Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy (a Cochrane systematic review)

Abstract

Background: For many patients with head and neck cancer, oral nutrition will not provide adequate nourishment during treatment with radiotherapy or chemoradiotherapy due to the acute toxicity of treatment, obstruction caused by the tumour, or both (Unsal 2006). The optimal method of enteral feeding for this patient group has yet to be established. The aim of this systematic review was to compare the effectiveness of different enteral feeding methods used in the nutritional management of patients with head and neck cancer receiving radiotherapy or chemoradiotherapy using the clinical outcomes, nutritional status, quality of life and rates of complications. Methods: An extensive literature search was undertaken to include the Cochrane ENT Group Trials Register, CENTRAL, PubMed, EMBASE, CINAHL, AMED and ISI Web of Science. The date of the most recent search was May 2009. The selection criteria was randomised controlled trials comparing one method of enteral feeding with another, e.g. nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) feeding, for adult patients with a diagnosis of head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Two authors independently assessed trial quality and extracted data using standardised forms. Study authors were contacted for additional information. Results: One randomised controlled trial was eligible for inclusion in this review (Corry 2008). However, a high degree of bias was identified in the study. Patients diagnosed with head and neck cancer, being treated with chemoradiotherapy, were randomised to PEG or NG feeding. In total only 33 patients were eligible for analysis as the trial was terminated early due to poor accrual. Weight loss was greater for the NG group at 6 weeks post-treatment than for the PEG group (P = 0.001). At six months post treatment, however, there was no significant difference in weight loss between the two groups. Anthropometric measurements recorded 6 weeks post-treatment demonstrated lower triceps skin fold thickness for the NG group compared to the PEG group (P = 0.03). No statistically significant difference was found between the two different enteral feeding techniques in relation to complication rates or patient satisfaction. The duration of PEG feeding was significantly longer than for the NG group (P = 0.0006). In addition, the study calculated the cost of PEG feeding to be 10 times greater than that of NG. There was no difference in the treatment received by the two groups. Four PEG fed patients and two NG fed patients required unscheduled treatment breaks of a median of 2 and 6 days respectively. No studies were identified of enteral feeding involving any form of radiologically inserted gastrostomy (RIG) feeding or comparing prophylactic PEG versus PEG for inclusion in the review. Discussion: After an extensive literature search one randomised controlled trial was located. Interpretation of the findings from this study was limited due to the small recruitment number of patients and bias was established through missing data. Additionally, no consideration was given to the fact that the distribution of tumour sites was different in each of the two groups, which may impact on the interpretation of the results, especially in relation to the duration of enteral feeding. Conclusions: There is not sufficient evidence to determine the optimal method of enteral feeding for patients with head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Further trials of the two methods of enteral feeding, incorporating larger sample sizes, are required.