• Assessment
    Are the measured energy needs of head and neck cancer patients receiving radiation therapy different from estimated needs?
    • Conclusion

      One neutral quality prospective, time-series study found that the HBE underestimated the REE of head and neck cancer patients receiving radiation therapy when compared with indirect calorimetry.  The researchers found that REE as measured by indirect calorimetry formed a U-shaped curve, with higher measures before, at end, and after treatment.  Resting energy expenditure as estimated by the HBE decreased throughout the study period.  The researchers concluded that the HBE is unsuitable for use in determining the REE of advanced head and neck cancer patients receiving radiation therapy, and suggested that indirect calorimetry should be used.  This study was limited by small sample size.   Further research is needed to determine the energy needs of head and neck cancer patients.

    • Grade: III
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: Calorie needs vs RDA: Radiation Therapy 2006
       
    Are the protein needs of head and neck cancer patients undergoing radiation therapy different than the RDA?
    • Conclusion

      One study (positive quality timeseries) assessed the impact of protein intake on weight and body composition in 38 head and neck cancer patients receiving RT. It appears that higher than RDA intake is needed to prevent loss of FFM.

      During RT participants’ protein intake decreased from 1.33 ± 0.46g/kg to 0.82 ± 0.54g/kg (p<0.001) and patients experienced a significant decrease in weight and LBM during treatment (p<0.001, p<0.001 respectively). Although protein intake increased to 1.54 ± 0.54g/kg (p<0.001) 2 months post-RT, there was no improvement in weight and a small improvement in LBM (p<0.01). This study did not assess impact of protein intake on nitrogen balance or protein turnover, thus it is difficult to interpret the results in terms of the RDA for protein. Although it appears that the protein needs of patients during radiation are higher than the RDA, more research is needed to identify more defined recommendations for actual grams of protein required.

    • Grade: III
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: Protein Needs vs. RDA: Radiation 2006
       
  • Intervention
    Is there a relationship between nutrition intervention by a dietitian to improve nutritional intake (protein and kcals) and the reduction of side effects associated with radiation therapy for head and neck cancer patients?
    • Conclusion

      Three positive quality studies and one neutral study found routine, nutrition intervention is beneficial and may prevent nutritional deterioration, improve calorie and protein intake, maintain anthropometric measurements and improve QOL in patients receiving radiation therapy for head and neck cancers. 

      One RCT found patients who received regular nutrition counseling from an RD based on the American Dietetic Association MNT protocol for cancer (radiation oncology) lost significantly less weight and FFM than controls.  Another RCT found nutrition counseling improves outcomes for patients with counseling having an equal or greater benefit than supplementation; and that at 3 months post-treatment, only counseling significantly impacted patient outcomes.  The prospective nonrandomized trial found that intensive nutrition intervention, including instruction to maintain caloric intake of 40 kcals/kg body weight, provided beneficial effects for head and neck cancer patients by minimizing weight loss, preserving FFM, and promoting maintenance of nutrition parameters. A two-group comparison showed that increased interaction or visits by a RD help decrease post-surgery and post-radiation therapy weight loss in patients with squamous cell cancer of the oral cavity.

      Further research is needed to determine the frequency, duration and optimal length of nutrition intervention for improved treatment-related outcomes and survival.

    • Grade: II
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: Radiation therapy: Diet Changes, Protein, Nutritional Intake, EN, Dietitian Involvement 2006
       
    Is there a relationship between the topical application of honey to the oral mucosa of a patient with head and neck cancer and improved tolerance to radiation therapy and the reduction of complications associated with radiation therapy?
    • Conclusion

      One small study of neutral quality, suggests that topical application of honey to the oral mucosa is effective in decreasing radiation-induced mucositis in head and neck cancer patients, improving tolerance of radiation therapy by decreasing mucositis-related treatment interruptions, and helping patients gain weight during treatment. Larger randomized, placebo-controlled studies with greater patient heterogeneity are needed to strengthen these findings.

       

    • Grade: III
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: Honey and Symptoms/Complications 2003
       
    Is there a relationship between the use of medical food supplements to improve nutritional intake (protein, kcals) and the reduction of symptoms associated with radiation therapy for patients with head and neck cancer?
    • Conclusion

      Two (2) RCTs (one positive quality, one neutral quality) found that MFS for patients with head and neck cancer undergoing radiation therapy may be helpful in preventing treatment interruptions, in reducing the number of mucosal reactions during therapy, and in minimizing weight loss.  In the positive quality study, 5 out of 12 control patients had to suspend treatment due to Grade III treatment toxicities. No intervention patient experienced Grade III toxicities, and none required suspension of treatment.  The other study found that supplement calories did not displace food calories in MFS patients, but added to total nutrient intake.  The neutral quality study was limited by compliance issues; no supplemented patient consumed the recommended volume of MFS, and only 7 out of 23 intervention patients consumed at least 80%.  The researchers concluded that all patients in this population should be considered for nutrition intervention.  Further research is needed to determine the appropriate use of MFS during radiation therapy for patients with head and neck cancer.

    • Grade: II
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: Radiation therapy: Diet Changes, Protein, Nutritional Intake, EN, Dietitian Involvement 2006
       
    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?
    • Conclusion

      Two positive quality RCTs found that head and neck cancer patients receiving radiation therapy may benefit from EN.  Energy and protein goals for patients in the RCTs were 40 kcals/kg and 1.0 - 1.5 g/kg body weight, respectively.  The researchers found that oral nutrition alone may not be adequate to maintain nutritional status during radiation therapy, and that EN may be required to meet nutrition goals.  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 maintenance of nutritional status by EN during radiation therapy 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.

    • Grade: II
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: Radiation therapy: Diet Changes, Protein, Nutritional Intake, EN, Dietitian Involvement 2006
       
    Is there a relationship between supplementation of antioxidant vitamin E and the efficacy of radiotherapy treatment in patients with head and neck cancer?
    • Conclusion

      Results of one RCT of strong design suggests three-year use of high-dose a-tocopherol supplements for older patients with stage I and II head and neck cancer receiving radiation therapy may be associated with an increased occurance of second primary cancers and decreased duration of cancer-free survival.

    • Grade: II
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: Antioxidants and Radiation Therapy 2006
       
    Is there a relationship between supplementation of antioxidant vitamin E, which may interact with radiation therapy treatment, tolerance of radiation therapy treatment and late-effects of radiation therapy treatment in patients with osteoradionecrosis resulting from head and neck cancer treatment?
    • Conclusion

      Research neither supports nor refutes the use of oral vitamin E supplementation to improve tolerance or treatment outcome in head and neck cancer patients receiving radiation therapy; however, limited evidence shows that supplementation with vitamin E may be beneficial for late-effects of treatment. In a neutral quality, before-after time series study, a combination of pentoxifylline (800 mg per day) and vitamin E (1,000 IU/day), boosted for the most serious cases with clodronate (1,600 mg per day, 5 days per week), for 6 to 24 months induced mucosal and bone healing in patients with osteoradionecrosis.  Well-designed studies are needed to determine the benefits of vitamin E supplementation.

    • Grade: III
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: Antioxidants and Radiation Therapy 2006