Experiences with nutritional follow-up and barriers and opportunities of implementing digital seamless nutrition care in the head and neck cancer treatment course: a qualitative study from patient, family caregiver, and healthcare professional perspectives

Head and neck cancer treatment has developed over the last decade, with improved mortality and survival rates, but the treatments often result in dysphagia (a difficulty in swallowing) as a side effect. This may be acute, resolving after treatment, or remain as a long-term negative sequela of head and neck cancer (HNC) treatment. Interventions to counteract the problems associated with dysphagia include swallowing exercises or modification of diet (bolus texture, size), or both. To determine the effects of therapeutic exercises, undertaken before, during and/or immediately after HNC treatment, on swallowing, aspiration and adverse events such as chest infections, aspiration pneumonia and profound weight loss, in people treated curatively for advanced-stage (stage III, stage IV) squamous cell carcinoma of the head and neck. The Cochrane ENT Information Specialist searched the ENT Trials Register; Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 6); MEDLINE; PubMed; Embase; CINAHL; LILACS; KoreaMed; IndMed; PakMediNet; Web of Science; ClinicalTrials.gov; ICTRP; speechBITE; Google Scholar; Google and additional sources for published and unpublished trials. The date of the search was 1 July 2016. We selected randomised controlled trials (RCTs) of adults with head and neck cancer (stage III, stage IV) who underwent therapeutic exercises for swallowing before, during and/or immediately after HNC treatment to help produce safe and efficient swallowing. The main comparison was therapeutic exercises versus treatment as usual (TAU). Other possible comparison pairs included: therapeutic exercises versus sham exercises and therapeutic exercises plus TAU versus TAU. TAU consisted of reactive management of a patient's dysphagia, when this occurred. When severe, this included insertion of either a percutaneous endoscopic gastroscopy or nasogastric tube for non-oral feeding. We used the standard methodological procedures expected by Cochrane. Our primary outcomes were: safety and efficiency of oral swallowing, as measured by reduced/no aspiration; oropharyngeal swallowing efficiency (OPSE) measures, taken from videofluoroscopy swallowing studies; and adverse events, such as chest infections, aspiration pneumonia and profound weight loss. Secondary outcomes were time to return to function (swallowing); self-reported changes to quality of life; changes to psychological well-being - depression, anxiety and stress; patient satisfaction with the intervention; patient compliance with the intervention; and cost-effectiveness of the intervention. We included six studies (reported as seven papers) involving 326 participants whose ages ranged from 39 to 83 years, with a gender bias towards men (73% to 95% across studies), reflecting the characteristics of patients with HNC. The risk of bias in the studies was generally high.We did not pool data from studies because of significant differences in the interventions and outcomes evaluated. We found a lack of standardisation and consistency in the outcomes measured and the endpoints at which they were evaluated.We found no evidence that therapeutic exercises were better than TAU, or any other treatment, in improving the safety and efficiency of oral swallowing (our primary outcome) or in improving any of the secondary outcomes.Using the GRADE system, we classified the overall quality of the evidence for each outcome as very low, due to the limited number of trials and their low quality. There were no adverse events reported that were directly attributable to the intervention (swallowing exercises). We found no evidence that undertaking therapeutic exercises before, during and/or immediately after HNC treatment leads to improvement in oral swallowing. This absence of evidence may be due to the small participant numbers in trials, resulting in insufficient power to detect any difference. Data from the identified trials could not be combined due to differences in the choice of primary outcomes and in the measurement tools used to assess them, and the differing baseline and endpoints across studies.Designing and implementing studies with stronger methodological rigour is essential. There needs to be agreement about the key primary outcomes, the choice of validated assessment tools to measure them and the time points at which those measurements are made.

PurposeTo identify and review the nature, scope and use of web-based interventions for patients with head and neck cancer (HNC).MethodA scoping review guided by the methodological framework described by the Joanna Briggs Institute was performed to review empirical studies and websites. Seven electronic databases (CINAHL, Medline, Scopus, Embase, Cochrane, PubMed and PsycInfo) were searched from 2010 to 2020, data extracted and synthesised using thematic analysis. The Google search engine was employed, identifying the first 100 websites, using the search term head and neck cancer. Websites meeting eligibility criteria were assessed using the QUEST analysis tool, and descriptively summarised.ResultsThirteen empirical studies and 32 websites were included. As identified by empirical studies, web-based interventions were developed to provide (1) patient information on HNC and related treatments, (2) advice and support during treatment and (3) management strategies promoting adjustment to life with and beyond HNC. The reviewed websites provided minimal information to aid shared decision-making and facilitate preparedness for treatment, with few utilising patient narratives. Web-based interventions for HNC patients were mainly text based and focused on survivorship.ConclusionsThere is a paucity of theory-based, co-designed web-based interventions using patient narratives.Implications for Cancer SurvivorsAs patients increasingly look to the internet for advice and support, healthcare professionals are in a position to provide high-quality web-based interventions. There is an opportunity to rigorously develop a web-based intervention, containing narratives of peoples’ lives before and after HNC treatment, aiding decision-making, preparedness for treatment and self-management.

The eating experience after treatment for head and neck cancer: A review of the literature

This study investigated the assignment of preference values to health states which may follow head and neck cancer (HNC) treatment. Preference values for these health states were provided by HNC patients, HNC health-care providers, and a group of college students representing individuals with little knowledge of HNC. A time trade-off technique was used by participants to assign preference values to four health states in the domains of appearance, eating, speech, breathing, pain, and work/social functioning. Patients' and health-care professionals' rank-ordered preference value scores for health states in appearance, breathing, eating, and speech were not significantly different (p < .05). These two groups differed significantly in ranking four of the eight pain and work/social functioning health states. Patients and students differed significantly in ranking 21 of the 24 health states (p < .05). Health-care professionals and patients had very similar perspectives regarding health states in the HNC-specific domains, indicating that these professionals appear to be a legitimate proxy for patients' attitudes in these domains. Healthcare professionals placed a significantly greater value on avoiding both pain and social confinement than did patients. Students, representing individuals naive regarding HNC, differed from patients and health-care professionals in their rankings of these health-state outcomes.

IntroductionFamily caregivers (FCGs) play an integral, yet often invisible, role in the Canadian health-care system. As the population ages, their presence will become even more essential as they help balance demands on the system and enable community-dwelling seniors to remain so for as long as possible. To preserve their own well-being and capacity to provide ongoing care, FCGs require support to the meet the challenges of their daily caregiving responsibilities. Supporting FCGs results in better care provision to community-dwelling seniors receiving health-care services, as well as enhancing the quality of life for FCGs. Although FCGs rely upon health-care professionals (HCPs) to provide them with support and services, there is a paucity of research pertaining to the type of health workforce training (HWFT) that HCPs should receive to address FCG needs. Programs that train HCPs to engage with, empower, and support FCGs are required.ObjectiveTo describe and discuss key findings of a caregiver symposium focused on determining components of HWFT that might better enable HCPs to support FCGs.MethodsA one-day symposium was held on February 22, 2018 in Edmonton, Alberta, to gather the perspectives of FCGs, HCPs, and stakeholders. Attendees participated in a series of working groups to discuss barriers, facilitators, and recommendations related to HWFT. Proceedings and working group discussions were transcribed, and a qualitative thematic analysis was conducted to identify key themes.ResultsParticipants identified the following topic areas as being essential to training HCPs in the provision of support for FCGs: understanding the FCG role, communicating with FCGs, partnering with FCGs, fostering FCG resilience, navigating healthcare systems and accessing resources, and enhancing the culture and context of care.ConclusionsFCGs require more support than is currently being provided by HCPs. Training programs need to specifically address topics identified by participants. These findings will be used to develop HWFT for HCPs.

BackgroundSurvivors with head and neck cancer (HNC) face challenging treatment consequences that can lead to severe disruptions in swallowing and result in weight loss, malnutrition, and feeding tube dependence. Caregivers (family or friends who provide support), therefore, often encounter distressing nutritional caregiving burdens and feel unprepared to provide adequate support at home.ObjectiveThe purpose of this mixed methods study was to develop a mobile support app to support HNC caregiving with an emphasis on nutritional support following treatment.MethodsWe assessed perspectives on nutritional recovery challenges and mobile support app preferences in (1) a national panel of oncology dietitians using a web-based cross-sectional survey and (2) survivors with HNC completing treatment within the past 24 months and their nominated caregivers using dyadic semistructured interviews. Descriptive statistics for survey data were synthesized with thematic analysis of interview data to characterize nutrition-related perceptions and intervention preferences; results were integrated, and themes were translated to high-priority main menu domains and subdomains for a mobile app for caregivers.ResultsSurveys were completed by dietitians (n=116, 100%; female n=87, 50%, with >10 years practice experience). Interviews included survivors with HNC (n=15; 12/15, 80% male, and 6/15, 40% with oropharynx cancer) and their caregivers (n=13; 11/13, 85% female, and 10/13, 77% spouses). Dietitians, survivors, and caregivers perceived that the majority of nutritional concerns assessed (eg, swallowing, feeding tube management, weight maintenance, and caregiver distress about nutrition) were very or extremely important to caregiving in the 6 months following treatment conclusion. The caregiving tasks rated highest in importance by dietitians included tracking nutritional concerns (n=113, 97%), working together as a team on nutritional concerns (n=104, 90%), and making care decisions (n=102, 88%). Five themes emerged from dyadic interviews, including types of nutritional challenges faced, that competing symptoms were difficult to separate from nutritional challenges, the emotional challenges related to nutrition and recovery, the diverse set of medical and support tasks taken on by caregivers, and information and resource needs in caregivers. Qualitative interview and survey themes guided the content of the Healthy Eating and Recovery Together (HEART) app with an intake tracker and sections for nutrition recovery support, other competing caregiving tips, peer support, and caregiver self-care.ConclusionsResults pinpointed optimal content for a mobile app for caregivers of individuals with HNC and support the acceptability of implementing the HEART app following HNC treatment.

Head and neck cancer (HNC) is a genetically complex cancer type having treatment difficulties due to affecting multiple organs in complex anatomical sites. Radiotherapy resistance, chemotoxicity, post-surgery disability makes HNC treatment more complicated. Therefore, there is need to developed new treatment approaches. Nanoparticle-based therapies especially cerium oxide nanoparticles with its anti-cancer features, high catalytic activity, anti- or pro-oxidant and radio-protective properties give a boon for HNC treatment. In the current study, two dextran-coated cerium oxide nanoparticles (Dex-CeNPs) namely SD1 and SD2 were synthesized and characterized by using two types of dextran (D1 and D2) having distinct molecular weights and branching characteristics to understand their potential as a new HNC treatment strategy while evaluating the role of dextran type. The effectivity of the SD1 and SD2 on the HNC cell lines (A253, SCC-25, FaDu) were investigated by analyzing their cytotoxicity, genotoxicity, reactive oxygen species (ROS) generation properties. Low IC50 value, high ROS generation and stability profiling of SD2 compared to SD1 indicates the distinct function of dextran type on Dex-CeNPs effectivity on HNC. To better elucidate the effectivity of SD2, flow cytometry analysis and pro-apoptotic (TP53, CASP3, BAX) and anti-apoptotic (Bcl-2) gene expression profiling were investigated in detail. The findings indicate that SD2 exhibits an influence on head and neck cancer cells via the apoptotic pathway. Our research sets the framework for the development of Dex-CeNPs as remarkable nanotherapeutic candidates for treatment of head and neck cancer.

Treatment of head and neck cancer (HNC) results in severe weight loss, mainly due to the loss of lean body mass. Consequently, decreases in muscular strength and health-related quality of life (HRQL) occur. This study investigated the feasibility of a 12-week novel strength training (NST) and conventional strength training (CST) intervention delivered after HNC treatment. Participants were randomized to a NST group (n = 11) involving eccentric overloaded strength training and neuromuscular electrical stimulation (NMES), or a CST group (n = 11) involving dynamic resistance exercises matched for training volume. Feasibility outcomes included recruitment, completion, adherence, and evidence of progression. A neuromuscular assessment involving maximal isometric voluntary contractions (MIVCs) in the knee extensors was evaluated prior to and during incremental cycling to volitional exhaustion at baseline and after the interventions. Anthropometrics and patient-reported outcomes (PROs) were also assessed. Although recruitment was challenging, completion was 100% in NST and 82% in CST. Adherence was 92% in NST and 81% in CST. Overall, MIVC increased by 19 ± 23%, muscle cross-sectional area improved 18 ± 22%, cycling exercise time improved by 18 ± 13%, and improvements in HRQL and fatigue were clinically relevant. Both interventions were found to be feasible for HNC patients after treatment. Strength training significantly improved maximal muscle strength, muscle cross-sectional area, and PROs after HNC treatment. Future research should include fully powered trials and consider the use of eccentric overloading and NMES during HNC treatment. Eccentric- and NMES-emphasized strength training may be useful alternatives to conventional strength training after HNC treatment.

Effect of treatments for head and neck cancer on sinus shadow on computed tomography

Literature about ocular toxicity after head and neck cancer (HNC) treatment is scarce. This study aimed to describe visual function and ocular symptoms among HNC patients. The study used a cross-sectional design. Two surveys, The National Eye Institute Visual Functioning Questionnaire (NEI-VFQ) and an Ocular Symptom Scale, were sent to participants via e-mail. Descriptive statistics were used to describe the sample in the vision change and non-vision change groups. Chi-square and t-tests were used to compare groups. Of the 485 HNC patients emailed, 126 responded to the survey (26%). Of those, 114 completed the surveys. The scores of NEI-VFQ were significantly lower in the vision change group than in the non-vision change group (p < 0.001). Similarly, all ocular symptoms were significantly different between the two groups (p < 0.05). These findings and a scarcity of literature suggest that vision screening after HNC treatment is warranted.

Esophageal pathology in patients after treatment for head and neck cancer

The present study assessed the diagnostic and prognostic significance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for suspected intrathoracic metastasis after HNC treatment. A retrospective analysis was conducted on 75 patients with a prior history of head and neck cancer treatment who underwent EBUS-TBNA for suspected intrathoracic metastases between March 2012 and December 2021. A total of 126 targeted lesions, including 107 mediastinal/hilar lymph nodes and 19 intrapulmonary/mediastinal masses, were sampled. The metastatic head and neck cancer (HNC) cases detected by EBUS-TBNA consisted of nasopharyngeal carcinoma (n = 24), oropharyngeal carcinoma (n = 3), hypopharynx carcinoma (n = 6), laryngeal carcinoma (n = 6), and oral cavity carcinoma (n = 6). Cases with negative EBUS-TBNA results consisted of tuberculosis (n = 9), sarcoidosis (n = 3), anthracosis (n = 9), and reactive lymphadenitis (n = 9). Six false-negative cases were found among the 75 patients with suspected intrathoracic metastases. The diagnostic sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of the EBUS-TBNA procedure for metastatic HNC were 88.2, 100.0, 100.0, 80, and 92.0%, respectively. The diagnosis of HNC intrathoracic metastasis by EBUS-TBNA correlated with an adverse prognosis in terms of overall survival (OS) (P = .008). The log-rank univariate analysis and Cox regression multivariate analysis results indicated that the detection of metastatic HNC through EBUS-TBNA was a significant independent prognostic factor for patients with HNC who had received prior treatment. Endobronchial ultrasound-guided transbronchial needle aspiration is a safe, effective, and minimally invasive procedure for assessing suspected intrathoracic metastasis in HNC patients after treatment. The intrathoracic metastasis detected by EBUS-TBNA has crucial prognostic significance in previously treated HNC patients.

The patient experience of having a feeding tube during treatment for head and neck cancer: A systematic literature review

Background: Head and neck cancer (HNC) treatment often involves extensive surgical procedures, which require patients to be hospitalized. Increased hospital stay following HNC treatment contributes substantial costs to both the patient and the hospital, and is considered an indicator of quality of care. Cost containment is at the forefront of responsible health care delivery, and one way to decrease costs is to decrease hospital length of stay (LOS). To reduce hospital LOS and decrease cost of treating HNC patients, it is important to first characterize factors associated with increased hospital LOS. However, data are lacking on factors contributing to increased LOS in patients with HNC. This study aims to examine predictors of length of stay among patients following HNC cancer treatment in a national sample. Methods: Data on 75,984 hospital records from the Nationwide Inpatient Sample 2008 – 2013 with a diagnosis of HNC using the International Classification of Diseases, ninth edition, were examined. The outcome variable, LOS, was calculated by subtracting the admission date from the discharge date, with same-day stays coded as 0. Patient level characteristics included age, sex, race, insurance type, residential income, comorbidity score, metastatic cancer status, and anatomic site. Hospital-level characteristics included hospital teaching status, hospital bed size, and hospital regional location. Weighted, multilevel generalized model was used to assess correlates of LOS. Results: Mean LOS among cases was 6.7 ± 8.0 days. The adjusted multilevel analysis indicated that patients with advanced comorbidities (b = 2.17 per 1 unit increase in Elixhauser comorbidity score, 95% CI = 1.66 – 2.69) were more likely to have a longer LOS. Compared with women, men were more likely to have a longer LOS (b = 0.20, 95% CI = 0.06, 0.33), as well as African Americans (b = 0.31, 95% CI = 0.11, 0.49) compared with Caucasians. In addition, patients with Medicaid (b = 1.38, 95% CI = 1.19, 1.58) vs. private insurance payers and those with metastatic cancer (b = 1.21, 95% CI = 1.07, 1.35) had longer LOS. Patients were more likely to have longer LOS if the sites of their cancer were floor of the mouth (b = 3.51, 95% CI = 3.12, 3.89), hypopharynx (b = 3.05, 95% CI = 2.68, 3.41), gum (b = 2.79, 95% CI = 2.34, 3.23), or larynx (b = 2.43, 95% CI = 2.15, 2.70) compared with salivary gland. Hospital-level factors also were associated with LOS among HNC patients in the adjusted multilevel model. Patients admitted to hospitals located in the South (b = -0.82, 95% CI = -1.11, -0.52), Midwest (b = -1.63, 95% CI = -1.98, -1.28), and West (b = -0.73, 95% CI = -1.08, -0.39) had shorter LOS compared with those admitted to hospitals located in the Northeast. Finally, patients admitted to a nonteaching hospital (b = -0.87, 95% CI = -1.08, -0.66), and small bed size (b = -0.95, 95% CI = -1.30, -0.60) or medium bed size (b = -0.58, 95% CI = -0.82, -0.34) hospital vs. large bed size had shorter LOS. Conclusion: Other than the index head and neck cancer, comorbidities seem to be the most important factor associated with increased patient LOS. Additionally, male patients, African Americans, those who had Medicaid insurance, had metastatic cancer, and were admitted to a teaching hospital were more likely to stay at the hospital longer. Understanding these factors associated with increased LOS will help efforts to decrease health care cost and improve quality of care. Citation Format: Eric Adjei Boakye, Betelihem B. Tobo, Jiajing Chen, Paula Buchanan, Shubhra Malik, Nosayaba Osazuwa-Peters. Multilevel factors associated with increased in-hospital length of stay among patients following head and neck cancer treatment [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr A29.

Introduction: Family caregivers play a key role in the care of stroke survivors post-discharge. Without a standard of practice for supporting caregivers, many experience negative health outcomes. Literature supports establishing system-level infrastructure to provide education and support to family caregivers. However, the implementation of such programs has yet to be actualized. Objective: This study examined factors that influence the implementation of caregiver programs into the Ontario Stroke System from the perspectives of healthcare professionals Methods: Health care professionals providing stroke care in acute, rehabilitation and community care settings were invited to participate in the study by their Regional Education Coordinators. Health care professionals who were interested in participating in the study contacted the first author to set up the interview. Semi-structured interviews were conducted with participants. Interviews were audiotaped, professionally transcribed and reviewed for accuracy. Transcripts were coded, data was analyzed using a constant comparison approach and themes were identified. Results: A total of nineteen health care professionals participated in this study (7 acute, 5 rehab, 6 community, 1 private). Interviews lasted between 28 and 74 minutes. Data analysis identified five themes: 1) It is important for key stakeholders to understand the value of caregiver education and support programs; 2) Caregiver education and support requires dedicated resources; 3) Delineate ownership and responsibility for program implementation; 4) Provide training to health care professionals regarding caregiver needs and program materials to obtain buy-in and facilitate implementation; and 5) Establish a clear identity for the program and promote awareness of the program to potential implementers and users. Conclusions: This is the first study to identify factors that influence the implementation of family caregiver education and support programs from the perspectives of health care professionals involved in providing stroke care. Addressing these factors will enable the health care system to establish such programs, ensuring family caregivers receive the support they need.