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«Nutrients 2015, 7, 2145-2160; doi:10.3390/nu7042145 OPEN ACCESS nutrients ISSN 2072-6643 Article Oral Cancer ...»

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Nutrients 2015, 7, 2145-2160; doi:10.3390/nu7042145



ISSN 2072-6643



Oral Cancer Malnutrition Impacts Weight and Quality of Life

Nils-Claudius Gellrich 1, Jörg Handschel 2,*, Henrik Holtmann 2 and Gertrud Krüskemper 3


Department of Cranio-Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Street 1, Hannover D-30625, Germany; E-Mail: gellrich.nils-claudius@mh-hannover.de 2 Department for Oral and Maxillofacial Surgery, Heinrich Heine University of Düsseldorf, Moorenstr. 5, D-40225 Düsseldorf, Germany; E-Mail: Henrik.Holtmann@med.uni-duesseldorf.de 3 Department of Medical Psychology, Ruhr University of Bochum, Universitätsstr. 150, Building MA 0/145, D-44780 Bochum, Germany; E-Mail: krueskem@uni-duesseldorf.de * Author to whom correspondence should be addressed; E-Mail: Handschel@med.uni-duesseldorf.de;

Tel.: +49-211-81-18181; Fax: +49-211-81-08922.

Received: 27 January 2015 / Accepted: 24 March 2015 /Published: 27 March 2015 Abstract: Diet is important for both quality of life (QoL) and survival of patients with oral cancer. Their intake of food is impeded by functional restrictions in chewing and swallowing. In the DÖSAK REHAB STUDY 1652 patients from 38 hospitals within the German-language area of Germany; Austria and Switzerland were examined with regard to functional and psychological variables having an impact on diet. Chewing and swallowing are correlated with mobility of the tongue and the mandible as well as opening of the mouth.

Thirty five percent of the patients lost weight; 41% maintained their weight and 24% gained weight. The QoL of patients who were able to maintain their weight and of those who gained weight was significantly better than that of patients who lost weight. A normal diet was important for maintaining weight. Mashed food; liquid food and loss of appetite were closely associated with loss of weight; although it was possible for nutritional counseling and dietary support to be implemented particularly favorably in this respect. Due to problems with eating patients’ strength deteriorated; thus restricting activity. Radiotherapy had a negative impact on diet and weight. It influenced sense of taste; dryness of the mouth; swelling and discomfort when ingesting food. Pain and scars in the region of the operation also cause patients to dislike hard; spicy and sour food. Support from a nutritional counselor in implementing a calorie-rich diet remedied this and such support needs to be integr

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support of the operated patients; particularly those who also have had radiotherapy.

Keywords: oral cancer; weight loss; quality of life; nutrition; diet; swallow

1. Introduction Insufficient calorie intake leads to malnutrition and loss of weight in patients with oral cancer [1–7].

As a consequence of this, patients have more difficulty in coping with the negative impact of disease and treatment [8]. The chances of survival are diminished [9,10]. The reasons for malnutrition are to be found in functional impairments. These concern facial muscles and defects in the chewing apparatus [11–14]. However, malnutrition can also arise due to negative personality variables, for example attitude to coping with disease and negative future expectations [15–18]. The importance of a change in weight is not underestimated but remedial measures are not sufficiently implemented in patients’ management. Only recently has it been pointed out that it is important to document loss of weight over a long period of time and that a single theoretical nutritional counseling session is not sufficient [6,19,20]. Furthermore, the nutritional counselor must work together with the patient and family members until the practical implementation is embedded in the patient’s everyday routine [21].

Functional impairment of facial muscles, tongue and temporomandibular joint make it more difficult for the patient to chew and swallow [18]. These problems can be alleviated by special physiotherapeutic measures, for which measuring methods and also therapy instructions are available [22–24]. However, they need to be systematically integrated into the therapy. This requires interdisciplinary cooperation going beyond surgical, radiotherapeutical and rehabilitative reconstruction, which necessitates a great deal of work in comprehensive patients’ management. Neither are patients sufficiently and continuously informed about the consequences of radiotherapy, for example dryness of the mouth and how to reduce it, although these are important with regard to weight [21,25]. Not only does the diet need to be enriched with more calories but also adjusted to the patient’s needs [20,26]. A loss of teeth and problems with dental prostheses also play a part, the relevant facts need to be checked over a long period of time [14,27,28]. Overall, patients need support when they are supposed to change their behavior, whether it be in their diet or in methods of preparing food and its ingestion.

Loss of weight and malnutrition have a negative impact on quality of life and lead to patients having a gloomy view of their future [28–31]. They feel weak and tend to restrict their activities and avoid appearing in public [5,6,32]. Psychological support frequently fails because of resistance from patients so that care by specially trained medical staff is often the chosen means [33–35]. But coping with the disease is not the only thing to be dealt with; attitude towards diet, reliability in keeping the regular check-up appointments and checking on chewing and swallowing functions all have to be discussed with the patient. The patient’s family or caregivers need to be included when dealing with the patient’s attitude to their disease and the coping strategies which have thus become necessary [36].

Nutrients 2015, 7 2147

2. Methods and Materials

Thirty-eight clinics in Germany, Austria and Switzerland participated in the multi-center retrospective DÖSAK REHAB (REHABILITATION) study of tumors in the maxillofacial region. An ethics approval was performed in every participating clinic successfully. The Bochum patient questionnaire on rehabilitation containing 147 questions in nine chapters (personal data, course of disease prior to treatment, during treatment and post-treatment, coping with disease, life circumstances and lifestyle) was used. The doctor’s questionnaire attached to each patient questionnaire included questions about tumor size, localization, neck dissection and reconstruction. Tumor size was determined according to the UICC classification of malignant tumors (1987): T1 ≤ 2 cm, T2 2 to 4 cm, T3 4 cm, T4 infiltrating neighboring structures. 1761 questionnaires were returned anonymously. The data was analyzed with the SPSS program 21.0 including descriptive statistics, correlations, chi-square test and ANOVA calculations and with a step-by-step regression analysis. The questionnaires were checked for systematic and non-systematic errors to avoid bias. A five-point Likert scale was used to measure 19 impairments (Table 1) which are important from the experience of surgeons in the Department of Maxillofacial Surgery and further symptoms that arose throughout the disease and therapy (no impairment = 0, slight impairment = 1, moderate impairment = 2, severe impairment = 3, very severe impairment = 4). Quality of life was measured using a 100-point scale (from 0 = completely dissatisfied to 100 = completely satisfied).

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connections between two variables. The psychological variables were measured using German versions of the following scales in their short forms: depressiveness with the Depression Scaleby vs. Zerssen D (Depression Scale 1976; published by Hogrefe) [37], fear with STAI by Laux (State-Trait Anxiety Inventory 1972; published by Hogrefe) [38], coping with the disease with the Freiburg Questionnaire on Coping with Disease by Muthny (Freiburg Questionnaire of Coping with Disease 1996; published by Beltz/Hogrefe) [39]. Higher figures indicate a greater mental strain. The 1652 patients from the total random sample were divided into three groups: those who had lost weight, gained weight or maintained the same weight. Besides this, the groups of patients who had lost or gained weight were sub-divided into those who had lost or gained up to 10 kilograms in weight and those who had lost or gained more than 10 kg.

3. Results

Out of the total of 1652 patients 1526 are available concerning change in weight. Seventy five percent were men. Fifty-three Patients (3%) were 40 years and younger, 829 patients (52%) were 41 to 60 years, 594 patients (37%) were 61 to 75 and 114 (7%) patients were 76 years and older. More than one-third of the patients lost weight (Table 2). The largest group consisted of patients whose weight remained the same and a quarter of the patients gained weight. With regard to diet the differences are highly significant: within the normal diet group, 46% maintained the same weight, which is significantly the highest part. Within the liquid food group, most patients (61%) lost weight; within the mashed food group, the majority also (51%) lost weight (Table 3). Most of the patients who lost weight have to eat liquid or mashed food. Nose-stomach tube group consist of only 15 patients. This may explain the lack of significant findings. The PEG group comprises only 46 patients, which probably explains the lower statistical difference.

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3.1. Classification of Change in Weight in Groups The “lost weight” group (a, Table 2) was sub-divided into patients who had lost up to 10 kg and those who had lost 10 kg or more. The patients with a loss of weight of up to 10 kg differ from the group of patients with a greater loss of weight. The patients with a gain in weight do not differ regardless of the number of kilograms. The patients who had lost up to 10 kg were more frequently able to eat a normal diet compared with patients who had lost more than 10 kg (p 0.001). Patients who lost more than 10 kg more frequently had to eat mashed food (p 0.001).

The small group of 15 patients who still had a nose-stomach tube at least six months after the operation are equally distributed among the groups “gained weight”, “same weight” and “lost weight” (n.s. p 0.506), which is to be seen in relation to the fact that calorie intake was determined externally.

The number of PEG patients six months after the operation amounted to 3% of the total random sample.

Astonishingly, these patients much more frequently belong to the group of those who lost weight (p 0.001). In these cases as well, calorie intake was regulated externally.

Out of the 19 impairments the following factors were important for the amount of weight lost according to Pearson (Pearson chi-square): eating/swallowing (p 0.001), mobility of the tongue (p 0.001), mobility of the mandible (p 0.003), mouth opening (p 0.008) and dryness of the mouth (p 0.054), strength (p 0.001), appearance (p 0.001) and speech (p 0.003). But the other impairments were significant as well in their correlation with the loss of weight, even if to a lesser extent.

The following somatic variables were of importance in the group with weight loss of more than 10 kg: more lost teeth correlated with greater loss of weight (p 0.001) and lower satisfaction with dental prostheses (p 0.007) was also more frequently associated with greater weight loss. Small tumors T1 ≤ 2 cm were greater in number in the group of patients who had lost under 10 kg (p 0.044) and correspondingly also in patients who had only undergone an operation (p 0.001). Patients who lost more weight differed in their behavior regarding public appearances, on the one hand because of their speech impairment (p 0.019) and on the other because of their appearance (p 0.023).

3.2. Size of Tumor, Form of Treatment and Change in Weight

The size of the tumor determines the change in weight. Forty-eight percent of the patients with small tumors T1 ≤ 2 cm maintain their weight. Forty-five percent of the patients with tumour size T4 (infiltrating neighboring structures) lose weight and only 13% can maintain their weight. As the size of the tumor is linked to the form of treatment, the differences are also highly significant (p 0.001). The group of patients who only underwent an operation did best with 47% maintaining their weight. On the other hand, the three groups (1) operation and radiotherapy; (2) operation and chemotherapy; and (3) operation, chemotherapy and radiation come off worse. Only a third of the patients in these groups can maintain their weight, more than 40% lose weight and only a quarter show a gain in weight.

Radiotherapy was the reason that patients much more frequently ate mashed or liquid food (p 0.001 Pearson chi-square). Patients who underwent radiotherapy suffered a loss of weight significantly more frequently compared with other forms of treatment. Patients who only underwent an operation ate a normal diet considerably more frequently (p 0.001 Pearson chi-square). Radiotherapy had a negative impact on dryness of the mouth (p 0.001), sense of taste (p 0.001) and swelling (p 0.009).

Nutrients 2015, 7 2150

3.3. Loss of Teeth and Change in Weight

The number of teeth lost during therapy has a significant negative impact on weight (p 0.001). The number of teeth lost during treatment is also important for diet. In particular, patients who have lost more than 10 teeth during treatment have to eat mashed and mainly liquid food (p 0.001). Patients’ satisfaction with their dental prostheses also plays a crucial part for their weight (p 0.001). The worse the patients cope with their prostheses, the more weight they lose. In the group of patients who are satisfied with their dental prostheses 50% maintained their weight. In contrast, only 23% of the patients with loss of weight manage well with their prostheses.

3.4. Chewing/Swallowing, Normal Diet and Other Patient Impairments 6 Months after Operation The most important factor for patients being able to eat a normal diet is no impairment in chewing and swallowing (Table 4). A negative correlation means that the more impairments patients have in chewing/swallowing the more unlikely it is that they can eat a normal diet. Chewing/swallowing is positively correlated with the other impairments, the most important of which are listed in Table 4.

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