LOGO

The effects of swallowing disorders, dysgeusia and

xerostomia on nutritional status, oral intake and weight loss in Head

and Neck Cancer patients: a systematic review

Valentina Bressan, PhD student, MSN, BSN, RN; Simone Stevanin MSN, BSN, RN; Monica Bianchi MSN, BSN, RN;

Annamaria Bagnasco PhD, RN,  MEdSc; Prof. Loredana Sasso MEdSc, MSc, RN

. Department of Health Sciences University of Genoa, Italy

16th Healthcare Interdisciplinary Research Conference (HIRC2015)

Nutritional Impact Symptoms in Head and Neck Cancer patients

Cancer symptoms and treatment side effects can compromise food intake and quality of life, as well as contributing to weight loss (Farhangfar et al 2014)

The most common Head and Neck Cancer (HNC) is the oral and pharyngeal one, and it is also associated with the highest risk of malnutrition (Beaver et al 2001, Kubrak et al 2009)

What is Head and Neck cancer?

HNC is a group of tumors that includes cancers in several areas above the collar bone

HNC has three major subdivisions:Oral CancerLaryngeal CancerNasopharyngeal Cancer

V.Bressan – HIRC2015

EPIDEMIOLOGY (Torre et al 2015)

Oral Cavity Cancer Incidence Rates by Sex and World Area.

Nasopharyngeal Cancer Incidence Rates by Sex and World Area

What happens to the oral intake, weight loss and dehydration during and right after CRT ?

Antineoplastic treatments contribute to local disease control and patients’ survival, but they also cause multiple symptoms that can compromise oral intake (Dechaphunkul et al 2013)

Some acute therapy effects may persist, becoming permanent or late effects of the treatments (Ganzer et al 2015, van den Berg et al 2014)

Acute symptoms are mainly mucositis, xerostomia, and distortion of taste and smell (van den Berg et al 2006, Vissink et al 2003)

Late effects are dysphagia, pain, xerostomia, mucosal sensitivity, taste alterations, trismus, osteoradionecrosis and dental disease (Ottosson et al 2013, Vissink et al 2003, Raber-Durlacher et al 2012, Ganzer et al 2013; Rütten et al 2011)

Dysphagia is one of the most studied and cited nutritional impact symptoms (NIS) in HNC, but it is not the only one that has an

important influence on nutritional status of these patients (Dechaphunkul et al., 2013)

Symptoms like dysgeusia, xerostomia and oral mucositis seem to all contribute to the impact on patients’ appetite

(Ogama et al 2010, Ogama & Suzuki 2012)

The literature in HNC has grown significantly over the past decade, the relationship between NIS and reduced oral intake or

weight loss is not clear yet

AIMS OF THIS REVIEW

1. Retrieving current data on how swallowing disorders, dysgeusia and xerostomia affect nutritional status, oral intake, and weight loss in HNC patients.

2. Analyzing selected studies’ quality and level of evidence

METHOD

A systematic literature search of the electronic databases:PubMed, CINAHL, Scopus and Cochrane Library

Using a combination of specific keywords like: xerostomia, hyposalivation, dry mouth, dysgeusia, taste

disorders, taste perception, dysphagia, swallowing disorders, swallowing difficulties, head and neck cancer,

weighs loss, nutritional status.

Manual research was performed to retrieve additional studies

Two authors independently carried out the articles selection

Articles were included if they met some of the following criteria: • Randomized or non-randomized clinical trials, cohort studies, and

case-control studies, literature review• Articles published between January 2005 and April 2015 • Abstract available and peer-reviewed literature • Publication in English, Spanish and Italian

Quality assessment: • Edwards Method Score (Edwards et al 2000) and van Loon et al (2012) criteria • Level of Evidence (LoE) following Wasserman et al. (2006) and Oxford

Centre of Evidence-based Medicine (2009) definitions.

METHODOLOGY

Research results: from 1459 citations to 25 studies

Selected studies quality: 21 studies with LoE between 2 and 3, and 2 with LoE of 4. Edwards score showed a quality of evidence decreasing from moderate to low

Sample: the majority of the studies used convenience samples. Only one indicated the sample size calculation in their statistical analysis (Kubrak et al 2012)

Most of the studies had small sample sizes, which may have led to underpowered calculation

The symptoms impact on oral intake was measured with different instruments, specific assessments and validated tools

FINDINGS

Dysphagia, xerostomia and dysgeusia have an important impact on nutritional outcomes (Ogama et al 2010, Kubrak et al 2010, Jager-Wittenaar et al 2007)

There is a connection with the tumor location, food and dietary intake and dry mouth (Farhangfar et al 2014)

Loss of appetite and thick saliva were symptoms able to predict severely reduced food intake in HNC early stage (Farhangfar et al 2014)

As a consequence of the eating problems, weight loss occurred early during radiotherapy and worsened during the year after the treatment (Larsson et al 2005)

FINDINGS

Patients who received new radiation treatments during meals asserted less problems in oral intake and swallowing of solid and grounded food and less xerostomia (van Rij et al 2008, Bhatnagar et al 2013)

Patients experienced dry mouth and thick saliva at baseline of treatments, presented increased post treatment symptoms interfering with dietary intake and causing weight loss (Kubrak et al 2013)

Swallowing disorders are related to an involuntary weight loss of ≥10% at 6 months or ≥5% at 1 month after treatment (Jager-Wittenaar et al 2011)

Persistent severe dysgeusia may affect the ability to enjoy food, the appetite, the weight, the nutritional status and may modify the systemic health and QoL in HNC (Baharvand et al 2012, Irune et al 2014)

LIMITS OF THIS REVIEW

The findings are limited by the methodological quality of the included studies

No meta-analysis was conducted as the studies were too heterogeneous with regard to study population and data collected

The language inclusion criteria could be a limitation

IMPLICATIONS FOR RESEARCH

Further studies should be able to overcome obstacles like small sample size and no clear study design, and to improve the quality of data reporting solid criteria

A rigorous strain is required to combine the methodological differences across various studies

Future RCT and longitudinal studies, with longer follow-up, about NIS and oncology treatments may be conducted

Multicenter studies are suggested to guarantee a good sample size

Dietary supervision needs to be reinforced for a longer duration after CRT (Agarwal et al 2010)

Longer and larger studies are needed to validate data and to identify the malnutrition predictors in HNC (Agarwal et al 2010, Silander et al 2013)

IMPLICATIONS FOR NURSING

It is important to adopt a survelliance approach to NIS and to nutrition care

The association of NIS with reduced dietary intake and weight loss justifies the need for vigorous symptom management

It is important to use a standardized method of assessment and careful measurements

Intervention studies are needed in order to provide optimal clinical guidelines for nursing care of patients treated with radiotherapy for HNC

References

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