Move to Eat: Towards personalization of supportive care for patients with head and neck cancer undergoing chemoradiotherapy

Abstract

The diagnosis and treatment of head and neck cancer (HNC)significantly impact patients' lives. Tumor-related symptoms and toxicity of chemoradiotherapy (CRT) treatment often reduce oral food intake, leading to unintended weight loss, reduced muscle mass, and, malnutrition. Malnutrition negatively affects physical condition, treatment toxicity, complications, quality of life, healthcare costs, and survival. Dietary treatment aims to prevent or treat malnutrition early and optimize nutritional intake based on individual needs. When oral intake is insufficient, enteral nutrition via a nasogastric tube or gastrostomy is often required during CRT. Besides adequate nutritional intake is exercise a prerequisite for preventing muscle mass loss. Exercise programs in other cancer populations show benefits in fitness, fatigue, and treatment completion rates but has not been studied in the HNC population. A survey among 13 Dutch head and neck oncology centers revealed significant variation in dietetic care for head and neck cancer patients during CRT. The number of dietetic consultations ranged from two to seven during treatment. Also gastrostomy placement policy varied, with some centers placing them prophylactically in all patients (15%), prophylactically upon indication (39%), reactively (15%), or both (31%). Only 46% had protocols for placement. Standardized guidelines are recommended to optimize nutritional care. A predictive model for identifying patients needing prophylactic gastrostomy was developed using data from 450 HNC patients treated with CRT in two Dutch head and neck oncology centers. Key predictors for the use of tube feeding for at least four weeks included BMI, weight change, adjusted diet, weight change, performance status, tumor location, TNM classification, type of systemic treatment, and radiation doses to salivary glands. The model showed good discriminative value after internal validation (AUC 72.3%) and supports personalized decision-making but requires external validation. An updated model incorporating new predictors, such as radiation doses to swallowing muscles, was externally validated with data from four Dutch head and neck oncology centers (n=743). The final model includes pretreatment weight change, texture modified diet at baseline, ECOG performance status, tumor site, N classification, mean radiation dose to the contralateral parotid gland and oral cavity. The model demonstrated good accuracy (AUC 73%, 62% after validation). Prophylactic gastrostomy is recommended at a predicted risk of >90% and may be discussed at >70%. The feasibility of a 10-week tailored endurance and resistance training program during CRT was evaluated, quantitative and qualitative, in 40 HNC patients. Adherence (54%) and recruitment (36%) exceeded targets, based on studies in other cancer populations, but retention (65%) fell short, primarily due to treatment toxicity. Facilitators included physical/emotional benefits and home-based settings. A more personalized approach is needed to improve adherence and outcomes. Key findings highlight the need for personalized and integrated nutritional and exercise care pathways. The implementation of a gastrostomy decision model aligns with national healthcare priorities. Future research should focus on the long-term effects of combined nutrition and exercise interventions on quality of life, physical function, and clinical outcomes.