NEW YORK (Reuters Health) Sep 25 - Long-term swallowing outcomes in pharyngeal cancer patients are better maintained in those who continue to eat and practice swallowing exercises during their therapy, according to a new observational study.
"Referral to a speech pathologist for proactive swallowing therapy before radiation or chemoradiation should be considered best practice," Dr. Katherine A. Hutcheson from University of Texas MD Anderson Cancer Center in Houston told Reuters Health by email.
"The speech pathologist should follow the patient at regular intervals during treatment -- working toward 2 goals: 1) maintenance of oral intake, and 2) adherence to swallowing exercises," she said.
The benefits of continuing to eat and doing proactive swallowing exercises have been demonstrated in earlier studies, but the independent effects remain unclear, Dr. Hutcheson and her colleagues report in JAMA Otolaryngology -- Head & Neck Surgery online September 19.
The researchers tried to tease out these effects in a retrospective study of 497 patients with pharyngeal cancer. About three-quarters of patients (366/497, 74%) maintained full or partial oral intake throughout therapy, and 58% (286/497) of all patients reported adherence to swallowing exercise. Only 24% of patients met both goals with full oral intake throughout treatment and swallowing exercise adherence.
Of the patients who neither ate nor exercised, 65% returned to a regular diet after therapy, whereas 77% to 84% did among patients who maintained some eating and/or exercise goals; 92% of those meeting both goals returned to a regular diet.
More patients who ate pureed food or liquids during therapy without tube feeding returned to a regular diet, compared with patients who received tube feedings supplemented with partial oral intake (87% vs. 79%, p=0.19).
In adjusted models, both eating and exercise were independently associated with long-term diet levels. Patients who ate during therapy were twice as likely to eat a regular diet in long-term follow-up as were patients who did not eat. Those who exercised were four times more likely to return to a regular diet than patients who did not.
Eating and exercise were also associated with significantly shorter duration of gastrostomy dependence. The median duration of gastrostomy dependence was 222 days in patients who did neither, 151 to 157 days in patients who met some goals, and 111 days in patients who met both eat and exercise goals.
"Eat and exercise are now supported by findings of both randomized trials and observational studies, so many (institutional review boards) will not allow for a sham-controlled trial to validate the observations of this study in a clinical trial," Dr. Hutcheson said. "We are currently involved in a clinical trial of a behavioral therapy that targets patient adherence to preventive exercise during treatment. Adherence to swallowing exercise and oral intake during treatment has been prospectively collected in this trial. These data should provide prospective, albeit non-randomized subgroups in which to confirm these findings."
"Our motto is Use It or Lose It," Dr. Hutcheson said.�"Depending on the individual patient you can motivate them with a variety of supporting endpoints -- patients who do this have more normal muscles on MRI after treatment, or they tell you (per QOL questionnaires) that they swallow better even years after radiation, or they are less likely to have a feeding tube put in. I try to avoid information overload, so I focus on whatever endpoint seems to motivate the individual patient."
Dr. Hutcheson added, "Several major factors that likely impact a patient's ability to eat and exercise are: feeding tube practices of their provider and pain management.�Prophylactic gastrostomy tube placement is thought to discourage PO intake during treatment. Likewise, pain control, fatigue, and fear are likely key mediators of the patient's ability to keep eating and exercise.�Supportive care is critical to help patients keep the swallowing mechanism active during treatment."
Dr. Heather Starmer of Johns Hopkins Medical Institutions in Baltimore, who was not involved in the study, told Reuters Health, "Swallowing difficulties that emerge following radiation due to fibrosis and muscular atrophy are essentially non-responsive to therapeutic intervention.�Hence the importance of aggressive, proactive approaches."
"In my practice," she said in an email, "I stress to my patients that there is good evidence that both eating and exercise can help to maintain safe and efficient eating in the long term.�This data supports how beneficial both of these activities are together, but also reinforces that if one is not possible for some reason, there is still some protective benefit in completing the other."
Dr. Vinidh Paleri from Newcastle upon Tyne Hospitals NHS Trust, UK, has also looked at nutritional support for pharyngeal cancer patients.
"It is commonly believed that patients cannot be nutritionally supported through chemoradiotherapy without a gastrostomy," he told Reuters Health by email. "However, published data suggests that physicians can be reassured that patients can be nutritionally supplemented by nasogastric feeding alone during chemoradiation and do not necessarily need a pre-treatment gastrostomy.
SOURCE: http://bit.ly/14GgDUK
JAMA Otolaryngol Head Neck Surg 2013.
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