Causes And Rates Of Admission In Patients Undergoing Chemoradiation For Head And Neck Carcinoma In A Hospital Based Program Utilizing Prophylactic PEG Tube Placement

Abstract

Prophylactic PEG tube use in patients undergoing concurrent chemoradiation therapy for head and neck malignancies has been used to prevent admissions from treatment. There is limited data describing admission rates and cause in such a program. We sought to characterize the rate and primary reason for admission in a tertiary hospital setting. Patients were identified from an IRB approved retrospective database. All patients with a diagnosis of squamous cell carcinoma of the head and neck, regardless of subsite, were eligible as long as they received curative intent chemoradiation therapy and no previous radical surgery for current diagnosis and were treated at and admitted to the same tertiary hospital. Admission was defined as a hospital stay >1-day duration and were recorded from 30 days prior to day 1 of radiation up to 90 days post treatment. Reason for admission, subsite, chemotherapy type and dose, time of admission relative to therapeutic course, and length of stay were recorded. The chief listed admitting diagnosis as well as hospital interventions were used to determine primary cause of admission. For instance, if a patient was admitted with low blood pressure and received several liters of fluid without escalation of outpatient pain regimen, this was classified as a dehydration event relative to pain control. 310 patients met inclusion criteria, with 105 total admission events in 80 individual patients. Of the 105 admissions, 98 were due to complications of therapy and seven were for other reasons (diagnosis of pulmonary embolus, COPD exacerbation as examples). Median dose to gross disease was 70 Gy in 35 fractions, median intermediate risk dose was 60 Gy, and median low risk was 56 Gy. No patient received unilateral neck radiation. Of the eighty patients, 55 received cisplatin 100mg/m2. Three patients were admitted prior to therapy with infections secondary to PEG tube insertion, which all resolved with oral antibiotics prior to therapy. The average and median days post radiation fraction 1 to admission was 34 and 31 days, respectively. The latest was 77 days. Thirty-five admission events were related to hypovolemia/kidney injury, 7 of these had intractable nausea/vomiting, 27 events were due to infections or blood dyscrasias, 18 for uncontrolled pain, 7 for aspiration induced pulmonary symptoms, 4 with failure to thrive/caloric malnutrition, 3 due to hemoptysis, 1 from constipation. Of the patients who had repeat admissions, neither subsite nor chemotherapy dose was significantly associated. Use of prophylactic PEG tube showed a low level of caloric malnutrition as reason for admission, with a low procedural infection rate. Complications of therapy requiring admission remain sizable. Work is ongoing to identify factors that predict for admission and repeat admission, as well as the rate of long-term PEG retention in this population and swallowing function measured as diet consistency identified by speech therapy follow up.