title: Age most significant predictor of requiring enteral feeding in head-and-neck cancer patients.
abstract: BACKGROUND
  A significant number of patients treated for head and neck squamous cell cancer (HNSCC) undergo enteral tube feeding. Data suggest that avoiding enteral feeding can prevent long-term tube dependence and disuse of the swallowing mechanism which has been linked to complications such as prolonged dysphagia and esophageal constriction. We examined detailed dosimetric and clinical parameters to better identify those at risk of requiring enteral feeding.
  
  
  METHODS
  One hundred patients with advanced stage HNSCC were retrospectively analyzed after intensity-modulated radiation therapy (IMRT) to a median dose of 70 Gy (range: 60-75 Gy) with concurrent chemotherapy in nearly all cases (97%). Patients with significant weight loss (>10%) in the setting of severely reduced oral intake were referred for placement of a percutaneous endoscopic gastrostomy (PEG) tube. Detailed DVH parameters were collected for several structures. Univariate and multivariate analyses using logistic regression were used to determine clinical and dosimetric factors associated with needing enteral feeding. Dichotomous outcomes were tested using Fisher's exact test and continuous variables between groups using the Wilcoxon rank-sum test.
  
  
  RESULTS
  Thirty-three percent of patients required placement of an enteral feeding tube. The median time to tube placement was 25 days from start of treatment, after a median dose of 38 Gy. On univariate analysis, age (p=0.0008), the DFH (Docetaxel/5-FU/Hydroxyurea) chemotherapy regimen (p= .042) and b.i.d treatment (P=0.040) (used in limited cases on protocol) predicted need for enteral feeding. On multivariate analysis, age remained the single statistically significant factor (p=0.003) regardless of other clinical features (e.g. BMI) and all radiation planning parameters. For patients 60 or older compared to younger adults, the odds ratio for needing enteral feeding was 4.188 (p=0.0019).
  
  
  CONCLUSIONS
  Older age was found to be the most significant risk factor for needing enteral feeding in patients with locally advanced HNSCC treated with multimodal treatment. Pending further validation, this would support maximizing early nutritional guidance, targeted supplementation, and symptomatic support for older adults (>60) undergoing chemoradiation. Such interventions and others (e.g. swallowing therapy) could possibly delay or minimize the use of enteral feeding, thereby helping avoid tube dependence and tube-associated long-term physiologic consequences.
authors.affiliation: Department of Radiation Oncology, Northwestern University Robert H. Lurie Comprehensive Cancer Center, 251 E. Huron Street LC-178, Chicago, IL, 60611, USA. sean.sachdev@northwestern.edu.
authors.forename: Sean
authors.initials: S
authors.lastname: Sachdev
authors.affiliation: Department of Radiation Oncology, Northwestern University Robert H. Lurie Comprehensive Cancer Center, 251 E. Huron Street LC-178, Chicago, IL, 60611, USA. tamerabdelrhman2012@u.northwestern.edu.|Department of Clinical Oncology, Alexandria University, Alexandria, Egypt. tamerabdelrhman2012@u.northwestern.edu.
authors.forename: Tamer
authors.initials: T
authors.lastname: Refaat
authors.affiliation: Department of Radiation Oncology, Northwestern University Robert H. Lurie Comprehensive Cancer Center, 251 E. Huron Street LC-178, Chicago, IL, 60611, USA. ian.bacchus@northwestern.edu.
authors.forename: Ian D
authors.initials: ID
authors.lastname: Bacchus
authors.affiliation: Department of Radiation Oncology, Northwestern University Robert H. Lurie Comprehensive Cancer Center, 251 E. Huron Street LC-178, Chicago, IL, 60611, USA. vsathias@nmh.org.
authors.forename: Vythialinga
authors.initials: V
authors.lastname: Sathiaseelan
authors.affiliation: Department of Radiation Oncology, Northwestern University Robert H. Lurie Comprehensive Cancer Center, 251 E. Huron Street LC-178, Chicago, IL, 60611, USA. bmittal@nmh.org.
authors.forename: Bharat B
authors.initials: BB
authors.lastname: Mittal
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects; D002294:Carcinoma, Squamous Cell / Q000473:pathology / Q000628:therapy*; D059248:Chemoradiotherapy / Q000009:adverse effects*; D000077143:Docetaxel; D004750:Enteral Nutrition / Q000706:statistics & numerical data*; D005260:Female; D005472:Fluorouracil / Q000008:administration & dosage; D005500:Follow-Up Studies; D006258:Head and Neck Neoplasms / Q000473:pathology / Q000628:therapy*; D006801:Humans; D006918:Hydroxyurea / Q000008:administration & dosage; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011379:Prognosis; D011880:Radiotherapy Planning, Computer-Assisted; D050397:Radiotherapy, Intensity-Modulated / Q000009:adverse effects; D012189:Retrospective Studies; D043823:Taxoids / Q000008:administration & dosage
chemical_list: D043823:Taxoids; D000077143:Docetaxel; D005472:Fluorouracil; D006918:Hydroxyurea