Nutritional issues are common among all cancer diagnoses throughout all stages of treatment. For those with head and neck cancer (HNC), it is especially important. Due to the location of the disease, patients commonly experience symptoms and side effects that interfere with eating and drinking normally. Results of radiation therapy, chemotherapy, major dental procedures prior to treatment, and surgeries to the oral cavity, oropharynx, and larynx may contribute to compromised nutritional status.
Importance of Nutrition
Many cancer patients are already experiencing some degree of malnutrition at the time of diagnosis while others are extremely susceptible to malnutrition during treatment. The stress and burden of cancer often increase an individual's metabolic rate, increasing the amount of macronutrients required to maintain nutritional stores. It is challenging for HNC patients to meet increased nutrient needs as they commonly experience symptoms and side effects that prevent optimal nutrition intake such as xerostomia, thick salvia, dysgeusia, dysphagia, mucositis, and mouth sores.
Research shows malnutrition and inadequate oral intake are associated with poor treatment outcomes, reduced quality of life, and increased mortality (Reports of Practical Oncology & Radiotherapy 2016;20(4):249-258). Early and aggressive intervention can reduce the degree of malnutrition and slow weight loss (Nutr Hosp 2008;23(5):458-468). Oncology-certified registered dietitians (RDs) can work with patients to optimize nutrition intake and manage side effects alongside medical management from oncologists and oncology nurses.
Managing Symptoms & Side Effects
Oncology RDs will work with patients to individualize nutrition suggestions based on their weight goals, nutrition status, food preferences, and symptoms they are experiencing. Following are a few of the highlighted suggestions.
Dysgeusia: Practice good oral hygeine. Avoid alcohol-containing mouthwashes. If the patient has hypogeusia, choose foods with strong flavors such as tart or sweet flavors, use herbs, spices, marinades, and sauces to enhance the flavor or flavor water with mint, lemon, or a splash of fruit juice. If they have a salty, bitter, metallic, or acidic taste, try foods with sweet flavors; season foods with herbs, spices, or other seasonings such as ginger, garlic, cinnamon, or rosemary; use plastic utensils; suck on sugar-free candies such as lemon drops or mints; if certain foods/beverages taste strange like water or meat, choose other alternatives for liquids to maintain adequate hydration or sources of protein such as beans, tofu, or Greek yogurt.
Xerostomia/thick saliva: Maintain adequate hydration with 64-96 ounces of fluids per day. Limit caffeinated beverages and alcohol. Choose soft or liquid, bland foods. Moisten foods with sauce, broth, or gravy to make them easier to chew and swallow. If the patient does not have mouth sores, he or she may try and use tart foods to stimulate saliva production, like lemon or citrus. Suck on small pieces of frozen fruit or sorbet, fruit pops, sorbet, or ice chips.
Dysphagia: A modified consistency diet may be necessary. Meeting with a speech-language pathologist is valuable as they can perform a swallow study and recommend the appropriate diet consistency, while providing exercises to improve and maintain swallowing ability. He or she may recommend a liquid diet, pureed diet, or a mechanical soft diet. Using liquid nutritional supplements may help the patient meet estimated nutrient needs if they cannot consume adequate solid food. Nutrient dense soups and smoothies can be prepared as well. If the patient cannot consume adequate food to meet their estimated nutrient needs for an extended period of time, he or she may require artificial nutrition support.
Weight loss/decreased appetite: Consume small frequent meals dense in calories and protein. Create an eating schedule that will ensure the patient eats 5-6 times per day, as hunger cues are likely limited. Choose high-calorie beverages such as full-fat milk, high-calorie smoothies, milkshakes, or nutritional supplements to sip on between meals. Have easy-to-prepare meals and snacks available. Distract the unpleasantness of eating by alternating surroundings (Oncology Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics 2013;115-121).
Top Nutrition Concerns
Patients who cannot meet their estimated nutrient needs by mouth for an extended period of time may require artificial nutrition support. The best route of enteral nutrition support is via percutaneous endoscopic gastrostomy tube if the individual has a functional gastrointestinal tract as it provides the most physiological normal route of feeding. The most common indicator for nutrition support is dysphagia. Although artificial nutrition support may be associated with a negative stigma, it may significantly improve a patient's experience when unable to meet nutrition needs by mouth. Some HNC patients may concurrently use nutrition support while consuming liquid or soft foods by mouth. In addition to providing a sense of normalcy for the patient, maintaining some degree of swallow function may help prevent muscle atrophy. Oncology-certified RDs can help patients optimize their diet and meet nutrition goals, whether it is oral, enteral, or a combination. They are an invaluable part of the multidisciplinary care team.
JESSICA IANNOTTA MS, RD, CSO, CDN, and CHELSEY WISOTSKY MS, RD, CSO, CDN, are oncology dietitians with Savor Health, New York, N.Y.