Nutrition Is Vital for Patients with Head and Neck Cancer

The nutritional impact of head and neck cancer (HNC) doesn’t begin with diagnosis. Approximately 30% of affected patients are malnourished prior to diagnosis and treatment due to odynophagia, early satiety, and fatigue. (Cancers. 2023;15:822). Therefore, the key to nutritional support for patients with HNC is a multidisciplinary care plan that begins before treatment, continues during therapy, and extends well after the end of treatment.

“Eating and drinking are one of life’s pleasures,” said Allen L. Feng, MD, assistant professor of otolaryngology–head and neck surgery at Harvard Medical School and surgeon at Massachusetts Eye and Ear Institute, in Boston. “Most of what we do as surgeons is about function: making sure that patients aren’t nutritionally depleted and have adequate reserves to withstand surgery, radiation, or chemotherapy, or sometimes all three.”

Most of what we do as surgeons is about function: making sure that patients aren’t nutritionally depleted and have adequate reserves to withstand surgery, radiation, or chemotherapy, or sometimes all three.  — Allen L. Feng, MD

Surgeons, medical oncologists, and radiation oncologists are critical to the care of these patients; however, registered dietitian nutritionists (RDNs), speech pathologists, and social workers also play an important role, experts noted.

“Evaluation by a qualified dietician and speech pathologist prior to starting treatment is the key to successful completion of therapy,” said Kalika P. Sarma, MD, a clinical assistant professor at Carle Illinois College of Medicine and a radiation oncologist at Carle Cancer Institute, Urbana, Ill.

“As a head and neck cancer surgeon, I have come to appreciate just how important a multidisciplinary team is to the quality of life of patients,” agreed Dr. Feng.

Best Practices for HNC Patients

Because of tumor locations and associated treatments, “HNC patients experience exceptionally high rates of nutritional impact symptoms [NIS] that affect their ability and desire to eat,” said Anna Arthur, PhD, MPH, RDN, an assistant professor in the department of dietetics and nutrition at Kansas University Medical Center in Kansas City, Kan. A recent study reported that 90% of HNC survivors who undergo chemotherapy/radiation therapy experience one or more NIS (Cancers. 2023;15:822). In addition, nearly 40% of HNC patients are unaware that NIS could become chronic and could persist well beyond the completion of their therapy.

Patients with head and neck cancers are at higher risk of unintentional weight loss, reduced muscle mass, malnutrition, and cachexia than many other patients with cancer.— Anna Arthur, PhD, MPH, RDN

NIS include taste changes, dry mouth, difficulty swallowing, mucositis, reduced appetite, and early satiety, to name a few. “In my clinical and research experience, these NIS are more prevalent in HNC patients compared to other cancer types that don’t directly involve the gastrointestinal tract,” Dr. Arthur said. “This means HNC patients are at higher risk of unintentional weight loss, reduced muscle mass, malnutrition, and cachexia than many other patients with cancer.” According to Dr. Sarma, significant weight loss “hampers patients through cancer treatment.”

The experts agree that to prevent significant weight loss, early referral of HNC patients to a specialized oncology registered dietitian should be part of standard care. “Patients need a thorough evaluation of their nutritional status prior to starting definitive cancer treatment. They need to be evaluated by a dietician and speech pathologist before, during, and after completion of treatment so that the patients can maintain their weight and complete their treatments without significant interruption,” Dr. Sarma said.

Guidelines for Clinicians

Dr. Sarma noted that most otolaryngologists who see cancer patients are aware of the specific challenges that HNC patients face with regard to nutritional requirements. The National Comprehensive Cancer Network (NCCN) includes information related to nutrition in their guidelines for head and neck cancer (J Natl Compr Canc Netw. 2022;20:224–234). One recommendation has been the placement of feeding tubes prior to starting therapy “in anticipation that [patients] may be unable to maintain oral nutritional supplementation subsequent to starting treatment,” Dr. Sarma said. “This would be done to maintain weight, prevent aspiration, and reduce the risk of treatment interruption. The NCCN guidelines for nutritional support are particularly helpful to determine which patients may need tube feedings.”

With the advent of less-invasive surgical techniques, such as transoral robotic surgery (TORS), in patients with human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma, “overall survival rates are greater than 90%,” Dr. Feng said. He and his colleagues published a study that showed that feeding tubes are seldom required after TORS for early-stage HNC (Otolaryngol Head Neck Surg. 2021;166:696–703).

The newer studies have been incorporated into the NCCN guidelines for nutritional support of HNC patients and serve as an invaluable tool in the management of these patients’ needs, said Dr. Sarma.

The Oncology Evidence-Based Nutrition Practice Guideline for Adults published by the Academy of Nutrition and Dietetics states that “registered dietitian nutritionists should provide medical nutrition therapy and be members of interdisciplinary teams providing multimodal therapy to adult oncology patients undergoing chemotherapy and/or radiation therapy” (J Acad Nutr Diet. 2017;117:297-310.e47).

Research suggests that early and intensive medical nutrition therapy intervention delivered by an RDN is effective in improving multiple treatment outcomes in patients undergoing anticancer treatment, said Dr. Arthur. “Once a patient has experienced significant unintentional weight loss, it’s very difficult to reverse. For this reason, it’s recommended that HNC patients are referred to RDNs for nutrition assessment and intervention prior to starting any anticancer treatment,” she added. “Ideally, the RDN would provide nutrition counseling early and often throughout the course of active treatment and into recovery, until the patient is no longer experiencing NIS and has resumed a normal diet.”

A major challenge of getting HNC patients the nutritional care they need before, during, and after treatment is low availability of enough oncology RDNs in cancer centers. The supply doesn’t meet patient demand, Dr. Arthur said. “This is because oncology nutrition services are unfortunately not currently reimbursable by most insurance plans.”

Cancer specialists are still in the process of learning about the long-term nutritional needs of HNC patients. “My team’s research and the research of others suggest that many of these patients experience NIS that persist for months and even years into survivorship and that aren’t being adequately addressed by their care team,” Dr. Arthur said.

“Post treatment, many of these patients have to face issues with aspiration, lack of or impaired taste, and lymphedema and fibrosis secondary to treatment limiting oral intake,” agreed Dr. Sarma.

According to Dr. Arthur, NIS is underreported. One way to get the word out to otolaryngologists about the importance of long-term nutritional follow-up would be for the NCCN to incorporate “even more detailed evidence-based nutrition care guidelines, with the involvement of oncology RDNs, into the NCCN guidelines for HNC treatment and survivorship than what is currently included,” she said.

Barriers to Nutritional Therapy

All the experts agree that cancer therapy can be expensive, especially for patients who don’t have access to good medical coverage, which can significantly impact postoperative care. “Unfortunately, head and neck cancer does tend to disproportionately affect folks from disadvantaged socioeconomic status who may not have access to good, healthy food sources,” noted Dr. Sarma.

Healthcare disparities are caused in part by barriers to quality medical care and social determinants of health, according to the American Society of Clinical Oncology (ASCO). “Cancer disparities more often negatively affect racial and ethnic minorities, people with fewer financial resources, sexual and gender minorities (LGBTQ+), adolescent and young adult populations, older adults, and people who live in rural areas or other underserved communities,” noted ASCO on its website.

Patients with HNC also tend to have rates of alcohol, smoking, and other substance use that may compromise their nutritional status. Risk factors for HNC (Viruses. 2019;11:922) include:

• Smoking/chewing tobacco (34%);
• Alcohol (5%);
• Smoking/alcohol use (36%); and
• HPV infection (25%).

“Because of all these factors, these patients lack the social support that’s so crucial while navigating treatment,” Dr. Sarma said.

Many of the nutritional supplements that are recommended to patients to increase caloric intake, including Boost and Ensure, aren’t covered by private insurance, Medicare, or Medicaid. Although nutritional supplements may not be covered, placement of a feeding tube is, noted Dr. Feng. “We want to avoid having these patients undergo another procedure, but because of [lack of coverage of nutritional supplements], patients may fall behind nutritionally, which is frustrating for us and for them.” Dr. Feng is an advocate for more coverage of preventive nutritional solutions, such as nutritional supplements, rather than waiting until a patient needs a more invasive, and more costly, treatment.

“Ultimately, medical nutrition therapy from an RDN during active treatment and long-term follow-up would be much more accessible to patients with HNC if these services were reimbursable by insurance plans,” agreed Dr. Arthur. She encourages all otolaryngologists and oncologists to advocate for these treatments.

The bottom line is that the care of patients with HNC extends well beyond the point of diagnosis and treatment. “In some cases, it has a tremendous impact on their day-to-day life well after surgery,” said Dr. Feng. “Having support services is key to making sure that they do well and can have a good quality of life.” 

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Nikki Kean is a freelance medical writer based in New Jersey.