Choosing Optimal Feeding Method in Head–Neck Cancer Patients Receiving Radiation: Percutaneous Endoscopic Gastrostomy Versus Nasogastric Tube—Is It Pertinent?

Abstract

The current standard of care for locally-advanced head–neck cancer is multidisciplinary, using bimodality or trimodality therapy as appropriate. These patients are frequently malnourished either due to disease or due to treatment related toxicities. Both chemotherapy and radiotherapy are associated with acute and late toxicities which in turn exacerbate malnutrition in these patients. Malnutrition is found to be associated with poor survival outcomes. To maintain nutrition in such patients, enteral feeding can be done using either percutaneous endoscopic gastrostomy tube (PEG) or a nasogastric tube (NGT). Both PEG and NGT have been found effective in adequate maintenance of weight; however, both have their own set of advantages and disadvantages. Nutritional counselling forms an integral part of weight management during treatment and oral feeding should be encouraged in all unless contra-indicated.

Introduction

About 800,000 head–neck squamous-cell carcinomas (HNSCC) are diagnosed worldwide currently, ¹ majority of which are locally advanced at presentation. ² The treatment of head–neck cancers depends on stage and comprises of either surgery or radiation in early-stage cancers, or various combinations of these modalities with or without systemic therapy (chemotherapy and/or target agents) in advanced stages. However, both chemotherapy and radiotherapy are associated with acute and late toxicities. The frequently encountered common acute side effects like mucositis, pain, dermatitis, xerostomia, loss of taste, weight loss, nausea, and dysphagia in turn lead to malnutrition in patients.

A total of 10% or more weight loss in the preceding 6 months may lead to problems like increased risk of infection, delayed wound healing, increased risk of post-operative complications, reduced response to chemotherapy and radiation, and poor quality of life. Significant weight loss during and after chemo has been identified as an independent predictor of poor outcomes in locally advanced HNSCC. ³ A prospective study by Brooks et al. in 1985 had showed a statistically significant difference between 2-year survival rate of undernourished patients and adequately nourished patients (7.5% vs. 57.5%).

Role of Nutritional Screening

Screening Tools

Various screening tools and questionnaires have been validated for use in cancer patients. The Subjective Global Assessment (SGA) tool assess nutritional status based on history and examination in patients. ⁵ The Patient generated Subjective Global Assessment tool has been adapted from SGA and is patient generated. Apart from these, other tools like The Malnutrition Screening tool are also available. ⁵

Nutritional Monitoring

It is advisable that for patients receiving treatment on outpatient basis, weight should be monitored at each visit. Weight loss of >/ = 2 kg in a span of 2 weeks should be reported to dietician. ⁵ However, for screening inpatients, weight should be recorded weekly.

Nutritional Assessment

Nutritional assessment should be done prior to starting treatment and at regular intervals during treatment. Assessment should be done by clinical examination, reviewing dietary charts, calculation of energy, protein, fluids requirements, monitoring weight, body mass index, mid-arm circumference, triceps skinfold thickness, monitoring biochemical parameters like albumin, serum electrolytes, C-reactive protein, and others.

Optimal Choice of Feeding Tube

Around 50%–70% of patients treated with radiotherapy or chemoradiotherapy have severely impaired swallowing and require an enteral feeding tube (FT) either during or immediately after treatment. This may be done with either PEG or a NGT.^{6, 7}

NGTs are made of polyvinyl chloride, polyurethane, or silicone and are available in numerous sizes. For feeding purpose, usually the smaller, more flexible NGTs (3.5–12 French) are preferred. ⁸ NGTs are inserted in either outpatient basis or at bedside by physicians or nursing staff. However, when indicated in certain cases, NGTs need to be placed directly under endoscopic or fluoroscopic guidance.

PEG insertion is a method of percutaneously placing a tube into the stomach under general anesthesia, aided by endoscopy. Various techniques of insertion include the pull (Ponsky), push (Sachs-Vine), introducer (Russell), and Versa (T-fastener) methods; pull method is the most commonly used. Gastroscope is inserted into stomach and after a gentle insufflation of air, the most transluminant point of indentation on the anterior abdominal wall is marked. After sterilizing skin of anterior abdominal wall, skin is incised under local anesthesia and a trocar with a needle is pushed through into the stomach under endoscopic visualization. A thread or a guide wire is inserted through the trocar, thread is snared, and endoscope is withdrawn with the snare holding the thread. PEG tube of appropriate size is connected to the thread and the thread is pulled from the skin incision pulling the tube into the patient’s mouth through the esophagus. Internal bolster is used to retain tube in stomach ⁹ and external bolster keeps it loosely attached to skin. In cases where endoscopic negotiation cannot be done, percutaneous radiologic gastrostomy can be done which uses fluoroscopic guidance. Both PEG and PRG are reported as safe methods in literature. ¹⁰

Although PEG insertion was popular and widely practiced in the late 1980s, NGT re-emerged as an appealing alternative given the morbidities and risk of long-term tube dependence associated with PEG. ¹¹

Advantages and Disadvantages of PEG and NGT

Potential advantages of NGT are easier placement, lesser cost, minimal chances of major complications, lower chances of late dysphagia, shorter duration of tube dependence, and lesser requirement of pharyngo-esophageal dilation. PEG, on the other hand, is more aesthetic, has lower chances of dislodgements, causes less discomfort, results in better weight preservation, and better quality of life in patients. ⁸

Tube-related Morbidity

Both PEG and NGTs have their own set of complications. Minor complications such as tube dislodgement and clogging requiring replacement of tubes are frequently encountered with NGTs. Risks of major complications like aspiration pneumonia, perforation, and bleeding are minimal; however, these cannot be ruled out. Corry et al. ¹² in their prospective study had reported significantly higher dislodgements (62% vs. 19%) of NGT as compared to PEG. Though NGT can be inserted most often in the outpatient clinics but inpatients undergoing radiotherapy, mucositis often makes the procedure uncomfortable and painful.

Tube blockage or dislodgement, tube leakage, minimal bleeding, ileus, or superficial infections are the usually encountered minor complications following PEG insertion. ¹³ PEG tubes can also cause significant morbidity like bowel perforation, gastrointestinal hemorrhage, fistula, abscess, sepsis, and even death; however, such complications are rare. A systematic review and meta-analysis of around 2,000 head and neck cancer patients has reported fatality rates of 2.2% and 7.4% major complication rates following PEG. ¹³

Cost Implication

While NGT can be inserted on outpatient basis by physician or nursing staff, PEG insertion usually requires hospitalization for placement as well as monitoring. So, insertion of PEG indirectly increases the expenditure. Corry et al. in their prospective study reported the overall direct cost of PEG placement as around 8–10 times more as compared to that of NGT. ¹² However, if NGT insertion is done under endoscopic guidance and PEG insertion done on outpatient basis, the difference in cost narrows down. Also, though the cost of PEG is higher as compared to NGT, repeated dislodgement of NGT should also be taken into consideration. ⁸

Tube Dependence and Dysphagia

It has been seen in a study from Cleveland Clinic that patients with PEG have significantly more grade 2 dysphagia at 3 months and at 6 months compared to NGT patients. The median tube duration, too, was higher for PEG patients (28 weeks vs. 8 weeks, p < .001). Patients with PEG had to undergo pharyngo-esophageal dilatation more frequently in comparison to the NGT group. These findings were consistent with all age groups, stage, tumor site or tracheostomy placement. ¹⁴ Another prospective study corroborated these findings showing that PEG patients had a significantly prolonged tube dependence, and more grade 3 dysphagia at 6 months post-CRT. ¹²

Impact on Quality of Life

As survival continues to improve with recent advances in treatment, maintaining a good quality of life (QOL) has become an increasingly important. Several studies have shown significant negative impact of FT on QOL.^15–19 It is seen that PEG tubes are associated with more tube-related pain (p < .001), while NGTs are more frequently associated with an altered body image (p = .03). ¹² No differences have been observed regarding difficulty in learning how to use the tube, overall physical condition or overall QOL. Till 1-to-2-month post-radiation, no difference in tube-related pain has been seen between PEG and NGT. However, patients with NGT have been seen to experience more tube-related inconvenience, uncomfortable feeds, greater impact on body image, and family life. ¹²

Conclusion

In head and neck cancer patients undergoing radiation therapy, both NGT and PEG feeding have been found to be effective in achieving higher protein and energy intakes and better weight maintenance compared to oral intake alone. The decision of choice of FT should be taken by the treating physician after considering all pertinent factors. However, oral feeding and dietary counselling must be encouraged in all patients unless contraindicated.