Patients with head and neck cancer are at high risk of developing malnutrition. This can be due to the location of the tumor, its stage, surgical and radio-chemotherapy treatments to which he/she is subjected, and the metabolic alterations induced by the cancer process.
At the time of diagnosis, the percentage of patients suffering from malnutrition is between 3-52%; As a result of radio-chemotherapy treatments, the proportion of malnourished patients increases to between 44-88% (1).
Tumors in the head and neck affect areas such as oral cavity, oropharynx, hypopharynx, larynx, rhinopharynty, nasal cavities and sinuses. These areas are involved in important vital functions needed for nutrition such as chewing, swallowing and breathing. These functions can be compromised due to the localization of the tumor. Additional issues may occur during the treatments.
Due to radiotherapy, mucositis, stomatitis from Candida albicans, xerostomia, osteoradionecrosis, trisma, dysgeusia, dysphagia and pain (2) can develop in almost all cases.
Following chemotherapy, the most frequent side effects are nausea, vomiting, diarrhea, constipation, asthenia, anemia and leukopenia.
Due to the issues mentioned, the patient’s ability to feed him/herself is often compromised and this can lead to state of malnutrition.
Malnutrition is defined as a condition of functional, structural and development of the organism resulting from the imbalance between nutrient requirements, input and use of nutrients. This results in an excess of morbidity and mortality or an alteration of the quality of life (3).
Malnutrition associated with pathologies also leads to a deterioration of muscle tone and other bodies functions. In addition, malnutrition has a negative impact on clinical outcomes. Ongoing chemo-radio therapy treatments may determine the need to reduce doses or to stop the treatment resulting in increased complications and mortality rate (4).
Providing the patient, who is suffering from head and neck cancer, with a nutritional plan is necessary to reduce the risk of incidence of malnutrition. The nutritional status of the patient suffering from head and neck cancer must be assessed at the beginning of the diagnostic-therapeutic process and monitored constantly during all phases.
The nutritional process is modulated according to the patient’s needs and new clinical conditions. The aim is to identify those who need specific nutritional support early on in order to promote survival and response to cancer therapy.
The main purposes of nutritional intervention in the patient are:
The management of the nutritional path consists of three stages:
1 SCREENING
To identify those at risk of malnutrition.
2 NUTRITIONAL VALUTATION
Performed through a detailed physiological, pathological and accurate objective examination (anamnestic data, dietary data, anthropometry, bioumoral parameters, functional parameters). This will allow us to define the patient’s nutritional status and the possibility of malnutrition.
3 NUTRITIONAL SUPPORT AND MONITORING
Based on the result of the nutritional assessment performed, a specific dietary plan is developed for each patient. If the patient is not able to fully meet metabolic demands with normal nutrition, supplements and/or nutritional supplements are prescribed. If the patient is unable to feed him/herself, artificial nutrition is used.
We would like to point out some dietary and behavioural advice in order to improve some of the most common side effects caused by therapeutic treatments to facilitate nutrition in patients who are able to feed themselves.
Please note that these recommendations are in no way intended to replace the drug therapies prescribed by your doctor.
XEROSTOMY – DRY MOUTH
xerostomia is a pathological condition characterized by a particular and long-lasting dryness of the mucous of the mouth which is caused by a prolonged lack of saliva secretion.
The following tips can help alleviate the discomfort caused by xerostomia:
- Sip drinks frequently, especially during meals. Drink at least 1-1.5 liters of liquid and rinse your mouth often. Drinking water or sugar-free drinks during meals will facilitate chewing and swallowing. Alternatively, you can keep an ice cube in your mouth to hydrate the mucosa.
- Choose soft blended food or chopped up food. You can enrich food with sauces and toppings (smoothies, milkshakes, yogurt, fruit and vegetable puree, soft cheeses). These can help soothe the discomfort and moisten the mouth.
- Eat fresh fruits which have a high-water content (melon, watermelon, peach).
- To stimulate saliva production, add lemon juice to food and beverages if no mouth ulcers are present.
- Chewing gum or candy without sugar. Itcan help stimulate saliva production.
- Avoid spicy or salty foods that irritate your mouth.
- Reduce caffeine Avoid drinks that contain it such as coffee, tea and some carbonated drinks.
- Reduce alcohol intake, which causes irritation and dehydration.
MUCOSITIS – STOMATITIS
Inflammation of the oral cavity is a very common side effect in patients suffering from head and neck cancers. This can manifest itself in several forms: mouth ulcers, ulcers, bacterial and fungal infections. To resolve these inflammations the doctor will prescribe specific drugs. It is still important to maintain proper oral hygiene and pay attention to your choice of food.
For oral hygiene, it is recommended to use soft toothbrushes and rinse with water and baking soda (avoid using alcoholic based mouthwashes). Another option is to rinse out mouth with a tablespoon of sunflower oil. The oil must be passed between one tooth and between the tongue and teeth. If the cleaning is done correctly, the sunflower oil will become whiteish. At this point you can expel sunflower oil, and rinse your mouth out one last time with water to eliminate toxins and microbes.
You can follow the following food tips:
- consume soft, very moist and unsalted food. It is easier to chew and swallow and causes less irritation. Foods such as smoothies, purees, homogenized, puddings, yogurt, ice cream are also recommended. Prepare peeled fruit or vegetable shakes. Yogurt can be added. Alternately, you can cook vegetables and create creams. If severe mucositis arises, it is recommended to consume whole grains in the form of a cream (see cream of brown rice).
- drink plenty of water during the day, with the aid of a straw if necessary.
- pay attention to the temperature of food. Avoid hot foods as they can irritate the mouth or throat. Consume cold, room temperature or lukewarm food.
- use a teaspoon to eat, so as not to ingest high amounts of food.
- avoid acidic or salty food and drinks as they cause irritation (citrus fruits, fruits with small seeds, tomatoes, pickled and pickled foods).
- avoid irritating spices and seasonings (pepper, chilli, horseradish, curry, mustard, etc.).
- avoid dry foods e.g. crackers, chips, bread as they can scratch your mouth.
- avoid alcoholic beverages.
NAUSEA AND VOMITING
Nausea and vomiting can be caused by the location of the, the pharmacological treatments patients are subjected to, possible infections, psychological factors and the patient’s emotional state. If these are not properly managed, they can cause weight loss, dehydration, metabolic problems and electrolyte imbalance.
Nausea is a feeling of discomfort of the stomach, sometimes accompanied by dizziness, cold sweat and abundant salivation, which can be followed by vomiting.
Vomiting is the rapid and forced emission from the mouth, through the oesophagus and the faringe, of the contents of the stomach and in exceptional cases, of the intestine (food or other substances ingested, gastric juices, mucus, blood).
Oncologists prescribe special drugs to counteract nausea and vomiting. In addition, it may also be helpful to follow some dietary advice to alleviate symptoms. Following are some recommendations to limit the perception of these unpleasant effects.
- Eat small and frequent meals: split meals into 5-6 snacks so that the stomach is never empty. Chew food slowly.
- It is preferable to have someone prepare meals for you. Alternatively, you can prepare meals, freeze them and then heat them up on days when you don’t feel well enough to cook.
- Avoid foods with strong odours such as garlic, onions, peppers, horseradish, broccoli, cabbage, etc.
- Avoid sweets, fried foods, fatty foods and very tasty/spicy foods.
- Avoid alcoholic beverages which contain teine and caffeine.
- Consume food at room temperature as they have less smell than hot food.
- Consume salty and dry food which is high in carbohydrates and easy to digest e.g. pasta, bread, breadsticks, crackers or better still rice cakes.
- Eat a bowl of brown salted rice. You can add a small teaspoon of miso (fermented condiment rich in protein and vital enzymes, with yellow soya, salt, rice or barley).
- Ginger can be of help. However, do not exceed the recommended You can sip a ginger herbal tea, eat candied ginger, or add freshly chopped or dried root to food preparations. However, if you have an inflammation at the oral cavity, the use of ginger is not recommended.
- With nausea, it is initially useful to eat only light food such as soups or cream puddings. You can then gradually add small portions of your favorite dishes to your diet.
- Drink plenty of water during the day and not just at meal time. Liquids should be sipped. You can also drink tea or herbal teas e.g. mint and fruit juices.
- Malnutrition and cachexia in patients with head and neck cancer treated with (chemo) radiotherapy. Gorenc M. et al. Rep Pract Oncol Radiother. (2015).
- Complicanze orali della radioterapia della testa e del collo: prevalenza e gestione. Germano F. et al. Minerva Stomatologica (2015).
- American Society for Parenteral and Enteral nutrition Board of Directors: Definition of terms used in A.S.P.E.N. guidelines and standards. JPEN (1995).
- Malnutrition and clinical outcomes: The case for medical nutrition therapy. Gallagher-Allred CR et al. Journal of the American Dietetic Association (1997).