title: Requirement of percutaneous endoscopic gastrostomy tube placement in head-and-neck cancer treated with definitive concurrent chemoradiation therapy: An analysis of clinical and anatomic factors.
abstract: OBJECTIVE
  There is significant variation in recommendation for percutaneous endoscopic gastrostomy (PEG) tube placement in patients undergoing definitive chemoradiation therapy (CRT) for locally advanced squamous cell carcinoma of the head and neck (LAHNC), with some clinicians globally recommending prophylactic PEG and others waiting until toxicity has occurred. The present study was conceived to identify specific factors associated with PEG requirement, in a population of LAHNC patients who did not have up-front PEG placement.
  
  
  METHODS
  Using a quality assurance database, we identified patients with oropharyngeal (ORP) or laryngeal-hypopharyngeal (LHP) LAHNC who were treated with CRT for inclusion in a cohort study of factors impacting PEG placement. Eligibility included stage III/IV squamous cell carcinoma of ORP and LHP. Patients were excluded if they had a PEG placement prior to commencement of CRT. The primary endpoint compared across groups was PEG placement, and multivariate analysis of factors was performed.
  
  
  RESULTS
  We identified 107 patients with LAHNC who did not receive PEG tubes prior to treatment. After treatment initiation, 41% of patients with ORP tumors required PEG placement during treatment compared with 16% of LHP patients (P = .03). After adjusting for covariates, multivariate analysis revealed that the only predictor for PEG placement was ORP primary (odds ratio 4.77; 95% confidence interval 1.6-13.8, P = .009) using LHP as reference.
  
  
  CONCLUSIONS
  Our findings suggest that the patients with ORP cancers are more likely to require PEG placement during treatment and should be considered for prophylactic PEG placement, while LHP sites were associated with lower likelihood of PEG requirement. The primary reason for this difference appears to be severity of pharyngitis; proactive nutritional monitoring and supplementation should be implemented early. Patients with pretreatment risk stratification for PEG placement in LAHNC may improve quality of care and avoid unnecessary treatment breaks.
authors.affiliation: Southcoast Cancer Center, Fall River, Massachusetts. Electronic address: ajzauls@gmail.com.
authors.forename: A Jason
authors.initials: AJ
authors.lastname: Zauls
authors.affiliation: Bismarck Cancer Center, Bismarck, North Dakota.
authors.forename: John M
authors.initials: JM
authors.lastname: Watkins
authors.affiliation: Department of Radiation Oncology, Medical University of South Carolina, Charleston, South Carolina.
authors.forename: John
authors.initials: J
authors.lastname: Lucas
authors.affiliation: Department of Medicine, Division of Hematology and Oncology, Medical University of South Carolina, Charleston, South Carolina.
authors.forename: Keisuke
authors.initials: K
authors.lastname: Shirai
authors.affiliation: Department of Radiation Oncology, Medical University of South Carolina, Charleston, South Carolina.
authors.forename: Anand K
authors.initials: AK
authors.lastname: Sharma