ORIGINAL ARTICLE New radiotherapy techniques do not reduce the need for nutrition intervention in patients with head and neck cancer T Brown 1,2 , M Banks 2 , BGM Hughes 3,4 , C Lin 3 , LM Kenny 3 and JD Bauer 1 BACKGROUND/OBJECTIVES: Since 2007, our institution has used validated guidelines for the insertion of proactive gastrostomy feeding tubes in patients with head and neck cancer. Helical intensity-modulated radiotherapy (H-IMRT) delivered by Tomotherapy, is an advanced radiotherapy technique introduced at our centre in 2010. This form of therapy reduces long-term treatment-related toxicity to normal tissues. The aim of this study is to compare weight change and need for tube feeding following H-IMRT (n = 53) with patients that would have previously been treated with three-dimensional conformal radiotherapy (n = 134). SUBJECTS/METHODS: Patients with head and neck cancer assessed as high nutritional risk with recommendation for proactive gastrostomy were identified from cohorts from 2007 to 2008 and 2010 to 2011. Retrospective data were collected on clinical factors, weight change from baseline to completion of treatment, incidence of severe weight loss (⩾10%) and tube feeding. Statistical analyses to compare outcomes between the two treatments included χ 2 -test, Fisher’s exact and two-sample Wilcoxon tests (P o0.05). RESULTS: The H-IMRT cohort had higher proportions of patients with definitive chemoradiotherapy (P = 0.032) and more advanced N stage (P o0.001). Nutrition outcomes were not significantly different between H-IMRT and conformal radiotherapy, respectively: need for proactive gastrostomy (n = 49, 92% versus n = 115, 86%, P = 0.213), median percentage weight change (-7.2% versus - 7.3%, P = 0.573) and severe weight loss incidence (28% versus 27%, P = 0.843). CONCLUSIONS: Both groups had median weight loss 45% and high incidences of tube feeding and severe weight loss. Nutrition intervention remains critical in this patient population, despite advances in radiotherapy techniques, and no changes to current management are recommended. European Journal of Clinical Nutrition (2015) 69, 1119–1124; doi:10.1038/ejcn.2015.141; published online 26 August 2015 INTRODUCTION Patients with mucosal squamous cell carcinoma cancer of the head and neck have a high incidence of malnutrition and frequently require enteral tube feeding. Since 2007, our institution has used validated local hospital guidelines: the RBWH Swallowing and Nutrition Management Guidelines for Patients with Head and Neck Cancer (S&N Guidelines), for a proactive approach to the insertion of enteral feeding tubes. 1 Implementation of the S&N Guidelines has reduced unplanned hospital admissions and length of stay, 2 and adherence to the S&N Guidelines has improved nutrition outcomes. 3 There is no international consensus for the optimal method of tube feeding 4 and centres have adapted either a proactive or reactive approach. The majority of studies supporting prophylactic gastrostomy insertion have been under- taken in patients receiving treatment with conformal radiotherapy or radiotherapy alone. 5–7 As radiotherapy techniques and treat- ment regimens evolve, nutrition support recommendations also require ongoing review. Intensity-modulated radiotherapy (IMRT) is a targeted form of radiotherapy. When compared with three-dimensional (3D) conformal radiotherapy, IMRT allows better preservation of organs and tissues in close proximity to the cancer being treated (for example, parotid glands), and so reduces late side effects such as xerostomia and thereby improves quality of life. 8 Although, some authors have postulated this may lead to a reduced need for a gastrostomy, 9 there are studies that continue to support the role of a prophylactic gastrostomy with IMRT, in particular with concurrent treatment. 10 There have been concerns that prophy- lactic gastrostomy insertion increases the risk of gastrostomy dependency, with longer duration of tube usage and increased dysphagia post treatment, 11–13 although some studies with IMRT have not found this to be of concern. 14–16 Since 2010, the majority of patients with squamous cell carcinoma of the head and neck in our centre have been treated with helical-IMRT (H-IMRT) using Tomotherapy (TomoTherapy Inc., Madison, WI, USA). Several studies have suggested H-IMRT can achieve superior dose sparing to organs at risk versus other forms of IMRT. 17–20 This has strengthened the hypothesis that intensive nutrition support with a feeding tube may no longer be warranted. However, the extent of nutrition outcomes and requirement for tube feeding following H-IMRT has not been widely reported. Therefore, the aim of this study was to investigate weight change and the requirement for tube feeding in a cohort of high-risk patients receiving H-IMRT compared with a high-risk cohort receiving standard conformal radiotherapy to see whether any change to nutrition management is warranted. 1 Centre for Dietetics Research (C-DIET-R), School of Human Movement and Nutrition Sciences, University of Queensland, St Lucia, Queensland, Australia; 2 Department of Nutrition and Dietetics, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia; 3 Cancer Care Services, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia and 4 School of Medicine, University of Queensland, St Lucia, Queensland, Australia. Correspondence: T Brown, Department of Nutrition and Dietetics, Royal Brisbane and Women’s Hospital, Level 2, Dr James Mayne Building, Butterfield Street, Herston, Queensland 4029, Australia. E-mail: teresa.brown@uqconnect.edu.au Received 20 April 2015; revised 15 July 2015; accepted 21 July 2015; published online 26 August 2015 European Journal of Clinical Nutrition (2015) 69, 1119 – 1124 © 2015 Macmillan Publishers Limited All rights reserved 0954-3007/15 www.nature.com/ejcn