Impact of Prophylactic Enteral Nutrition in
Cancer PatientsJasmine Ditter
12.7.2018
Dietetic Intern – UW Green Bay
Reason for Research
Cancer affects everyone
Malnutrition is a common side effect of
cancer
What can we do as dietitians to reduce
malnutrition in cancer patients?
Impact of Nutrition Intervention on Cancer
• Screening & Assessment
Access to Necessary Care
• Nutrition Intervention
Quality Nutrition Care
• Improved Nutrient Intake
Intermediate Outcomes
• Prevent Malnutrition
Clinical Outcomes
• Decrease or Prevent Hospitalization
Cost Outcomes
• Increase Survival & Quality of Life
Patient Outcomes
Note: Adapted from “Evidence Based Review: Prophylactic percutaneous endoscopic gastrostomy tube placement in head and neck cancer patients undergoing radiotherapy or chemo-radiotherapy,” by Brown, T., et al., 2006, Queensland Government, Queensland Health, Allied Health.
Prophylactic PEG
Enteral nutrition increased protein and energy intake
Decreased weight loss
Allows for an earlier start
Patients on enteral feeding for longer time
Better maintenance of quality of life
Reduced hospital admissions
Source: “Evidence Based Review: Prophylactic percutaneous endoscopic gastrostomy tube placement in head and neck cancer patients undergoing radiotherapy or chemo-radiotherapy,” by Brown, T., et al., 2006, Queensland Government, Queensland Health, Allied Health.
PEG vs. NG
Image 1: [PEG Tube]. (n.d.). Retrieved from https://pinnt.com/Enteral-Nutrition.aspx Image 2: [NG Tube]. (n.d.). Retrieved from https://pinnt.com/Enteral-Nutrition.aspx
Study #1: Impact of early prophylactic feeding on long term tube dependencyoutcomes in patients with head and neck cancer
Teresa Brown, Merrilyn Banks, Brett G.M. Hughes, Charles Lin, Lizbeth M. Kenny, Judith D. Bauer | 2017
Oral Oncology | Australia
Study 1 - Impact of early prophylactic feeding on long term tube dependency outcomes in patients with head and neck cancer | Brown, T., et al. | Oral Oncology | 2017
Study Design
• Studied long-term effect of tube feeding
• Randomized control trial• Study Group: Early intervention with
prophylactic PEG (61 patients)
• Control Group: Usual care (70 patients)
• Measurements taken at the end of treatment, 1, 2, 3, 4, 5, 6, and 12 months follow-up
Study 1 - Impact of early prophylactic feeding on long term tube dependency outcomes in patients with head and neck cancer | Brown, T., et al. | Oral Oncology | 2017
Results
• Tube removal was not significant between the two groups
• Removal of those with persistent disease showed some difference
• Showed increased use during acute phase
Study 1 - Impact of early prophylactic feeding on long term tube dependency outcomes in patients with head and neck cancer | Brown, T., et al. | Oral Oncology | 2017
Results
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%Pe
rcen
tage
of
Pati
ents
Months Post treatment
Graph 1: Patterns of Gastrostomy Use Over 12 Months
Full Supplementary Nil Removed
Note: Adapted from “Impact of early prophylactic feeding on long term tube dependency outcomes in patients with head and neck cancer,” by Brown, T., et al., 2017, Oral Oncology. Copyright 2017 Elsevier Ltd.
Study 1 - Impact of early prophylactic feeding on long term tube dependency outcomes in patients with head and neck cancer | Brown, T., et al. | Oral Oncology | 2017
* Statistical Significance
p < 0.05
Strengths and Limitations
Strengths:
• Studied tube use, not tube presence
• Randomized patients into groups
• Discussed the role of the dietitian
Limitations:
• Did not measure swallowing function
• Lack of quality of life assessment
Study 1 - Impact of early prophylactic feeding on long term tube dependency outcomes in patients with head and neck cancer | Brown, T., et al. | Oral Oncology | 2017
Study Take-away
Prophylactic PEG plays a positive role in acute phase
May prolong time, but not significantly
Important to involve patient for their input
Study 1 - Impact of early prophylactic feeding on long term tube dependency outcomes in patients with head and neck cancer | Brown, T., et al. | Oral Oncology | 2017
Study #2: Impact of prophylactic gastrostomy or reactive NG tube upon patient-reported long term swallow function following chemoradiotherapy for oropharyngeal carcinoma: A matched pair analysis
Brinda Sethugavalar, Mark T. Teo, Catriona Buchan, Ekin Ermis, Gillian F. Williams, Mehmet Sen, Robin J.D. Prestwich | 2016 | Oral Oncology | United Kingdom
Study 2 - Impact of prophylactic gastrostomy or reactive NG tube upon patient-reported long term swallow function following chemoradiotherapy for oropharyngeal carcinoma: A matched pair analysis | Sethugavalar, B., et al. | Oral Oncology | 2016
Study Design
• Long-term swallowing function
• Retrospective cohort study; matched pair analysis• Study Group: Prophylactic PEG (26
patients)
• Control Group: Reactive NG (26 patients)
• Assessment utilizing MDADI• Validated tool for swallow function
assessment
Study 2 - Impact of prophylactic gastrostomy or reactive NG tube upon patient-reported long term swallow function following chemoradiotherapy for oropharyngeal carcinoma: A matched pair analysis | Sethugavalar, B., et al. | Oral Oncology | 2016
Results
• Control group reported higher swallowing function
• Normalized pre-treatment diet associated with higher MDADI scores
• Overall, prophylactic gastrostomy resulted in lower MDADI scores
Study 2 - Impact of prophylactic gastrostomy or reactive NG tube upon patient-reported long term swallow function following chemoradiotherapy for oropharyngeal carcinoma: A matched pair analysis | Sethugavalar, B., et al. | Oral Oncology | 2016
Results
0
10
20
30
40
50
60
70
80
Total Global Physical Emotional Functional
Sco
re V
alu
e
Subscales
MDADI Scores
Prophylactic Gastrosomy NG as needed
Study 2 - Impact of prophylactic gastrostomy or reactive NG tube upon patient-reported long term swallow function following chemoradiotherapy for oropharyngeal carcinoma: A matched pair analysis | Sethugavalar, B., et al. | Oral Oncology | 2016
Note: Adapted from “Impact of prophylactic gastrostomy or reactive NG tube upon patient-reported long term swallow function following chemoradiotherapy for oropharyngeal carcinoma: A matched pair analysis,” by Sethugavalar, B., et al., 2016, Oral Oncology. Copyright 2016 Elsevier Ltd.
* * * *
* Statistical Significance
p < 0.05
Strengths and Limitations
Strengths:
• Use of MDADI
• Comparable baselines in both groups
• Study design allowed researchers to focus on a single outcome
Limitations:
• No information on current nutritional status
• Patient reported results
• Unclear nutrition intervention/counseling
• Compared NG tube to PEG
Study 2 - Impact of prophylactic gastrostomy or reactive NG tube upon patient-reported long term swallow function following chemoradiotherapy for oropharyngeal carcinoma: A matched pair analysis | Sethugavalar, B., et al. | Oral Oncology | 2016
Study Take-away
Importance of assessing in a time-frame that allows optimal healing
Prophylactic gastrostomy negatively affects long-term swallow function
Study 2 - Impact of prophylactic gastrostomy or reactive NG tube upon patient-reported long term swallow function following chemoradiotherapy for oropharyngeal carcinoma: A matched pair analysis | Sethugavalar, B., et al. | Oral Oncology | 2016
Study #3: Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer – a randomized study
Ewa Silander, RD, Jan Nyman, MD, PhD, Mogens Bove, MD, PhD, Leif Johansson, MD, PhD, Sven Larsson, MD, Eva Hammerlid, MD, PhD | 2011 | Head & Neck | Sweden
Study 3 - Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer – a randomized study | Silander, E., et al. | Head & Neck | 2011
Study Design
• Studied benefits of prophylactic PEG in preventing malnutrition
• Randomized controlled trial• Study Group: Use of prophylactic PEG (64
patients)
• Control Group: Clinical praxis (70 patients)
• Assessment at 1, 2, 3, 6, 12, 24-month follow-ups
Study 3 - Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer – a randomized study | Silander, E., et al. | Head & Neck | 2011
Assessment
Nutritional Assessment
Clinical Assessment
Performance Status
Quality of Life Questionnaires
Tumor Treatment
Study 3 - Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer – a randomized study | Silander, E., et al. | Head & Neck | 2011
Results
• 97 patients completed trial
• Enteral nutrition• Study group utilized for longer periods
• 23 days earlier
• Dysphagia increased in both groups• Study group showed better outcomes
• No difference in hospital stay time
• Quality of Life Questionnaires• Study group reported better scores
Study 3 - Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer – a randomized study | Silander, E., et al. | Head & Neck | 2011
Results
0
2
4
6
8
10
12
14
0 6 12 24
Perc
enta
ge
Time in Months
Percentage of Weight Loss
Study Group Control Group
Study 3 - Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer – a randomized study | Silander, E., et al. | Head & Neck | 2011
Note: Adapted from “Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer – a randomized study,” by Silander, E., et al., 2011, Head & Neck. Copyright 2011 Wiley Periodicals, Inc.
*
* Statistical Significance
p < 0.05
Results
0
5
10
15
20
25
30
0 6 24
Perc
enta
ge
Time in Months
Percent of Patients with a BMI <20
Study Group Control Group
Study 3 - Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer – a randomized study | Silander, E., et al. | Head & Neck | 2011
Note: Adapted from “Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer – a randomized study,” by Silander, E., et al., 2011, Head & Neck. Copyright 2011 Wiley Periodicals, Inc.
* Statistical Significance
p < 0.05
Results
0
10
20
30
40
50
60
70
80
0 2 3 6 12 24
Perc
enta
ge
Time in Months
Percent of Malnourished Patients
Study Group Control Group
Study 3 - Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer – a randomized study | Silander, E., et al. | Head & Neck | 2011
Note: Adapted from “Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer – a randomized study,” by Silander, E., et al., 2011, Head & Neck. Copyright 2011 Wiley Periodicals, Inc.
* Statistical Significance
p < 0.05
Strengths and Limitations
Strengths:
• Large study population
• Utilized validated assessments
• Used patient-reported data
Limitations:
• Clinical praxis - undefined
• Higher survival rates in the study group
• Limited differences in group outcomes due to nutritional counseling
• Explanation for higher malnutrition and weight loss at 24-months
Study 3 - Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer – a randomized study | Silander, E., et al. | Head & Neck | 2011
Study Take-away
Earlier start may cause less severe malnutrition
Increased quality of life
Nutrition counseling improves patient outcomes
Study 3 - Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer – a randomized study | Silander, E., et al. | Head & Neck | 2011
Conclusion
• Complete enteral nutrition education prior to treatment
• Discuss placement prophylactic PEG
• Be an advocate for the Dietitian’s role
References
• Brown, T., Hill, J., Isenring, E., & Nottage, M. (2006). Evidence Based Review: Prophylactic percutaneous enodoscopic gastrostomy tube placement in head and neck cancer patients undergoing radiotherapy or chemo-radiotherapy. Queensland Government.
• Brown, T., Banks, M., Hughes, B. G., Lin, C., Kenny, L. M., & Bauer, J. D. (2017). Impact of early prophylactic feeding on long term tube dependency outcomes in patients with head and neck cancer. Oral Oncology, 72, 17-25. doi:10.1016/j.oraloncology.2017.06.025
• Brown, T. E., Banks, M. D., Hughes, B. G., Lin, C. Y., Kenny, L. M., & Bauer, J. D. (2017). Randomised controlled trial of early prophylactic feeding vs standard care in patients with head and neck cancer. British Journal of Cancer, 117(1), 15-24. doi:10.1038/bjc.2017.138
• Chen, A. Y. (2001, July 01). The Development and Validation of a Dysphagia-Specific Quality-of-Life Questionnaire for Patients With Head and Neck Cancer. Retrieved from https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/482382
• Gapany, M. (2011). Evaluating the role of prophylactic gastrostomy tube placement prior to definitive chemoradiotherapy for head and neck cancer. Yearbook of Otolaryngology-Head and Neck Surgery, 2011, 27-28. doi:10.1016/j.yoto.2011.01.003
• Kramer, S., Newcomb, M., Hessler, J., & Siddiqui, F. (2013). Prophylactic versus Reactive PEG Tube Placement in Head and Neck Cancer. Otolaryngology-Head and Neck Surgery, 150(3), 407-412. doi:10.1177/0194599813517081
• Mayre-Chilton, K. M., Talwar, B. P., & Goff, L. M. (2011). Different experiences and perspectives between head and neck cancer patients and their care-givers on their daily impact of a gastrostomy tube. Journal of Human Nutrition and Dietetics, 24(5), 449-459. doi:10.1111/j.1365-277x.2011.01165.x
• NCI Dictionary of Cancer Terms. (n.d.). Retrieved from https://www.cancer.gov/publications/dictionaries/cancer-terms/def/karnofsky-performance-status
• [NG Tube]. (n.d.). Retrieved from https://pinnt.com/Enteral-Nutrition.aspx
• [PEG Tube]. (n.d.). Retrieved from https://pinnt.com/Enteral-Nutrition.aspx
• Sethugavalar, B., Teo, M. T., Buchan, C., Ermiş, E., Williams, G. F., Sen, M., & Prestwich, R. J. (2016). Impact of prophylactic gastrostomy or reactive NG tube upon patient-reported long term swallow function following chemoradiotherapy for oropharyngeal carcinoma: A matched pair analysis. Oral Oncology, 59, 80-85. doi:10.1016/j.oraloncology.2016.06.007
• Silander, E., Nyman, J., Bove, M., Johansson, L., Larsson, S., & Hammerlid, E. (2011). Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer - a randomized study. Head & Neck, 34(1), 1-9. doi:10.1002/hed.21700
• Silva, F. R., Mirella Gondim Ozias Aquino De Oliveira, Souza, A. S., Figueroa, J. N., & Santos, C. S. (2015). Factors associated with malnutrition in hospitalized cancer patients: A croos-sectional study. Nutrition Journal, 14(1). doi:10.1186/s12937-015-0113-1
Thank You!Jasmine Ditter
Slides available at: https://uwgbresearchreviews.weebly.com/
Questions?