Bianca Santo1
Niccolò Bertini2*
Carlo Guglielmo Cattaneo3
Sara De Matteis1
Paola De Franco1
Roberta Grassi4
Giuseppe Carlo Iorio5
Silvia Longo6
Luca Boldrini6
Antonio Piras7,8,9
Isacco Desideri2Francesca De Felice3
Viola Salvestrini10- 1Radiation Oncology Unit, Dipartimento di Oncoematologia, Ospedale “Vito Fazzi”, Lecce, Italy
- 2Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
- 3Department of Radiotherapy, Policlinico Umberto I, Department of Radiological, Oncological and Pathological Sciences, “Sapienza” University of Rome, Rome, Italy
- 4Department of Precision Medicine, University of Campania “L. Vanvitelli”, Naples, Italy
- 5Department of Oncology, Radiation Oncology, University of Turin, Turin, Italy
- 6Unità Operativa Complessa (UOC) Radioterapia Oncologica, Fondazione Policlinico Universitario Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) “A. Gemelli”, Roma, Italy
- 7Unità Operativa (UO) Radioterapia Oncologica, Villa Santa Teresa, Palermo, Italy
- 8Department of Biomedical Image Processing and Analysis, Ri.Med Foundation, Palermo, Italy
- 9Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Molecular and Clinical Medicine, University of Palermo, Palermo, Italy
- 10Radiation Oncology Unit, Centro Cyberknife, Istituto Fiorentino di Cura e Assistenza, Florence, Italy
Introduction
Weight loss is a frequent occurrence among patients with head and neck cancer (HNC) and can be observed before, during, and after cancer treatment, especially radiation therapy (RT) with or without concurrent chemotherapy (CRT). Patients with HNC are at a high risk of malnutrition at the time of diagnosis, and nutritional support or intervention is often needed during and after RT or concurrent CRT. Given the severe consequences of malnutrition and cachexia on treatment outcomes, mortality, morbidity, and quality of life, it is essential to identify patients who are at higher risk of developing this condition. The nutritional status of patients is a crucial factor in terms of adherence to treatment and recovery. Malnutrition may have a significant impact on treatment outcomes and, consequently, tumor progression. However, in clinical practice, identifying and standardizing nutritional interventions can be challenging. In this commentary, we aim to identify the components of screening and assessment that are commonly used in both literature and clinical practice and suggest the appropriate timing for nutritional interventions in patients with HNC undergoing RT or CRT.
At the time of diagnosis, 35%–60% of head and neck cancer (HNC) patients are malnourished due to cancer-related impairment such as pain, obstruction, or loss of appetite (1, 2). Compared to patients with other primary neoplasms, HNC patients are at a higher risk of malnutrition due to the location of the tumor and the impact of the treatment-related side effects on quality of life (3, 4). Indeed, malnutrition can cause a range of clinical symptoms, including metabolic and electrolytic imbalances, immune system depression, and increased morbidity and mortality (5). Weight loss can lead to discontinue cancer treatments and to a negative impact on oncological outcomes, with approximately 55% of patients losing an additional 10% or more of their body weight during RT or CRT (5–7). This note aims to provide an overview on the role of nutritional counseling in HNC patients undergoing CRT, either in an exclusive or adjuvant setting.
Screening
Malnutrition screening is an essential component of multimodal care in HNC patients. It involves the systematic identification of patients who are at risk of malnutrition and the provision of appropriate interventions to prevent or treat malnutrition (8). In this regard, the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines for screening suggests that the purpose of nutritional screening is to predict the outcome and the impact of nutritional intervention (9).There are no standardized guidelines regarding nutritional screening. Screening should occur at the time of diagnosis, before treatment begins, and at regular intervals throughout treatment and follow-up. This allows for early identification of malnutrition and timely intervention to prevent or treat it. Despite its acknowledged role, there are no standardized guidelines regarding nutritional screening.
Nutritional assessment
The risk of malnutrition is frequent in HNC patients, and for this reason, it is mandatory to primarily identify patients at higher risk. Currently, standardized parameters are adopted, and although there is not a single assessment tool, we suggest that the use of a standardized assessment is essential to identify patients at risk at baseline. The commonly used nutrition assessment tools are the following:
1. Mini Nutrition Assessment (MNA) includes anthropometric, general, dietary, and autonomy of food self-assessments (self-perception of health and nutrition) (10–12).
2. Nutritional Risk Screening 2002 (NRS2002) detects the presence or the risk of undernutrition (9, 13).
3. Patient-Generated Subjective Globe Assessment (PG-SGA) is focused on the preeminent interdisciplinary patient assessment and allows for triaging of nutrition interventions (14).
4. Malnutrition Universal Screening Tool (MUST) is a five-step screening tool to identify malnourished adults (15, 16).
The appropriate nutritional assessment should be performed for all patients before CRT. For defining the severity of malnutrition, we recommend the use of the new GLIM (Global Leadership Initiative on Malnutrition) score, already adopted by ESPEN, ASPEN, FELANPE, and PENSA. In particular, the GLIM includes three phenotypical criteria (weight loss, low BMI, and reduced muscle mass) and two etiological criteria (reduced food intake or absorption and increased disease burden or inflammation) (17).
Nutritional intervention
The aim of the nutritional intervention is to improve the subjective quality of life, enhance anti-tumor treatment effects, reduce the adverse effects of oncological care, prevent the interruption of therapy, and treat RT/CRT-related undernutrition. In this regard, Table 1 summarizes the main studies analyzing the impact of nutritional counseling and nutritional intervention strategies in HNC patients (18–32). The onset of oral mucositis in HNC patients during RT or CRT may result in weight loss and intensive dietary counseling, and oral nutrition support is recommended. This is also advised to prevent interruptions to CRT (33). There are different types of nutritional support that can be adopted to reach the needs of the patient. Main options of nutritional support are oral, enteral, and parenteral. Nutritional interventions include relaxation of previous therapeutic diets, to minimize further nutritional compromise and to positively influence quality of life outcomes (34). However, this may not necessarily be appropriate, due to the side effects and intensity of treatment regimens. Patients may require more intensive nutritional support methods from the beginning of treatment over and above traditional food fortification methods with the early use of oral nutrition support. The choice of feeding route in HNC patients will depend upon local arrangements; however, clinical considerations should include site of primary tumor, treatment plan and intent, predicted duration of enteral feeding, and patient choice (35, 36). Tube feeding is recommended if swallowing is impaired or if mucositis is anticipated, which may interfere with oral and/or pharyngeal functionality. If enteral feeding is expected to be required for longer than 4 weeks, then gastrostomy insertion is recommended but not in a prevention way, except for limited cases (37). The optimal method of tube feeding still remains unclear, and any approach should be discussed with the patient in order to ensure an individualized nutritional care. Moreover, the optimal screening and assessment for suitability and method of gastrostomy insertion by endoscopic, radiological, or surgical approach is essential. Assessment of co-morbidities and contraindications should be taken into account to prevent complications prior to oncological treatment (35, 36).
Table 1 Nutritional counseling and intervention strategies in HNC patients.
The type and volume of enteral nutrition will depend upon patients’ symptoms and current intake and is likely to change throughout and after treatment. There are no data to suggest a role for cancer-specific enteral formulae. Monitoring nutritional intervention is essential, as compliance with recommendations can be a problem and should be organized weekly during CRT. Supplementation with immunonutrient-enriched formulas such as arginine, nucleotides (RNA), and omega-3 fatty acids up to the end of (C)RT or until withdrawal in HNC patients during RT and CRT may improve or maintain nutrition status (37–39). Moreover, it can delay the onset of oral mucositis and reduce the incidence of severe oral mucositis (38–40). Much evidence is showing a possible beneficial effect of immunonutrition on the control of the onset of local recurrences of the disease after esophagectomy, an improvement in immunosurveillance mechanisms, and a reduction in inflammatory status. Finally, by modulating gene expression, the immunonutrition may make it easier for the body to adapt to systemic inflammation and oxidative stress induced by RCTs and may improve 3-year survival (25, 30, 41, 42). However, further studies focusing on the timing, dosage, and duration of immunonutrition in HNC patients are awaited.
Conclusion
In conclusion, HNC patients undergoing cancer treatment are at high risk of malnutrition before, during, and after oncological care. The nutritional screening, assessment, and support play a crucial role on the maintenance of nutritional status providing specific interventions such as oral nutritional supplements increasing dietary intake and preventing therapy-associated weight loss. It is well-reported in the literature that the interruption of CRT may contribute to worse oncological outcomes. In this regard, the present overview highlighted that an adequate nutritional screening, assessment, and interventions might increase the adherence of HNC patients to oncological treatments and encourages radiation oncologists to set up multidisciplinary care paths.
Author contributions
BS: Conceptualization, Methodology, Validation, Formal analysis, Data curation, Writing - original draft, Writing - review and editing, Supervision. NB: Methodology, Data curation, Writing – original draft, Writing – review and editing, Visualization. CC: Methodology, Data curation, Writing – original draft, Writing – review and editing, Visualization. SM: Methodology, Data curation, Writing – original draft, Writing – review and editing, Visualization. PF: Conceptualization, Validation, Formal analysis, Writing – review and editing, Visualization, Supervision. RG: Conceptualization, Validation, Formal analysis, Writing – review and editing, Visualization, Supervision. GCI: Conceptualization, Validation, Formal analysis, Writing – review and editing, Visualization, Supervision. SL: Data curation, Writing – original draft, Writing – review and editing. LB: Conceptualization, Validation, Formal analysis, Writing – review and editing, Visualization, Supervision. AP: Conceptualization, Validation, Formal analysis, Writing – review and editing, Visualization, Supervision. ID: Conceptualization, Validation, Formal analysis, Writing – review and editing, Visualization, Supervision. FF: Conceptualization, Validation, Formal analysis, Writing – review and editing, Visualization, Supervision. VS: Conceptualization, Methodology, Data curation, Writing – original draft, Writing – review and editing. All authors contributed to the article and approved the submitted version.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The reviewer ND is currently organizing a Research Topic with the authors GCI, ID.
Publisher’s note
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Keywords: head and neck, nutrition, chemotherapy, radiation therapy, weight
Citation: Santo B, Bertini N, Cattaneo CG, De Matteis S, De Franco P, Grassi R, Iorio GC, Longo S, Boldrini L, Piras A, Desideri I, De Felice F and Salvestrini V (2024) Nutritional counselling for head and neck cancer patients treated with (chemo)radiation therapy: why, how, when, and what? Front. Oncol. 13:1240913. doi: 10.3389/fonc.2023.1240913
Received: 16 June 2023; Accepted: 14 December 2023;
Published: 09 January 2024.
Edited by:
Dirk Van Gestel, Université libre de Bruxelles, BelgiumReviewed by:
Nerina Denaro, IRCCS Ca ‘Granda Foundation Maggiore Policlinico Hospital, ItalyCathy Lazarus, Icahn School of Medicine at Mount Sinai, United States
Copyright © 2024 Santo, Bertini, Cattaneo, De Matteis, De Franco, Grassi, Iorio, Longo, Boldrini, Piras, Desideri, De Felice and Salvestrini. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Niccolò Bertini, niccolo.bertini@unifi.it