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Nutritional Issues

Nutritional changes related to dysphagia are another concern for patients with head and neck cancer. The side effects of treatment can contribute to malnutrition and dehydration in head and neck cancer patients. Cancer patients have the highest incidence of proteincalorie malnutrition of all hospitalized patients.[48] Approximately one third of patients with advanced head and neck cancers are severely malnourished and another third of them experience mild malnutrition.[49] The degree of malnutrition is related to the patient's nutritional status before tumor development, to the characteristics of the tumor, and to the cancer treatment itself. Aggressive cancer treatments may worsen the severity of nutritional status. In severe cases, interruption or discontinuation of cancer treatment may be required.50

Head and neck surgery can have a negative effect on nutritional status due to loss of swallowing function and cosmetic deformities.51 Alterations in taste and smell may affect enjoyment and motivation to eat. The increased time required to consume a meal with a structural alteration may reduce the amount of oral intake. Diet modifications, such as a liquid-only diet, may result in reduced caloric intake. The physical effort of swallowing or the accompanying pain may also render patients unwilling or unable to meet the nutritional requirements for optimal healing.

Radiation therapy can also have a deleterious effect on nutritional status. Used as a primary intervention or as an adjunct or palliation, radiation can cause xerostomia, stomatitis, mucositis, dysgeusia, dysosmia, and odynophagia. Pain from mucosal ulcerations can lead to reduced intake. Many patients develop food aversions or loss of taste sensation due to radiation-induced damage to the taste buds. Xerostomia, caused by damage to the salivary glands, may become progressively worse during and after treatment. It can be a factor in poor nutrition as a result of reduced tolerance to various food textures, temperatures, and acidities. The thick, ropey secretions that may result often interfere with adequate intake.

Chemotherapeutic agents can negatively impact nutritional intake primarily as a result of its effects on the lining of the oral cavity, oropharynx, and esophagus, causing mucositis and odynophagia. Contributing to cachexia and malnutrition are the side effects of nausea and vomiting. Cisplatin, a chemotherapeutic agent frequently used in head and neck cancer management, has a high emetic potential. Diarrhea, constipation, and malabsorption also may occur. These side effects generally subside shortly after treatment has been completed. However, without nutritional intervention, the effects of the undernourishment can be long-lasting. Combined chemoradiation can put patients at even higher nutritional risk due to the combined toxicities of the two modalities and their effects on swallowing.

Although nutritional support does not directly improve survival rates, proper nutrition and hydration can improve tolerance to cancer treatments and functional outcomes. Patients also experience fewer complications and express a greater sense of well-being. Fewer rehospitalizations occur with those patients who receive early nutritional interventions and supplemental nutritional support. Interdisciplinary interventions by the dietician and speech pathologist can help to ensure that adequate nutrition is achieved by either oral or non-oral routes.