Prophylactic versus reactive gastrostomy tube placement in advanced head and neck cancer treated with definitive chemoradiotherapy: A systematic review

Although chemoradiotherapy (CRT) has improved disease outcomes in advanced head and neck cancer (aHNC), toxicity remains a major concern. Treatment interruptions and decreased quality of life (QOL) can occur due to malnutrition, secondary to mucositis, dysphagia and odynophagia. Gastrostomy tubes are used in many patients to improve nutrition during CRT. The optimal timing of PEG placement in patients with aHNC undergoing CRT remains controversial. Using the PubMed database, we performed a systematic review of published CRT series in aHNC to guide decision-making regarding optimal timing of percutaneous endoscopic gastrostomy (PEG) placement. We aimed to compare outcomes when patients are treated with prophylactic PEG (pPEG) versus reactive PEG (rPEG). Twenty-two studies examining the role of PEG placement in CRT for aHNC were reviewed. pPEG reduces the number of malnourished patients (defined as > 10% of body weight), but average weight loss at various time points following treatment appears similar to patients with rPEG. pPEG is also associated with improved QOL at 6 months, and greater long term PEG dependence. Clinical and dosimetric parameters that correlate with malnutrition in patients without pPEG include advanced age, percent weight loss preceding treatment, and radiation dose to the pharyngeal constrictor muscles. Based on this evidence, our institutional strategy is to encourage pPEG in those patients deemed at greatest risk of becoming malnourished during the course of treatment, and to approach the remainder of patients with rPEG.