This study is the first UK-based cohort to our knowledge to report on unplanned hospital admissions for HNC patients receiving non-surgical treatment. The frequency of admissions was lower than reported in other studies; 21% compared with 36 [7, 8] despite similar demographics. During the data collection period, the COVID-19 pandemic placed unprecedented pressure upon surgical services [12] with a subsequent increase in non-surgical management of HNC. Services aimed to reduce unplanned hospital admissions and risk of COVID-19 exposure in this vulnerable group meaning that criteria for admission was likely temporarily elevated. There was advice published suggesting increased caution with the use of chemoradiotherapy with the majority of those patients over 60 years of age receiving radiotherapy alone or palliative RT (with reduced volumes). [13] This may explain the reduction in unplanned admissions in our study compared to published cohorts. Despite this, almost one fifth of HNC patients required hospital admission, and one fifth of these had multiple admissions, similar to findings elsewhere. [7]
In keeping with previous work, patients receiving primary chemoradiotherapy were at greater risk of an admission, many of whom had substantial deterioration in their diet and fluid intake. [8, 9] Reasons for chemoradiotherapy-related admissions include nausea and vomiting, dehydration/malnutrition, mucositis-related eating and drinking problems and pneumonia. [14] Although not coded for within our data, it is likely that reduced intake (one of the predominant reasons for admission in our study) was due to mucositis. Prevention and treatment strategies for mucositis should be a core part of clinical care and patient education. [15] A quarter of patients admitted also had nausea and vomiting with decreased oral intake/dehydration. Although implicated as a reason for admission in other cancer groups, [16] nausea and vomiting appears more common in HNC patients (25% vs. 13%).
Importantly, placing a prophylactic gastrostomy did not seem to prevent hospital admission, as 27% of those with a prophylactic gastrostomy required admission compared with 15% of patients without a tube. Conversely, other centres have reported prophylactic gastrostomy does reduce unplanned admissions. [17] In our cohort, the decision to place a prophylactic gastrostomy was on a personalized case-by-case basis rather than a protocol-driven approach. The placement of prophylactic versus reactive feeding tubes has long been debated within the literature and there are no nationally agreed selection criteria, with demonstrable variation in clinical practice. [18] Recent work to identify a clinical algorithm suggests performance status, tumour subsite, stage and nodal involvement, and platinum-based chemotherapy are predictors of need for prophylactic gastrostomy. [19, 20]
Tumour stage was also a predictor of an admission. Patients with higher staged tumours are more likely to have multi-modality treatment, but may also present at diagnosis with significant weight loss, dysphagia and multiple co-morbidities rendering them more vulnerable to hospital admission. [21, 22] The analysis showed that age was an important variable, those < 50 years having a higher percentage of admissions, although patient numbers in this category were low. Whether other previously identified predictors such as social circumstances influenced these findings is an unknown. [7]
There are a number of limitations in this study. We did not include co-morbidities, frailty score or social circumstances in our data collection as these were details not uniformly entered into medical records. These may be significant influencing factors [23, 9], and may help to identify vulnerable groups at an earlier stage.
A better understanding of unplanned hospital admissions is important as such events can lead to a change in treatment plan e.g reduced chemotherapy cycles, to manage severe side effects, thus negatively impacting on overall survival. [24] In summary, whilst our admission rates appear favourable, findings suggest that concurrent chemoradiotherapy results in more severe toxicities and increased unplanned admission rates. Pre-emptive management of treatment side effects, such as mucositis, nausea and dysphagia should be prioritized, particularly in vulnerable groups. Regional data is also important in order to appropriately consent patients when discussing treatment plans. Patient’s nutrition and hydration status should be closely monitored throughout treatment. An increased focus on nutritional support may help to reduce the frequency of hospital utilisation in this patient group in the future.