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Recommendations Summary

ONC: Head and Neck Cancer: Radiation and Use of Enteral Nutrition (EN) 2007

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.

• Recommendation(s)

  ONC: Head and neck cancer: Radiation and use of EN

  Use enteral nutrition (EN) to increase calorie and protein intake for outpatients with stage III or IV head and neck cancer undergoing intensive radiation treatment. Maintenance of nutritional status by EN during radiation therapy may improve tolerance of therapy to promote better outcomes.

  Rating: Strong
  Imperative

  • Risks/Harms of Implementing This Recommendation

    • Typical risks associated with implementing EN apply (Elliott et al, 2006).
    • Insertion of a PEG tube using the pull technique has been associated with an increased risk for tumor implantation in the gastrostomy site (Adelson and Ducic, 2005; Cruz et al, 2005).

  • Conditions of Application

     No conditions limit the application of this recommendation.

  • Potential Costs Associated with Application

    • Costs related to administering EN.

  • Recommendation Narrative

    • Two positive quality RCTs (Daly et al, 1984; Hearne et al, 1985) found that oral nutrition alone may not be adequate for patients with head and neck cancer in order to maintain nutrition status during radiation therapy. 
      • The energy and protein goals used for patients in the RCTs were 40 kcal per kg and 1.0 - 1.5g per kg body weight, respectively.
      • Outpatient EN resulted in improvement or maintenance of weight status and increased mean calorie and protein intake when compared with controls.
      • The researchers concluded that EN may be required to meet nutrition goals during radiation therapy and may improve tolerance of therapy to promote better outcomes. 
    • Further research is needed to determine the role of EN in improving nutritional intake in head and neck cancer patients.   

  • Recommendation Strength Rationale

    • Based on two positive quality RCTs,  conclusion statement is Grade II.

• Supporting Evidence

  The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

  Is there a relationship between enteral nutrition to improve nutrition intake (protein and kcals) and the reduction of side effects associated with outpatient radiation therapy for head and neck cancer patients?

  • References

    ­­­­­­­­­­­­­­­­Hearne BE, Dunaj JM, Strong EW, Vikram B, LePorte BJ, DeCosse JJ. Enteral nutrition support in head and neck cancer: Tube feeding vs. oral feeding during radiation therapy. Journal of the American Dietetic Association. 1985 June; 85 (6): 669 – 74, 677.
    
    Daly JM, Hearne B, Dunaj, J, LePorte B, et al. Nutritional Rehabilitation in Patients with Advanced Head and Neck Cancer Receiving Radiation Therapy. Am J Surg, October, 48:514-520, 1984. 

  • References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process

    Adelson, RT and Ducic, Y. Metastic Head and Neck Carcinoma to a Percutaneous Endoscopic Gastrostomy Site. Head Neck 27: 339– 343, 2005.

    Cruz, I, Mamel, J, Brady, J, Cass-Garcia, M. Incidence of abdominal wall metastasis complicating tube placement in untreated head and neck cancer. Gastrointest Endosc 62:708-11, 2005.

    Elliott, L, Molseed, L, Davis-McCallum, P. editors, Grant, G, technical editor. The Clinical Guide to Oncology Nutrition, 2^nd ed., Oncology Nutrition Dietetic Practice Group; American Dietetic Association, 2006.