12 Nutrition for Oral Cancer Patients
Optimal nutrition is essential for all patients with head and neck cancer (HNC). More specifically, patients with oral cavity cancer (OCC) are at very high risk of suboptimal nutrition. Factors such as the site of the cancer and the types of treatment used can significantly affect a patient’s nutritional status and put them at high risk for malnutrition. When the patient is malnourished, that increases susceptibility to a whole host of other issues that can affect tolerance to treatment and long-term survivability. Early nutrition intervention and continued involvement of the registered dietitian (RD) with this patient population across the continuum of care is recommended by the National Comprehensive Cancer Network (NCCN). The RD has the education and training to support the patient nutritionally throughout the treatment process and beyond to survivorship.
The relationship between cancer and malnutrition has long been known. Malnutrition can occur at all stages of the disease. Thirty to 90% of patients with head and neck cancers (HNCs) are affected by malnutrition. 1 Optimal nutrition is essential for everyone, and especially for the patient with oral cavity cancer (OCC). From the day of diagnosis, throughout the various treatments, and well into survivorship, poor nutrition is frequently a significant issue. Having treatment for OCC impacts the patient’s ability to eat and drink. This can lead to impaired wound healing, increased length of hospital stay, poor quality of life (QoL), and interruptions to treatment. 2 Side effects of treatments also include swallowing difficulties, dry mouth, nausea, and a reduced appetite—rendering eating and drinking a significant challenge for a majority of these patients. The purpose of this chapter is to identify and address nutrition concerns in patients with OCC from diagnosis to survivorship.
12.2 NCCN Guidelines: Principles of Nutrition: Management and Supportive Care
The National Comprehensive Cancer Network (NCCN) Guidelines for Head and Neck Cancers recommend that the multidisciplinary evaluation of patients with HNC include a registered dietitian (RD) before and after treatment to assess the need for nutrition interventions (e.g., enteral support via feeding tubes). 3 Historically, and unfortunately still common today, the first time a patient with HNC would encounter an RD along the spectrum of care would be after a large weight loss had occurred or the patient had suffered significant side effects from cancer treatment and required hospital admission. 2 A proactive approach to nutrition in any patient with cancer is preferable to the commonly seen reactive approach, but especially the patient with OCC.
12.3 Diagnosis and Evaluation
12.3.1 Pretreatment Nutrition Evaluation
Part of a proactive approach to nutrition for patients with HNC is a pretreatment nutrition evaluation and intervention. The vast majority of this patient population will develop side effects from treatment that will affect his or her ability to maintain optimal nutrition status. They may begin with no identified issues, but pretreatment represents a good time to address not only any current nutrition issues, but also the potential nutrition issues expected to arise during treatment that can have serious implications.
The screening of all patients with HNC for malnutrition, especially those with OCC, early in the diagnosis process will help identify those patients at a higher nutritional risk. This screening allows for identification of patients who would benefit from a more extensive nutrition assessment. A nutrition screening is a brief evaluation to identify potential patients at high risk for malnutrition. A nutrition assessment is a more complex process meant to explore further their nutrition status. 4 Nutrition assessment is a detailed evaluation and interpretation of multiple factors, including height, weight, physical assessment, laboratory values, social issues, etc. This assessment seeks to identify those patients at risk of developing nutrition-related medical complications.
Although screening for malnutrition is not routinely done in the outpatient setting, it should be done for any patient with suspected HNC. There are numerous screening tools available and careful attention needs to be given to tools that have been validated for use with oncology patients. An ideal screening tool is one that can be administered quickly, can be interpreted by a variety of health care providers, and is useful across a range of cancer diagnoses. 5 The Academy of Nutrition and Dietetics’ Evidence Analysis Library has reviewed and graded the most common nutrition screening tools available. Four tools were found to be appropriate for the oncology patient population: the Patient-Generated Subjective Global Assessment (PG-SGA), 6 , 7 the Malnutrition Screening Tool (MST), 8 Malnutrition Screening Tool for Cancer Patients (MSTC), 9 and the Malnutrition Universal Screening Tool (MUST). 10
Of the four listed, the MST 8 has been favored as an easy to administer and interpret tool for early identification of potential malnutrition. This is a two-item, validated screening tool that includes weight loss and any recent change in appetite as its parameters. It is scored to determine their risk and can be used for both inpatient and outpatient across all age groups. A patient with a MST score of 2 or more is determined to be “at risk” and requires further nutrition assessment and intervention. Additionally, for any patient scoring 2 or more on the MST, an oral liquid nutrition supplement is recommended to help achieve a greater oral intake.
A comprehensive nutrition assessment is the next step in a complete pretreatment evaluation. The Evidence Analysis Library Oncology Working Group of the Academy of Nutrition and Dietetics states that “an adult oncology nutrition assessment should characterize and document the presence of (or expected potential for) altered nutrition status and nutrition impact symptoms (NIs) that may result in a measurable adverse effect on body composition, function, QOL or clinical outcome, and may also include indicators of malnutrition.” 11 The key components of a nutrition assessment are grouped into five categories: food-/nutrition-related history; anthropometric measures; labs, medical tests, and procedures; nutrition-focused physical findings; and client medical/health/social history.
12.3.2 Food/Nutrition-Related History
This category includes not only the patient’s diet history, but also the patient’s medication history and any modifications they have made to their diet in order to consume adequate calories and protein. Are they able to eat whatever they want? Do they restrict any particular food or groups of food for any reason (e.g., meats or tough-to-chew foods, any foods containing sugar, only able to swallow liquids)? Are they eating the same amount of food they normally do or are they eating less? Is it taking them longer to eat? How many meals per day do they normally consume? Has this changed recently? Do they regularly drink alcohol? If so, what type of alcohol and how much? Are there any prescribed or over-the-counter medications that can affect their appetite either positively or negatively (e.g., appetite stimulants, narcotics, steroids)? Are they using any stool softeners/laxatives? If so, are these medications working? Do they need to modify the texture of any of the foods they are eating in order to make it easier to eat? Are they using only liquid oral nutritional supplements because they cannot tolerate solid foods of any type? If so, what type and how many per day?
These questions represent the majority of the nutrition assessment for this patient population. Considering where OCC is located and how the proposed treatment can alter these basic and life-sustaining activities, the functions of eating and drinking are at direct risk.
12.3.3 Anthropometric Measurements
This category includes the patient’s height (actually measure this when able; do not rely on patient report), current weight, usual weight, and any weight changes over time (document weight lost over what time period). Any weight loss in this patient population has potential significance. Regardless of the patient’s calculated body mass index (BMI) at assessment, unintentional weight loss has been associated with negative postoperative outcomes and functional decline. 12 When patients are unsure of any weight loss, ask if they have noticed their clothes fitting any differently (e.g., had to take in a notch or two on their belt buckle?). Other measurements can be taken such as triceps skin fold or mid-arm muscle circumference measured over time, though this is not commonly used in general practice.
12.3.4 Labs, Medical Tests, and Procedures
Although historically serum proteins such as albumin and prealbumin have been widely used by physicians, generally no laboratory data are a reliable predictor of nutritional status. The current consensus is that laboratory markers are not reliable by themselves; however, these could be used as a complement to a thorough physical examination. 13 Lab values pertaining to the patient’s comorbidities, such as glycated hemoglobin for those with diabetes, still need attention as lack of proper glucose control can affect outcomes as well. One procedure/test that can be of value in nutrition assessment is the videofluoroscopic swallow study. Does the patient require education on diet modification regarding fluid viscosity or texture to avoid aspiration? Ensuring the safe consumption of nutrition is just as important as the nutrition itself, and the speech-language pathologist (SLP) is an important member of the multidisciplinary team (see Chapters 11 and 44).
12.3.5 Nutrition-Focused Physical Findings
A nutrition-focused physical examination will uncover any potential muscle wasting and other signs of malnutrition. For example, signs of temporal wasting or prominent clavicles can alert you to potential malnutrition. NIS, a variety of symptoms that can compromise oral intake, can be discovered during this part of the assessment as well. 14 Examples of NIS include nausea, vomiting, diarrhea, constipation, altered taste, depression, anxiety, and pain. Patients with HNC are likely to also experience dysphagia, mouth sores, xerostomia, dental problems, and difficulty chewing, which are also associated with reduced dietary intake. 14 Other issues to be aware of in this group of patients is trismus, tongue range of motion, fit of dentures if they have them, and tolerance to various food temperatures, acidity, and textures.
12.3.6 History: Medical/Health/Social
Understanding how the proposed treatment regimen will affect the patient nutritionally is a vital part of the nutrition assessment. Often a pretreatment nutrition assessment will not uncover any nutrition issues/deficiencies; however, the majority of these patients will likely develop nutrition issues as part of the proposed treatment. Educating the patient early in treatment is important to help avoid major nutrition issues in the future. Remember, a proactive approach is better than a reactive approach to the nutritional management of the patient with HNC.
A patient’s social history is important to obtain in the HNC population. Knowing what support the patient has available to them and their living circumstances can help prevent potential complications. It can be a substantial challenge for patients to get to treatments or deal with dressing changes following a surgery if they live alone and lack friends or family who can help them. From a nutrition perspective, this is also a challenge, as many times the patient may not be motivated to prepare the foods necessary to maintain their nutritional status and will need to rely on their social supports to prepare foods. This is especially true if the patient is required to modify the texture of the foods they need to consume safely (e.g., pureed or ground foods). Nutritional supplements and tube feeding formulas can be a financial burden for the HNC patient. Most insurance companies do not cover the cost of the formulas if taken orally and some will only cover the cost of supplies like the 60-mL syringes used to administer the feeding.
Obtaining accurate alcohol intake history is vital. Malnutrition is significantly greater among alcohol users. 2 When patients are asked to stop drinking alcohol, a significant source of calories in their diet can be taken away. Micronutrients are also affected by chronic alcohol use, and a B-complex vitamin (especially thiamine) may be recommended. 15 The involvement of a behavioral health specialist can further motivate and support abstinence from alcohol.
Once all this information has been gathered, a nutrition plan is made for the patient. Regardless of the proposed treatment, nutrition plays an important role for patients with OCC. Preparing the patient for the upcoming treatment includes not only nutrition advice, but also education regarding what to expect from treatment that can affect the patient’s nutritional status. A forewarned patient is forearmed.
Nutritional goals for HNC: 11
Weight maintenance during and after treatment.
Weight maintenance posttreatment until the patient is able to consume solid food safely.
Successful, break-free completion of treatment.
Minimal, if any, weight loss in overweight or obese patients until the patient is fully recovered from treatment and able to eat without difficulties.
Weight maintenance during transitional feedings from enteral nutrition support to oral diet.
Goals are a good thing to have when treating this patient population. Of the five goals listed, four refer to weight maintenance or minimal weight loss for these patients. Weight loss in patients with HNC is not just loss of body fat but also potential muscle loss (somatic protein stores). It is important to make the patient aware of the potential loss of lean body mass so that they realize the importance of maintaining an adequate nutritional status from the start of the cancer journey, regardless of start weight or history of obesity. Now is not the time to consider weight loss a desired goal.
12.4.1 Pretreatment Nutrition Plan
Keeping in mind all the information that was gathered as part of the pretreatment nutrition assessment and the nutritional goals for these patients, a nutrition care plan is developed and shared with the patient. Spending the time necessary to review and explain the nutrition care plan to the patient is important for adherence and ultimately better outcomes. Use the teach-back method to assess for understanding of the main points of the care plan. Make sure written materials provided to the patient are clear and easy to read/understand and at the appropriate literacy level for the patient (e.g., within patient-facing medical information a fifth grade reading level is considered appropriate). Individualizing the nutrition care plan is important; however, there are some standard nutrition recommendations for all patients with HNC.
A high-calorie, high-protein diet is recommended as these patients are at a high risk of significant weight loss as a result of treatment. Additionally, patients with HNC have high protein needs for wound and tissue healing throughout treatment. A factor of 1.2 to 2.0 g of protein per kilogram of body weight per day has been suggested as a guide for protein goals in physically stressed patient populations, which is certainly true of this patient population. 12 As eating and drinking can become challenging for patients with OCC, patients need to make every bite and every sip count. Encourage the patient to begin these higher calorie/higher protein foods as soon as possible, preferably prior to treatment. Weight loss is a known complication for patients with OCC and the sooner it is addressed the better. Advise patients to eat when they feel hungry, not waiting until mealtime to eat. Other patients may not feel hungry and need to be reminded every couple of hours to eat. Most people have their best appetite in the morning, because they have not eaten all night; thus, encouragement to take in as many calories in the morning is prudent. Do not wait until later to choose high-calorie and high-protein foods. Box 12.1lists some ideas to share with patients that can help them increase calorie and protein content in the food they are already eating.
Box 12.1 Ways to add calories and protein to foods
Rather than serving broth, puree vegetable soup or bean soup as part of the liquid.
Serve gravies or sauces made with pureed beans or blended soft/silken tofu over potatoes.
Add butter or sour cream to mashed potatoes.
Add powdered milk to liquid full fat milk. Ratio of 1 cup liquid milk to 1/3 cup powdered milk. Use this fortified milk wherever milk is required.
Make ice cubes from milk or fruit nectar. Use these high-calorie ice cubes in smoothies or to keep drinks cold. As they melt, they will add calories and not water down the beverage.
Choose creamy soups rather than broth-based soups.
Have puddings and custards rather than gelatin desserts.
Add sauces, gravies, or extra vegetable oil/butter to meals.
Drink apricot or peach fruit nectars. They are less acidic than others.
Drink fruit shakes or fruit smoothies made with yogurt or ice cream.
Use a liquid nutritional supplement instead of milk to make a nutritious, high-calorie milkshake.
Add sour cream, half and half, heavy cream, or whole milk to foods like mashed potatoes, sauces, gravies, cereals, soups, and casseroles. Consider adding mayonnaise to eggs, chicken, tuna, pasta, or potatoes to make a smooth, moist salad.
Add avocado to dishes or smoothies.
Add nut butters such as peanut butter to shakes and smoothies.