1. Department of Nutrition and Dietetics, Royal Brisbane and Women’s Hospital, Queensland.
2. Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, New South Wales and Cancer Institute NSW Oncology Group (Head and Neck), New South Wales.
The aim of this study was to provide a baseline measure of current dietetic practice throughout Australia in the care of patients with head and neck cancer. An online survey was distributed to members of the Dietitians Association of Australia Oncology Interest Group. Questions covered parameters including service structure and workforce arrangements, as well as the clinical care pathway for the patient continuum of care. There were a total of 81 sites identified. Sites with incomplete data, duplications or without dietetics services for patients with head and neck cancer were excluded, leaving a final dataset of 60 sites. Of the 60 sites, 47 provided surgical services and 43 provided radiotherapy services with dietetic services for 96%, and 91% of these sites respectively. Other dietetic services were provided in pre-treatment (62%), post-treatment (85%) and palliative care (87%) settings. Nutrition screening, referral processes and clinical practice, during and post-treatment, were varied as were staffing levels. Nutrition assessment was performed using validated tools in 62% of centres. Dietetic practice in managing patients with head and neck cancer is varied. These findings will provide baseline data for comparison once the national Evidence-Based Practice Guidelines for the Nutritional Management of Patients with Head and Neck Cancer are implemented in 2011.
Malnutrition is common in patients with head and neck cancer, with rates reported between 30-50%.1 The causes of malnutrition are multifactorial and include tumour location and burden, pre-morbid nutritional status and intake, lifestyle factors such as tobacco and alcohol abuse and side-effects of multi-modal treatment regimens.2 Furthermore, malnutrition can have a significant adverse impact on immune function, post-operative infection rates, treatment interruptions, unplanned admissions, length of stay and quality of life.3,4,5 Consequently, nutrition support plays a crucial role in the provision of best practice care to this population.
Nutrition has been recognised as the second most important factor in predicting long-term prognosis in head and neck cancer.6 While recently developed guidelines exist for some aspects of primary treatment,7 there are currently no comprehensive evidence-based guidelines for the nutritional management of this patient population. Hence there is no uniform model of care. In the absence of current Australian guidelines, other international standards, such as the United Kingdom’s National Institute for Health and Clinical Excellence Guidance on Cancer Services: Improving Outcomes in Head and Neck Cancers, provides a best practice framework. It includes aspects of multidisciplinary team care such as service requirements for nutrition intervention.8,9 While this document does not provide clinical practice guidelines regarding specific nutrition management of patients with head and neck cancer, it does indicate the resource framework required for optimum multidisciplinary team care and highlights the importance of timely and appropriate dietetic intervention at all points in the head and neck cancer patient care pathway.
Some areas of nutrition intervention for patients with head and neck cancer remain controversial in current literature. For example, the use of immune modulating formulae as pre-operative immunonutrition is well supported in patients undergoing upper gastrointestinal surgery, but a recent systematic review was unable to conclude that strong benefits can be extrapolated to head and neck surgical patients.10 The optimal route of tube feeding (nasogastric versus gastrostomy) is also unclear for this patient group,11 as is the use of prophylactic tube feeding. Whilst a recent systematic review concluded that prophylactic feeding tubes may improve or maintain nutritional status in some groups,12 a recent UK study found there was no national consensus among healthcare professionals with regard to gastrostomy insertion in these patients.13
The lack of standardised practice indicates a need for clear evidence-based guidelines. Accordingly, the Cancer Institute NSW Oncology Group (Head and Neck) has supported development of Evidence Based Practice Guidelines for the Nutritional Management of Patients with Head and Neck Cancer.14 The aim of this study was to provide a baseline measure of current dietetic practice for patients with head and neck cancer throughout Australia, prior to the implementation of these guidelines.
A web-based questionnaire was developed to collect demographic and dietetic practice data focusing on key aspects of the guidelines framework.15,16 The survey was promoted to members of the Dietitians Association of Australia Oncology Interest Group through an email discussion group. To capture departmental trends rather than individual practice, it was requested that one dietitian represent each hospital or community centre when completing the survey. The survey was distributed in September, 2010. Descriptive statistics were used for data analysis. Categorical variables are presented as counts (percentages). The continuous variables are presented as median (range) for not-normally distributed variables.
There were a total of 81 sites responding from a possible 202 cancer treatment centres identified by the Clinical Oncological Society of Australia, including private hospitals and regional community healthcare centres. Responses were excluded: if the hospital did not treat head and neck cancer patients; if the data was submitted incomplete; or if responses were duplicates within one hospital. After these exclusions, 60 centres were included in the data analysis (table 1).
Dietetics services are currently provided across the patient continuum of care from pre-treatment to palliative care, although only 20 centres provided services in all stages of the patient care pathway. Most respondents were unable to give precise full-time equivalent (FTE) staffing figures, as few centres have dedicated resources for head and neck cancer patient services. Figures for FTE estimates were provided by 51 respondents (85%), however in many cases the nominated FTE count represented staffing available for the entire oncology dietetics workforce, not just head and neck cancer services. The median dietetic workforce available for all oncology was 0.70 FTE (range 0.1-2.4FTE). However, this varied from low volume centres with follow-up services only (median 0.45 FTE (range 0.3-0.6 FTE)) to high volume services with >100 patients with head and neck cancer treated by surgery and >100 patients treated by radiotherapy, with or without chemotherapy, each year (median 1.60 FTE (range 1.0-2.4 FTE)). Joint clinics with the speech pathologist occurred in 45% of centres, and a dietitian attended the multidisciplinary head and neck treatment planning meetings in 73% of centres.
The funding of home enteral nutrition products and equipment varied nationally. While some centres (19%) reported home enteral nutrition products were provided free of charge to their patients, more than half (55%) reported patients bearing the entire cost of the products. A sizeable number (37%) of sites reported their patients pay a co-payment or contribution and others reported funding through hospital departments, state funding, or various combinations of the above. A comparison of typical costs for a week’s supply of nutritional formula to provide bolus feeds of 8400kJ/day was also found to vary nationally (figure 1). If additional equipment was required for gravity bags or pump feeding, there was an additional cost associated with this in 57% of cases. Of the patients paying >$60 per week, 80% of those with benefit cards and 44% of those without benefit cards were seen at private hospitals.
Referral processes varied and may have included multiple approaches such as blanket referral system for all patients (47%), referral by medical or nursing staff only (22%) or some form of automatic referral triggered by the use of a malnutrition screening tool (27%), or identification of high risk patient groups (20%). The preferred method of nutrition assessment was the scored PG-SGA17 (nominated by 48% of respondents).
Forty-seven hospitals indicated they had surgical services for patients with head and neck cancer. Preoperative nutrition management varied with 3.7% of respondents reporting that this was provided to all patients, 33% providing pre-operative care sometimes and 31.5% providing it to malnourished patients only. One third of hospitals (31.5%) do not provide any pre-operative nutrition support. Thirty-seven centres reported providing pre-operative nutrition support, either orally or a combination of routes. Four centres were using pre-operative immunonutrition and one centre used both pre and post-operative immunonutrition. A sizeable proportion (59%) reported the most common reason for insertion of a gastrostomy feeding tube in surgical patients was due to an anticipated functional deficit post surgery. Gastrostomy placement was reported as rarely used in surgical treatment of head and neck cancer in 40% of hospitals.
The most common method of estimating energy requirements in the surgical setting was the Schofield equation (66%).18,19 Other methods such as kilojoules/kilogram (29.5%), or Harris-Benedict equation (4.5%) were also reported.20 The most commonly used factors for the Schofield or Harris-Benedict equations were 1.1-1.2 for activity, and 1.2-1.4 for injury/stress. For estimating protein requirements, 62% of respondents used the range 1.2-1.5g/kg/day. Most centres used enteral nutrition formulas containing fibre as their routine post operative feed (79.5%), with use of a 1.5kcal/mL energy dense feed most frequently reported (59.5%). Post-operative tube feeding was largely commenced within 24-48 hours (93%) and the timing was dependent on the consultant (34%) or the type of surgical procedure (33%). Oral intake generally resumed within 1-7 days post-surgery (75%). This was also frequently determined by the consultant (26%), type of surgical procedure (25%), or speech pathologist’s recommendation (26%). It was considered a multidisciplinary decision in 12% of centres.
The majority of respondents (89.5%) have implemented the Evidence Based Practice Guidelines for the Nutritional Management of Patients Receiving Radiation Therapy,7 either fully (42%) or to some degree (47%). Patients receiving Epidermal Growth Factor Receptor inhibitors, such as monoclonal antibodies, as part of their treatment were unlikely to receive any additional dietetic input (89%). If patients were receiving induction chemotherapy, they were more likely to have additional dietetic input and services (38%). The use of prophylactic gastrostomy tubes was reported in 76% of centres, with 94% of these commencing tube feeding once nutrition support was indicated (ie. following reduction in oral intake or weight loss). Only 6% reported commencing nutrition support irrespective of current nutritional status. Bolus feeding was the most frequently reported method of delivery (92%). This decision was dependent on a number of factors: patient preference (27%); patient tolerance (29%); cost of equipment/feeds (19%); limitations with time/appointment schedules (21%); and other reasons such as patient mobility and capacity (3.5%). No respondents reported recommending antioxidants during treatment, although 69% reported that they sometimes recommend multivitamins. Some respondents (11%) stated they occasionally recommend antioxidants following treatment, however, in the case of multivitamins, 18.5% reported they always recommend multivitamins and 78% recommend them sometimes.
Only three hospitals did not provide any services for patients following completion of treatment, with two of these referring patients to other local services. Twenty-five centres (23%) referred to local centres, but also continued to review at the treating centre. All other follow-up was carried out in a range of settings such as telephone reviews (36%) and outpatient clinics (38.5%). The frequency and duration of follow-up was largely determined by the patient’s individual requirements for an appointment in most cases, with some centres using a structured protocol. Just over half of the centres had clear criteria for removal of a feeding tube (51%). Education on long-term cancer survivorship with respect to nutrition was also varied with the topic discussed routinely (reported by 33%), sometimes (reported by 37%), or not at all (31%).
The results of this study demonstrate the wide variation in practice for the dietetic management of patients with head and neck cancer in Australia. Of particular note, and key areas for improvement, are the method and timing of screening for referral to the dietitian to ensure efficiency and early intervention, particularly in the case of malnourished patients who benefit from early nutrition support. The mode of enteral feeding was also varied in both the surgical setting and during radiotherapy. Although prophylactic gastrostomy placement is reported as common practice, the indications and decision remain variable, as has been found in the UK.13
A key finding of the survey confirms the gross inequity between patients requiring home enteral nutrition products across Australia. For example, for patients requiring enteral feeds in Victoria, the prescription is free in the majority of centres, whereas in some states, patients are required to pay over $60 per week for a similar script. Costs generally increase further if patients are required to pay more for equipment such as those associated with gravity bags, giving sets and feeding pumps. Cost of feeds and equipment was reported to influence feeding method selection in nearly 20% of cases. This may have clinical implications if a patient who better tolerates tube feeding via a pump still chooses to continue with inadequate nutrition via poorly tolerated bolus feeding, as they are unable to afford the additional associated costs.
One of the major limitations of this study is the methodology used in the survey dissemination. Some centres may have been missed in the distribution process if their dietitian was not a member of the Dietitians Association of Australia Oncology Interest Group. Within a department, individual dietitians may practice in different ways and respond differently to some of the clinical practice questions, such as estimating requirements,21 selection of feed type and mode of feeding. Analysis of the data was complicated by the survey design, which did not always prevent multiple responses to a question and free text responses were problematic to categorise. Improvements in web-based survey design would eliminate this difficulty for future questionnaires.
Variation in dietetic practices is influenced by many factors, such as hospital size, treatment capacity and the availability and experience of the dietitian with this patient group. In many cases there was no specific funding for a dietetic service for patients with head and neck cancer. Departments either provided ad hoc services when referrals were received, or patients with head and neck cancer were seen with general resources from cancer care as a whole, which made it difficult to determine staffing allocation to head and neck cancer services.
Consequently, the median figure of 1.60 FTE in the largest head and neck cancer treatment centres appears overly optimistic and likely an overestimate of the dietetic resources available to patients with head and neck cancer. These centres reported managing more than 100 new patients per year for both head and neck surgery and (chemo)radiotherapy. In the absence of any national workforce benchmark, comparison with the UK National Institute for Health and Clinical Excellence Guidance recommendations for 4.7 FTE specialist head and neck dietitians per 1.5 million population (equating to 100 new referrals per year) indicates services within Australia fall significantly short. Previous attempts at mapping multidisciplinary team membership profiles has methodological limitations, in that merely identifying the presence or absence of a dietitian within the multidisciplinary team fails to consider patient volume and complexity of case mix or the dietitian’s available hours and scope of practice.22 The severe nutrition-impact symptoms associated with multi-modal treatment regimens and the nature and location of the disease itself has led to an increasing reliance on nutrition support in this patient group. As such, it is essential to ensure patients have access to adequate support services to meet the significant and resource-intensive needs of nutrition monitoring and rehabilitation.
With reported existing dietetic resources, it would not be possible to meet the evidence-based recommendations for weekly to fortnightly dietetic review of patients during radiotherapy and for at least six weeks thereafter.7 There would also be insufficient resources available for pre-treatment assessment, surgery and long-term follow-up, which are also considered to be part of best practice care. Consideration should also be given to the need for a specialist caseload to encompass other important aspects of professional practice, including protected time for audit, research, participation in multidisciplinary team activities and maintenance of professional development.
This survey has confirmed that dietetic practice for the nutritional management of patients with head and neck cancer is varied throughout Australia. The upcoming publication of theEvidence Based Practice Guidelines for the Nutritional Management of Patients with Head and Neck Cancer will provide a foundation for practice.14 It will also allow the benchmarking of dietetic resources required for best practice care for this complex and vulnerable patient group, which is intended to enhance multidisciplinary care and improve patient outcomes in Australia.
The authors would like to acknowledge the Cancer Institute NSW Oncology Group (Head and Neck) for the sponsorship funding of the project. Thank you also to Ana Munroe (Project Co-ordinator, Sydney Medical School, University of Sydney) for her assistance in developing the survey tool and provision of raw data, and to all the survey participants.
1. van Bokhorst-de van der Schueren MAE, Leeuwen PAM, Kuik DJ, Klop WMC, Sauerwein HP, Snow GB, et al. The Impact of nutritional status on the prognoses of patients with advanced head and neck cancer. Cancer. 1999; 86(3):519-527.
3. Capuano G, Grosso A, Gentile PC, Battista M, Bianciardi F, Di Palma A, et al. Influence of weight loss on outcomes in patients with head and neck cancer undergoing concomitant chemoradiotherapy. Head and Neck. 2008; 30: 503-508.
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7. Isenring E, Hill J, Davidson W, Brown T, Baumgartner L, Kaegi K, et al. Evidence based practice guidelines for the nutritional management of patients receiving radiation therapy. Nutrition and Dietetics. 2008; 65 (1):S1-20.
8. National Institute of Health and Clinical Excellence (NICE 2004), Guidance on cancer services; Improving outcomes in head and neck cancers – The Manual.[Internet] London: NICE 2004. [Cited 2011 January 31]. Available from: http://guidance.nice.org.uk/CSGHN
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10. Stableforth WD, Thomas S, Lewis SJ. A systematic review of the role of immunonutrition in patients undergoing surgery for head and neck cancer. International J Oral Maxillofacial Surg. 2009;38:103-110.
11. Nugent B, Lewis S, O’Sullivan JM. Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy (review). Cochrane Database of Systematic Reviews. 2010;Issue 3:1-15.
13. Moor JW, Patterson J, Kelly C, Paleri V. Prophylactic gastrostomy before chemoradiation in advanced head and neck cancer; a multiprofessional wed-based survey to identify current practice and to analyse decision making. Clinical Oncology. 2010;22:192-198.
14. Findlay M, Bauer J, Brown T, Davidson W, Hill J, Isenring E, et al. Evidence based practice guidelines for the nutritional management of patients with head and neck cancer. [Internet]. [Cited 2011 April 11]. Available from: http://wiki.cancer.org.au/australia/COSA:Head and neck cancer nutrition guidelines
22. Cancer Institute NSW. Multidisciplinary teams in NSW 2006 and 2008. [Internet]. Cancer Institute NSW, 2010. [Cited 2011 March 25]. Available from: http://www.cancerinstitute.org.au/cancer_inst/publications/pdfs/2010_5_12_mdt-teams-nsw-2006-2008.pdf