Impact of Prophylactic Enteral Nutrition in Cancer Patients · Impact of Nutrition Intervention on...

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


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


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.


* 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 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 #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


Results

• Control group reported higher swallowing function

• Normalized pre-treatment diet associated with higher MDADI scores

• Overall, prophylactic gastrostomy resulted in lower MDADI scores


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


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.

* * * *


p < 0.05


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 Take-away

Importance of assessing in a time-frame that allows optimal healing

Prophylactic gastrostomy negatively affects long-term swallow function


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


Assessment

Nutritional Assessment

Clinical Assessment

Performance Status

Quality of Life Questionnaires

Tumor Treatment


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


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


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.

*


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





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





p < 0.05


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 Take-away

Earlier start may cause less severe malnutrition

Increased quality of life

Nutrition counseling improves patient outcomes


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

https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/482382

https://www.cancer.gov/publications/dictionaries/cancer-terms/def/karnofsky-performance-status

https://pinnt.com/Enteral-Nutrition.aspx

https://pinnt.com/Enteral-Nutrition.aspx

Thank You!Jasmine Ditter

Slides available at: https://uwgbresearchreviews.weebly.com/

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