title: When is the optimal time for placing a gastrostomy in patients undergoing treatment for head and neck cancer?
abstract: OBJECTIVE
  Determining the optimal timing for placing a gastrostomy in patients undergoing treatment for head and neck cancer involves complex decision making and multifactorial analysis. Lack of high-quality studies with appropriate end points for nutritional outcomes and heterogeneity of patient, clinical and organizational factors makes determining best practice nutritional care challenging. This review provides a background rationale for gastrostomy placement and evaluates the relevant literature extending beyond the past 12 months due to limited numbers of published studies. Emerging concepts and controversies are highlighted to demonstrate that the decision to place a gastrostomy or not has eclipsed the significance of patients' nutritional needs leading to much debate and inconsistencies in clinical practice.
  
  
  RESULTS
  While the optimal method of tube feeding remains unclear due to challenges with study design, improved outcomes have been demonstrated with prophylactic tube feeding. Variation exists with selection criteria in the decision for gastrostomy placement based on clinical opinion rather than evidence-based practice. Gastrostomy use as a measure of swallowing outcomes and the presence of a feeding tube for quality of life (QOL) have led to the concept of gastrostomy dependency and a perceived association with poorer outcomes. The multidimensional contributors have been inadequately explored leaving this phenomenon poorly defined and misinterpreted. Best practice nutritional care incorporates malnutrition screening and nutritional assessment using validated tools, early referral to the dietitian and ongoing monitoring to optimize nutritional status throughout the patient's entire care pathway.
  
  
  CONCLUSIONS
  The decision for timing of gastrostomy placement should be made at diagnosis given the benefits of prophylactic tube feeding. Accountability for insertion and removal of gastrostomies with alignment of services will facilitate risk assessment, appropriate placement, effective patient counselling and monitoring for major and minor complications. Nutritional outcomes need to be distinguished from swallowing and QOL measures and evaluated to include effects on nutritional status, gastrostomy complications, intensity and frequency of dietetic support and effect on survival.
authors.affiliation: Department of Nutrition & Dietetics in Head and Neck Cancer Services, University College London Hospitals NHS Foundation Trust, London, UK. bella.talwar@uclh.nhs.uk
authors.forename: Bella
authors.initials: B
authors.lastname: Talwar
authors.forename: Merran
authors.initials: M
authors.lastname: Findlay
mesh_terms: D003657:Decision Making; D003680:Deglutition Disorders / Q000209:etiology / Q000628:therapy*; D005774:Gastrostomy; D006258:Head and Neck Neoplasms / Q000150:complications / Q000523:psychology / Q000628:therapy*; D006801:Humans; D044342:Malnutrition / Q000517:prevention & control; D009752:Nutritional Status; D018529:Nutritional Support; D011788:Quality of Life / Q000523:psychology*; D018570:Risk Assessment; D013997:Time Factors