Nutritional Status and Its Association With Radiation-Induced Oral Mucositis in Patients With Nasopharyngeal Carcinoma During Radiotherapy: A Prospective Study

Zekai Shu, Ziyi Zeng, Bingqi Yu, Shuang Huang, Yonghong Hua, Ting Jin, Changjuan Tao, Lei Wang, Caineng Cao, Zumin Xu, Qifeng Jin, Feng Jiang, Xinglai Feng, Yongfeng Piao, Jing Huang, Jia Chen, Wei Shen, Xiaozhong Chen, Hui Wu, Xiushen Wang, Rongliang Qiu, Lixia Lu, Yuanyuan Chen, Zekai Shu, Ziyi Zeng, Bingqi Yu, Shuang Huang, Yonghong Hua, Ting Jin, Changjuan Tao, Lei Wang, Caineng Cao, Zumin Xu, Qifeng Jin, Feng Jiang, Xinglai Feng, Yongfeng Piao, Jing Huang, Jia Chen, Wei Shen, Xiaozhong Chen, Hui Wu, Xiushen Wang, Rongliang Qiu, Lixia Lu, Yuanyuan Chen

Abstract

Background and aims: Malnutrition is a concern in patients with nasopharyngeal carcinoma (NPC) during chemoradiotherapy (CRT)/radiotherapy (RT), which is considered to be related with radiation-induced oral mucositis (ROM). The study aimed to evaluate the nutritional status of NPC patients during RT and investigate its association with ROM.

Methods: A prospective study was conducted in NPC patients. Patients were divided into three subgroups (mild, moderate, and severe groups) based on the duration of severe ROM (≥ grade 3). Body weight, body mass index (BMI), albumin, prealbumin, NRS2002, and ROM grade were assessed on a weekly basis before and during CRT/RT. The statistical analysis was performed in the overall group and between three subgroups.

Results: A total of 176 patients were included. In the overall group, body weight and BMI kept decreasing since week 1 of RT, and NRS2002 score and ROM grade increased (p < 0.001). NRS2002 score and prealbumin levels were significantly different between each subgroup (p ≤ 0.046). Significant differences were observed in the proportion of patients receiving enteral nutrition, duration of parenteral nutrition, and total calories provided by nutritional support among three subgroups (p = 0.045-0.001).

Conclusions: Malnutrition occurred early in NPC patients and worsened continuously during RT. ROM was strongly associated with nutritional status. Nutritional support should be provided at the start of RT, especially in patients at high-risk of severe ROM.

Keywords: head and neck cancer; nasopharyngeal carcinoma (NPC); nutritional status; radiation–induced oral mucositis; radiotherapy.

Copyright © 2020 Shu, Zeng, Yu, Huang, Hua, Jin, Tao, Wang, Cao, Xu, Jin, Jiang, Feng, Piao, Huang, Chen, Shen, Chen, Wu, Wang, Qiu, Lu and Chen.

Figures

Figure 1
Figure 1
Changes in clinical factors, BWR (A), BMI (B), NRS2002 score (C), ROM grade (D), albumin (E), and prealbumin (F), of all patients during CRT/RT treatment.
Figure 2
Figure 2
Changes in clinical factors, BWR (A), BMI (B), NRS2002 score (C), ROM grade (D), albumin (E), and prealbumin (F), in mild, moderate, and severe groups during CRT/RT treatment.

References

    1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer (2010) 127:2893–917. 10.1002/ijc.25516
    1. Chen YP, Chan ATC, Le QT, Blanchard P, Sun Y, Ma J. Nasopharyngeal carcinoma. Lancet (2019) 394:64–80. 10.1016/s0140-6736(19)30956-0
    1. Chan AT, Teo PM, Ngan RK, Leung TW, Lau WH, Zee B, et al. Concurrent chemotherapy-radiotherapy compared with radiotherapy alone in locoregionally advanced nasopharyngeal carcinoma: progression-free survival analysis of a phase III randomized trial. J Clin Oncol (2002) 20:2038–44. 10.1200/jco.2002.08.149
    1. Lee AW, Ng WT, Chan LL, Hung WM, Chan CC, Sze HC, et al. Evolution of treatment for nasopharyngeal cancer–success and setback in the intensity-modulated radiotherapy era. Radiother Oncol (2014) 110:377–84. 10.1016/j.radonc.2014.02.003
    1. Lee AW, Lau WH, Tung SY, Chua DT, Chappell R, Xu L, et al. Preliminary results of a randomized study on therapeutic gain by concurrent chemotherapy for regionally-advanced nasopharyngeal carcinoma: NPC-9901 Trial by the Hong Kong Nasopharyngeal Cancer Study Group. J Clin Oncol (2005) 23:6966–75. 10.1200/jco.2004.00.7542
    1. Peng G, Wang T, Yang KY, Zhang S, Zhang T, Li Q, et al. A prospective, randomized study comparing outcomes and toxicities of intensity-modulated radiotherapy vs. conventional two-dimensional radiotherapy for the treatment of nasopharyngeal carcinoma. Radiother Oncol (2012) 104:286–93. 10.1016/j.radonc.2012.08.013
    1. Su SF, Han F, Zhao C, Chen CY, Xiao WW, Li JX, et al. Long-term outcomes of early-stage nasopharyngeal carcinoma patients treated with intensity-modulated radiotherapy alone. Int J Radiat Oncol Biol Phys (2012) 82:327–33. 10.1016/j.ijrobp.2010.09.011
    1. Elting LS, Cooksley CD, Chambers MS, Garden AS. Risk, outcomes, and costs of radiation-induced oral mucositis among patients with head-and-neck malignancies. Int J Radiat Oncol Biol Phys (2007) 68:1110–20. 10.1016/j.ijrobp.2007.01.053
    1. Sonis ST, Elting LS, Keefe D, Peterson DE, Schubert M, Hauer-Jensen M, et al. Perspectives on cancer therapy-induced mucosal injury: pathogenesis, measurement, epidemiology, and consequences for patients. Cancer (2004) 100:1995–2025. 10.1002/cncr.20162
    1. Lalla RV, Bowen J, Barasch A, Elting L, Epstein J, Keefe DM, et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer (2014) 120:1453–61. 10.1002/cncr.28592
    1. Vera-Llonch M, Oster G, Hagiwara M, Sonis S. Oral mucositis in patients undergoing radiation treatment for head and neck carcinoma. Cancer (2006) 106:329–36. 10.1002/cncr.21622
    1. Peterson DE, Boers-Doets CB, Bensadoun RJ, Herrstedt J. Management of oral and gastrointestinal mucosal injury: ESMO Clinical Practice Guidelines for diagnosis, treatment, and follow-up. Ann Oncol (2015) 26 Suppl 5:v139–51. 10.1093/annonc/mdv202
    1. Mallick S, Benson R, Rath GK. Radiation induced oral mucositis: a review of current literature on prevention and management. Eur Arch Otorhinolaryngol (2016) 273:2285–93. 10.1007/s00405-015-3694-6
    1. Li G, Gao J, Liu ZG, Tao YL, Xu BQ, Tu ZW, et al. Influence of pretreatment ideal body weight percentile and albumin on prognosis of nasopharyngeal carcinoma: Long-term outcomes of 512 patients from a single institution. Head Neck (2014) 36:660–6. 10.1002/hed.23357
    1. Meng L, Wei J, Ji R, Wang B, Xu X, Xin Y, et al. Effect of Early Nutrition Intervention on Advanced Nasopharyngeal Carcinoma Patients Receiving Chemoradiotherapy. J Cancer (2019) 10:3650–6. 10.7150/jca.33475
    1. Xu Y, Guo Q, Lin J, Chen B, Wen J, Lu T, et al. Benefit of percutaneous endoscopic gastrostomy in patients undergoing definitive chemoradiotherapy for locally advanced nasopharyngeal carcinoma. Onco Targets Ther (2016) 9:6835–41. 10.2147/ott.S117676
    1. Institute NC. Common Terminology Criteria for Adverse Events (CTCAE) v4.0. National Cancer Institute (2009). Available at: .
    1. Li K, Yang L, Hu QY, Chen XZ, Chen M, Chen Y. Oral Mucosa Dose Parameters Predicting Grade ≥3 Acute Toxicity in Locally Advanced Nasopharyngeal Carcinoma Patients Treated With Concurrent Intensity-Modulated Radiation Therapy and Chemotherapy: An Independent Validation Study Comparing Oral Cavity versus Mucosal Surface Contouring Techniques. Transl Oncol (2017) 10:752–9. 10.1016/j.tranon.2017.06.011
    1. Li K, Yang L, Xin P, Chen Y, Hu QY, Chen XZ, et al. Impact of dose volume parameters and clinical factors on acute radiation oral mucositis for locally advanced nasopharyngeal carcinoma patients treated with concurrent intensity-modulated radiation therapy and chemoradiotherapy. Oral Oncol (2017) 72:32–7. 10.1016/j.oraloncology.2017.06.026
    1. Poulia KA, Klek S, Doundoulakis I, Bouras E, Karayiannis D, Baschali A, et al. The two most popular malnutrition screening tools in the light of the new ESPEN consensus definition of the diagnostic criteria for malnutrition. Clin Nutr (2017) 36:1130–5. 10.1016/j.clnu.2016.07.014
    1. Gobbo M, Ottaviani G, Perinetti G, Ciriello F, Beorchia A, Giacca M, et al. Evaluation of nutritional status in head and neck radio-treated patients affected by oral mucositis: efficacy of class IV laser therapy. Support Care Cancer (2014) 22:1851–6. 10.1007/s00520-014-2155-x
    1. Zhu C, Wang B, Gao Y, Ma X. Prevalence and relationship of malnutrition and distress in patients with Cancer using questionnaires. BMC Cancer (2018) 18:1272. 10.1186/s12885-018-5176-x
    1. Caillet P, Liuu E, Raynaud Simon A, Bonnefoy M, Guerin O, Berrut G, et al. Association between cachexia, chemotherapy and outcomes in older cancer patients: A systematic review. Clin Nutr (2017) 36:1473–82. 10.1016/j.clnu.2016.12.003
    1. Chen YJ, Chen SC, Wang CP, Fang YY, Lee YH, Lou PJ, et al. Trismus, xerostomia and nutrition status in nasopharyngeal carcinoma survivors treated with radiation. Eur J Cancer Care (Engl) (2016) 25:440–8. 10.1111/ecc.12270
    1. Cox JD, Pajak TF, Marcial VA, Coia L, Mohiuddin M, Fu KK, et al. Interruptions adversely affect local control and survival with hyperfractionated radiation therapy of carcinomas of the upper respiratory and digestive tracts. New evidence for accelerated proliferation from Radiation Therapy Oncology Group Protocol 8313. Cancer (1992) 69:2744–8. 10.1002/1097-0142(19920601)69:11<2744::aid-cncr2820691119>;2-u
    1. Kwong DL, Sham JS, Chua DT, Choy DT, Au GK, Wu PM. The effect of interruptions and prolonged treatment time in radiotherapy for nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys (1997) 39:703–10. 10.1016/s0360-3016(97)00339-8
    1. Feng JF, Chen QX. Significance of the prognostic nutritional index in patients with esophageal squamous cell carcinoma. Ther Clin Risk Manag (2014) 10:1–7. 10.2147/tcrm.S56159
    1. Kanda M, Fujii T, Kodera Y, Nagai S, Takeda S, Nakao A. Nutritional predictors of postoperative outcome in pancreatic cancer. Br J Surg (2011) 98:268–74. 10.1002/bjs.7305
    1. Nozoe T, Ninomiya M, Maeda T, Matsukuma A, Nakashima H, Ezaki T. Prognostic nutritional index: a tool to predict the biological aggressiveness of gastric carcinoma. Surg Today (2010) 40:440–3. 10.1007/s00595-009-4065-y
    1. Pinato DJ, North BV, Sharma R. A novel, externally validated inflammation-based prognostic algorithm in hepatocellular carcinoma: the prognostic nutritional index (PNI). Br J Cancer (2012) 106:1439–45. 10.1038/bjc.2012.92
    1. Yang L, Xia L, Wang Y, Hong S, Chen H, Liang S, et al. Low Prognostic Nutritional Index (PNI) Predicts Unfavorable Distant Metastasis-Free Survival in Nasopharyngeal Carcinoma: A Propensity Score-Matched Analysis. PloS One (2016) 11:e0158853. 10.1371/journal.pone.0158853
    1. Du XJ, Tang LL, Mao YP, Guo R, Sun Y, Lin AH, et al. Value of the prognostic nutritional index and weight loss in predicting metastasis and long-term mortality in nasopharyngeal carcinoma. J Transl Med (2015) 13:364. 10.1186/s12967-015-0729-0
    1. Peng H, Chen BB, Tang LL, Chen L, Li WF, Zhang Y, et al. Prognostic value of nutritional risk screening 2002 scale in nasopharyngeal carcinoma: A large-scale cohort study. Cancer Sci (2018) 109:1909–19. 10.1111/cas.13603
    1. Ding H, Dou S, Ling Y, Zhu G, Wang Q, Wu Y, et al. Longitudinal Body Composition Changes and the Importance of Fat-Free Mass Index in Locally Advanced Nasopharyngeal Carcinoma Patients Undergoing Concurrent Chemoradiotherapy. Integr Cancer Ther (2018) 17:1125–31. 10.1177/1534735418807969
    1. Huang JF, Sun RJ, Jiang WJ, Wu P, Zhang L, Xu MQ, et al. Systematic nutrition management for locally advanced nasopharyngeal carcinoma patients undergoing radiotherapy. Onco Targets Ther (2019) 12:8379–86. 10.2147/ott.S213789
    1. Qiu C, Yang N, Tian G, Liu H. Weight loss during radiotherapy for nasopharyngeal carcinoma: a prospective study from northern China. Nutr Cancer (2011) 63:873–9. 10.1080/01635581.2011.582223
    1. Arribas L, Hurtós L, Taberna M, Peiró I, Vilajosana E, Lozano A, et al. Nutritional changes in patients with locally advanced head and neck cancer during treatment. Oral Oncol (2017) 71:67–74. 10.1016/j.oraloncology.2017.06.003
    1. Jager-Wittenaar H, Dijkstra PU, Vissink A, Langendijk JA, van der Laan BF, Pruim J, et al. Changes in nutritional status and dietary intake during and after head and neck cancer treatment. Head Neck (2011) 33:863–70. 10.1002/hed.21546
    1. Hong JS, Wu LH, Su L, Zhang HR, Lv WL, Zhang WJ, et al. Effect of chemoradiotherapy on nutrition status of patients with nasopharyngeal cancer. Nutr Cancer (2016) 68:63–9. 10.1080/01635581.2016.1115099
    1. Nourissat A, Bairati I, Samson E, Fortin A, Gélinas M, Nabid A, et al. Predictors of weight loss during radiotherapy in patients with stage I or II head and neck cancer. Cancer (2010) 116:2275–83. 10.1002/cncr.25041
    1. Beaver ME, Matheny KE, Roberts DB, Myers JN. Predictors of weight loss during radiation therapy. Otolaryngol Head Neck Surg (2001) 125:645–8. 10.1067/mhn.2001.120428
    1. Jager-Wittenaar H, Dijkstra PU, Vissink A, van der Laan BF, van Oort RP, Roodenburg JL. Critical weight loss in head and neck cancer–prevalence and risk factors at diagnosis: an explorative study. Support Care Cancer (2007) 15:1045–50. 10.1007/s00520-006-0212-9
    1. Fearon K, Strasser F, Anker SD, Bosaeus I, Bruera E, Fainsinger RL, et al. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol (2011) 12:489–95. 10.1016/s1470-2045(10)70218-7
    1. Waitzberg DL, Correia MI. Nutritional assessment in the hospitalized patient. Curr Opin Clin Nutr Metab Care (2003) 6:531–8. 10.1097/00075197-200309000-00006
    1. Malecka-Massalska T, Smolen A, Zubrzycki J, Lupa-Zatwarnicka K, Morshed K. Bioimpedance vector pattern in head and neck squamous cell carcinoma. J Physiol Pharmacol (2012) 63:101–4.
    1. Guerra LT, Rosa AR, Romani RF, Gurski RR, Schirmer CC, Kruel CD. Serum transferrin and serum prealbumin as markers of response to nutritional support in patients with esophageal cancer. Nutr Hosp (2009) 24:241–2.
    1. Beck FK, Rosenthal TC. Prealbumin: a marker for nutritional evaluation. Am Fam Physician (2002) 65:1575–8.
    1. Unal D, Orhan O, Eroglu C, Kaplan B. Prealbumin is a more sensitive marker than albumin to assess the nutritional status in patients undergoing radiotherapy for head and neck cancer. Contemp Oncol (Pozn) (2013) 17:276–80. 10.5114/wo.2013.35281
    1. Saito N, Imai Y, Muto T, Sairenchi T. Low body mass index as a risk factor of moderate to severe oral mucositis in oral cancer patients with radiotherapy. Support Care Cancer (2012) 20:3373–7. 10.1007/s00520-012-1620-7
    1. Chen SC, Lai YH, Huang BS, Lin CY, Fan KH, Chang JT. Changes and predictors of radiation-induced oral mucositis in patients with oral cavity cancer during active treatment. Eur J Oncol Nurs (2015) 19:214–9. 10.1016/j.ejon.2014.12.001
    1. Raber-Durlacher JE. Current practices for management of oral mucositis in cancer patients. Support Care Cancer (1999) 7:71–4. 10.1007/s005200050229

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera