title: Impact of nutrition support on treatment outcome in patients with locally advanced head and neck squamous cell cancer treated with definitive radiotherapy: a secondary analysis of RTOG trial 90-03.
abstract: BACKGROUND
  The aim was to evaluate the relationship between nutrition support (NS) on host toxicity and cancer outcome in patients with locally advanced head and neck squamous cell carcinoma (HNSCC) undergoing definitive radiotherapy (XRT).
  
  
  METHODS
  We performed a secondary analysis of Radiation Therapy Oncology Group (RTOG) 90-03, a prospective randomized trial evaluating four definitive XRT fractionation schedules in patients with locally advanced HNSCC, which prospectively collected data on NS delivered before treatment (BNS), during treatment (TNS), and after definitive XRT. NS data and pretreatment characteristics of the 1073 evaluable patients were analyzed against therapy toxicity and outcome.
  
  
  RESULTS
  Patients receiving BNS experienced significantly less weight loss by the end of treatment and less grade 3 to 4 mucositis than patients not receiving BNS. However, patients receiving BNS had a poorer 5-year actuarial locoregional control rate than patients receiving TNS or no NS (29%, 55%, and 57%, respectively, p < .0001) and a poorer 5-year overall survival rate (16%, 36%, and 49%, respectively, p < .0001). Patients receiving BNS were significantly more likely to have a higher T classification, N status, and overall American Joint Committee on Cancer (AJCC) stage and initial presentation with greater pretreatment weight loss, and a poorer Karnofsky Performance Status (KPS) than patients not receiving BNS. After adjusting for the impact of these prognostic factors through a recursive partition analysis, a multivariate analysis with a stratified Cox model found that BNS was still a highly significant independent prognostic factor for increased locoregional failure (hazards ratio [HR], 1.47; 95% confidence interval [CI], 1.21-1.79; p < .0001) and death (HR, 1.41; 95% CI, 1.19-1.67; p < .0001).
  
  
  CONCLUSIONS
  In this study, the largest prospective evaluation of nutrition data in treated patients with cancer, BNS was associated with inferior treatment outcome in the patients with HNSCC undergoing XRT. These results should be considered hypothesis generating and encourage prospective clinical research and identification of the mechanisms underlying this finding.
authors.affiliation: Department of Radiation Oncology, University of Colorado Health Sciences Center, Anschutz Cancer Pavilion, 1665 N. Ursula Street, Suite 1032, Box F706, Aurora, CO 80045, USA. rachel.rabinovitch@uchsc.edu
authors.forename: Rachel
authors.initials: R
authors.lastname: Rabinovitch
authors.forename: Barbara
authors.initials: B
authors.lastname: Grant
authors.forename: Brian A
authors.initials: BA
authors.lastname: Berkey
authors.forename: David
authors.initials: D
authors.lastname: Raben
authors.forename: Kie Kian
authors.initials: KK
authors.lastname: Ang
authors.forename: Karen K
authors.initials: KK
authors.lastname: Fu
authors.forename: Jay S
authors.initials: JS
authors.lastname: Cooper
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002294:Carcinoma, Squamous Cell / Q000401:mortality* / Q000473:pathology / Q000532:radiotherapy*; D019583:Dose Fractionation, Radiation; D005260:Female; D006258:Head and Neck Neoplasms / Q000401:mortality* / Q000473:pathology / Q000532:radiotherapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D018529:Nutritional Support / Q000379:methods*; D017063:Outcome Assessment, Health Care; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D013280:Stomatitis / Q000517:prevention & control; D015431:Weight Loss