Head and neck cancer: managing the side effects of therapies

The patient with head and neck neoplasms because of the location of the tumor and its stage, the surgeries and radio-chemotherapy treatments to which he is subjected, and the metabolic alterations induced by the cancer process frequently risk developing a state of malnutrition.

The percentage of patients suffering from malnutrition at the moment of the diagnosis of the disease ranges from 3 to 52%; as a result of radio-chemotherapy treatments, the percentage of malnourished patients increases to the range 44 to 88% (1).

Cancer of the head and neck affect areas such as oral cavity, oropharynx, hypopharynx, larynx, rhinopharynx, nasal cavities and paranasal sinuses. These areas are involved in important vital functions necessary for nutritional functions such as chewing, swallowing and breathing, which are compromised due to the localization of the tumor. Moreover, other issues may occur due to the treatments received.

In almost all cases, radiotherapy causes side effects such as mucositis, stomatitis by Candida  albicans, xerostomia, osteoradionecrosis, trismus, dysgeusia, dysphagia and pain (2).

Following chemotherapy, the most common side effects are nausea, vomiting, diarrhea, constipation, asthenia, anemia and leukopenia.

Due to the mentioned issues, the patient’s ability to feed himself is often impaired and a state of malnutrition is developed.

Malnutrition is defined as a condition of functional and structural change and impaired development of the organism caused by the imbalance between nutrient requirements, intake and utilization, with resulting excess morbidity and mortality or impaired quality of life (3).

When associated with pathologies, malnutrition also causes the deterioration of muscle tone and of other bodily functions. Furthermore, malnutrition has a negative impact on clinical outcomes (it can result in the need to reduce doses of or discontinue radio-chemotherapy) leading to more complications and increased mortality rate (4).

Providing the patient suffering from head-neck neoplasms with a nutritional pathway is necessary to reduce the risk of malnutrition. The nutritional status of the patient suffering from head and neck cancer should be assessed at the beginning of the diagnostic-therapeutic process and constantly monitored during all therapeutic phases.

The nutritional process is adapted according to the needs and new clinical conditions of the patient in order to identify earlier who needs specific nutritional support, so as to promote survival and response to cancer therapy.

The main purposes of a nutritional intervention are:

  • Preventing and treating malnutrition
  • Enhancing the effects of cancer therapy
  • Reducing the side effects of cancer therapy
  • Improving quality of life

The management of the nutritional path includes three stages:

  1. SCREENING: it makes possible to identify those at risk of malnutrition
  2. NUTRITIONAL EVALUATION: it is performed through a thorough physiological and pathological anamnesis and an accurate physical examination (anamnestic data, food intake, anthropometry, biohumoral parameters, functional parameters). It allows to define nutritional status; specific tests allow to define even the degree of a possible state of malnutrition
  3. NUTRITIONAL SUPPORT AND MONITORING: on the basis of the results of the nutritional evaluation performed, a specific nutrition plan is developed for each patient. If the patient with natural nutrition is not able to fully meet metabolic demands, then nutritional supplements are prescribed to reach compensation. If the patient is unable to feed himself naturally, artificial nutrition is used.

We now point out some dietary and behavioral tips aimed to improve some of the most common side effects caused by therapeutic treatments, in order to facilitate nutrition in patients who are able to feed themselves. Please note that these recommendations do not intend in any way to replace the pharmacological therapies prescribed by your doctor.

 

XEROSTOMIA (dry mouth)

Xerostomia is defined as a pathological condition characterized by particular and lasting dryness of the mucosa of the mouth resulting from a prolonged absence of saliva production.

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 liquids and rinse your mouth often. Drinking water or drinks without sugar during meals will facilitate chewing and swallowing. Alternatively, you can hold an ice cube in your mouth to keep the mucosa moist.
  • Prefer soft foods, reduced in purée, chopped, reduced in cream, smoothies, enriched with sauces and toppings (such as smoothies, milkshakes, yogurt, fruit and vegetable purée, soft cheeses). These can help alleviate the discomfort and moisten your mouth.
  • Eat fresh fruit with a high content of water (such as melon, watermelon, peach).
  • To stimulate saliva production (if there are no ulcers in the mouth) add lemon juice to food and drink.
  • Chewing a sugar-free chewing gum or candy can help stimulate saliva production.
  • Avoid spicy or salty foods that irritate the mouth.
  • Reduce caffeine intake. Therefore, avoid drinks that contain it such as coffee, tea and some fizzy drinks.
  • Reduce alcohol intake: it causes irritation and dehydration.

 

 

MUCOSITIS (stomatitis)

Oral cavity inflammation is a very common side effect in patients suffering from head and neck area neoplasms. This can occur in several forms: aphthae, ulcers, bacterial and fungal infections. To resolve these inflammations the doctor will prescribe you appropriate medications. Yet, it is important to maintain proper oral hygiene and to take some precautions in the choice of foods.

As for oral hygiene, it is recommended to use soft bristle brushes and to rinse your mouth with water and baking soda (avoid the use of alcoholic mouthwashes).

Another option is to rinse your mouth with sunflower oil: this practice consists in taking a tablespoon of sunflower oil and making rinses, as usual. The oil must be passed between one tooth and another and between the tongue and teeth. If the cleansing is performed correctly, the sunflower oil will eventually turn whiteish. At that point you can expel the oil, and if necessary rinse your mouth one last time with water to expel toxins and microbes.

As regards food, here are some useful tips:

  • Prefer soft, very moist and low-salted foods since they are easier to chew or swallow in order to cause less irritation. Prefer foods like smoothies, purées, homogenized foods, puddings, yogurt, ice creams. As an example, you could make (peeled) fruit smoothies and mix them with yogurt or vegetable drinks; or you can cook the vegetables and make creams. If severe mucositis arises, it is recommended to consume whole grains in the form of a cream (see brown rice cream).
  • Drink a lot of water throughout the day with the aid of a drinking-straw in more difficult situations, if necessary.
  • Be careful about the temperature of foods: avoid hot foods since they can irritate the mouth or throat; it is better to eat cold, room-temperature or warm foods.
  • Use a spoon when eating, so as to ingest smaller bites of food.
  • Avoid very sour, acidic or salty foods and drinks because they cause irritation (citrus fruits, fruits with small seeds, pickled foods).
  • Avoid spices and irritating seasonings (pepper, chili, horseradish, curry, mustard, etc.).
  • Avoid dry foods (crackers, chips, bread) since they can scratch your mouth.
  • Avoid drinking alcohol.

 

 

NAUSEA and VOMITING

Nausea and vomiting can be caused both by the location of the tumor, as well as by the pharmacological treatments to which patients are subjected, but also by possible infections, psychological factors and emotional state. If these are not properly managed, they can cause weight loss, dehydration, metabolic problems and electrolyte imbalance.

Nausea is a sensation of discomfort and clutter at the level of the stomach, accompanied at times 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 esophagus and pharynx, of the contents of the stomach and exceptionally of the intestine (foods or other ingested substances, gastric juices, mucus, blood).

Oncologists prescribe special medications to fight nausea and vomiting. In addition, it may also be helpful to follow some dietary advice to relieve symptoms. Nutrition can be a good strategy to limit the perception of these unpleasant effects.

  • Make small and frequent meals: split meals into 5-6 snacks so that the stomach never stays empty, and chew food slowly
  • It is preferable to have someone prepare your meals, or you can prepare meals, freeze them and then heat them on days when you do not feel well
  • Avoid foods with strong smells such as garlic, onions, peppers, horseradish, broccoli, cabbage, etc.
  • Avoid sweets, fried foods, fatty foods and very tasty/spicy foods
  • Avoid alcoholic and theine-containing beverages and caffeine
  • Prefer cold or room-temperature foods (they smell less than hot foods)
  • Choose salty and dry foods, with a high content of easy-to-digest carbohydrates (pasta, bread, breadsticks, crackers or better still rice cakes)
  • It can be useful to chew a brown rice cake, better if salted. Alternatively, you can add a tip of a teaspoon of miso  (fermented seasoning rich in protein and vital enzymes, consisting of yellow soy, salt, rice or barley)
  • You can get help from ginger (without exceeding in quantities): you can sip a ginger herbal tea, eat candied ginger, or add to the preparations the fresh chopped root or dried ginger. However, if you have problems with inflammation at the level of the oral cord, the use of ginger is not recommended
  • When you have nausea, initially it is useful to eat only light foods such as soups or cream puddings and gradually add small portions of your favorite dishes
  • Drink plenty of water throughout the day and not only during meals making small sips. Also drink tea (mint for example), fruit juices and herbal teas

 

 

  1.  Malnutrition and cachexia in patients with head and neck cancer treated with (chemo) radiotherapy. Gorenc M. et al. Rep Pract Oncol Radiother. (2015).
  2. Complicanze orali della radioterapia della testa e del collo: prevalenza e gestione. Germano F. et al. Minerva Stomatologica (2015).
  3. 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).
  4. Malnutrition and clinical outcomes: The case for medical nutrition therapy. Gallagher-Allred CR et al. Journal of the American Dietetic Association (1997).