‘Time is of the essence’:

Proactive vs Reactive Tube feeding and swallowing outcomes with Head and Neck Cancer Patients

Rachelle Robinson

(Prince of Wales Hospital)

Anne Spencer

(Liverpool Hospital) On behalf of NSW H&N EBP Group

EBP Showcase Dec 2014

New EBP Group in the Network

H&N Speech Pathology EBP Group Newly formed EBP group in 2014 that is part of NSW Speech Pathology EBP Network 2 EBP Leaders and 1 Academic Link from Sydney Uni & 18 speech pathologists as members 12 sites in NSW critiqued papers (8 sites in Sydney; Also in Tweed Heads, Coffs Harbour, Wollongong, Newcastle) Conducted over 7 Teleconference meetings in 2014 organised through Telstra Funding of these TC meetings rotated between members EBP Showcase Dec 2014

In head and neck cancer patients having chemo-radiation therapy, does prophylactic vs reactive tube feeding result in improved functional oral intake?

EBP Showcase Dec 2014

What does a typical H&N patient look like (on the inside) who speech pathology would manage?

EBP Showcase Dec 2014

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Barriers to Oral Intake: Needs Multi-Disciplinary Management

Odynophagia Dysphagia Poor appetite / nausea Xerostomia/ saliva changes Impaired/ altered taste

Impaired dentition Trismus Fatigue EBP Showcase Dec 2014

Timing of feeding tube placement is challenged Traditionally mainly Reactive Feeding Tubes

Previous belief re prophylactic PEGs: Stop swallowing/NBM “Learned non use of swallowing” & the patients end up with long term dysphagia and worse swallowing outcomes.

When reactive NGTs are used: Remember that tube in area of radiation therapy fields and impacts on swallow/patient comfort EBP Showcase Dec 2014

Do prophylactic feeding tubes (vs reactive) have a positive or negative impact on swallowing/oral intake outcomes?

Group identified and read 27 papers. 10 suitable to critique & include in CAT .

EBP Showcase Dec 2014

Clinical Bottom Line

NO conclusive evidence of improved functional oral intake in the short or long term with use of a prophylactic feeding tube placement compared to reactive feeding tube.

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Weaknesses in Methodology

Eligible studies for this review were wrought with methodological weaknesses, such as: Group selection bias

(i.e. prophylactic tubes placed for patients with more severe swallowing problems at baseline)

Lack of descriptive criteria for patient selection and timing of reactive feeding tubes Inconsistent reporting of dysphagia intervention and speech pathology involvement Use of very generalised or ‘crude’ measures of dysphagia and oral intake EBP Showcase Dec 2014

Clinical Bottom Line (ctd)

There is no reported deterioration in functional oral intake for patients who continued oral intake and/or continue swallowing exercises, while feeding tubes were insitu. Placement of a prophylactic or reactive tube does not negatively impact functional oral intake. Instead the severity of dysphagia at baseline, tumour staging, field of RTx and other factors determine swallow EBP Showcase Dec 2014

What does this mean for our clinical practice??

We cannot say that putting in prophylactic feeding tubes improves functional oral intake in short or longer term EBP Showcase Dec 2014

What does this mean for our clinical practice???

Patients with prophylactic feeding tubes must continue to eat and drink throughout their treatment And/Or a range of exercises implemented pro-actively to prevent any further dysphagia EBP Showcase Dec 2014

Implications for Service Delivery

• Being mindful that pts with prophylactic feeding tubes, need to be seen during and after their RT +/- CT • Impacts of service delivery in metropolitan, rural and remote hospitals.

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Where to from here?

We completed a review of our newly established EBP Group using Survey Monkey at end of 2014 meetings Key Findings: Meeting: Day & time, (70%) duration (100%) and frequency (90%) suited the majority EBP Showcase Dec 2014

Key Findings from survey (ctd)

New styles of: Service delivery method for meeting (teleconference, 100%) Information dissemination (Wiki, 90%) were liked by the majority Some small teething issues (cost of teleconference issue for 1 member and issues with Wiki access for 2 members) >75% of members saw Academic Link’s role in the group included completion of CATs, CAPs and in the provision of education to members Only those going on leave were those planning not to be members in 2015 EBP Showcase Dec 2014

Clinical Question 2015

We are planning on revisiting our 2009 clinical question around: P rophylactic exercises in patients having radiation +/- chemotherapy?

There is more recent research emerged and also potentially looking at: Benefits of swallow therapy in the H&N CRT population?

Prophylactic versus reactive swallowing exercises Regimes and compliance rates Specific exercises of focus EBP Showcase Dec 2014

Thanks to our group members who were all ‘Active’ and Wonderful!!

Molly Barnhart Sophie Chandler Virginia Simms Katrina Blyth Emma Charters Danielle Stone Elise Hamilton Foster Jessica Cooke Katherine Kelly Armalie Muller Jessica Boehm Therese Dodds Dr Hans Bogaardt Amanda Bailey Asta Fung Jenna Binstead Elizabeth Walker EBP Showcase Dec 2014

References of papers included in CAT

Sheth, C. H, Sharp, S., & Walters, E. R. (2013) Enteral feeding in H&N cancer pts at a UK cancer centre. Journal of Human Nutrition & Dietetics Morton, Crowder et al (2009) . Elective gastrostomy, nutritional status and QOL in advanced H&N Ca pts receiving CRT. ANZ J Surg Langmore, Krisciunas et al (2011) Does PEG use cause dysphagia in H&N Cancer? Dysphagia Ames, Karnell et al (2011) Outcomes after the use of gastrostomy tubes in patients whose H&N cancer was managed with RT. Head & Neck Corry, Poon et al (2009). Prospective study of PEG tubes vs. NGT for enteral feeing in patients with H&N Cancer undergoing (C)RT. Head & Neck Silander, Nyman et al. (2012) Impact of PEG on malnutrition and QOL in patients with H&N cancer – a randomised study. Head & Neck Oozer, Corsar et al. (2011) The impact of enteral feeding route on patient-reported long term swallowing outcome after CRT for H&N cancer. Oral Oncology Williams & Teo et al (2012) Enteral feeding outcomes after CRT for oropharyngeal cancer: a role for a prophylactic gastrostomy. Oral oncology Prestwich & Teo et al. (2014). Long-term swallow function after CRT for oropharyngeal cancer: the influence of prophylactic gastrostomy or reactive nasogastric tube. Clinical oncology Chen et al (2009). Evaluating the role of prophylactic gastrostomy tube placement prior to definitive CRT for H&N Cancer. Head & Neck EBP Showcase Dec 2014