Patients who underwent prophylactic PEG experienced significant improvements in nutritional status and QoL while also showing increased treatment adherence during radiotherapy. Nonetheless, among patients with head and neck cancer, the role of PEG in terms of long-term QoL and adverse effects is debatable. In this study, xerostomia was more common in the PEG group than in the non-PEG group. The frequency of other adverse effects such as dysphagia did not vary statistically significantly between the two groups. There was no statistically significant difference between the two groups in terms of QoL. However, the patients' high general QoL scores showed that both groups of patients had a decent general QoL. To our knowledge, this is the first research that examines the impact of prophylactic PEG on long-term QoL and adverse effects in NPC patients. PEG does not appear to have a detrimental effect on long-term QoL, including swallowing function, according to our findings.
Similar results were observed in several head and neck cancer studies[22–24]. Axelsson et al used a EORTC QLQ-head and neck 35 scale and a 5-level oral intake scale to test swallowing outcomes in a randomized study that included patients with head and neck cancer who were randomly assigned to one of two groups: prophylactic PEG or nutritional support according to clinical practice. The patients' capacity to swallow foods did not vary between the groups, according to the findings. Prestwich et al. retrospectively included 56 patients with head and neck cancer in two matched groups who received either a prophylactic gastrostomy tube (GT) or a nasogastric tube as required and used the MD Anderson Dysphagia Inventory questionnaire to assess swallowing outcomes. In line with our findings, there was no significant difference in long-term swallowing function between the groups. Another study conducted by Prestwich et al. showed the same results, as well.
However, some studies indicated that prophylactic PEG increases the risk of long-term dysphagia[25–28]. Patients who received prophylactic GT before treatment had a higher incidence of GT dependence and stricture diagnosis than those who did not. The authors hypothesized that the high incidence of long-term GT dependency in patients may be due to atrophy of the muscles that control the swallowing process. Oozeer et al. performed another analysis that yielded the same findings. Prophylactic PEG tubes were independent predictors of PEG tube dependency at least 1 year after treatment in patients with head and neck cancer who received definitive chemoradiation, according to a retrospective review. A retrospective study supports the hypothesis that patients treated with PEG feeding have higher severe late dysphagia than patients treated with R-NG feeding. The convenience of PEG placement, according to the authors, can deter patients from working hard to become nutritionally independent after therapy is completed. The opposite was found in our research. There was no significant difference between PEG and non-PEG groups in terms of long-term QoL, including dysphagia. Unlike the studies above, only NPC patients were included in our study. During radiotherapy, we encouraged patients in PEG groups to do swallowing exercises like drinking. In addition, the PEG tube was removed after the acute mucositis has resolved, allowing for adequate food intake orally (approximately 4–6 weeks after the end of radical radiotherapy). Moreover, to avoid interference with recurrence and metastasis, only patients without progression were included in our analysis.
Using the EORTC QLQ-C30 scale to assess the QoL of NPC patients who survived more than two years, a study included 216 NPC survivors found that these patients had a slightly high incidence of dry mouth, fatigue, hearing loss, depression and anxiety, but had a good QoL . Another randomized controlled trial showed that the observation group (nutritional support) had a lower incidence of adverse effects and had better short-term outcomes and QoL than the control group, which was likely due to the patients' improved nutritional status. Of the 148 patients in our study, 102 (68.9%) had hearing loss and 75 (50.7%) were troubled by xerostomia. Patients, however, had higher mean scores for overall QoL as well as the five major functions of somatic, social, task, emotional, and cognitive functioning, and lower scores for the remaining symptoms. The fact that all of our study participants received intensity-modulated radiotherapy may have contributed to their high QoL. Intensity-modulated radiotherapy, as compared to traditional radiotherapy, helps protect normal tissues, reduce the occurrence of long-term side effects, and increase patients' long-term QoL[34–37]. The other possible reason may be that final analysis included only patients without progression. The presence of xerostomia was significantly higher in the PEG group compared to the non-PEG group (51.7% vs. 50%, P = 0.044). However, there was no significant difference in Grade > or = 2 xerostomia between groups.
There are several limitations to the current study. First, there was selection bias in this study since it was not a prospective randomized controlled trial and the decision to conduct PEG was based on the patients' wishes. Second, investigators gathered information on patients' QoL mostly through telephone follow-up inquiries, resulting in information bias. Bias may be minimized to some extent in this study because the questionnaire was filled out by the same professionally qualified investigator after interviewing the patients, item by item via telephone follow-up.