orals Inaugural Victorian Integrated Cancer Services Conference 2013

Creating Guidelines for Reactive and Prophylactic Enteral Feeding in Definitive (Chemo) Intensity Modulated Radiotherapy (IMRT) for Head and Neck Cancer (#4)

Nigel Anderson 1 , James Jackson 1 , Morikatsu Wada 1 , Michal Schneider-Kolsky 2 , Maureen Rolfo 1 , Hui Gan 3 , Kate Kaegi 1 , Fiona Sneyd 1 , Daryl Lim Joon 1 , Vincent Khoo 1 4
  1. Olivia Newton John Cancer & Wellness Centre, Austin Health- Radiation Oncology, Heidelberg, VIC, Australia
  2. Faculty of Medical Imaging & Medical Radiations Sciences , Monash University, Melbourne, AUSTRALIA
  3. Ludwig Institute for Cancer Research, Austin Health, Heidelberg, VIC, AUSTRALIA
  4. Department of Clinical Oncology , Royal Marsden NHS, Chelsea, UK

Purpose/Objectives:
Enteral feeding tubes (FT) are commonly utilized in patients undergoing intensity modulated radiotherapy (IMRT) for head and neck cancer to assist nutritional maintenance. Enteral feeding (EF) protocols vary between institutions: prophylactic centres (PC) insert FTs prior acute toxicity onset in most patients and reactive centres (RC) generally insert FTs upon failure of adequate oral nutrition. Nutritional guidelines recommend a prophylactic FT if EF is likely to persist for more than 4-6 weeks. This study examined several pre-treatment factors that could predict the likelihood of inadequate oral intake, with the aim of creating guidelines for identifying patients who should receive prophylactic or reactive FTs.

Methods/Materials:
This study identified 115 patients treated with definitive IMRT in a PC (2007-2012). Gross disease was treated to 70Gy. EF duration and intensity was gleaned from a prospective nutritional database to identify patients as: a) low feeding (LF) - FT use for 25-75% of dietary needs for < 4 weeks OR b) high feeding (HF) - FT for ≥ 75% of needs for > 6 weeks. Differences in frequency distributions of demographics, use of chemotherapy, disease site and stage were analyzed.

Results:
Table 1 displays univariate predictors of LF and HF. Both LF and HF were associated with advanced disease and chemotherapy use. While nodal stage was a significant discriminator of LF, only the primary tumor extent was significant for HF. Oropharyngeal primaries were larger than those in the larynx (mean 41.1 vs. 7.8cc; p=0<0.001) and EF rates reflect this. No patient factors, including malnutrition, morbidity and substance use, predicted EF outcomes.

Table 1. Feeding predictors

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Conclusion:
Irrespective of institutional philosophy, these findings legitimize reactive FTs in patients with low volume primary and nodal disease, treated without chemotherapy, and prophylactic FTs in patients with advanced primary tumors, treated with chemotherapy, regardless of neck disease.