Head and neck (HN) cancers include cancers of the lip, oral cavity, oropharynx, hypopharynx, tonsil, salivary glands, nasopharynx, nose paranasal sinus, and middle ear
. They are the sixth most common cancer worldwide
. HN cancers account for approximately 3% of all cancers in the United States and are nearly twice as common among men as they are among women
. In 2011, approximately 52,000 people in the United States were diagnosed with HN cancers and over 5000 in Canada, and the 5-year survival rate is currently at 57%
[1, 3]. Advances in medical detection and interventions are helping to increase 5-year overall cancer survival rates, leading to an ever-growing number of cancer survivors
. Since the long-lasting effects of the disease and treatments may impact all survivors, the focus on survivorship care and patient outcomes is paramount
There is persuasive evidence to suggest that two lifestyle behaviors, physical activity (PA) and nutrition are necessary components in cancer survivorship programming
. PA has been shown to enhance patient functional capacity, physical functioning, and body composition, as well as facilitate the management of treatment related symptoms and side-effects including fatigue, and nausea
[7–11]. Nutritional counseling has been found to improve dietary intake in patients who face increased risk of malnutrition, thereby improving outcomes and timely healing
[12, 13]. It is well established that PA and nutrition interventions also promote improved quality of life (QoL) in cancer survivors, regardless of tumour site. To date, the vast majority of lifestyle interventions have focused their attention on breast cancer
[12, 14–16]. This has left other cancer populations drastically underserved, including HN cancer survivors, who are at significant risk of long-term disability
While HN cancer patients face issues similar to other cancer survivor populations (i.e., fatigue, distress, physical functioning), these populations also experience further physical and psychological burden into survivorship, affecting overall QoL status, rehabilitation, and return to work
[17–21]. HN cancer patients deal with severe weight loss, with upwards of 70% attributed to lean muscle wasting, leading to decreased physical functioning with regards to locomotion, strength and respiration after treatment
[19, 22]. This cancer-related skeletal muscle wasting, or cachexia, exists due to imbalances between muscle protein synthesis and degradation, and is unique from starvation in the sense that it cannot be reversed or treated solely with nutritional supplementation
. Cachexia is defined as an unintentional weight loss of at least 5% premorbid weight occurring over 3 to 6 months and will be the main cause of death for 20-40% of HN cancer patients, a group especially challenged with this syndrome
Current interventions are largely focused on nutrition, despite findings indicating that decreased food intake is probably not directly related to this muscle wasting, and that dietary intervention alone may increase fat mass without affecting muscle tissue
. Couch et al. (2007) also reported that although nutritional therapy is necessary, alone it might be insufficient, prompting additional or complementary treatment options
. At present there is a lack of complementary treatment options to help sustain or rebuild this wasted muscle, yet since cachexia is a muscle wasting disease, interventions targeted at increasing protein anabolism and decreasing catabolism are warranted
. Strength training and exercise hold great potential due to the associated increases in lean muscle mass and improvements in body composition, which have been seen in other cancer populations
[8, 27]. Currently, there are very few clinical trials that examine the impact of strength training in combination with a nutritional intervention for cachexia. Besides the negative impact on overall health and survival, this muscle wasting syndrome is associated with substantial mental and emotional fatigue, and significantly decreased QoL, particularly in scores of emotional, physical and social functioning categories
[18, 23, 24, 28, 29]. Exercise and diet have been found to enhance QoL in HN survivors and help manage fatigue, but the specific benefits of a lifestyle intervention during treatment has yet to be investigated, and the question pertaining to the appropriate time of intervention, during treatment or following treatment, has yet to be answered
The purpose of this proposed research is to examine the immediate and long term physical and psychosocial benefits of a clinic-supported physical activity and nutrition program during and after treatment for HN cancer survivors, and to investigate the clinical implications associated with increasing the promotion of healthy lifestyle behaviors for this population. This research will address the pressing need for clinic-supported HN cancer lifestyle interventions that effectively demonstrate physical and psychosocial patient benefit.
Specifically, this study is designed to examine the potential benefits of a lifestyle (PA, nutrition, and health education) intervention. Specific objectives include the following:
Whether a lifestyle intervention will improve outcomes, including physiological (muscle mass maintenance), fitness, psychological (QoL and depression), smoking status, inflammatory markers, and functional (return to work).
Whether it is optimal, in terms of outcomes, to deliver the program during or after treatment completion.
Whether a survivorship care plan (SCP) maintenance program improves long-term healthy lifestyle adherence.
Without exploration into these questions, HN cancer care will continue to only partially serve patients in their quest towards healthy cancer recovery, strong physical functioning ability, improved QoL, and timely return to work. These studies will provide concrete evidence for a clinic-supported lifestyle intervention and maintenance program as a means to mediate these currently unaddressed factors and improve functioning and psychosocial outcomes.
The study hypotheses directly reflect the aims. It is hypothesized that patients who are randomized to the 12-week lifestyle intervention at treatment start will experience improved symptom management throughout treatment compared to controls (delayed intervention) as evaluated by: a) decreased loss of lean body mass, improved physical functioning and fitness outcomes, improved Karnofsky Performance scores and decreased levels of serum inflammatory markers b) improved patient sense of wellbeing and feelings of control and therefore overall reported QoL. It is also hypothesized that patients who are randomized to the 12-week lifestyle intervention at treatment start (immediate intervention) will experience improved symptom management following treatment compared to delayed intervention patients who begin the 12-week intervention following treatment. Improved symptom management will be evaluated following intervention by: a) decreased loss of lean body mass, improved physical functioning and fitness outcomes, improved Karnofsky Performance scores and decreased levels of serum inflammatory markers as well as the associated b) improvement in patient sense of wellbeing, feelings of control, and overall reported QoL score.