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Nutrition for Patients with Head and Neck Cancer

Source: www.utmb.edu
Topic: Head/Neck
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Sort Desciption: Cancer patients often present to their physicians in a poor nutritional state. Their nutritional deficits have a significant impact on mortality, morbidity and quality of life. Head and neck cancer patients are no exception. ...

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Cancer patients often present to their physicians in a poor nutritional state. Their nutritional deficits have a significant impact on mortality, morbidity and quality of life. Head and neck cancer patients are no exception. The literature indicates that up to 57% of patients with head and neck cancer present with significant malnutrition (manifest by greater than 10% weight loss from baseline body mass). Alcohol and tobacco use frequently exacerbates this problem. Alcohol provides a large amount of simple carbohydrates without essential vitamins, proteins, and fats. These â empty caloriesâ may actually contribute to cancer growth and further nutritional decay. Tobacco is an appetite suppressant. Moreover, head and neck cancers may cause significant trismus, odynophagia, dysphagia, and aspiration. Large tumors can actually obstruct the aerodigestive system. Treatment options for head and neck cancer include surgery, chemotherapy, and radiation therapy. Each of these interventions have side effects that contribute to malnutrition. Thus, it is especially important that patients with head and neck cancer undergo pretreatment nutritional evaluation, appropriate nutritional supplementation, and continued attention to this detail during and after treatment.

Malnutrition is generally divided into two typesâ marasmus and kwashiorkor. The former is characterized by normal serum protein levels and total calorie deprivation from all food sources (starvation). Kwashiorkor is caused by a decrease in protein intake. Serum levels of protein are reduced. Most head and neck cancer patients present with protein-deficiency malnutrition. Thus, diminished nutrient intake, or diminished appropriate nutrient intake is one etiology of cancer malnutrition. As previously discussed, cancers of the head and neck can physically impede the intake of nourishment or cause trismus and odynophagia that limit oral intake. Alcohol and tobacco use, commonly seen in this patient group, add to the problem by providing â empty caloriesâ devoid of essential nutrients, and suppressing appetite. Patients who consume excessive amounts of alcohol have also been shown to have a much decreased intake of fresh fruits and vegetables. A diet low in essential vitamins and minerals has been associated with increased risk of head and neck cancer. The treatment regimens for head and neck cancer often result in side effects that decrease oral intake. Surgical treatment can alter the anatomy such that chewing and swallowing can be temporarily or permanently dysfunctional. Radiation therapy and chemotherapy commonly result in mucositis, dysgeusia, anosmia, xerostomia, nausea, and vomiting. Poor dentition may also contribute by increasing difficulty with mastication. Radiation-induced dental disease can further exacerbate this.

The other factors that can lead to a malnourished state include increased nutritional losses, increased nutritional demand, and tumor-induced metabolic dysfunction. Increased nutritional losses are most commonly seen with vomiting and diarrhea, but can be caused by enterocutaneous fistulae or gastrointestinal malabsorption. Increased nutritional demands result from surgery, radiation, and chemotherapy. Pneumonia, wound infections, and sepsis can further increase nutritional demands. These demands often correspond to the time that oral nutrition is impossible or very limited, i.e. the early postoperative period, or during daily radiation treatments. The nutritional demands during this acute phase result in catabolism of stored glycogen (exhausted during the first 24 hrs) and proteins in the muscles and tissues. Energy stored in fat does not appear to be mobilized to meet the nutritional needs of this phase. After 3 to 7 days the body begins to slowly return to normal metabolism.

Finally, specific tumor-induced anorexia and metabolic dysfunction contribute to malnutrition. Anorexia of cancer is thought to result from alterations in neurotransmitters (possibly serotonin) and possibly from learned food aversions. Alterations in metabolism are profound. Most solid tumors derive their energy from glucose. They are unable to use amino acids or fat to create energy. Tumor factors (thought to include tumor necrosis factor, and interleukins IL-1, and IL-6) result in catabolism of muscle and tissue proteins which are converted to glucose in the liver and used for cell replication by cancer cells. Fat is also catabolized. Elevated levels of plasma free fatty acids are thought to be secondary to hepatic neoketogenesis and are responsible for a relative insulin insensitivity by normal body tissues. This results in a decreased ability for normal tissues to take up amino acids and further fuels gluconeogenesis which feeds the tumor.

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