ORIGINAL ARTICLE
Decreased hospital stay and significant cost savings after routine use of prophylactic gastrostomy for high-risk patients with head and neck cancer receiving chemoradiotherapy at a tertiary cancer institution Brett G. M. Hughes, FRACP,1* Vikram K. Jain, FRACP,1 Teresa Brown, BSc (Hons),2 Ann-Louise Spurgin, BSp Path (Hons),3 Gemma Hartnett, FRACP,4 Jacqui Keller, BBus (HIM),5 Lee Tripcony, BSc,5 Mark Appleyard, FRACP,6 Robert Hodge, FRACS7 1
Department of Medical Oncology, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia, 2Department of Nutrition and Dietetics, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia, 3Department of Speech Pathology, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia, 4Department of Medical Oncology, Redcliffe Hospital, Brisbane, Queensland, Australia, 5Cancer Care Services, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia, 6Department of Gastroenterology, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia, 7Department of ENT/Head and Neck Surgery, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia.
Accepted 25 January 2012 Published online 18 May 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.22992
ABSTRACT: Background. Evidence-based nutritional and swallowing guidelines were developed to identify patients at high risk of developing malnutrition during chemoradiation for head and neck cancer. These guidelines recommended a prophylactic gastrostomy and were actively implemented at our institution in January 2007. This study assesses the effect of this policy change on patient outcomes. Methods. This retrospective cohort study was carried out for the years before (2005) and after (2007) implementation of these guidelines. Results. In all, 165 patients were treated with radical chemoradiation for head and neck cancer at our institution in the years 2005 and 2007.
INTRODUCTION Squamous cell carcinoma of the head and neck accounted for 2430 new cases of cancer in Australia in 2001, likely causing over 3000 new cases in the year 2011.1 Patients with these neoplasms are at high risk of dysphagia and malnutrition, from preexisting risk factors, secondary to the cancer itself or from the cancer-specific management modalities. Approximately 25% to 50% of these patients already have a markedly reduced nutritional status even before commencing therapy.2 Multimodality therapy for the treatment of these patients, involving surgery, chemotherapy, and radiotherapy, often produces significant mucositis, dysphagia, and xerostomia, leading to further worsening of their nutritional status, and weight loss.3 Patients undergoing combined chemoradiation treatment for head and neck cancer typically undergo a weight loss of at least 10% during their treatment.3
*Corresponding author: B. G. M. Hughes, Department of Medical Oncology, Royal Brisbane and Women’s Hospital, Herston, Qld, Australia Q 4029. E-mail:
[email protected] This work is presented on behalf of the Royal Brisbane and Women’s Hospital Nutrition and Swallowing for the working party of patients with head and neck cancer and was presented at the ASCO Annual Scientific meeting in June 2011.
436
HEAD & NECK—DOI 10.1002/HED
MARCH 2013
Gastrostomy tube complications were low. Patients in 2007 had significantly fewer hospital admissions, unexpected admissions, and a shorter mean duration of hospital stay in comparison with those in 2005. Conclusions. Prophylactic gastrostomy tubes in patients with high-risk head and neck cancer resulted in a significant decrease in hospital admissions and length of stay, and led to increased bed availability. C 2012 Wiley Periodicals, Inc. Head Neck 35: 436–442, 2013 V
KEY WORDS: head and neck cancer, nutrition support, prophylactic gastrostomy, chemoradiotherapy, hospital admission
Consequences of impaired nutrition evidenced initially by loss of weight also include reduced kidney function,4 which is clinically important, considering the need for optimal renal function for cisplatin-based chemotherapy. Malnutrition during treatment has also been associated with more emergency department visits, hospitalizations, treatment interruptions, compromising treatment efficacy, and diminished quality of life.5–8 Moreover, nutritional deficiency is an important adverse prognostic factor for patients with head and neck carcinoma both at the time of diagnosis and for eventual treatment outcomes.9 Enteral nutritional support measures such as nasogastric (NG) tube and percutaneous endoscopic gastrostomy (PEG) tube have been described for patients undergoing treatment for head and neck cancer. However, currently there is insufficient evidence and consensus to determine the optimal method of enteral feeding10 and the timing to initiate enteral feeding along a patient’s care pathway. Gastrostomy tubes, inserted prophylactically, have proved to be safe and effective for nutritional supplementation in patients with head and neck cancer.11–13 In Australia, there are currently no published evidencebased clinical pathways to support early identification and management of both dysphagia and malnutrition risk in patients with head and neck cancer. In 2006, evidencebased guidelines (head and neck guidelines, currently
PROPHYLACTIC
under review for separate publication) were developed by the multidisciplinary head and neck cancer clinic at our institution to ensure appropriate proactive management of swallowing and nutritional issues that arise during the treatment of head and neck cancer (see Figure 1). These were designed to identify patients at high risk of developing swallowing and nutritional difficulties during treatment, and recommended insertion of a PEG tube prior to commencement of treatment in these patients. We report a retrospective review of the effect of the implementation of these guidelines on the duration of hospital stay and associated health cost analysis in patients treated with curative intent chemoradiation for head and neck cancer at our hospital. An effect of these guidelines on other clinical parameters, such as nutritional outcomes and gastrostomy complications, will be reported in more detail in separate publications.
MATERIALS AND METHODS A working group comprising medical and allied health staff from all disciplines of the multidisciplinary head and neck clinic was formed in year 2006 at the Royal Brisbane and Women’s Hospital (Brisbane, Australia). This group, based on their integrated clinical experience and an extensive literature review, developed evidencebased head and neck guidelines to ensure appropriate proactive management of swallowing and nutritional issues for patients with head and neck cancer at our institution (see Figure 1). These guidelines were actively implemented by the multidisciplinary head and neck cancer clinic in January 2007 and recommended prophylactic gastrostomy tube (gastrostomy) for high-risk patients based on diagnosis, nutritional status, presence of dysphagia at presentation, and treatment modalities recommended. These guidelines have been retrospectively validated at our institution and show a sensitivity and specificity of 55% and 93%, respectively, for identifying high nutritional risk patients who would benefit from a PEG tube. Prior to these guidelines, tube feeding was commenced when clinically indicated during or after treatment. For this study, data were collected in 2 cohorts using chart review for the years 2005 (n ¼ 77) and 2007 (n ¼ 88) for consecutive patients with squamous cell carcinoma of the head and neck who received radical or postoperative chemoradiation treatment with curative intent at the Royal Brisbane and Women’s Hospital. These years were specifically chosen to assess differences in outcomes before and after active implementation of the head and neck guidelines and minimize other potential changes in clinical practice as potential confounders. All patients were discussed at the weekly multidisciplinary head and neck cancer clinic meeting. The decision to proceed with chemoradiotherapy for each individual patient was the consensus opinion of the multidisciplinary team. Ethics approval was obtained to collect these data and all patient information was deidentified. Data collected included patient demographics including age and sex, tumor site and classification, specific chemotherapy regimen (including cetuximab), number of hospitalizations, length of stay (defined as any unplanned prolongation of stay of an elective admission or unexpected admission), reason
GASTROSTOMY FOR CHEMORADIOTHERAPY
for admission, and death within 30 days of treatment completion. Nutritional outcomes and gastrostomy complications were prospectively collected for the 2007 cohort only. Patients were admitted to the hospital overnight for the placement of a gastrostomy tube, usually within 1 week before starting chemoradiation. Gastrostomy tubes were mostly inserted under endoscopic guidance by a gastroenterologist or by an interventional radiologist under ultrasound guidance. All patients received prophylactic antibiotics prior to the procedure. All patients were given education regarding gastrostomy tube usage and care and were checked weekly during treatment by a dietitian and speech pathologist for nutritional status, body weight, swallowing function, and aspiration risk. If appropriate, patients commenced early targeted swallowing rehabilitation. Tube feeding was started when food or water intake was considered insufficient orally (10 days) or when loss of weight occurred. Patients were encouraged to continue on some oral intake as tolerated for as long as possible, and recommendations to modify diet and fluid texture were made where appropriate. Patients were also reviewed weekly in the medical oncology and radiation oncology clinics in accord with standard practice. Upon completion of treatment, all patients were followed up regularly in the outpatient clinic by medical and allied health staff. Patients were encouraged to maintain some oral intake or restart as soon as possible after recovery from mucositis and restoration of swallowing function. Once sufficient oral intake was established and weight had stabilized, a multidisciplinary decision was made for the removal of the gastrostomy tube and this procedure was done on an outpatient basis. A generalized linear interactive modeling package (GLIM4) was used to examine the data. A regression model was fitted to the data to assess the significance of explanatory variables. The binary event for the dependent variable in the general linear model was defined as (1) prolongation of hospital stay of any duration and (2) prolongation of hospital stay of 7 or more days. Routine admissions (such as for overnight post-cisplatin intravenous hydration) were not included. The independent factors included age, sex, death within 30 days, T classification, N classification, M classification, site, chemotherapy regimen, gastrostomy placement, and presentation cohort. Chi-square tests were used to compare proportions for discrete variables, and to compare differences for continuous variables between groups, t tests were used.
RESULTS In all, 165 patients were treated with curative intent concurrent chemoradiation for head and neck cancer at the Royal Brisbane and Women’s Hospital in the years 2005 and 2007. Of these, 77 patients were treated before and 88 after implementation of the head and neck guidelines. Table 1 summarizes the demographic and clinical characteristics for those patients. There were 139 men and 26 women, with median age of 58 years (range, 21 to 93 years). There was a significantly higher percentage HEAD & NECK—DOI 10.1002/HED
MARCH 2013
437
FIGURE 1. The Royal Brisbane and Women’s Hospital Nutritional and Swallowing Guidelines for patients with head and neck cancer. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
HUGHES ET AL.
438
HEAD & NECK—DOI 10.1002/HED
MARCH 2013
PROPHYLACTIC
GASTROSTOMY FOR CHEMORADIOTHERAPY
TABLE 1. Patient characteristics. Characteristic
Total
2005
2007
p value
All patients Median age [range] Sex Male Female T classification T1 T2 T3 T4 Tx Not classified/Other N classification N0 N1 N2 N3 Nx/Unknown Site Oral Oropharynx Hypopharynx Laryngeal Unknown primary Salivary Skin Other Chemotherapy High-dose Cisplatin Weekly Cisplatin Cisplatin þ 5FU Carboplatin þ 5FU Cisplatin þ Tira Cetuximab Other Treatment Chemo RT Surg þ Chemo RT PEG Prophylactic Emergency Nil
165 58 [21–93]
77 57 [21–85]
88 58 [25–93]
.22
139 26
66 (86%) 11 (14%)
73 (83%) 15 (17%)
.62
17 33 43 44 14 14
9 (12%) 16 (21%) 19 (25%) 21 (27%) 8 (10%) 4 (5%)
8 (9%) 17 (19%) 24 (27%) 23 (26%) 6 (7%) 10 (11%)
.72
34 21 75 15 20
11 (14%) 10 (13%) 37 (48%) 10 (13%) 9 (12%)
23 (26%) 11 (13%) 38 (43%) 5 (6%) 11 (13%)
.24
47 63 12 11 1 1 10 20
29 (38%) 27 (35%) 7 (9%) 5 (6%) 0 (0%) 0 (0%) 0 (0%) 9 (12%)
18 (20%) 36 (41%) 5 (6%) 6 (7%) 1 (1%) 1 (1%) 10 (11%) 11 (13%)
.03
84 40 15 2 5 9 10
45 (58%) 10 (13%) 13 (17%) 2 (3%) 5 (6%) 0 (0%) 2 (3%)
39 (44%) 30 (34%) 2 (2%) 0 (0%) 0 (0%) 9 (10%) 8 (9%)
