Received: 4 May 2017

| Accepted: 22 May 2017

DOI: 10.1002/hed.24866

PRACTICE GUIDELINES

AHNS Series – Do you know your guidelines?

Assessment and management of malnutrition in patients with
head and neck cancer: A review of the NCCN Clinical Practice
Guidelines In Oncology (NCCN Guidelines®)
Amarbir Gill, MD1 | Babak B. Givi, MD2 | Michael G. Moore, MD1

1
University of California at Davis,
Department of Otolaryngology - Head and
Neck Surgery, Sacramento, California
2
Department of Otolaryngology - Head
and Neck Surgery, New York University
Langone Medical Center, New York,
New York
Correspondence
Michael G. Moore, Department of
Otolaryngology - Head and Neck
Surgery, University of California at
Davis School of Medicine, 2521
Stockton Boulevard, Suite 7200,
Sacramento, CA 95817.
Email: mgemoore@ucdavis.edu
Abstract
This article is a part of the “Do you know your guidelines” series by the Education
Committee of the American Head and Neck Society. The aim is to summarize the
core principles outlined by the NCCN Clinical Practice Guidelines In Oncology
(NCCN Guidelines®) on management of malnutrition in patients with head and neck
cancer. We outline the current recommendations from the National Comprehensive
Cancer Network® (NCCN®) for the screening and management of malnutrition,
including indications for nutritional supplementation and placement of a nasogastric
or gastrostomy tube. We also include a brief review of the available literature on
additional screening tools, alternative guidelines, as well as an update on the emerg-
ing data surrounding the use of immune-enhancing nutrition.
KEYWORDS
guidelines, head and neck cancer, malnutrition, nutrition

1 | INTRODUCTION evaluation by a registered dietitian and speech language/swal-

The incidence of malnutrition within the head and neck can-
cer patient population has been reported to range as high as
35%-50%.1 This is usually multifactorial. Underlying causes
include dysphagia, odynophagia, trismus, decreased appetite,
loss or alteration of taste, depression, as well as poor dietary
habits and social support. Such impairment can precede, coin-
cide with, or follow the development and treatment of cancer.
Moreover, malnutrition, at least transiently, is usually wors-
ened by any combination of definitive cancer therapies.
The impact of this malnutrition can be profound. Studies
have demonstrated that malnutrition can negatively impact
quality of life (QOL)2 and that it increases the incidence of
postoperative complications.3,4 Similarly, several studies have
even demonstrated an increase in short and long-term mortal-
ity in malnourished patients compared with nonmalnourished
patients, indicating that intervention in this population could
have an impact on survival.3,4
Consequently, the NCCN recommends that all patients
with head and neck cancer receive nutrition and swallowing
lowing therapist, respectively, as well as any indicated inter-
ventions (see Figure 1).5 Nevertheless, these statements and
recommendations often provide limited practical guidance for
the head and neck oncology team. Thus, much of the nutri-
tional assessment in this patient population is left to the discre-
tion of the treating physicians, who may or may not be
familiar with management of malnutrition. Thus, a standar-
dized algorithm for screening malnourished patients and pro-
viding intervention may be useful.
2 | ASSESSMENT AND SCREENING
FOR MALNUTRITION
2.1 | What are the current tools
recommended by the NCCN to assess for
clinically significant malnutrition?
Several studies have shown weight loss (specifically, >10% of
body weight lost in the last 6 months or 5% weight loss over

Head & Neck. 2017;1–7. wileyonlinelibrary.com/journal/hed V

C 2017 Wiley Periodicals, Inc. | 1
2 | GILL ET AL.

FIGURE 1 NCCN nutrition recommendations (NCCN nutrition recommendations.

(Reproduced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2017.
®
V
C 2017 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines and illustrations herein may not be reproduced in any

form for any purpose without the express written permission of NCCN. To view the most recent and complete version of the NCCN Guidelines, go online
to NCCN.org. The NCCN Guidelines are a work in progress that may be refined as often as new significant data becomes available).5
Disclaimer: NCCN makes no warranties of any kind whatsoever regarding their content, use or application and disclaims any responsibility for their appli-
cation or use in any way.

the past month [the criteria recommended for malnutrition
screening by the NCCN]) to be the most useful and predictive
tool in identifying patients who may benefit from nutritional
supplementation.5,6 Specifically, van Bokhorst-de van der
Schueren et al7 prospectively examined malnutrition and post-
operative complications in 64 patients with T2-T4 head and
neck squamous cell carcinoma of the larynx, oral cavity, oro-
pharynx, and hypopharynx in the Netherlands. The group
prognosticated different measurements of malnutrition in rela-
tion to postoperative complications, including percent weight
loss, percent ideal body weight, nutritional index (a measure of
total lymphocyte count, albumin, and percent ideal body
weight), and serum albumin. In this study, no patient received
nutritional supplementation perioperatively and all patients
received enteral feeds postoperatively. The authors found no
association between malnutrition (as measured by the above
markers) and minor complications, although there was signifi-
cant association between malnutrition and major complications.
After logistic regression analysis, weight loss, as well as albu-
min and leukocytes, were the prognostic measures of
malnutrition that remained significantly associated with major
complications (P < .022). Once weight loss >10% was incor-
porated into the baseline statistical model, no other variable
measured by the study was predictive of major complications.
Thus, based on their findings, >10% weight loss in the last 6
months seems to be an acceptable means by which to screen
for clinically significant malnutrition.
2.2 | Additional tools to assess malnutrition
Outside of what is listed in the NCCN Guidelines, malnutri-
tion can also be evaluated using the Ottery Patient Generated
Subjective Global Assessment (PG-SGA).8 The PG-SGA
incorporates weight changes, specific symptoms (anorexia,
nausea, constipation, mucositis, and vomiting), and altera-
tions in food intake and function. Additionally, the survey
includes components of metabolic stress (sepsis, neutropenic
or tumor fever, and corticosteroids) and physical examination
findings (fat, muscle bulk, tone in the temporalis, deltoid
and quadriceps areas, low extremity edema, or ascites). The
GILL ET AL.
| 3

F I G U R E 2 The Patient-Generated SGA of Nutritional Status evaluates for weight changes, specific symptoms, and alterations in food intake and
function. This information can be used to aid in the assessment of malnutrition. Republished from Ottery, F. D. (1996). Definition of standardized nutri-
tional assessment and interventional pathways in oncology. Nutrition, 12(1 Suppl), S15–19, V C 1996, with permission from Elsevier.

survey tool then assigns patients into 1 of 3 different classes
based on their score; patients that fall into category C are
considered severely malnourished (see Figure 2).
Ravasco et al9 compared the following measures of mal-
nutrition: percent weight loss, body mass index (BMI), and
PG-SGA. In their investigation, the Youden Index was used
to compare the sensitivity and specificity of the PG-SGA,
BMI, and percentage weight loss in detecting malnutrition
based on their correlation with energy intake. The authors
demonstrated that energy intake did not correlate with BMI,
but it did correlate significantly with percentage of weight
lost as well as with PG-SGA. They noted that weight loss
was the best indicator of malnutrition. However, the authors
also demonstrated that the use of the PG-SGA combined
with weight loss helped increase the sensitivity and positive
predictive value of identifying malnourished patients by 9%
compared to the use of percent weight loss alone.
Gianotti et al6 similarly used the Youden Index to compare
various measures of malnourishment to determine those most
predictive of postoperative infection among >300 patients
4 |
with cancer. The authors compared weight loss, albumin, total
lymphocyte count, total iron binding capacity, and serum cho-
linesterase. After logistic regression analysis, weight loss >10%
was the only screening tool that was a significant prognosticator
of postoperative infection, whereas the remaining measures
demonstrated a nonsignificant improvement in predictive ability.
Of note, their study did not incorporate the use of the PG-SGA.
2.3 | Summary
The NCCN Guidelines recommend close nutritional monitor-
ing in patients who demonstrate significant weight loss (>10%
of body weight lost in the last 6 months or 5% weight loss
over the last month), or in patients who have difficulty swal-
lowing because of pain or tumor involvement before the initia-
tion of therapy.5 Additional tools are available to aid in the
assessment of malnutrition, however, further investigation is
needed to determine their added benefit over weight loss alone.
3 | WHAT ARE THE CURRENT
GUIDELINES FROM THE NCCN
REGARDING SUPPORTIVE CARE
AND PROPHYLACTIC FEEDING
TUBE PLACEMENT?5
As is well known by patients with head and neck cancer
and their treating physicians, there is tremendous overlap
between swallowing function and malnutrition. As a result, it
is recommended by the NCCN that: All patients with preex-
isting swallowing dysfunction, as well as those whose treat-
ment is likely to have a significant impact on swallowing
function be formally evaluated by a qualified speech-
language pathologist.5
Patients with identified abnormal function should be fol-
lowed longitudinally by a therapist with both subjective and
objective assessments, and should be provided therapy to
optimize function. This therapy should be ongoing until the
patient achieves an acceptable stable baseline after therapy.
The NCCN advocates against the prophylactic placement
of nasogastric or gastrostomy tubes in patients with no pretreat-
ment performance status impairment, significant pretreatment
weight loss, airway obstruction, or dysphagia.5 However, in
select high-risk patients, prophylactic feeding tube placement
should be considered. Table 1 summarizes the NCCN’s criteria
for recommending prophylactic feeding placement. Even in
individuals in whom a feeding tube is placed, it is recom-
mended that they continue to take nutrition orally if they are
safely able to do so.
The NCCN cites a review by Locher et al10 that examined
the literature on prophylactic versus reactive percutaneous gas-
trostomy (PEG) tubes in patients with head and neck cancer
receiving radiotherapy, chemotherapy, or chemoradiotherapy.
GILL ET AL.
T A BL E 1 The NCCN’s criteria for consideration of prophylactic
feeding tube placement prior to head and neck cancer therapy5
Prophylactic feeding tube placement should be considered for
patients demonstrating one or more of the following:
Severe weight loss (5% over 1 month or 10% over the past 6 months).
Ongoing dehydration or dysphagia, anorexia, or pain interfering
with the ability to eat and drink.
Medical comorbidities that could be exacerbated by dehydration,
lack of caloric intake, or the inability to take oral medications.
Severe aspiration or mild aspiration in the context of poor
underlying cardiopulmonary function.
Patients where long-term dysphagia is deemed likely based
on their baseline and the proposed treatment.
This table was developed with permission from the NCCN Clinical Practice
Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers
V.2.2017. VC 2017 National Comprehensive Cancer Network, Inc. All rights
reserved.
The authors state that about 40% of patients who undergo
radiotherapy will have oral side effects affecting nutrition.10,11
Commonly, the patients in the various studies analyzed by the
authors are not stratified based on preintervention malnourish-
ment. Rather, the patient populations are divided into PEG
tube before the aforementioned treatment versus PEG tube as
treatment progresses, either because of developing malnutri-
tion or progressive dysphagia.
Additional studies have shown that patients with prophy-
lactic PEG tubes do not require extra hospitalization compared
to those who have reactive tubes placed and have less weight
loss.10–14 Moreover, a randomized controlled trial (RCT) based
out of France examined QOL associated with prophylactic ver-
sus reactive PEG tubes among malnourished patients receiving
chemoradiotherapy. The authors demonstrated that QOL was
significantly higher at 6 months in those who received prophy-
lactic treatment, although no differences in mortality, locore-
gional control, or BMI were noted. Moreover, 70% of patients
who did not get prophylactic treatment eventually required
a PEG tube.10,15 A strong limitation of the literature relating
to prophylactic PEG tubes is the lack of standardization to a
malnourished-only population. In addition, studies do not exam-
ine the relationship between PEG tubes and surgical resection,
but rather focus on radiotherapy or chemoradiotherapy.
The literature documents both advantages and complica-
tions associated with prophylactic placement of PEG tubes.
One study described a higher rate of wound/surgical complica-
tions in patients with prophylactic versus reactive PEG
tubes.10,16 Additionally, patients who receive a prophylactic
PEG tube are commonly dependent upon its use for an average
of 4-9 months.10,17,18 Moreover, although some studies10,15,16
have demonstrated an improved QOL with prophylactic PEG
tubes, others have shown that prophylactic PEG tubes are
GILL ET AL.
associated with lower QOL scores when compared to no PEG
tube and retaining the ability to swallow.10,19,20 Another study
demonstrated a longer dependence on enteral feeds when
patients had PEG tubes compared with nasogastric feeding
tubes, as well as a greater degree of dysphagia and an
increased need for pharyngoesophageal dilation.10,21 The PEG
tubes may also be associated with atrophy and weakening of
muscles of swallowing due to nonuse. The longer that patients
are PEG tube-dependent and not swallowing, the harder it may
be to regain swallow function.10,22
Recently, Bossola23 also examined the literature on pro-
phylactic enteral feeding tube placement in patients with head
and neck cancer treated with definitive chemoradiation. Again,
their review revealed that applicable studies were not focused
on examining the relationship with surgical interventions. The
authors concluded that, compared to reactive feeding tube, a
prophylactic PEG tube “does not offer significant advantages
in terms of nutritional outcomes, interruptions of radiotherapy,
and survival.” Nevertheless, due to a limited number of RCTs,
no definitive conclusion could be drawn about the benefit of
prophylactic versus reactive feeding tube placement.
3.1 | Summary
The NCCN Guidelines advocate against the prophylactic
placement of nasogastric or gastrostomy tubes in patients
with a lack of pretreatment performance status impairment,
significant pretreatment weight loss, airway obstruction, or
dysphagia. However, in select, high-risk patients, prophylac-
tic feeding tube placement should be considered per the
NCCN.
4 | ADDITIONAL AVAILABLE
GUIDELINES
4.1 | American Society for Parenteral
and Enteral Nutrition
The American Society for Parenteral and Enteral Nutrition
(ASPEN) is a group of various healthcare professionals,
including physicians, nurses, pharmacists, and dietitians
working toward creating evidence-based guidelines in patient
care. In 2009, the organization published nutrition guidelines
for all patients with cancer.24
In their publication, ASPEN recommends that all patients
with cancer undergo screening for malnutrition in order to
determine who may benefit from formal nutrition evaluation;
this is the same position taken by the NCCN. ASPEN men-
tions that there are several validated means by which to
screen patients, including the PG-SGA, nutrition risk index,
and subjective global assessment; the authors state it “makes
sense to utilize these instruments in detecting malnutrition.”24
| 5
ASPEN guidelines cite strong evidence in arguing
against offering routine nutritional support therapy (NST) to
all patients undergoing major cancer surgeries, chemother-
apy, or radiation.24 Garg et al25 analyzed 10 small RCTs
(<50 patients per trial arm) comparing dietary counseling,
NST, and drug interventions in patients with cancer. Because
of the lack of adequate sample size in the trials and compara-
tive studies, the authors recognized significant limitations of
these studies and advocated for more research before making
a definitive conclusion. Nevertheless, the authors concluded
that megestrol, dietary counseling, and prophylactic enteral
tube feeding could potentially have a benefit in this patient
population.25
ASPEN also presents strong evidence in recommending
that moderately or severely malnourished patients with can-
cer be given 7-14 days of perioperative NST, but that bene-
fits should be weighed against possible risks. Again, this is
similar to the recommendation made by the NCCN. Per
ASPEN, malnourished patients who are undergoing cancer
surgeries may benefit from immune-enhancing nutrition. The
NCCN Guidelines do not comment upon the superiority (or
inferiority) of immune-enhancing nutrition to standard
enteral therapy.
4.2 | Immune-enhancing nutrition
Several prospective cohort studies have demonstrated the
superiority of immune-enhancing nutrition over standard
enteral nutrition.26,27 However, the use of immunotherapy is
neither endorsed nor discouraged by the NCCN Guidelines,
suggesting that the current level of evidence is inadequate to
draw definitive conclusions.
Riso et al26 compared a postoperative enteral diet supple-
mented with arginine (ie, immune-enhancing nutrition)
against an isocaloric, isonitrogenous standard enteral feed in
44 patients with head and neck cancer. The authors demon-
strated a statistically significant decrease in postoperative
wound and infection complications in the immune-enhancing
nutrition cohort. Length of stay in this patient population
was also significantly lower than in controls (P < .05).
Braga et al27 conducted an RCT with 200 patients com-
paring standard enteral diet to immune-enhancing nutrition
with arginine, omega 3, and RNA in patients with gastroin-
testinal cancer. Their intent-to-treat analysis showed a signif-
icant decrease in complications and postoperative length of
stay within the immune-enhancing nutrition cohort (P 5 .02
and P 5 .01, respectively).
Finally, Daly et al28 performed an RCT on 85 patients
undergoing surgery for gastrointestinal cancer; the authors
compared immune-enhancing nutrition with arginine, RNA,
and omega 3 against standard enteral therapy. No significant
differences between groups were found when all patients
6 |
were included in the analysis. However, when only success-
fully fed patients were analyzed, significantly fewer compli-
cations, as well as a shorter hospital stay were noted in the
immune-enhancing nutrition group.
Schilling et al29 performed an RCT with conflicting
results; 41 patients were randomly assigned to 1 of 3 groups:
(1) enteral formula supplemented with arginine and omega 3
(ie, immune-enhancing nutrition); (2) standard enteral for-
mula; and (3) hypocaloric intravenous feeds without amino
acids. There was no significant difference in postoperative
infections among the 3 groups. Nevertheless, the sample size
was likely too small to draw any useful conclusions.
4.3 | Summary
The NCCN neither endorses nor discourages the use of
immune-enhancing nutrition in patients with head and neck
cancer. Further research is needed to evaluate its potential
benefit over standard nutritional supplementation in these
individuals.
5 | CONCLUSION
Malnutrition and dysphagia are common in patients being
managed for head and neck cancer and can have a profound
impact on morbidity, mortality, and QOL. Patients should be
screened for significant malnutrition at their initial and subse-
quent appointments and appropriate interventions should be
made in those demonstrating moderate to severe malnutri-
tion. For high-risk patients undergoing a major surgical inter-
vention, preoperative dietary assessment as well as
perioperative nutritional supplementation may reduce postop-
erative complications and improve survival. Individuals
undergoing surgical and/or nonsurgical cancer treatment with
significant preexisting or acquired dysphagia should be
assessed for candidacy for prophylactic or reactive feeding
tube placement. Further study is needed to allow for a more
refined algorithm to guide clinicians in their assessment and
management of malnutrition in patients with head and neck
cancer.
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How to cite this article: Gill A, Givi BB, Moore MG.
AHNS Series – Do you know your guidelines?. Head
& Neck. 2017;00:000–000. https://doi.org/10.1002/hed.
24866