Malnutrition in patients with advanced head and neck cancer: Exploring the Global Leadership Initiative on Malnutrition (GLIM) criteria, energy balance and health-related quality of life.

Abstract

Background & aims: Head and neck cancer (HNC) involves several tumor locations, the most common of which are the oropharynx and oral cavity. Patients with HNC are at high risk of developing malnutrition. Together with treatment, the tumor location contributes to difficulties in eating and swallowing, which can lead to a negative energy balance and weight loss. This study aimed to examine malnutrition via the Global Leadership Initiative on Malnutrition (GLIM) criteria, explore the different combinations of the GLIM criteria, study changes in body energy content and evaluate health-related quality of life (HRQoL) in patients with locally advanced HNC.

Methods: Malnutrition was diagnosed via the GLIM criteria. Body weight, muscle mass, body fat, C-reactive protein (CRP) levels, energy intake, use of enteral feeding tubes or parenteral nutrition were assessed, and HRQoL scales from the European Organization for Research and Treatment of Cancer (EORTC), including the Quality of Life Questionnaire-Core 30 (QLQ-C30) and the Quality of Life Questionnaire-Head and Neck 35 (QLQ-HN35), and the M.D. Anderson Dysphagia Inventory (MDADI) were completed at baseline, 6 weeks and at 3, 6 and 12 months after the start of treatment. Body composition was measured via dual-energy X-ray absorptiometry, and body energy content was calculated.

Results: Eighty patients were included. The prevalence of malnutrition varied over time and peaked at the end of treatment at 71%, and at this time, the most common combination of the GLIM criteria was weight loss + reduced food intake + inflammation (31%), followed by weight loss + reduced muscle mass + reduced food intake + inflammation (20%). At the end of treatment patients were in a negative energy balance, and compared to baseline, body weight, body fat, and muscle mass had decreased with 6.0% (p<0.0001), 5.9% (p<0.0001), and 8.0% (p<0.0001) respectively. At the 3-month follow-up, the reduction in muscle mass had ceased, despite a negative energy balance, and patients started to regain muscle mass. At 12 months body weight had decreased with 7.4% (p<0.0001), body fat with 18.9% (p<0.0001), and muscle mass with 2.4% (p<0.0001) compared to baseline. Patients with malnutrition reported significantly worse HRQoL on a majority of the 16 quality of life scales at all time points, except at the end of treatment, when no significant differences were found between malnourished and nonmalnourished patients.

Conclusions: Patients with advanced HNC receiving combined treatment experience major nutritional problems, and malnutrition is common at the end of treatment. Inflammation-driven muscle depletion during treatment is challenging, but it seems possible to recover muscle mass after treatment. Patients with malnutrition reported worse HRQoL at all time points, except at the end of treatment, when all patients' quality of life was very negatively affected.