Transcript Head and Neck Cancer - Kerry B Barbera, RDN, LDN

Base of the Tongue Cancer
CASE STUDY
KERRY BARBERA
PRIORITY NUTRITION CARE
DIETETIC INTERN
Behavioral Objectives
 You will be able to name the two leading risk factors for
head and neck cancer.
 You will be able to identify at least 2 symptoms of head and
neck cancer.
 You will be able to recall 2 nutritional problems that can
result from treatment intervention.
BOT Cancer
Head and neck cancer
 Incidence
 Risk factors
 Treatment and their side effects and their impact on nutrition
 Prognosis
 Research
Patient B
 PMH, labs, meds
 Diagnosis
 Medical treatment
 Nutritional ADIME
 Summary and questions
Head and Neck
Cancer
o Oral cavity
o Pharynx
o Larynx
Incidence
 Head and neck cancer accounts for approximately 3% of all
cancer diagnosis with Squamous cell carcinoma being the
most prevalent.1
 Oropharyngeal cancer patients are typically between the
ages of 50-70 years old and is more common in men than
women. 2
 Human Papillomavirus infection can affect the tonsils and
back of throat during oral sex and has been linked to the
increase in the number of oral cancer diagnoses in the
younger population.3
Base of the Tongue Cancer
 Tobacco and alcohol are among
the strongest risk factors of
these cancers.
 7 of 10 patients dx with this
type of cancer are heavy
drinkers.1
Signs &
Symptoms
Speech and swallowing
Pain
Dysphagia
Weight loss
Otalgia
Treatment
Main goal preserving speech and swallowing
• Surgical resection
• Radiotherapy
• Chemotherapy –adjunct therapy
Procedures
• Tracheostomy for preservation of the airway
• NG or PEG tube for nutritional support
Enteral Nutrition
 NG tubes
 PEG Tubes
Smoking sensation
Nutritional Implications
Inability to eat
 Dysphagia
 NPO post surgery
 Pain
 Mucositis
 Nausea and vomiting
Malnutrition and cachexia
are very common
Mucositis
 Frequent complication of
cancer treatment
 Painful and debilitating
inflammation and ulceration
 Patients unable to speak, eat or
tolerate treatments
 Lead to reduction and even
cessation of radiation or
chemotherapy
Treatment
 Good oral hygiene- brush teeth
2-3 times a day with mild
tasting toothpaste
 Avoid acidic or spicy foods
 Sucking on ice chips during
chemotherapy
 Magic Mouthwash
Prognosis
5 year survival rate:
• 75% local occurrence –stage l, ll, or lll
• 38% regional cancer – stage lll or lV that has spread to the
nearby tissue or lymph node
• 20% distal occurrence- metastasis
Screening
Research
TROS
 Transoral robotic surgery
has been utilized to
improve access to tumors
during surgery.
 Positive outcomes and
disease control maybe
achieved with TORS as a
primary therapy
Prophylactic versus reactive PEG tube Placement
 Reactive PEG tube placement was found to provide a
shorter duration of usage without incurring greater
weight loss or poorer oncology outcomes.9
 Higher rate of unnecessary PEG placement were
found when done prophylactically.10
Patient B
 45 y/o female who presented to the emergency department
with complaints of difficulty with swallowing and tongue
swelling. She described her difficulty swallowing as a
foreign body sensation.
 Reported that she has been having dysphagia over the last
three weeks.
 Presents with a 40-pound unintentional weight loss.
CT Scan
 BOT squamous cell carcinoma with
bilateral subglottic and glottic
involvement
 Left worse than right sided mass in
the BOT extends into hypoglossal
and genioglossus muscle.
 Second mass supraglottic region
involving the false and true vocal
cords
 Multiple necrotic enlarged lymph
nodes
 CT with contrast negative for METs
Medical and Social History
 Admitted to the hospital 10/12/15-BOT cancer with
laryngeal and necrotic lymph node involvement.
 Pack a day smoker > 10 years.
 Alcohol abuse in past
 No medical insurance & no previous medical care
 Unemployed, widowed, adult niece lives with patient
Labs
 HGB & HCT low-common with cancer
 BUN low ( 6) creatinine was WNL
 Anion Gap ( 14) High
 All electrolytes and other lab results were WNL
Admit Medications
IVF:
 Dilaudid for pain- can cause increase
thirst/dehydration
 Methylpredisone- Corticosteroid- monitor labs
Can decrease Ca, Vit D, Vit A, Vit K, Vit C, P, and Zn.
Can increase Na.
 Ondansetron for nausea- can increase thirst
Nutrition Assessment
 Nutrition assessment on admission for unintended weight
loss.
 Patient reports normal appetite until ~ 1 month ago.
 Poor intake > 1-month r/t difficulty in swallowing. Did not
eat > 1 week prior to admission r/t severe pain with eating.
 Patient reports usual weight of 115-120 lb, wt loss of > 35 lb
(29%) over the last 4 weeks.
Nutrition Assessment
 Patient is currently NPO.
 RN reports patient to have a speech evaluation, pt
diagnosed with oropharyngeal dysphagia.
 Patient B underwent surgery for a tracheotomy to
protect her airway, biopsy and the placement of a
PEG tube.
Estimated Energy Needs
 Anthropometrics: Height: 64 in. Adm Weight: 37.8 kg BMI:
14.3 kg/m2 UBW: 115-120 lb (52.27-54.55kg) UBW% 69%
 Clinical nutrition weight: 37.8 kg
 Estimated Energy Needs: MSJ 1008 X 1.2-1.3 + 250 Kcal/day
for wt gain = 1460-1560 Kcal/day
 Estimated Protein Needs: 53-60 Gm/day ( 1.4-1.6 Gm/kg)
 Estimated fluid Needs: 1.4L-1.6L/day (1mL/Kcal)
 Nutrition therapy: NPO
Nutrition Diagnosis
Patient B meets the criteria for diagnosis of severe
malnutrition of chronic illness as evidenced by 29% weight
loss X 4 weeks, meeting <75% of estimated nutrition needs
for > 1 month, and evidenced of muscle wasting at temples.
 1.Malnutrition r/t chronic disease, dysphagia AEB 29% wt
loss X 4weeks, meeting <75 of estimated nutrition needs > 1
month, and evidence of muscle wasting at temples.
 2. Inadequate PO intake r/t dysphagia AEB inability to take
oral intake.
Nutritional Intervention/Analyses
 Tube feeding regimen of 4 cans of Osmolite 1.5 Cal + 60 mL
H20 before/after each feeding + 100 mL H2O BID.
 This provides 1440 Kcal (98% of estimated needs) 60 Gm of
protein (1.2 Gm/kg) 193 Gm CHO, 0 fiber, 730 mL of free
water (1410 mL free water with H2O flushes), 96 % of
recommended daily allowance (RDI).
 Patient B is meeting 98% of her estimate energy needs and
96% of her RDI.
 Per SLP, Frazier water protocol
Monitoring
Throughout Medical course monitor
•
TF tolerance
•
Weights
•
Intake and Outputs
•
Labs
Treatment
 Medical: Patient B underwent a laryngoscopy, biopsy, tracheostomy
and PEG tube placement.
 MNT: Emphasis on initiating PEG Tube bolus regimen and monitoring
Patient B‘s weights, input and outputs, and labs closely for tube feeding
tolerance. Patient B was independent with tube feedings upon
discharge.
 Modified barium swallow -Patient B was diagnosed with oropharyngeal
dysphagia.
 SLP-initiated the Frazier Water Protocol and worked with patient on
how to utilize a communication board
Discharge plan
 Patient was discharged to a rehabilitation facility.
 Discharge follows up with :
Otolaryngologist
Radiation Oncologist
Medical Oncologist.
Summary
 Head and neck cancer accounts for approximately 3% of all
cancer diagnosis with Squamous cell carcinoma being the most
prevalent.1
 Tobacco and alcohol are among the strongest risk factors of these
cancers.
 Symptoms include pain, difficulty talking, dysphagia, weight
loss, Otalgia
 Treatment significantly impacts nutrition, malnutrition and
cachexia are common.
 Screening can save lives
Behavioral Objectives
 You will be able to name the two leading risk factors for
head and neck cancer.
 You will be able to identify at least 2 symptoms of head and
neck cancer.
 You will be able to recall 2 nutritional problems that can
result from treatment intervention.
BOT Cancer
Bibliography

1.Schoeff S, Barrett DM, Gress CD, Jameson MJ. Nutritional Management For
Head And Neck Cancer Patients. Practical Gastroenterology.2013; (121):43-51.
 2.National Cancer Institute. Oropharyngeal Cancer Treatment. Updated in 2015.
Available at: http://www.cancer.gov/types/head-and-neck/hp/oropharyngealtreatment-pdq#link/_303_toc19 Oct. 2015. Accessed on October, 19, 2015.
 3.National Cancer Institute. Head And Neck Cancers. Available at:
http://www.cancer.gov/types/head-and-neck/head-neck-fact-sheet. Accessed
October 18, 2105.
 4.Emedicine.medscape.com. Malignant Tumors Of The Base Of Tongue:
Background, Etiology, Pathophysiology.2015. Available at:
http://emedicine.medscape.com/article/847955-overview.Accessed October 16,
2015.
 5.Oralcancerfoundation.org. Treatment - The Oral Cancer Foundation. Available at:
http://www.oralcancerfoundation.org/cdc/cdc_chapter6.php. Accessed:24 Oct.
2015.
Bibliography

6.Cancer.org. Survival Rates For Oral Cavity And Oropharyngeal Cancer By Stage. Available at:
http://www.cancer.org/cancer/oralcavityandoropharyngealcancer/detailedguide/oral-cavityand-oropharyngeal-cancer-survival-rates1. Accessed on November 1, 2015.

7.Cancer.org. Survival Rates For Oral Cavity And Oropharyngeal Cancer By Stage. 2015.
Available at:
http://www.cancer.org/cancer/oralcavityandoropharyngealcancer/detailedguide/oral-cavityand-oropharyngeal-cancer-survival-rates. Accessed on: November 1, 2015.

8.Moore E J, Olsen SM, Laborde RR, Garcia JJ, Walsh FJ, Price DL, Janus JR, Kasperbauer JL,
and Olsen, KD. Long-Term Functional And Oncologic Results Of Transoral Robotic Surgery
For Oropharyngeal Squamous Cell Carcinoma. Mayo Clinic Proceedings. 2012; (87): 219-225.

9.Kramer, S. et al. Prophylactic Versus Reactive PEG Tube Placement In Head And Neck
Cancer'. Otolaryngology - Head and Neck Surgery.2013; 150 (3): 407-412. 2015.

10.Madhoun, Mohammad F. Prophylactic PEG Placement In Head And Neck Cancer: How
Many Feeding Tubes Are Unused (And Unnecessary)? World Journal of Gastroenterology.
2011;17 (8): 1004.