stress — must be met to avoid catabolism and weight loss.
This overview — presented in conjunction with National Oral, Head and Neck Cancer Awareness Week, observed this year from April 2-9 — examines the nutrition-related challenges faced by patients with head and neck cancer, as well as nutrition strategies and other suggestions that may help patients overcome these challenges and maintain good nutritional status.
Challenges during treatment
Adequate nutritional status has been shown to benefit patients with cancer in multiple ways, including higher therapy completion rates, longer survival and improved quality of life. However, patients with head and neck cancer face unique challenges that interfere with their ability to eat due to the location of their disease.
Many patients require significant dental work prior to starting treatment. As a result, they may require diets of modified textures.
Large tumors may cause dysphagia, odynophagia and trouble chewing.
Dysphagia — the most common side effect of head and neck cancer — often results from obstruction of the tumor, odynophagia or other factors. A speech language pathologist should be part of the care team to conduct swallowing studies and determine appropriate diet consistencies.
The multimodality nature of treatment — which includes surgery, chemotherapy or radiation therapy — also creates challenges for patients.
Surgery may impact anatomy, and this could affect a person’s ability to chew and swallow. Radiation therapy to the head and neck often damages tissues, causing dysgeusia, oral mucositis, stomatitis, xerostomia and thick salvia. Chemotherapy enhances the side effects of radiation therapy, and it also may cause nausea, vomiting and decreased desire to eat.
It is vital that patients with head and neck cancer consult with a registered dietitian — if possible, one who is a certified specialist in oncology — to create a nutrition plan for each phase of treatment. Registered dietitians can provide instructions about how to modify textures of food while meeting estimated nutrient needs.
It is imperative that oncologists and oncology nurses expand the conversation on nutrition and refer to oncology-credentialed dietitians as part of the interdisciplinary team.
The multidisciplinary approach allows for patients to optimize their nutrition status, reduce complications, ensure safety and enhance quality of life during treatment.
Patients who experience severe dysphagia — who often are not able to meet estimated nutrient needs by mouth — should be considered for nutrition support.
Percutaneous endoscopic gastrostomy tubes — which provide the best route of artificial nutrition support — are associated with better quality of life, greater mobility, and higher satisfaction in appearance and functionality of the tube.
Common predictors of percutaneous endoscopic gastrostomy placement are low BMI, large tumor size, lymph node involvement, and floor-of-mouth or base-of-tongue tumors.
No standards or protocols exist, so the interdisciplinary team should assess each case for appropriateness of nutrition support.
Registered dietitians are an invaluable resource for patients with head and neck cancer if a feeding tube is placed, as they can provide instructions on proper tube feeding rates, regimens and formulas.
A patient’s medical history may indicate the need for specialty tube feeding formulas, such as low fiber, diabetic or renal. Registered dietitians will ensure patients are tolerating their regimen properly and receiving optimal nutrition support based on their goals.
Some patients with head and neck cancer may concurrently use nutrition support with oral intake. Patients who are on nutrition support often are encouraged to continue with oral intake as tolerated or engage in swallowing exercises to prevent atrophy of swallowing muscles.
Patients with head and neck cancer often experience short- and long-term treatment-related side effects that impact nutritional status and result in suboptimal nutrition intake. Aggressive symptom management with both pharmacologic and nutrition approaches is important for optimizing nutrition.
Patients with head and neck cancer often experience thick saliva, xerostomia, mucositis, sore mouth, dysgeusia and decreased appetite. Sore mouth and mucositis occur in nearly all patients who receive concurrent chemoradiation therapy.
Clinicians can offer several suggestions to help patients with head and neck cancer manage common nutrition-related side effects.
Those with xerostomia and thick saliva should:
- Adequately hydrate with 64 to 96 ounces of noncaffeinated fluids per day;
- Sip 100% pure papaya juice to stimulate saliva and break up secretions;
- Use citrus to increase production of saliva (contraindicated if mouth sore and mucositis are present);
- Use nonalcohol mouthwashes;
- Choose soft and moist foods as they are easier to chew/swallow, and liberally add extra gravies and sauces to moisten foods; and
- Avoid or limit caffeinated foods and beverages, alcohol and dry foods (eg, tough meats, raw vegetables, breads and pretzels).
Those with sore mouth or mucositis should:
- Practice good oral care;
- Choose soft and bland foods, such as creamy soups, hot cereal, yogurt, pudding, mashed potatoes, eggs, smoothies and shakes, custards or casseroles;
- Drink liquids and semisoft solids through a straw to bypass areas with sores;
- Moisten and blend food to make it easier to chew/swallow;
- Consume soft, probiotic-containing foods, such as yogurt or kefir, or let one spoonful of yogurt soak in the mouth for up to 5 minutes (may be contraindicated in severe immunosuppression); and
- Avoid tart, acidic, salty, tomato-based or pickled food or beverages.
Many people with head and neck cancer experience hypogeusia or dysgeusia. Suggestions can be tailored to the specific changes patients report.
Consider using the acronym FASS, which stands for using extra fat (extra virgin olive oil), acidic flavors (lemon, lime, orange), salt (sea salt), and sweet (maple syrup, honey) to enhance flavors of food and provide vehicles for more intense taste.
If patients experience metallic taste, they should use plastic utensils and balance out the taste with sweet flavors.
Also, it is not uncommon for patients to enjoy foods and flavors they do not expect to, so it is important to explore foods outside of their comfort zone.
More information and resources for patients and health care professionals are available at yourcancergameplan.com.
Nutrition is an essential part of comprehensive care for patients with head and neck cancer, a population for whom nutritional status often is adversely affected.
Research has shown that identification of nutrition problems and treatment of symptoms stabilized or reversed weight loss in 50% to 88% of patients with cancer.
Head and neck cancer requires consistent follow-up by an oncology-registered dietitian.
Intervention should be early and aggressive to prevent or reduce the degree of malnutrition in this population. Oncologists and oncology nurses should expand the conversation around nutrition and provide comprehensive care by integrating oncology registered dietitians to support patients.
by Jessica Iannotta, MS, RD, CSO, CDN, and Chelsey Wisotsky, MS, RD, CSO, CDN
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For more information:
Jessica Iannotta, MS, RD, CSO, CDN, is an oncology dietitian and chief operating officer at Savor Health. She can be reached at firstname.lastname@example.org.
Chelsey Wisotsky, MS, RD, CSO, CDN, is an oncology dietitian with Savor Health. She can be reached at email@example.com.
Savor Health — a technology-enabled platform designed by cancer nutrition experts — provides evidence-based nutrition solutions and educational programs to help patients be well nourished, gain control over side effects, and experience improved treatment journey and clinical outcomes.
Disclosure: Savor Health is a partner with Your Cancer Game Plan, an awareness campaign designed to help people with cancer meet their emotional, nutritional and communication needs.