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Nutrition in Head and Neck Cancer

Nutrition in Head and Neck Cancer. Karen L. Stierman, M.D. Francis B. Quinn, M.D. December 09, 1998. Introduction. Malnutrition is present in 20% of patients with head and neck cancer Malnutrition is associated with decreased cell-mediated immunity and increased postoperative sepsis

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Nutrition in Head and Neck Cancer

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  1. Nutrition in Head and Neck Cancer Karen L. Stierman, M.D. Francis B. Quinn, M.D. December 09, 1998

  2. Introduction • Malnutrition is present in 20% of patients with head and neck cancer • Malnutrition is associated with decreased cell-mediated immunity and increased postoperative sepsis • Early recognition and correction of malnutrition could result in decreased morbidity and mortality

  3. Definition and Classification • Malnutrition is weight loss greater than 10% of ideal body weight associated with loss of muscle • Marasmus - total caloric intake decreased, serum protein level is normal • Kwashiorkor - protein caloric intake decreased

  4. Mechanisms of Malnutrition • Reduced dietary intake • alcohol, local tumor effects, XRT mucositis, poor dentition • Anorexia • learned aversion, sensory deficits • Cancer cachexia • Cori(lactate) vs. Krebs(CO2 and H2O) • Amino acids sacrificed to make glucose

  5. Mechanisms of Malnutrition(cont’d) • Specific nutrient deficiencies • Decreased vitamin A or B-carotene is associated with cancer of the head and neck • Decreased selenium is associated with cancer of the esophagus

  6. Assessing Nutrition • History - diet, weight loss • Physical Exam - loss of subQ fat, muscle wasting, edema, anthropometrics • Subjective global assessment(SGA) • Labs - albumin, transferrin, prealbumin, retinol binding protein, total lymphocyte count • Antigen skin testing

  7. Nutritional Requirements • Energy required = Basal + additional secondary to illness • Basal - 25 to 45 kcal/kg/day • Major trauma/surgery with complications may require up to 50% more energy • Calorie:nitrogen ratio 120 - 180:1 in severely stressed patients

  8. Response to surgery • Phase I - Catabolic phase lasting 3-7 days • Phase II - Protein consumption and production are equal • Phase III - Anabolic phase of protein and total calories • Phase IV - Restoration of lipid stores

  9. Amino acids / Micronutrients • Arginine - positive effect on immune function and collagen synthesis • Animal studies show increased lysine and decreased arginine in tumor bearing vs. control rats • Phosphate replacement is important because it is important in energy metabolism • Selenium, trace metals

  10. Lipids • Fat - 9 kcal/g • Providing fat may help preserve protein • Lipid composition of tumor cell membranes is sensitive to change in diet • Consider n-3 PUFA in cancer patients • May help to make more sensitive to chemotx. and hyperthermia

  11. Delivering Nutrition • Oral • Enteral • NJ, PEG vs G-tube, G-J, J-tube • Parenteral hyperalimentation • PPN vs TPN

  12. Nutritional Formulas • Total calories, protein • Volume restriction • Osmolality • Cost • Taste • Composition

  13. Studies on the effect of nutritional replacement • Preop TPN for 1 week decreased postop morbidity and mortality by 21 to 31 % in G.surg patients • In chemotx and xrt patients, no change was seen • Need more prospective, randomized trials

  14. Enteral vs. Parenteral Nutrition • Enteral is safer, more convenient, and less expensive • Enteral prevents mucosal atrophy, decreases the body’s stress response, and preserves normal flora • TPN - ? effect on tumor growth

  15. Conclusions • Head and neck cancer patients are frequently malnourished • Perioperative nutritional support may be associated with decreased morbidity, mortality and cost • Further studies needed

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