1
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 HN EBP Group

2
New EBP Group in the Network

• HN 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

3
In head and neck cancer patients having
chemo-radiation therapy, does prophylactic vs
reactive tube feeding result in improved
functional oral intake?
4
What does a typical HN patient look like (on
the inside) who speech pathology would manage?
5
Barriers to Oral Intake Needs
Multi-Disciplinary Management

• Odynophagia
• Dysphagia
• Poor appetite / nausea
• Xerostomia/ saliva changes
• Impaired/ altered taste
• Impaired dentition
• Trismus
• Fatigue

6
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

7
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.

8
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.

9
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

10
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

11
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

12
What does this mean for our clinical practice???

• And/Or a range of exercises implemented
  pro-actively to prevent any further dysphagia

• Patients with prophylactic feeding tubes must
  continue to eat and drink throughout their
  treatment

13
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.

14
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

15
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)
• gt75 of members saw Academic Links 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

16
Clinical Question 2015

• We are planning on revisiting our 2009 clinical
  question around- Prophylactic exercises in
  patients having radiation /- chemotherapy?
• There is more recent research emerged and also
  potentially looking at
• Benefits of swallow therapy in the HN CRT
  population?
• Prophylactic versus reactive swallowing
  exercises
• Regimes and compliance rates
• Specific exercises of focus

17
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

18
References of papers included in CAT

• Sheth, C. H, Sharp, S., Walters, E. R. (2013)
  Enteral feeding in HN 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 HN Ca pts receiving CRT. ANZ J Surg
• Langmore, Krisciunas et al (2011) Does PEG use
  cause dysphagia in HN Cancer? Dysphagia
• Ames, Karnell et al (2011) Outcomes after the use
  of gastrostomy tubes in patients whose HN 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 HN Cancer undergoing (C)RT. Head Neck
• Silander, Nyman et al. (2012) Impact of PEG on
  malnutrition and QOL in patients with HN 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 HN 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 HN Cancer. Head Neck