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Our unit is involved in the management of patients with head
and neck cancer within the regions of Hertfordshire and
North and East Bedfordshire, a catchment population of
approximately 1.5 million. The unit comprises
otolaryngologists and oral and maxillofacial surgeons with
an interest in head and neck oncology, a dedicated
oncologist, a Macmillan head and neck oncology dietitian,
speech and language therapists and specialist nurse
practitioners.
Outline of the problem:
Protein-energy malnutrition is the most common secondary
diagnosis in patients with cancer [1]. Weight loss is often
rapid and over a short period of time and has been
implicated as an important prognostic indicator of
malnutrition in many cancers of the western world [2-4].
This in itself is detrimental to outcome. Adverse clinical
outcomes associated with malnutrition include prolonged
hospital stay, depression and increased anxiety, post
operative complications such as wound dehiscence and
impaired wound healing, and increased morbidity and
mortality. One study found that weight loss over 10% in the
preceding six months to be a predictor of major
postoperative complications in head and neck cancer patients
[5]. Stratton et al (2003) show that the provision of
nutritional supplements to malnourished patients to correct
protein-energy deficiencies reduces complications such as
infections and wound breakdown by 70% and mortality by 40%
[6]. In addition, it has been shown that swallowing
dysfunction after curative chemoradiation in head and neck
cancers has a strong negative impact on health-related
quality of life [7,8]. Most of our patient group are
particularly vulnerable to these problems due to long-
standing poor diets that have been supplemented with chronic
alcohol and tobacco consumption; the site of the tumours
within the aerodigestive tract and the resulting anorexia,
dysphagia, odynophagia or trismus; the need to undergo
complex surgery and/or chemoradiotherapy of the
aerodigestive tract and their profound effects on swallowing
post-treatment. It was with this in mind that our group
aimed to provide the patients with a food that is of high
quality and nutrition and a pleasure to eat, thereby
increasing acceptability and compliance, especially in the
peri- and post-treatment phases of their management. It
would also have to be of a safe consistency and which would
not disrupt any recent surgery.
Key measures for improvement:
There is not sufficient evidence to determine the optimal
method of enteral feeding for patients with head and neck
cancer receiving radiotherapy and/or chemoradiotherapy. For
many patients with head and neck cancer, oral nutrition will
not provide adequate nourishment during treatment [9]. The
bulk of enteral nourishment is therefore delivered via
nasogastric or gastrostomy tubes. Despite this, it has been
the experience of our group that most patients are keen to
resume oral feeding as soon as possible. A normal diet is
oftentimes not immediately, if ever, possible. Nutrition is
therefore supplemented with protein-energy drinks, which,
though providing the recommended caloric intake, are not
popular with our patients. It was the view of many patients
asked that the availability of food that could effectively
do the job of the protein-calorie drinks, but which was also
tasty and familiar would be an improvement on their
immediate quality of life.
Strategy for change:
The solution to the problem seemed to be ice cream. The ice
cream already available in the hospital provides only 50
kcal and less than 1 g of protein and was not found to be
palatable (patients reporting a synthetic after taste) or of
a texture that was safe for initial swallow. The coldness of
the soft ice cream was described as soothing to both post-
operative and chemo-radiotherapy patients alike. Patients
seemed to tolerate it well and enjoyed it once oral feeding
was commenced. The Macmillan head and neck oncology
dietitian (K-TM) suggested the introduction softer ice
cream, and following funding from charitable donations, an
ice cream machine was purchased for approximately £4400
(Malibu Corporation Ltd.) and installed on the ward. Head
and neck patients now receive regular servings daily, and
ice cream is available on request 24 hours a day. Each 100 g
of ice cream contains 162 kcal and 4.2 g or protein. Serving
sizes are approximately 200 g. The ice cream mix is pre-made
and comes in 1 litre packs. Twelve packs provide for seventy
200 g servings and each serving costs approximately £0.22,
including the cup and tongue depressor it is served with.
Effects of change:
Feedback, both verbally and from an ongoing patient
satisfaction survey has told us that the introduction of the
ice cream has been popular. It is a welcome addition to
their daily diet, many regarding it as a treat. They now
receive a nutritionally balanced dietary supplement that is
safe for them to swallow and additionally provides pleasure.
We also feel that it has helped to boost patient morale,
especially in the early post-operative period. Many look
forward to their daily helpings and compliance with early
oral feeding regimes has increased. Patients are more likely
to finish their helpings of ice cream than nutritionally
equivalent protein-energy drinks. Anecdotally, nursing staff
report that patients seem overall happier when offered the
ice cream during their meal times, many often opting for
second helpings. We have now started offering the ice cream
to all patients on our ward which include bowel or upper
gastrointestinal surgical as well as our non-oncological
patients who have other conditions causing odynophagia and
dysphagia such as tonsillitis, peritonsillar abscess and
patients undergoing uvulovelopharyngopalatoplasty, We are
currently undertaking a formal questionnaire study on the
effect on quality of life the introduction of the ice cream
has had on our cancer patients during their treatment
period.
Lessons learnt:
The inability of patients undergoing multi-modal treatment
for upper aerodigestive tract cancer to enjoy normal foods
and its effects of their quality of life is underestimated.
Providing a food to that is palatable, familiar and
acceptable as it is safe and nutritionally sound can
increase compliance with oral feeding regimes. Soft, energy
and protein dense ice cream seems to best fit these needs
and can provide an important addition to patients’ diet.
Other patient groups are also likely to benefit from this
practice, including the elderly and patients with
neurological dysphagia resulting from stroke.
References:
1.Harvey KB, Bothe A Jr, Blackburn GL. Nutritional
assessment and patient outcome during oncological therapy.
Cancer. 1979 May;43(5 Suppl):2065-9
2.Digant Gupta , Carolyn A Lammersfeld , Pankaj G Vashi ,
Jessica King, Sadie L Dahlk , James F Grutsch, et al.
Bioelectrical impedance phase angle as a prognostic
indicator in breast cancer. BMC Cancer 2008, 8:249
3.Gupta D, Lis CG, Dahlk SL, Vashi PG, Grutsch JF,
Lammersfeld CA. Bioelectrical impedance phase angle as a
prognostic indicator in advanced pancreatic cancer. Br J
Nutr 2004;92:957–62.
4.Gupta D, Lammersfeld CA, Burrows JL, Dahlk SL, Vashi PG,
Grutsch JF, et al. Bioelectrical impedance phase angle in
clinical practice: implications for prognosis in advanced
colorectal cancer. Am J Clin Nutr 2004;80:1634–8.
5.van Bokhorst-de van der Schueren MA, van Leeuwen PA,
Sauerwein HP, Kuik DJ, Snow GB, Quak JJ. Assessment of
malnutrition parameters in head and neck cancer and their
relation to postoperative complications. Head Neck
1997;19:419–25
6.Stratton RJ, Green CJ, Elia M. Disease Related
Malnutrition: an Evidence Based Approach to Treatment.
Oxford: CABI, 2003
7.Langendijk JA, Doornaert P, Verdonck-de Leeuw IM, Leemans
CR, Aaronson NK, Slotman BJ. Impact of late treatment-
related toxicity on quality of life among patients with head
and neck cancer treated with radiotherapy. J Clin Oncol.
2008 Aug 1;26(22):3770-6
8.Nugent B, Lewis S, O'Sullivan JM. Enteral feeding methods
for nutritional management in patients with head and neck
cancers being treated with radiotherapy and/or chemotherapy.
Cochrane Database Syst Rev. 2010 Mar 17;3:CD007904
9.van den Berg MG, Rasmussen-Conrad EL, van Nispen L, van
Binsbergen JJ, Merkx MA. A prospective study on malnutrition
and quality of life in patients with head and neck cancer.
Oral Oncol. 2008 Sep;44(9):830-7. Epub 2008 Feb 20
Competing interests:
None declared
Competing interests:
No competing interests
25 August 2010
Aaron Trinidade
Specialist Registrar in Otolaryngology
Katrina-Teresa Martinelli, Zenon Andreou and Prasad Kothari.
Soft, fortified ice-cream for head and neck cancer patients: a useful first step in nutritional and swallowing difficulties associated with multi-modal management.
Our unit is involved in the management of patients with head
and neck cancer within the regions of Hertfordshire and
North and East Bedfordshire, a catchment population of
approximately 1.5 million. The unit comprises
otolaryngologists and oral and maxillofacial surgeons with
an interest in head and neck oncology, a dedicated
oncologist, a Macmillan head and neck oncology dietitian,
speech and language therapists and specialist nurse
practitioners.
Outline of the problem:
Protein-energy malnutrition is the most common secondary
diagnosis in patients with cancer [1]. Weight loss is often
rapid and over a short period of time and has been
implicated as an important prognostic indicator of
malnutrition in many cancers of the western world [2-4].
This in itself is detrimental to outcome. Adverse clinical
outcomes associated with malnutrition include prolonged
hospital stay, depression and increased anxiety, post
operative complications such as wound dehiscence and
impaired wound healing, and increased morbidity and
mortality. One study found that weight loss over 10% in the
preceding six months to be a predictor of major
postoperative complications in head and neck cancer patients
[5]. Stratton et al (2003) show that the provision of
nutritional supplements to malnourished patients to correct
protein-energy deficiencies reduces complications such as
infections and wound breakdown by 70% and mortality by 40%
[6]. In addition, it has been shown that swallowing
dysfunction after curative chemoradiation in head and neck
cancers has a strong negative impact on health-related
quality of life [7,8]. Most of our patient group are
particularly vulnerable to these problems due to long-
standing poor diets that have been supplemented with chronic
alcohol and tobacco consumption; the site of the tumours
within the aerodigestive tract and the resulting anorexia,
dysphagia, odynophagia or trismus; the need to undergo
complex surgery and/or chemoradiotherapy of the
aerodigestive tract and their profound effects on swallowing
post-treatment. It was with this in mind that our group
aimed to provide the patients with a food that is of high
quality and nutrition and a pleasure to eat, thereby
increasing acceptability and compliance, especially in the
peri- and post-treatment phases of their management. It
would also have to be of a safe consistency and which would
not disrupt any recent surgery.
Key measures for improvement:
There is not sufficient evidence to determine the optimal
method of enteral feeding for patients with head and neck
cancer receiving radiotherapy and/or chemoradiotherapy. For
many patients with head and neck cancer, oral nutrition will
not provide adequate nourishment during treatment [9]. The
bulk of enteral nourishment is therefore delivered via
nasogastric or gastrostomy tubes. Despite this, it has been
the experience of our group that most patients are keen to
resume oral feeding as soon as possible. A normal diet is
oftentimes not immediately, if ever, possible. Nutrition is
therefore supplemented with protein-energy drinks, which,
though providing the recommended caloric intake, are not
popular with our patients. It was the view of many patients
asked that the availability of food that could effectively
do the job of the protein-calorie drinks, but which was also
tasty and familiar would be an improvement on their
immediate quality of life.
Strategy for change:
The solution to the problem seemed to be ice cream. The ice
cream already available in the hospital provides only 50
kcal and less than 1 g of protein and was not found to be
palatable (patients reporting a synthetic after taste) or of
a texture that was safe for initial swallow. The coldness of
the soft ice cream was described as soothing to both post-
operative and chemo-radiotherapy patients alike. Patients
seemed to tolerate it well and enjoyed it once oral feeding
was commenced. The Macmillan head and neck oncology
dietitian (K-TM) suggested the introduction softer ice
cream, and following funding from charitable donations, an
ice cream machine was purchased for approximately £4400
(Malibu Corporation Ltd.) and installed on the ward. Head
and neck patients now receive regular servings daily, and
ice cream is available on request 24 hours a day. Each 100 g
of ice cream contains 162 kcal and 4.2 g or protein. Serving
sizes are approximately 200 g. The ice cream mix is pre-made
and comes in 1 litre packs. Twelve packs provide for seventy
200 g servings and each serving costs approximately £0.22,
including the cup and tongue depressor it is served with.
Effects of change:
Feedback, both verbally and from an ongoing patient
satisfaction survey has told us that the introduction of the
ice cream has been popular. It is a welcome addition to
their daily diet, many regarding it as a treat. They now
receive a nutritionally balanced dietary supplement that is
safe for them to swallow and additionally provides pleasure.
We also feel that it has helped to boost patient morale,
especially in the early post-operative period. Many look
forward to their daily helpings and compliance with early
oral feeding regimes has increased. Patients are more likely
to finish their helpings of ice cream than nutritionally
equivalent protein-energy drinks. Anecdotally, nursing staff
report that patients seem overall happier when offered the
ice cream during their meal times, many often opting for
second helpings. We have now started offering the ice cream
to all patients on our ward which include bowel or upper
gastrointestinal surgical as well as our non-oncological
patients who have other conditions causing odynophagia and
dysphagia such as tonsillitis, peritonsillar abscess and
patients undergoing uvulovelopharyngopalatoplasty, We are
currently undertaking a formal questionnaire study on the
effect on quality of life the introduction of the ice cream
has had on our cancer patients during their treatment
period.
Lessons learnt:
The inability of patients undergoing multi-modal treatment
for upper aerodigestive tract cancer to enjoy normal foods
and its effects of their quality of life is underestimated.
Providing a food to that is palatable, familiar and
acceptable as it is safe and nutritionally sound can
increase compliance with oral feeding regimes. Soft, energy
and protein dense ice cream seems to best fit these needs
and can provide an important addition to patients’ diet.
Other patient groups are also likely to benefit from this
practice, including the elderly and patients with
neurological dysphagia resulting from stroke.
References:
1.Harvey KB, Bothe A Jr, Blackburn GL. Nutritional
assessment and patient outcome during oncological therapy.
Cancer. 1979 May;43(5 Suppl):2065-9
2.Digant Gupta , Carolyn A Lammersfeld , Pankaj G Vashi ,
Jessica King, Sadie L Dahlk , James F Grutsch, et al.
Bioelectrical impedance phase angle as a prognostic
indicator in breast cancer. BMC Cancer 2008, 8:249
3.Gupta D, Lis CG, Dahlk SL, Vashi PG, Grutsch JF,
Lammersfeld CA. Bioelectrical impedance phase angle as a
prognostic indicator in advanced pancreatic cancer. Br J
Nutr 2004;92:957–62.
4.Gupta D, Lammersfeld CA, Burrows JL, Dahlk SL, Vashi PG,
Grutsch JF, et al. Bioelectrical impedance phase angle in
clinical practice: implications for prognosis in advanced
colorectal cancer. Am J Clin Nutr 2004;80:1634–8.
5.van Bokhorst-de van der Schueren MA, van Leeuwen PA,
Sauerwein HP, Kuik DJ, Snow GB, Quak JJ. Assessment of
malnutrition parameters in head and neck cancer and their
relation to postoperative complications. Head Neck
1997;19:419–25
6.Stratton RJ, Green CJ, Elia M. Disease Related
Malnutrition: an Evidence Based Approach to Treatment.
Oxford: CABI, 2003
7.Langendijk JA, Doornaert P, Verdonck-de Leeuw IM, Leemans
CR, Aaronson NK, Slotman BJ. Impact of late treatment-
related toxicity on quality of life among patients with head
and neck cancer treated with radiotherapy. J Clin Oncol.
2008 Aug 1;26(22):3770-6
8.Nugent B, Lewis S, O'Sullivan JM. Enteral feeding methods
for nutritional management in patients with head and neck
cancers being treated with radiotherapy and/or chemotherapy.
Cochrane Database Syst Rev. 2010 Mar 17;3:CD007904
9.van den Berg MG, Rasmussen-Conrad EL, van Nispen L, van
Binsbergen JJ, Merkx MA. A prospective study on malnutrition
and quality of life in patients with head and neck cancer.
Oral Oncol. 2008 Sep;44(9):830-7. Epub 2008 Feb 20
Competing interests:
None declared
Competing interests: No competing interests