Download Impact of Squamous Cell Carcinoma of the Head/Neck on Weight

Impact of Squamous Cell Carcinoma
of the Head/Neck on Weight Status
A B I GA I L S M I T H
U N I V E RS I T Y O F K E N T U C K Y
DIETETIC INTERN
2 0 1 6 S U P E RV I S E D P R AC T I C E P RO G R A M
Overview
REVIEW OF
I . L I T E R AT U R E
V.
I I . H Y P OT H E S I S
VI.
I I I . S M A RT O B J E C T I V E S V I I .
I V. M E T H O D O L O GY
VIII.
R E S U LT S
DISCUSSION
C O N C LU S I O N S
REFERENCES
Review of Literature
I. INTRODUCTION
I I . T R E AT M E N T
III. WEIGHT LOSS
I V. I M P O RTA N C E O F N U T R I T I O N
V. C O N C LU S I O N S
Introduction
 1,630 people die of cancer every day (ACS, 2016)
 1,685,210 new cancer cases and 595,690 deaths in the
U.S. in 2016 (Siegel, Miller, & Jemal, 2016)
 48,330 new head/neck cancer (HNC) cases and 9,570
deaths (Siegel, Miller, & Jemal, 2016)
 Squamous cell carcinoma (SCC) accounts for 40% of
HNC cases (Mignogna, Fedele, & Lo Russo, 2004)
Treatment
 81% of patients express pain during treatment (NCI, 2016)
 Treatment options include surgery, radiation,
chemotherapy or combination (NCI, 2016)
 Primary complications: mucositis, infection, salivary
gland dysfunction, taste dysfunction, pain (NCI, 2016)
 Secondary complications: dehydration, dysgeusia,
malnutrition (NCI, 2016)
Treatment
 Radiation therapy is most common treatment for HNC
(Department of Health and Human Services, 2015)
 Complications: Difficulty chewing, swallow
dysfunction

Affect at least 2/3 of SCCHN patients (Silver et al., 2010)
 80% of patients treated with radiation experience
significant oral and nutritional problems (List & Bilir, 2004)
Weight Loss
 9% average weight loss over 7 weeks in SCCHN
patients treated with concurrent chemoradiation
therapy (CCRT) (Platek et al., 2013)

Attributed to dysphagia, xerostemia, radiation-induced
mucositis, and other CCRT-related toxicities
 12% loss of total body mass over 6 months in SCCHN
patients treated with CCRT (Silver et al., 2010)

Identified difficulty chewing and/or swallowing, weight
loss, fatigue, and perceived stress as four main factors of
functional decline
Weight Loss
 Comprehensive literature search identified advanced
tumor stage, higher pre-treatment BMI, and use of
CCRT as top three risk factors for weight loss in SCCHN
patients

Advanced tumor stage was an independent risk factor for
weight loss (Zhao, Zheng, Li, Zhang, Zhao, & Jiang, 2015)
Importance of Nutrition
 Poor nutritional status during cancer treatment
associated with increased morbidity and mortality
(Oncology Nutrition, 2014)
 Nutrition status during treatment is predictive of
survival rate (Oncology Nutrition, 2014)
 Malnutrition restricts patient ability to proceed with
treatment and reduces quality of life (Oncology Nutrition, 2014)
Importance of Nutrition
 Cachexia: weight loss exceeding 5% within 3-12
months combined with symtpoms including fatigue,
loss of skeletal muscle, and biochemical abnormalities
(Von Haehling & Anker, 2010)
 60-80% of patients with advanced cancer have
cachexia (Von Haehling & Anker, 2010)
 80% mortality rate of patients with cancer cachexia
(Von Haehling & Anker, 2010)
Conclusions
 Continued increase in new cases of and deaths from
HNC confirm it is a rising concern that warrants
additional research
 Malnutrition, weight loss, and cachexia are associated
with poorer outcomes including death
 Efforts should be focused on preventing malnutrition
and weight loss in this population
Hypothesis
Individuals diagnosed with and treated for squamous
cell carcinoma of the head/neck (SCCHN) will
experience significant weight loss within the first 5
weeks of treatment with radiation therapy.
SMART Objectives
 Measure the average weight change of individuals
treated for squamous cell carcinoma of the head/neck
within the first 5 weeks of treatment with radiation
therapy.
 Identify risk factors for increased weight loss in
individuals treated for squamous cell carcinoma of the
head/neck during treatment with radiation therapy.
Methodology
I. DESIGN & SETTING
I I . O U TC O M E S C O L L E C T E D
I I I . S TAT I S T I C A L A N A LY S I S
Design & Setting
 Design: Retrospective observational study
 Setting: University of Kentucky Markey Cancer Center
Lexington, Kentucky
Outcomes Collected
 Age
 Gender
 Tumor site
 Tumor stage
 Height
 Starting and ending weight
 Tube feeding
Outcomes Collected
 Weight change
 Percent weight change
 Starting and ending BMI
 BMI change
Statistical Analysis
 T-test assuming unequal variances

Compares means of two unequal variables
 Multiple linear regression

Quantify the strength of relationship between variables
 P value of 0.05 considered statistically significant
Results
 Average weight loss of 3.12% (2.38 kg) over 5-week
period (n=25)
 Sample means t-test results comparing starting and
ending weight were not statistically significant
(p=0.72)
Results
Figure 1: Comparison of average starting and ending weights
83
82.5
82.54
Weight (kg)
82
81.5
81
80.5
80.16
80
79.5
79
78.5
Starting Weight
Ending Weight
Results
Results
 60% of patients (n=20) had advanced tumor
progression

Defined as presence of “N” in TNM staging model,
indicating spread to lymph
 6% underweight (BMI <18.5) pre-treatment, 50%
normal weight (BMI 18.5-24.5), 44%
overweight/obese (BMI >25) (n=18)

Median starting BMI=23.8
Results
Discussion
I . S TAT I S T I C A L A N A LY S I S
I I . L I M I TAT I O N S
III. FUTURE RESEARCH
I V. C L I N I C A L I M P L I C AT I O N S
Statistical Analysis
 Results in agreement with research
 Weight loss during treatment in SCCHN patients (Platek et al., 2015;
Silver et al., 2010)

Female gender and oral cavity tumor site risk factors for
weight loss in SCCHN patients (Zhao et al., 2015)
 Clinical significance
 3.12% observed weight loss in 5 weeks compared to 5% loss in
3-12 months in cachexia
 Practical implications for clinical practice
Limitations
 Small sample size (n=25)
 Timeline

Most significant weight loss occurs beginning weeks 3-5 of
treatment (Silver et al., 2010)
 Incomplete medical records
 Weight label
 Height BMI (n=18)
 Tumor staging (n=20)
Zhao et al. (2015) identified as risk
factors for weight loss in HNC patients
 Tube feeding
Future Research
 Larger sample size
 Expanded research design that allows researchers to
follow patients during and after treatment
 Setting more supportive of research efforts
Clinical Implications
 Guide healthcare professionals and caregivers in
choosing an optimal prophylactic nutrition strategy
 Diminish the effects of cancer cachexia or prevent it
altogether, thereby improving prognosis
References
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American Cancer Society. (2016). Cancer Facts & Figures 2016. Retrieved April 15, 2016, from
http://www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2016/
Department of Health and Human Services, State Government of Victoria, Australia (2015). Patient
management framework Head and neck tumour stream… Retrieved April 11, 2016, from
https://www2.health.vic.gov.au/about/publications/policiesandguidelines/Head%20and%20nec
k%20tumour%20stream%20larynx%20pharynx%20and%20oral%20cancer
Gullett, N. P., Mazurak, V., Hebbar, G., & Ziegler, T. R. (2011). Nutritional Interventions for Cancerinduced Cachexia. Current Problems in Cancer, 35(2), 58–90.
http://doi.org/10.1016/j.currproblcancer.2011.01.001
List, M. A., & Bilir, S. P. (2004). Functional outcomes in head and neck cancer. Head and Neck Cancer,
14(2), 178-189. doi:doi:10.1053/j.semradonc.2003.12.008, M. D., Fedele, S., & Lo Russo, L. (2004).
The World Cancer Report and the burden of oral cancer. European Journal of Cancer
Prevention:the Official Journal of the European Cancer Prevention Organisation (ECP), 13(2), 139142. Retrieved April 15, 2016.
National Cancer Institute. (2013). Worldwide trends show oropharyngeal cancer rates increasing.
Retrieved April 20, 2016, from http://www.cancer.gov/news-events/pressreleases/2013/HPVOropharynxWorldwideTrend
National Cancer Institute. (2016). Oral Complications of Chemotherapy and Head/Neck Radiation.
Retrieved April 20, 2016, from http://www.cancer.gov/about-cancer/treatment/sideeffects/mouth-throat/oral-complications-hp-pdq
References
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Oncology Nutrition. A Dietetic Practice Group of the Academy of Nutrition and
Dietetics (2014). Assessing Relationships between Access to Standardized
Nutritional Care and Health Outcomes and Cost-Effectiveness of Care in
Outpatient Cancer Centers. Accessed January 26, 2016: http://dpgstorage.s3.amazonaws.com/ondpg/documents/36c67c706facc985/IOM_ONDPG_Workshop_2014.
pdf.
Platek, M. E., Myrick, E., Mccloskey, S. A., Gupta, V., Reid, M. E., Wilding, G. E., . . . Singh, A. K. (2013).
Pretreatment weight status and weight loss among head and neck cancer patients receiving
definitive concurrent chemoradiation therapy: Implications for nutrition integrated treatment
pathways. Supportive Care in Cancer, 21(10), 2825-2833. doi:10.1007/s00520-013-1861-0
Siegel, R. L., Miller, K. D., & Jemal, A. (2016). Cancer statistics, 2016. CA: A Cancer Journal for
Clinicians, 66(1), 7-30. doi:10.3322/caac.21332
Silver, H. J., Guimaraes, C. D., Pedruzzi, P., Badia, M., Carvalho, A. S., Oliveira, B. V., . . . Pietrobon, R.
(2010). Predictors of functional decline in locally advanced head and neck cancer patients from
South Brazil. Head Neck Head & Neck, 32(9), 1217-1225. doi:10.1002/hed.21322
Von Haehling, S., & Anker, S. D. (2010). Cachexia as a major underestimated and unmet medical
need: facts and numbers. Journal of Cachexia, Sarcopenia and Muscle, 1(1), 1–5.
http://doi.org/10.1007/s13539-010-0002-6
Zhao, J., Zheng, H., Li, L., Zhang, L., Zhao, Y., & Jiang, N. (2015). Predictors for Weight Loss in Head
and Neck Cancer Patients Undergoing Radiotherapy. Cancer Nursing, 38(6).
doi:10.1097/ncc.0000000000000231
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