NECN Head and Neck TSSG

Meeting 4 th December 2008 SRH: enteral feeding experience over 4 years FRH: natural history of G tubes FRH and SRH: comparative audit over 2 years FRH and SRH: factors involved in tube dependency Multi-centre survey: 3 month period North East regional audit of gastrostomy services FRH and SRH: swallow outcomes

In patients receiving treatment for HNC  Identify baseline data ▪ the nutritional support requirements ▪ swallowing impairment  Study the practices of nutritional support provided in the region  Identify nutritional and swallowing outcomes following treatment

 Treatment of missing data  No tube specified considered as oral intake  No date for feeding tube removal considered as still in situ  Disease free considered as so on 20/02/2011  Stomagastric tube included in the NG group  243 data points per person  data points

Centre Patient numbers Period Primary sites Carlisle7 1/709 to 5/8/09Hypopharyx: 10 Larynx: 24 Nasopharynx: 4 Oral cavity: 27 Oropharynx: 45 Unknown primary: 4 No data :1 Middlesbrough262/6/09 to 25/8/09 Newcastle507/5/09 to 27/8/09 Sunderland32 5/6/09 to 17/9/09 N=115; summer 2009 Mean age: 61.7 years Range: 19 to 90 M:F= 80:35

CentreNOCOPNPLxHxUPPrimary sites Carlisle Hypopharyx: 10 Larynx: 24 Nasopharynx: 4 Oral cavity: 27 Oropharynx: 45 Unknown primary: 4 No data :1 Middlesbrough Newcastle Sunderland N=115; summer 2009

T stageNOCOPNPLxHxUPTotalsPrimary sites T Hypopharyx: 10 Larynx: 24 Nasopharynx: 4 Oral cavity: 27 Oropharynx: 45 Unknown primary: 4 No data :1 T T T4a T4b

 BMI (n=107)  Mean (± SD): 25.2 (±5.45)  Grip strength (n=77)  Only one patient had greater “strength” after the first attempt  Mean (± SD): (± 11.13)  Range: 7.3 to 51

 Estimated energy requirements met PO (n=100) EERNPrimary sites 03Hypopharyx: 10 Larynx: 24 Nasopharynx: 4 Oral cavity: 27 Oropharynx: 45 Unknown primary: 4 No data :

PSSNormalcy of dietNPrimary sites 0Non-oral feeding3Hypopharyx: 10 Larynx: 24 Nasopharynx: 4 Oral cavity: 27 Oropharynx: 45 Unknown primary: 4 No data :1 10Cold liquids- 20Warm liquids- 30Pureed foods5 40Soft foods requiring no chewing 5 50Soft, chewable foods9 60Dry bread and crackers3 70Carrots, celery4 80All meats5 90Peanuts4 100Full diet61

 Pre-treatment MD Anderson (n=90)

Weight loss range at 3 months:-12.7kg to 26.4 kg Time Patient numbers Mean weight (kg) Std Dev Primary sites Pre-treatment Hypopharyx: 10 Larynx: 24 Nasopharynx: 4 Oral cavity: 27 Oropharynx: 45 Unknown primary: 4 No data :1 3 months months months

Time Patient numbers Mean weight (kg) SEM (kg) Pre-treatment months months months Repeated measures ANOVA: p<0.003 Mauchly’s Sphericity: <0.05 F=7.089, df=3

Time Compared withMean weight difference (kg) SEM (kg) p value Pre-treatment3 months months months Bonferroni correction applied for pairwise comparisons

Time Pre- treatment 3 months6 months12 months N Median th percentile th percentile th percentile100 Friedman’s test: p=0.003 Wilcoxon rank test: Pre vs 3 months (p=0.004) and 3 months vs 12 months (p=0.024)

Time Patient numbers Mean grip strength SEM Pre-treatment months months months Repeated measures ANOVA: p<0.126 Mauchly’s Sphericity: <0.05 F=2.037, df=3

Time Compared withMean grip strengthSEMp value Pre-treatment3 months months months Bonferroni correction applied for pairwise comparisons

Time Pre- treatment 3 months6 months12 months N Median th percentile th percentile th percentile 100 Friedman’s test: p=0.04 Wilcoxon rank test: Pre vs 3 months (p=0.004). 3 months vs 12 months (p=0.003) and pre vs 6 months (p=0.022)

Item1st2nd3rd N Activity Anxiety Appearance Chewing Mood Pain Recreation Saliva Shoulder Speech Swallow Taste

Item1st2nd3rd N Activity1 00 Anxiety 023 Appearance 300 Chewing 151 Mood 026 Pain 723 Recreation 100 Saliva Shoulder 343 Speech 133 Swallow 1541 Taste 163

Item1st2nd3rd N Activity3 30 Anxiety 014 Appearance 200 Chewing 321 Mood 121 Pain 853 Recreation 001 Saliva 1138 Shoulder 322 Speech 143 Swallow 881 Taste 452

 72 had enteral feeding, 43 did not  Gastrostomy 28, 42 NG, 1 stomagastric  Phase of treatment for enteral tube placement:  adjuvant treatment 2  CRT43  Surgery16  RT only5

Feeding route CarlisleNewcastleM’boroS’landTotals G tube NG Oral Totals patient with stomagastric tube at FRH

 Reasons for feeding tube placement (n=61):  Poor swallow: 20  Prophylactic: 29  Treatment toxicity: 1  Post surgery: 15  Timing of placement (n=30):  12 before and 18 during

ReasonG tube N=28 NG tube N= 42 Long term enteral feeding predicted 141 Short term enteral feeding predicted 020 Patient preference20 MDT preference104 Medical116

 Mean time to place tube from decision being made: 5.47 days (SEM 1.07) GroupNumberMean duration (days) SEMp value G tube NG tube

ET BeforeDuringAfterp value G tube800 NG tube3112  Second tube feed episode: 14  13 converted from NG to G tube

 No treatment breaks  Hospital stay  Replacement tubes: G =1 to 3; NG = 1 to >15 GroupNumberMean stay (days) SEMp value G tube NG tube

TimeGroupNumberMean weight loss (kg) SEM (kg) p value 3 months ET Oral months ET Oral months ET Oral

TimeGroupNumberMean grip strength SEMp value 3 months ET Oral months ET Oral months ET Oral

TimeGroupNumberMean weight loss (kg) SEM (kg) p value 3 months G NG months G NG months G NG

TimeGroupNumberMean grip strength SEMp value 3 months G NG months G NG months G NG

Group stage ETNo ETTotalsp value I II9615 III11415 IV Totals

Group stage GNGTotalsp value I II189 III4711 IV Totals274269

Primary treatment ETOralTotalsp value Neoadjuvant chemo Chemoradiation38846 Surgery Radiation* Supportive care033 * Includes adjuvant RT

 Crude survival: 74.03%  Disease free survival: 76%  Alive with disease: 7.7% N=104 Overall survival Disease free survival

P= 0.004

P= NG =reactive G = prophylactic

P= 0.898

Outcome G tubeNGNo tube Died of disease7410 Disease free Tube free Disease free Tube in situ 2 (incomplete data?) 4 Tube duration (mean days)

Disease free patientsMean swallow capacity Pre-treatment months months months patients completed all 4 time points Patients alive & disease free: Significant deterioration pre to 3 months post-tx (N=36) Trend for improvement from 3 to 12 months (N=30)

 Factors entered into the model:  baseline WST measure  Comorbidity, age, gender  Tumour site & stage  Treatment type  Baseline WST & comorbidity score strong predictor of 12 month WST (R 2 =0.65)

Selected CRT patients (N=49) prophylactic g-tube compared to no prophylactic g-tube No sig difference for baseline characteristics of site, stage, age, co-morbidity Higher number of males with g-tube than females (59% vs 23%) Comparison for WST limited to males*

NProphylactic g tube Swallow capacity (SD) NNo Prophylactic g tube Swallow capacity (SD) Pre-tx1218.2(10.5)1413.4(3.5) 3 m1711.9(9.1)88.6(6.8) 6 m1316.3(7.4)711.1(8.7) 12 m1219.5(8.1)910.9(7.0)* *p<0.05

Disease free patientsMean MDADI Pre-treatment86.7 (21.3) 3 months73.1(19.5) 6 months75.1(20.1) 12 months77.8(19.3) 25 patients completed all 4 time points Significant deterioration from pre to 3 months No change from 3 to 12 months (note large std deviation) Scale ranges from High score=better outcome

 Factors entered into the model:  baseline MDADI score  Comorbidity, age, gender  Tumour site & stage  Treatment type  Disease stage strongest predictor of 12 month MDADI (R 2 =0.35)

NProphylactic g tube (SD)NNo Prophylactic g tube (SD) Pre-tx2471.3(31.9)2568.6(32.4) 3 m1862.4(21.5)1465.6(16.7) 6 m1265.3(16.6)557.1(36.9) 12 m1564.1(17.8)1566.4(13.1) Chemoradiotherapy patients Mean MDADI scores (range , high = better outcome)

Disease free patientsMean PSS Pre-treatment87.6(18.1) 3 months71.1(32.0) 6 months76.3(30.6) 12 months79.6(27.5) 27 patients completed all 4 time points Significant deterioration from pre to 3 months Significant improvement from 3 to 12 months Scale ranges high score = better function

 Factors entered into the model:  baseline PSS score  Comorbidity, age, gender  Tumour site & stage  Treatment type  Disease stage strongest predictor of 12 month PSS (R 2 =0.32)

NProphylactic g tube (SD)NNo Prophylactic g tube (SD) Pre-tx1981.6(31.1)2377.6(27.8) 3 m1440.0(34.4)1065.0(34.4) 6 m1159.1(32.7)951.1(28.9) 12 m1460.7(33.2)1670.6(22.9) Chemoradiotherapy patients Mean PSS scores

Thank you