Dietetics


Good nutrition is essential to recovery from all types of Head and Neck disease especially cancers. Our team provides assistance and advice concerning feeding. This may include dietary supplements, feeding tubes, PEG feeding or even feed given directly into blood vessels.

Nutrition is of critical importance throughout the treatment journey in Head and Neck Cancer. As the clinical nutrition experts in the multi-disciplinary team, the Dietician plays a very important role in the treatment planning. Dieticians are university trained nutrition professionals who use their extensive knowledge of the science of food and nutrition to ensure best possible nutritional status in health and disease.

Treatment of Head and Neck Cancer is very likely to affect your ability to eat and drink. By ensuring you receive your nutritional requirements your Dietician contributes to achievement of best possible treatment outcomes.

National documents highlight the need to include the dietician at every stage of the patient’s journey in Head and Neck Cancer. Nutrition has been shown to be the second most important long-term prognostic factor in Head and Neck Oncology meaning that without appropriate nutritional management and management of nutritional status, poor outcomes in treatment are more likely.


Nutritional Status in the Head and Neck Cancer Population
Head and Neck cancer patients present a significant nutritional challenge, with approximately 50 -75% of diagnosed patients experiencing moderate to severe malnutrition before, during and after treatment. The consequences of malnutrition are well documented and include:

Decreased muscle, respiratory and immune functions
Impaired wound healing
Poor quality of life
Increased morbidity and mortality
Greater length and cost of hospital stay

Appropriate and timely nutritional support in this patient group through the provision of oral nutrition fortification and supplementation and/or implementation of alternative feeding via a tube has been shown to:

Correct nutritional deficiencies and prevent weight loss
Improve patients’ nutritional status to allow them to receive more intensive treatment
To minimise the risks of malnutrition-related morbidity and mortality
Reduce the risk of developing post operative complications
Prevent treatment interruptions and possible hospitalization
Maximise patient motivation to improve overall quality of life
Many of the treatments for Head & Neck cancer have an adverse impact on nutritional status.

Surgical resection (tumour removal by surgery) frequently results in swallowing problems. This then impacts on oral food and fluid intake and may result in weight loss. A weight loss of 10% or more (indicating impaired nutrition) during the 6 months prior to surgery is a significant predictor for the development of postoperative complications, which have a high incidence of between 20 – 50% .

Radiation and chemotherapy both cause acute and late problems with eating and drinking. Approximately 80% of patients undergoing radiotherapy experience such problems and may lose up to 10% of their body weight. During chemotherapy and radiotherapy, dehydration and severe weight loss may occur if nutritional support is inadequate. This can lead to interruption of treatment and subsequent reduction in tumour control and overall survival. It may also result in re-admission to hospital for symptom management.

Even patients who are disease-free post treatment may present with late side effects from both surgery and radiotherapy, which may impact on their oral intake and increase their risk of developing malnutrition.

Dietetic input throughout the patient pathway is needed in order to:

Assess patients’ nutritional needs
Evaluate how different treatments will impact on a patient’s nutritional status
Recommend the most appropriate short/long term nutritional interventions
Negotiate specific practical dietary changes to meet nutritional and/or therapeutic goals
Assist individuals to undertake dietary change(16)


As part of the multidisciplinary team, the dietician also:

Contributes nutritional expertise in developing protocols and policy relating to nutrition,
    and the auditing of these
Provides information, expert opinion or advice on current thinking / evidence based / best practice in nutrition
Develops clear, up-to-date and practical written information for patients on relevant aspects of diet or nutrition.

Dieticians - Out-patient Clinics

In order to achieve the above, the dietician is an essential member of the team at the following head & neck clinics:

Combined radiotherapy clinic
Radiotherapy clinic
Maxillofacial clinic

Dietician Led Pre-Treatment Assessment Clinic

The patient will usually be seen in this clinic within 10 days of treatment decision having been confirmed. In this clinic, patients have a 45minute appointment with the Dietician where the patient’s nutritional status is assessed using specialist anthropometric equipment, the impact of the treatment on nutritional status is discussed, planning is commenced for nutritional management through treatment and the patient is then counselled as to the best recommended strategy for nutritional management. As a result of the pre-treatment discussions and planning, the patient may need to be booked in to have a gastrostomy tube placed prior to treatment.

Gastrostomy Service

Placement of gastrostomies prior to patients receiving cancer treatment, or supportive nutritional care, could help patients maintain their nutritional status, improve quality of life and achieve clinical outcomes.

At UCLH, the Head & Neck Dieticians lead on the co-ordinated multi-disciplinary approach for the gastrostomy service. Bella Talwar, Clinical Lead Dietician is the service lead for developing an integrated service with gastroenterology and radiology as extended members of the head and neck cancer multidisciplinary team.

Placement of Gastrostomy Feeding Tubes

Gastrostomy placement is recommended by evidence-practice based selection criteria, followed by a medical assessment for suitability and method of insertion by endoscopic, radiological or surgical approach.

All patients will receive gastrostomy counselling pre placement in the Dieticians pre treatment assessment clinic to support the consent process with the use of visual aids and written information, and implement pro-active pre-treatment nutrition support. Following the clinic they are given a minimum of 24 hours to make an informed decision.

Patients will remain in hospital for a minimum of 24hours post placement to monitor signs or symptoms of tube placement related complications, and to undertake nursing led competency based training to manage feeding tubes, or safe discharge for home enteral feeding prior to discharge.

Removal of Gastrostomy Feeding Tubes

All gastrostomy patients will be assessed in the Dietetic led post treatment clinic for suitability of removing the gastrostomy tube. The Head and Neck dieticians require the patient to have a minimum 4 - 6 week trial period of not using the feeding tube, followed by a nutritional assessment to ensure weight maintenance and adequate oral intake in the short and long term.

Factors to be considered involving other members of the head and neck team include clinical condition of swallowing, disease status and timing of follow up diagnostic investigations.

Dietetic Led Post Treatment Clinic

In the early stages of rehabilitation, patients require specialist dietetic services, where a MDT approach can be adopted with relevant members of the team. The head and neck dieticians will provide ongoing dietetic support for patients who require more intensive nutrition support, counselling and rehabilitation, and when patients are not regularly attending the consultant led clinics. This is to provide psycho social support to the patient and carers in relation to eating and drinking, rehabilitation from tube feeding to oral diet where possible to prevent tube feeding dependency, and monitoring in the long term.

Head and Neck Cancer Dietetic Service Aims

Patients will have access to an efficient, effective, high quality dietetic service, which will contribute
    to overall clinical outcomes
 
All patients with identified need, will receive the specialist support and advice they need to optimise their nutritional status and correct nutrient deficiencies, resulting in improved functional and quality of life outcomes

Patients will have an improved understanding of the impact of different treatment options on their ability to eat and drink and will be better informed about their nutritional treatment options ensuring they are fully informed in the consent for treatment process

Patients requiring enteral feeding at home will be discharged safely and effectively, with adequate support,
   training and preparation, reducing the likelihood of readmission for feeding-related complications

The Cancer Centre will meet National Guidelines

Dietician Research and evidence-based practice

The Head and Neck Cancer Centre specialist dietetic service provides significant opportunities for leading and participating in national and international research projects. Audit and research relating to nutrition in head and neck oncology is currently fragmented and there is only a limited amount being carried out within the North London Cancer Network. Nationally there is an urgent need for high quality research within the field of Head and Neck nutrition. It is a key aim of this dietetic service to establish and develop research and audit in order to improve patient outcomes.

Dieticians -Training and Education

Part of the dietician’s role in the team is in training and education. We provide training and education of other members of the multidisciplinary team on aspects of nutrition in order to ensure consistent information is given to patients, and to ensure team members are aware of current advances and changes in practice. Education on nutrition is required at all levels, from pre and post-graduate training, through to induction sessions for new members of staff.

The Dieticians from the UCLH Head and Neck Cancer team present regularly at National and International Conferences and study days.

Palliative Care

UCH has excellent palliative care support with links into the hospice and hospice at home networks.

Contact Us
UCH Head and Neck Services
If you have any questions, please contact us at University College Hospital.

Postal address

Head and Neck Services,
First Floor East 250,
Euston Road,
London NW1 2PG

Telephone via Departmental Secretariat

Sally Zalita    020 7380 9755
Jill Wellard    020 7380 6949
Marlene Bell  020 7380 9859
Allied Health Professionals 020 7380 6948

Your message will be taken and passed on to the appropriate person or department.

e-mail headandneckcentre@uclh.nhs.uk

Fax referrals  020 7380 6952
Links
Cancer Backup (Cancer Information Website)
http://www.cancerbackup.org.uk/Cancertype/Larynx
http://www.cancerbackup.org.uk/Cancertype/Headneck
0808 800 1234   (freephone helpline)

Changing Faces
http://www.changingfaces.co.uk

The Health Professions Council
http://www.hpc-uk.org  

National Association of Laryngectomee Clubs   http://www.nalc.ik.com/  

Macmillan
http://www.macmillan.org.uk

Macmillan CancerLine
0808 808 2020
Copyright UCLH 2008
Sponsored by B. Braun Medical Ltd.