The Impact of Baseline Nutritional Support on Treatment Outcome in Patients with Locally Advanced Squamous Cell Cancer of the Head and Neck Treated with Definitive Radiotherapy: Report of the Radiation Therapy Oncology Group (RTOG) Trial 90-03

Reviewer: Ryan Smith, MD
OncoLink
Last Modified: October 9, 2002

Presenter: Barbara Eldridge
Presenter's Affiliation: RTOG
Type of Session: Scientific

Background

Head and neck cancers and treatment of these cancers are inherently associated with loss of appetite, swallowing dysfunction, and odynophagia. This leads to a decrease in nutritional uptake with obvious problems associated with it. However, there is limited clinical data denoting the effect of nutritional support in these patients. This reports on a secondary analysis of data obtained from a large randomized trial involving different radiation regimens in the treatment of head and neck cancer.

Materials and Methods

1073 patients were enrolled in RTOG 90-03, which studied four fractionation regimes in the treatment of head and neck cancer: standard fractionation, hyperfractionated therapy, accelerated fractionation in a split course, and accelerated fractionation with concominant boost
Data was collected prospectively in these patients and included TNM stage, KPS, weight loss, dysphagia severity, and treatment outcome.
Addition of and type of (oral, enteral, parenteral) nutritional support was also documented and correlated with outcome data

Results

27% were receiving baseline nutritional support (BNS) prior to beginning radiation therapy
86% received BNS during radiation therapy
Use of BNS was strongly correlated with KPS, as 35% of patients with KPS 90-100 were receiving BNS and 65% of patients with KPS 60-80 were receiving BNS
Patients with higher T stage and higher overall stage were more likely to be receiving BNS prior to therapy
Patients already on BNS prior to beginning radiation therapy had more weight loss than those not on BNS (7.8 kg vs. 3 kg)
Patients requiring BNS had a lower local control than those not requiring BNS (29% LC vs. 56%)
Patients requiring BNS had a lower overall survival than those not requiring BNS (16% vs. 39%)
Patients receiving BNS had a trend toward less Grade 3-4 mucositis at end of treatment
Need for BNS had no impact on amount of dose that could be delivered or on overall treatment time or need for treatment breaks
On multivariate analysis, stage, KPS, weight loss, and use of BNS were all prognostic factors

Author's Conclusions

Even though patients requiring BNS had more weight loss, had a lower KPS, and higher stage of disease, they completed therapy and received equivalent doses than those who did not receive BNS
Need for BNS is an independent prognostic factor for local control and survival
Metabolic mechanisms for these findings are unclear

Clinical/Scientific Implications

The importance of nutritional support in patients being treated for head and neck cancer can not be overstated. Not only does the need for BNS denote the overall health of the patient, but it also is required to deliver tumoricidal doses of radiation. The most important finding reported in this study is likely the fact that, even though patients requiring BNS were worse off in almost every aspect, these patients received the same amount of radiation in the same amount of time as those in a better prognostic group. As a dose reponse and overall treatment time corrrelation has already been demonstrated in head and neck cancer, this speaks volumes to the importance of nutritional support when treating these patients. It should be kept in mind that receiving BNS was not randomized or stratified and there is still the hypothesis that nutritional support actually increases tumor growth. However, the figures on local control and overall survival that are presented in this abstract are almost certainly related to patient factors themselves, and the use of aggressive nutritional support should continue to be employed.

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