ORIGINAL ARTICLE Decreased hospital stay and significant cost savings after routine use of prophylactic gastrostomy for high-risk patients with head and neck cancer receiving chemoradiotherapy at a tertiary cancer institution Brett G. M. Hughes, FRACP, 1* Vikram K. Jain, FRACP, 1 Teresa Brown, BSc (Hons), 2 Ann-Louise Spurgin, BSp Path (Hons), 3 Gemma Hartnett, FRACP, 4 Jacqui Keller, BBus (HIM), 5 Lee Tripcony, BSc, 5 Mark Appleyard, FRACP, 6 Robert Hodge, FRACS 7 1 Department of Medical Oncology, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia, 2 Department of Nutrition and Dietetics, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia, 3 Department of Speech Pathology, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia, 4 Department of Medical Oncology, Redcliffe Hospital, Brisbane, Queensland, Australia, 5 Cancer Care Services, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia, 6 Department of Gastroenterology, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia, 7 Department of ENT/Head and Neck Surgery, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia. Accepted 25 January 2012 Published online 18 May 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.22992 ABSTRACT: Background. Evidence-based nutritional and swallowing guidelines were developed to identify patients at high risk of developing malnutrition during chemoradiation for head and neck cancer. These guidelines recommended a prophylactic gastrostomy and were actively implemented at our institution in January 2007. This study assesses the effect of this policy change on patient outcomes. Methods. This retrospective cohort study was carried out for the years before (2005) and after (2007) implementation of these guidelines. Results. In all, 165 patients were treated with radical chemoradiation for head and neck cancer at our institution in the years 2005 and 2007. Gastrostomy tube complications were low. Patients in 2007 had significantly fewer hospital admissions, unexpected admissions, and a shorter mean duration of hospital stay in comparison with those in 2005. Conclusions. Prophylactic gastrostomy tubes in patients with high-risk head and neck cancer resulted in a significant decrease in hospital admissions and length of stay, and led to increased bed availability. V C 2012 Wiley Periodicals, Inc. Head Neck 35: 436–442, 2013 KEY WORDS: head and neck cancer, nutrition support, prophylactic gastrostomy, chemoradiotherapy, hospital admission INTRODUCTION Squamous cell carcinoma of the head and neck accounted for 2430 new cases of cancer in Australia in 2001, likely causing over 3000 new cases in the year 2011. 1 Patients with these neoplasms are at high risk of dysphagia and malnutrition, from preexisting risk factors, secondary to the cancer itself or from the cancer-specific management modalities. Approximately 25% to 50% of these patients already have a markedly reduced nutritional status even before commencing therapy. 2 Multimodality therapy for the treatment of these patients, involving sur- gery, chemotherapy, and radiotherapy, often produces sig- nificant mucositis, dysphagia, and xerostomia, leading to further worsening of their nutritional status, and weight loss. 3 Patients undergoing combined chemoradiation treat- ment for head and neck cancer typically undergo a weight loss of at least 10% during their treatment. 3 Consequences of impaired nutrition evidenced initially by loss of weight also include reduced kidney function, 4 which is clinically important, considering the need for optimal renal function for cisplatin-based chemotherapy. Malnutrition during treatment has also been associated with more emergency department visits, hospitalizations, treatment interruptions, compromising treatment efficacy, and diminished quality of life. 5–8 Moreover, nutritional deficiency is an important adverse prognostic factor for patients with head and neck carcinoma both at the time of diagnosis and for eventual treatment outcomes. 9 Enteral nutritional support measures such as nasogastric (NG) tube and percutaneous endoscopic gastrostomy (PEG) tube have been described for patients undergoing treatment for head and neck cancer. However, currently there is insufficient evidence and consensus to determine the optimal method of enteral feeding 10 and the timing to initiate enteral feeding along a patient’s care pathway. Gastrostomy tubes, inserted prophylactically, have proved to be safe and effective for nutritional supplementation in patients with head and neck cancer. 11–13 In Australia, there are currently no published evidence- based clinical pathways to support early identification and management of both dysphagia and malnutrition risk in patients with head and neck cancer. In 2006, evidence- based guidelines (head and neck guidelines, currently *Corresponding author: B. G. M. Hughes, Department of Medical Oncology, Royal Brisbane and Women’s Hospital, Herston, Qld, Australia Q 4029. E-mail: brett_hughes@health.qld.gov.au This work is presented on behalf of the Royal Brisbane and Women’s Hospital Nutrition and Swallowing for the working party of patients with head and neck cancer and was presented at the ASCO Annual Scientific meeting in June 2011. 436 HEAD & NECK—DOI 10.1002/HED MARCH 2013