Nutrition after Head and Neck Cancer Diagnosis, with Maureen Gardner, MA, RDN, CSO, and Annette M. Goldberg, MS, MBA, RDN, LDN

February 28, 2018
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Treatment for head and neck cancer can often cause side effects that make it difficult to eat. In this podcast, dietitians Maureen Gardner and Annette Goldberg discuss several side effects that may be caused by head and neck cancer treatment and offer tips for managing these side effects and taking in enough nutrients, including information about feeding tubes.

Transcript: 

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ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the world’s leading professional organization for doctors that care for people with cancer.

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience and conclusions. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement.

Treatment for head and neck cancer can often cause side effects that make it difficult to eat. In this podcast, dietitians Maureen Gardner and Annette Goldberg discuss several side effects that may be caused by head and neck cancer treatment and offer tips for managing these side effects and taking in enough nutrients, including information about feeding tubes.

Maureen Gardner is a Clinical Oncology Nutritionist at Florida Cancer Specialists & Research Institute. Annette Goldberg is an Outpatient Dietitian at the Boston Medical Center Cancer Care Center.

ASCO would like to thank Ms. Gardner and Ms. Goldberg for discussing this topic.

Annette Goldberg: Hi, my name is Annette Goldberg and I'm an oncology dietitian at Boston Medical Center: a private, not-for-profit, 487-bed, Academic Medical Center located in Boston, Massachusetts. And I'd like to introduce my colleague, Maureen.

Maureen Gardner: Thank you, Annette. My name is Maureen Gardner and I'm also a registered dietitian. I'm based in Tampa, Florida, working in an outpatient oncology clinic at Florida Cancer Specialists, which is the largest independent medical oncology-hematology practice in the United States.

Annette Goldberg: Great. Maureen, why don't we get started with you providing us some background on head and neck cancers.

Maureen Gardner: Certainly. Our topic today is head and neck cancer. It's the term used to describe many different cancers including, generally speaking, the larynx, throat, lips, mouth, nose, salivary glands, and tonsils. The treatment for head and neck cancers has become increasingly complex, with potential treatment including surgery, chemotherapy and/or radiation therapy. Some patients have all 3 of these treatments, and some might have 1 or 2. These different treatments can bring on distinctive struggle for our patients as they try to maintain their nutrition intake.

Sometimes chemotherapy and radiation are given at the same time and that's called concurrent therapy. When patients have that to the head and neck, it can be particularly challenging. So eating becomes so difficult and even getting fluids in. Sometimes it's insufficient before treatment begins. And, of course, during and after treatment, we'll also see difficulties. So our challenge lies in maintaining good nutrition because, well, getting nutrition is essential. Patients require increased amount of calories and protein to maintain strength and achieve the best outcomes.

The members of the team that you might see when you have treatments for head and neck cancer would be a surgeon, medical oncologist, radiation oncologist, nutrition, which would be a registered dietitian, dentistry, and the speech language pathologist. And, of course, always instrumental is the social work team to help patients get through all these treatments.

Ideally, before treatment, patients might get a swallowing assessment to make sure that they have a baseline for how the patient is swallowing and then to help make recommendations. Sometimes a patient might need a little more help before treatment from other modality, such as feeding tubes, which we'll talk about later.

Annette, I was going to ask you what are some of the side effects—when patients have chemo and have radiation, what kind of side effects would you see patients experiencing as they go through this treatment process?

Annette Goldberg: Well, side effects can impact patients at different times during the treatment process as well. So we can review some of those side effects when they may occur and some ideas to help the patient through these side effects. And remember, for some patients, not all the recommendations work. So don't become frustrated. And so you need to experiment with suggestions until you're able to find some of these.

Now, let's talk a little bit about nausea and vomiting which can occur any time throughout chemotherapy. I think it's very important that a patient ensures they understand that you take your antiemetic, or anti-nausea medication, as prescribed. But with that, you can try small, frequent meals and snacking versus large meals at breakfast, lunch, and dinner. Limit exposure to smells from both food and from lotions and perfumes, etc. Consider eating cool, light foods with little odor. Try ginger candy or ginger root in warm water. Consider experimenting with some complementary therapy such as acupressure bracelets, acupuncture, massage, relaxation techniques, etc. Feel free to ask your cancer center if they might offer any of these complementary therapies.

Depending on the treatment plan, head and neck patients may find challenges with a few or all of the following side effects that involve the mouth and throat such as difficulty chewing, dysphagia, odynophagia, xerostomia, and dysgeusia. And as we go through those, I'll define them for you.

So, to start, chewing difficulty can start before surgery, when a part of normal dentition is compromised, or occur after surgery. Many patients can have dental problems or missing teeth before treatment, which limits what they can eat. So choose soft, moist, bland foods, sort of cool or at room temperature. You can always puree foods in a blender to make them easier to eat. Avoid foods that might irritate your mouth and throat such as acidic foods or irritating seasonings and spices. And if dental or bone pain begins during treatment, make sure you notify your care team.

Dysphagia usually occurs during weeks three to five, during radiation. There are many causes of dysphagia or difficulty swallowing. Work with your team to determine the cause. That will help identify the best strategy for relief. But in general, when you're eating, use good posture. Be mindful and take your time when chewing and swallowing. Choose moist foods that easily form a cohesive bolus in the mouth, and feel free to alter textures or use thickeners as needed.

Odynophagia, which is quite a mouthful, is really pain associated with swallowing. And this has many potential causes as well. So your care team will perform an oral exam and provide recommendations. If medication is prescribed, make sure you follow as directed. Practice good oral hygiene, chew soft-textured foods, determine the optimal temperature for food that is comfortable for you.

Xerostomia, or dry mouth, may result from chemotherapy, radiation, or any other medication. To help manage xerostomia, drink plenty of fluids and carry water with you. To increase saliva within your mouth, try tart foods, drinks, and candies. Suck on fruit popsicles. Try lemon sorbet. It's best to avoid alcohol-based mouthwashes and practice good oral hygiene. There are several over-the-counter products that may help with dry mouth such as Biotène and TheraBreath, to mention just a couple.

Dysgeusia, or taste alterations, can be a significant deterrent to nutritional intake. And depending on the medications, the taste alterations may vary. So, for metallic taste, choose foods with tart flavors such as lemon wedges, lemonade, citrus fruits, vinegar and pickled foods. You can also try and use plastic utensils to avoid having additional metallic taste in your mouth. For medicinal taste, add sweeteners or a bit of sugar to foods. Season foods with herbs, spices or other seasonings. Sometimes patients say that meat tastes strange. So to try and be able to eat meat with a little bit more enjoyment, marinate and cook in sweet juices, fruits or acidic dressings.

And again, it's important to maintain good oral health. One of the things that a patient can make at home that is a great oral cleanser is a combination of baking soda, salt, and water. And you can make this with 1 quart of water, 3/4 teaspoon of salt and a teaspoon of baking soda. This will help keep the mouth clean and improve taste. Maureen, what other challenges around oral health have you seen while patients are undergoing treatment?

Maureen Goldberg: Annette, all those things that you mentioned are super prevalent and patients often complain about it. But 2 other ones that we could add on to that list would be mucositis or candidiasis. And that would be some side effects that would also occur right around the last weeks of radiation; maybe weeks 5 through 7 we would see this. But it could occur anytime.

Mucositis is a long word for mouth sores, or a sore mouth, or an inflamed mouth, or an ulcered mouth. You might see that after chemo, red spots in the mouth, or even the tongue, we might see that. But the doctor and nurse team should be alerted if you see something like that so they can take a look and do an assessment and maybe order some medication for it. Even though the lemon and the flavored items that Annette mentioned for poor taste, we sometimes say to put that lemon paste or the tomato products on hold because that can really tear up a sore mouth. We might recommend serving foods cool or room temperature because hot foods would just be painful. And with that, I'm speaking of hot foods and spicy foods, so temperature and spicy. Maybe choose some foods that are really bland and avoid those spicy foods. You could try cottage cheese, or yogurt, or puddings, or things of that nature. Definitely avoid alcohol and alcohol-containing mouthwashes right now because that will just be a painful experience to have that in your mouth when it's sore.

Candidiasis is a fungal infection of the mucus membranes, and that can be treated most often with medication. We ask patients to look inside their mouth and throat—it might be a sore throat that it feels like. But have a doctor or a nurse or even the dietitian can take a look at first to see what's going on. Medication is super important to get going right away with that and we can fix the infection in the mouth.

Practicing that good oral hygiene is super important. Annette mentioned that mixture with the baking soda, the salt, and the warm water. That's really great to keep your mouth clean. And for food we recommend soft, soft foods, very moist foods, and avoiding a lot of hard-to-swallow and hard-to-chew foods at this time, dunk it in some coffee or tea or milk to kind of make it really soft.

The last thing I can think of right now of just the many side effects, but the top ones we're covering today, would be the thick oral secretions. And sometimes patients describe this as a ropey saliva or just really thick saliva that stays in the mouth. Definitely see it in the last weeks of radiation, maybe weeks 3 to 5. And managing these secretions are really, really difficult. The mucus can get in your throat and cause nausea and gagging, sometimes vomiting from coughing.

One thing we recommend as dietitians is try to sip liquids throughout the day, and that can help with thinning the secretions. Also swish and spit using club soda or carbonated water. And try using a humidifier at home to get that air moist. Again, practice good oral hygiene is always on the list. So get that baking soda and salt water rinse going. And speak to your doctor: there might be a medication that they could recommend to help get those secretions under control.

All these side effects can make eating by mouth, super, super challenging. And a feeding tube is sometimes necessary in getting nutrition when eating by mouth is not possible. You think about all those side effects we just talked about. It's sometimes not possible.

Annette Goldberg: Maureen, that's a really good point. And so the use of feeding tubes and feeding tube recommendations, they vary among doctors and institutions. So tell me a little bit about your experience with feeding tubes during treatment for head and neck cancers.

Maureen Gardner: Annette, you're right. The use of feeding tubes can benefit patients immensely. Often a patient will have a tube in their stomach that's placed before any treatment begins because the physician knows that that patient will have difficulty. They definitely can help with patients' outcomes and help reduce the unplanned hospital admissions for dehydration and or poor nutrition.

So if they're placed upon the physician’s preference to have the tube placed before, the patients still could eat. If they're allowed to eat and they're safe to eat, they still can eat. And they may have the tube that will start being used right when the therapy becomes difficult with all those side effects we mentioned. In fact, if they have a tube, we even make sure they're evaluated by the speech therapist and that they have swallowing exercises, exercises to help their mouth open, voice exercises. The speech therapist is uniquely qualified to take care of those needs for the patient and help take care of them after treatment’s finished. So it's really important that they maintain those muscles that are used in swallowing. And then after recovery has ended, patients can return back to eating.

So one more thing about the feeding tubes. It can give the patients fluid and help them get through the treatment. it just enters the body from outside of the abdomen, kind of right above the belly button, and the food goes from the tube directly into the stomach. So if your doctors decided to have your tube placed before surgery to support you, definitely ask to see a registered dietitian and 1 of us can help you get through. Because your calorie needs are so high, and this tube can help you get through the treatment.

One of my patients called it his lifeline, and I kind of agree with that because it really did help them get through the treatment.

Annette, what about patients that you've had with feeding tubes? What's your experience with them during treatment and after treatment? What questions do patients have about that?

Annette Goldberg: Maureen, I agree. I think that many times it becomes a lifeline because patients feel a lot of pressure to be eating. Sometimes their caregivers are giving them pressure to be eating, and they just cannot take their nutrition orally. So you take a lot of pressure off the patient when they can start to take the food through their feeding tube. And then they're just-- if they can eat safely, then they're just eating for pleasure.

Sometimes it's concerning for me when I hear patients mention to me that they don't want a feeding tube because they're afraid they're going to become dependent on the feeding tube. And that is rarely the case. The only time patients become dependent on the feeding tube is if something has happened in surgery and it's going to be a long-term need. But as you had mentioned, you use the feeding tube when the treatment is at its peak and you're having difficulty recovering. And after that's over, you start working with speech and language, and you do your exercises, and you're able to start taking more intake orally, and then we back off the feeding tube. So I think sometimes patients are a little worried that they're going to be dependent on this tube, but I rarely see patients dependent on the tube. Do you find the same thing?

Maureen Gardner: Yes, Annette, I do see that often, and I agree completely with what you said. Now, what about after treatment? What do you recommend after treatment for patients that have gotten through the treatment, and they're ready to move on with their lives and get back to normal eating?

Annette Goldberg: So many patients need to remember that when treatment is over, they still have some lasting effects from radiation and the chemotherapy. So when treatment ends, they still have sometimes 4 to 6 to 8 weeks before they're really starting to feel back to themselves.

So I provide some general recommendations. I remind them that their goal is to maintain their weight and hydration, make sure they're fueling their body properly. Continue to eat small, frequent meals if you can have that oral intake 6 to 8 times a day. Drink fluids in between those meals to stay hydrated. We've said this several times: maintain good oral health. Keep your mouth clean. Those baking soda and salt mouth rinses really help. Avoid mouthwashes with a lot of alcohol and use gentle toothpaste until the lining of your mouth has recovered. Continue to focus on soft, moist foods until you're feeling better. Make every bite and sip count by making sure that you are eating calorie-dense foods. Try the various nutritional supplements that are out there. There's lots of drinks that will help you get some calories without having to eat a lot of food. So try to experiment around and see if you can find one you like.

Another tip is to carry food with you at all times. So have snacks with you. Have soft snacks with you. Put them in your handbag. Put them in your car. Make sure that they're around so you can continue to nibble during the day. And, as always, communicate any concerns to your healthcare team. Patients and caregivers can always ask their healthcare team for reliable resources and references as they go forward such as Cancer.Net, cancer.org, and there are several head and neck cancer organizations that specifically give guidance around head and neck cancers.

Maureen Gardner: Annette, that's great. I love that idea about carrying the food around with you at all times because you don't ever know when you'll be delayed at getting your meals. And carrying something with you is super helpful.

This is especially challenging, this type of cancer, when it comes to maintaining adequate nutrition and hydration. And the journey will be a lot easier if patients have access to a registered dietitian. So if anyone listening needs help, don't hesitate to ask a member of your healthcare team for a nutrition consult, and they can tailor the nutrition plan of care to what's going to suit you and help you get through your treatment.

Annette Goldberg: Thanks, Maureen. I think that's a great point. I definitely agree. So it was nice working with you. And I'd like to thank everybody for listening.

Maureen Gardner: Thank you, Annette. I'm so happy that we were allowed to share information with other patients and help them get best nutrition care.

ASCO: Thank you, Ms. Gardner and Ms. Goldberg. Learn more about head and neck cancer at www.cancer.net/headneck. And for more expert interviews and stories from people living with cancer, visit the Cancer.Net Blog at www.cancer.net/blog.

Cancer.Net is supported by the Conquer Cancer Foundation of ASCO, which is working to create a world free from the fear of cancer by funding breakthrough research, sharing knowledge with physicians and patients worldwide, and supporting initiatives to ensure that all people have access to high-quality cancer care. Thank you for listening to this Cancer.Net Podcast.

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