NCCN: Continuing Education
This activity has been designated to meet the educational needs of physicians, nurses, and pharmacists involved in the management of patients with cancer. There is no fee for this article. The National Comprehensive Cancer Network (NCCN) is accredited by the ACCME to provide continuing medical education for physicians. NCCN designates this journal-based CE activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
NCCN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center‘s Commission on Accreditation.
This activity is accredited for 1.0 contact hour. Accreditation as a provider refers to recognition of educational activities only; accredited status does not imply endorsement by NCCN or ANCC of any commercial products discussed/displayed in conjunction with the educational activity. Kristina M. Gregory, RN, MSN, OCN, is our nurse planner for this educational activity.
National Comprehensive Cancer Network is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. NCCN designates this continuing education activity for 1.0 contact hour(s) (0.1 CEUs) of continuing education credit in states that recognize ACPE accredited providers. This is a knowledge-based activity. UAN: 0836-0000-13-013-H01-P
All clinicians completing this activity will be issued a certificate of participation. To participate in this journal CE activity: 1) review the learning objectives and author disclosures; 2) study the education content; 3) take the posttest with a 66% minimum passing score and complete the evaluation at http://education.nccn.org/node/27285; and 4) view/print certificate.
Release date: August 22, 2013; Expiration date: August 22, 2014
Upon completion of this activity, participants will be able to:
Integrate into professional practice the updates to NCCN Guidelines for Head and Neck Cancers
Describe the rational behind the decision-making process for developing the NCCN Guidelines for Head and Neck Cancers
NCCN Categories of Evidence and Consensus
Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2B: Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate.
Category 3: Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate.
All recommendations are category 2A unless otherwise noted.
Clinical trials: NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
A new section on “Principles of Nutrition” was recently added to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Head and Neck Cancers. This new section outlines the management of nutrition and supportive care for patients with head and neck cancers who are prone to weight loss, which can often be severe, as a result of treatment-related toxicity, disease, and health behaviors.1 Multidisciplinary evaluation is integral to minimizing or decreasing weight loss and should involve a registered dietitian and a speech-language/swallowing therapist.
Before treatment, patients with head and neck cancer are prone to weight loss because they may have difficulty swallowing from pain or obstruction caused by their tumor; patients are also at risk for dehydration. Although multimodality treatment for head and neck cancers is improving outcomes, it can be associated with severe toxicities.1-3 Many patients with head and neck cancers will receive radiation-based treatments and should receive dietary counseling before treatment. Dysphagia, odynophagia, xerostomia, and dysgeusia are common complications contributing to nutrition problems.1,2,4-10 Surgery can lead to functional impairment regarding chewing and swallowing; chemotherapy is often associated with oral mucositis, nausea, and vomiting.1
Patients with head and neck cancers who have had significant weight loss (>10% ideal body weight) clearly need nutritional evaluation and close monitoring of their weight to prevent further loss.4,11 Therefore, patients should receive nutritional evaluation before and after treatment to assess the need for interventions (eg, enteral support via feeding tubes).12,13 Some patients may require ongoing follow-up if they have chronic nutritional problems. Patients are also at risk for problems with speech. Treatment and/or the progression of their disease may cause deterioration in their ability to speak and/or swallow.6 Patients have reported that swallowing disorders negatively affect their quality of life.9 Evaluation by a speech-language/swallowing specialist can help mitigate potential problems, including rehabilitation of speech in patients after total laryngectomy (eg, esophageal speech, tracheoesophageal puncture).14-16
Progress in radiation and surgical techniques has led to a decrease in the local side effects associated with treatment. For example, intensity-modulated radiation therapy maintains tumor control while decreasing radiation dosing to sites not at risk for cancer involvement, and has been shown to decrease dry mouth after treatment.17 Minimally invasive surgical technology (endoscopes, robots, lasers) facilitates complete removal of primary aerodigestive tract tumors, which can be accessed entirely through the mouth under anesthesia.18-22 When applicable, these surgical techniques result in fewer tracheotomies, shorter postsurgical hospital days, and more rapid resumption of swallowing than conventional surgical approaches.
Although clinically significant esophageal constriction or stricture is infrequent after treatment with modern radiation techniques, it nonetheless can occur, particularly in patients with primary tumors of the hypopharynx. When esophageal constriction or stricture is present, esophageal dilation can alleviate related dysphagia. In rare cases of complete esophageal obstruction, an anterograde/retrograde approach may be warranted, and referral to a center with this expertise should be strongly considered.
The NCCN Head and Neck Panel agrees that reactive feeding tube placement is appropriate in selected patients with head and neck cancers.1,13 However, the panel had varying opinions regarding the indications for prophylactic tube placement, although this is commonly performed if high-risk patients will be receiving intense multimodality therapy (eg, concurrent chemoradiation) that is anticipated to cause severe swallowing problems.1,9,11 The NCCN Guidelines provide recommendations for prophylactic tube placement, which should be strongly considered in high-risk patients (eg, those with severe pretreatment weight loss, ongoing dehydration or dysphagia, significant comorbidities, severe aspiration, anticipated posttreatment problems) (see NUTR-A, pages 919 and 920). The NCCN Guidelines do not recommend prophylactic tube placement in lower-risk patients (eg, those without significant pretreatment weight loss, significant aspiration, or severe dysphagia), although these patients must carefully monitor their weight.
Percutaneous endoscopic gastrostomy (PEG) tube feeding is useful for patients with swallowing disorders and those who need prolonged nutritional support.23-25 The amount of weight loss is significantly reduced in patients who undergo prophylactic PEG tube placement; however, complications may occur.1,26-28 PEG tubes can lead to infection, aspiration pneumonia, and decreased quality of life.29,30 Although patients prefer PEG over nasogastric tubes, they can become dependent on PEG tubes.26,27,31,32 More-advanced disease, altered fractionation, and concurrent chemoradiation are associated with a greater dependence on PEG tubes in patients with oropharyngeal cancer.32 A recent analysis among patients with swallowing disturbances indicates that mortality rates and pneumonia are similar between the different types of feeding tubes (eg, PEG vs nasogastric tubes); the authors reported that PEG tube feeding seemed to be more effective and as safe as nasogastric tube feeding.23 However, for patients with head and neck cancer, which is the optimal type of feeding tube is unclear.33
These NCCN Guidelines Insights focus on nutrition and supportive care for patients with head and neck cancers. Multidisciplinary evaluation is integral to minimizing or decreasing weight loss and speaking and/or swallowing disturbances, and should involve a registered dietitian and a speech-language/swallowing therapist. The NCCN Guidelines provide recommendations for prophylactic feeding tube placement, which should be strongly considered in high-risk patients (eg, those with severe pretreatment weight loss, ongoing dehydration or dysphagia, significant comorbidities, severe aspiration, or anticipated posttreatment problems) (see NUTR-A, pages 919 and 920). The NCCN Guidelines do not recommend prophylactic feeding tube placement in lower-risk patients (eg, those without significant pretreatment weight loss, significant airway obstruction, or severe dysphagia), although these patients must carefully monitor their weight (to view the most recent version of these guidelines, visit the NCCN Web site at NCCN.org).
EDITOR: Kerrin M. Green, MA, Assistant Managing Editor, JNCCN—Journal of the National Comprehensive Cancer Network, has disclosed that she has no relevant financial relationships.
CE AUTHORS: Deborah J. Moonan, RN, BSN, Manager, CE Supporter Outreach, has disclosed the following relationships with commercial interests: AstraZeneca: Stockholder/Former Employee. Kristina M. Gregory, RN, MSN, OCN, Vice President, Clinical Information Operations, has disclosed that she has no relevant financial relationships. James Prazak, RPh, Assistant Director, Continuing Education and Grants, has disclosed the following relationships with commercial interests: Bristol-Myers Squibb Company: Pension; Pfizer, Inc: Stockholder; United Healthcare Group: Stockholder; Johnson & Johnson: Stockholder. Nicole R. McMillian, MS, Guidelines Coordinator, has disclosed no relevant financial relationships. Miranda Hughes, PhD, Oncology Scientist/Senior Medical Writer, has disclosed no relevant financial relationships.