1. NECN Head and Neck TSSG

2. 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

3. 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

4.  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  27945 data points

6. 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

7. CentreNOCOPNPLxHxUPPrimary sites Carlisle723-11-Hypopharyx: 10 Larynx: 24 Nasopharynx: 4 Oral cavity: 27 Oropharynx: 45 Unknown primary: 4 No data :1 Middlesbrough261081611 Newcastle5014201851 Sunderland32 2142932 N=115; summer 2009

8. T stageNOCOPNPLxHxUPTotalsPrimary sites T12275-10- - 44 Hypopharyx: 10 Larynx: 24 Nasopharynx: 4 Oral cavity: 27 Oropharynx: 45 Unknown primary: 4 No data :1 T226109151 - 52 T31738-53 - 39 T4a37520246-74 T4b0-----0

9.  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): 28.91 (± 11.13)  Range: 7.3 to 51

10.  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 :1 256 504 602 753 802 905 10074

11. 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

12.  Pre-treatment MD Anderson (n=90)

14. Weight loss range at 3 months:-12.7kg to 26.4 kg Time Patient numbers Mean weight (kg) Std Dev Primary sites Pre-treatment11472.0117.61 Hypopharyx: 10 Larynx: 24 Nasopharynx: 4 Oral cavity: 27 Oropharynx: 45 Unknown primary: 4 No data :1 3 months 7068.9116.18 6 months 6167.1915.99 12 months 6270.3515.24

15. Time Patient numbers Mean weight (kg) SEM (kg) Pre-treatment39 74.893.23 3 months 39 70.052.80 6 months 39 70.132.53 12 months 3971.192.53 Repeated measures ANOVA: p<0.003 Mauchly’s Sphericity: <0.05 F=7.089, df=3

16. Time Compared withMean weight difference (kg) SEM (kg) p value Pre-treatment3 months 4.841.150.001 6 months 4.751.590.029 12 months 3.691.690.207 Bonferroni correction applied for pairwise comparisons

17. Time Pre- treatment 3 months6 months12 months N96 455156 Median100 25 th percentile10086.25100 50 th percentile100 75 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)

18. Time Patient numbers Mean grip strength SEM Pre-treatment 25 29.63 2.20 3 months25 27.82 1.91 6 months25 28.38 2.01 12 months25 29.442.09 Repeated measures ANOVA: p<0.126 Mauchly’s Sphericity: <0.05 F=2.037, df=3

19. Time Compared withMean grip strengthSEMp value Pre-treatment3 months 1.800.980.462 6 months 1.240.941.00 12 months 0.1841.051.00 Bonferroni correction applied for pairwise comparisons

20. Time Pre- treatment 3 months6 months12 months N98504757 Median 100 908090 25th percentile 67.5 4050 50th percentile 100 908090 75th 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)

21. Item1st2nd3rd N4637 26 Activity2.4 00 Anxiety 003.8 Appearance 9.58.17.7 Chewing 9.521.63.8 Mood 2.42.73.8 Pain 14.38.115.3 Recreation 003.8 Saliva 14.332.411.5 Shoulder 7.12.77.7 Speech 9.55.415.4 Swallow 21.58.119.2 Taste 9.510.87.7

22. Item1st2nd3rd N4739 29 Activity1 00 Anxiety 023 Appearance 300 Chewing 151 Mood 026 Pain 723 Recreation 100 Saliva 13106 Shoulder 343 Speech 133 Swallow 1541 Taste 163

23. Item1st2nd3rd N4535 26 Activity3 30 Anxiety 014 Appearance 200 Chewing 321 Mood 121 Pain 853 Recreation 001 Saliva 1138 Shoulder 322 Speech 143 Swallow 881 Taste 452

25.  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

26. Feeding route CarlisleNewcastleM’boroS’landTotals G tube 5291228 NG 0296742 Oral 218111344 Totals 7492632114 1 patient with stomagastric tube at FRH

27.  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

28. 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

29.  Mean time to place tube from decision being made: 5.47 days (SEM 1.07) GroupNumberMean duration (days) SEMp value G tube2513.591.760.000 NG tube240.780.51

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

31.  No treatment breaks  Hospital stay  Replacement tubes: G =1 to 3; NG = 1 to >15 GroupNumberMean stay (days) SEMp value G tube252.080.390.000 NG tube2419.912.47

32. TimeGroupNumberMean weight loss (kg) SEM (kg) p value 3 months ET457.271.020.002 Oral251.581.55 6 months ET386.901.650.04 Oral231.911.77 12 months ET385.711.570.08 Oral240.932.36

33. TimeGroupNumberMean grip strength SEMp value 3 months ET3827.941.440.78 Oral2128.682.29 6 months ET3227.2510.770.65 Oral2125.8112.04 12 months ET3329.0510.720.46 Oral2231.2911.09

34. TimeGroupNumberMean weight loss (kg) SEM (kg) p value 3 months G226.791.270.65 NG237.731.62 6 months G198.392.200.39 NG195.412.49 12 months G196.592.480.58 NG194.841.97

35. TimeGroupNumberMean grip strength SEMp value 3 months G1931.481.900.01 NG1924.411.89 6 months G1732.362.390.003 NG1521.462.90 12 months G1432.063.160.1 NG1926.832.19

36. Group stage ETNo ETTotalsp value I21416.000 II9615 III11415 IV471764 Totals6941110

37. Group stage GNGTotalsp value I022.14 II189 III4711 IV222547 Totals274269

38. Primary treatment ETOralTotalsp value Neoadjuvant chemo022.000 Chemoradiation38846 Surgery211839 Radiation*111324 Supportive care033 * Includes adjuvant RT

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

40. P= 0.004

41. P= 0.575 NG =reactive G = prophylactic

42. P= 0.898

43. Outcome G tubeNGNo tube Died of disease7410 Disease free Tube free 152428 Disease free Tube in situ 2 (incomplete data?) 4 Tube duration (mean days) 211.635.9-

44. Disease free patientsMean swallow capacity Pre-treatment17.2 3 months11.8 6 months11.9 12 months14.2 33 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)

45.  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)

46. 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*

47. 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

48. 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 20-100 High score=better outcome

49.  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)

50. 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 20-100, high = better outcome)

51. 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 0-100 high score = better function

52.  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)

53. 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

54. Thank you