Impact of Squamous Cell Carcinoma of the Head/Neck on Weight Status Abigail smith University of Kentucky Dietetic intern 2016 supervised practice program

Overview REVIEW OF LITERATURE RESULTS HYPOTHESIS DISCUSSION II. HYPOTHESIS VI. DISCUSSION III. SMART OBJECTIVES VII. CONCLUSIONS IV. METHODOLOGY VIII. REFERENCES

Review of Literature INTRODUCTION TREATMENT WEIGHT LOSS II. TREATMENT III. WEIGHT LOSS IV. IMPORTANCE OF NUTRITION V. CONCLUSIONS

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 DESIGN & SETTING OUTCOMES COLLECTED STATISTICAL ANALYSIS II. OUTCOMES COLLECTED III. STATISTICAL ANALYSIS

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

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 STATISTICAL ANALYSIS LIMITATIONS FUTURE RESEARCH II. LIMITATIONS III. FUTURE RESEARCH IV. CLINICAL IMPLICATIONS

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) Tube feeding Zhao et al. (2015) identified as risk factors for weight loss in HNC patients

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 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%20neck%20tumour%20stream%20larynx%20pharynx%20and%20oral%20cancer Gullett, N. P., Mazurak, V., Hebbar, G., & Ziegler, T. R. (2011). Nutritional Interventions for Cancer-induced 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), 139-142. 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/press-releases/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/side-effects/mouth-throat/oral-complications-hp-pdq

References 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://dpg-storage.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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