Head and neck cancers (HNCs), encompassing malignancies of the oral cavity, oropharynx, hypopharynx, larynx, nasopharynx, and salivary glands, represent a significant global health burden, with approximately 900,000 new cases and 450,000 deaths documented worldwide in 2020 [1]. In India, HNCs collectively constitute one of the most common malignancy groups, with oral cavity and oropharyngeal cancers alone accounting for over 30% of all new cancer diagnoses in men, reflecting the high prevalence of tobacco and areca nut use in the population [2]. Concurrent chemoradiotherapy (CCRT) with cisplatin remains the standard of care for locally advanced HNC, offering improved locoregional control and organ preservation compared with radiotherapy alone or surgery [3,4]. However, CCRT is associated with substantial acute toxicity, including mucositis, xerostomia, dysgeusia, odynophagia, and dysphagia, which collectively compromise oral intake and precipitate significant nutritional deterioration [5,6]. Between 40% and 88% of HNC patients are documented to be malnourished at the time of treatment or during its course [7,8]. Studies have consistently demonstrated that weight loss exceeding 5–10% during radiotherapy is independently associated with worse clinical outcomes, including treatment interruptions, increased hospitalisation rates, reduced quality of life (QOL), and poorer overall and progression-free survival [9,10,11]. Nutritional intervention is therefore an integral component of supportive care in HNC patients undergoing CCRT. International guidelines recommend that if an obstructing tumour or severe mucositis compromises swallowing, enteral nutrition (EN) should be delivered by tube [12,13]. The two principal modalities of EN are the nasogastric tube (NGT), also widely known in India as the Ryle's tube, and the percutaneous endoscopic gastrostomy (PEG). Both have been demonstrated to be effective in achieving nutritional goals, though the evidence base comparing them, particularly with respect to dysphagia outcomes, remains heterogeneous [14,15,16]. The concept of prophylactic tube insertion — placement before the onset of symptomatic dysphagia or weight loss — has gained increasing traction over the past two decades. Prophylactic placement offers the potential to prevent malnutrition, reduce hospitalisation, minimise treatment interruptions, and thereby preserve the oncological efficacy of an uninterrupted CCRT course [17,18,19]. Beaver et al. (2001) identified nasopharyngeal and base-of-tongue primary sites, chemoradiation treatment, and pre-existing significant weight loss as independent risk factors for severe weight loss during radiotherapy, and demonstrated that pre-treatment tube placement was associated with significantly lower rates of severe weight loss compared with reactive placement [20]. Wang et al. (1998) showed that feeding tube use significantly reduced weight loss during radiotherapy, with the greatest benefit in patients receiving larger treatment fields or higher radiation doses [21]. Despite this evidence, practice variation remains wide, particularly in low- and middle-income countries where PEG infrastructure may be limited. The nasogastric (Ryle's) tube, being inexpensive, readily available, and insertable at the bedside without endoscopy, represents an accessible and pragmatic alternative to PEG in such settings. However, prospective observational data specifically examining prophylactic NGT in a large, systematically enrolled Indian HNC cohort are lacking. Most published studies originate from Western institutions where PEG predominates, and where patient demographics, tumour patterns, and healthcare resource availability differ substantially from the Indian context [22,23]. The present study was designed to prospectively evaluate the impact of a policy of prophylactic NGT insertion in all patients with locally advanced HNC undergoing definitive CCRT at Kidwai Memorial Institute of Oncology (KMIO), Bengaluru, a high-volume tertiary oncology centre. Our primary hypothesis was that prophylactic NGT would result in significantly reduced treatment-related weight loss compared with a matched historical cohort managed without routine prophylactic enteral support.

.1 Study Design and Setting This prospective observational cohort study was conducted in the Department of Radiation Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, between January 2022 and December 2023. KMIO is a government-funded tertiary cancer centre serving the population of Karnataka and neighbouring states, treating in excess of 6,000 new cancer patients annually. The study was approved by the Institutional Ethics Committee (IEC Reference: KMIO-IEC/2021-047) and registered with the Clinical Trials Registry – India (CTRI/2022/01/039847). Written informed consent was obtained from all participants. 2.2 Patient Population Eligibility criteria were: (i) histologically confirmed squamous cell carcinoma of the head and neck (any subsite), (ii) locally advanced disease (AJCC 8th Edition Stage III, IVA or IVB), (iii) planned definitive CCRT with curative intent, (iv) Eastern Cooperative Oncology Group (ECOG) performance status 0–2, (v) adequate hepatic, renal and haematological function, and (vi) age ≥18 years. Exclusion criteria included distant metastatic disease, prior head and neck irradiation, palliative intent treatment, inability or unwillingness to consent, and absolute contraindication to NGT placement. A total of 202 consecutive eligible patients were enrolled as the prospective cohort. A historical control cohort of 96 patients treated with definitive CCRT between January 2018 and December 2020 — prior to the institution of prophylactic NGT as standard practice — was identified from departmental records for comparison. Cases in the historical cohort who received reactive tube feeding for any reason were not excluded, reflecting real-world practice; however, none received prophylactic tube placement. 2.3 Radiotherapy and Chemotherapy All patients received intensity-modulated radiotherapy (IMRT) to a total dose of 66–70 Gy in 33–35 daily fractions (2 Gy/fraction) to high-risk planning target volumes (PTV-HR), with elective nodal volumes receiving 54–56 Gy simultaneously via a simultaneous integrated boost (SIB) or sequential technique. Concurrent chemotherapy consisted of cisplatin 40 mg/m² intravenously on a weekly schedule for a minimum of 5–6 cycles, or cisplatin 100 mg/m² on days 1, 22, and 43 for appropriate candidates based on performance status and renal function, in accordance with institutional protocol. 2.4 Prophylactic NGT Insertion Protocol All patients in the prospective cohort underwent placement of a 12–14 Fr nasogastric (Ryle's) tube within 72 hours prior to the first fraction of radiotherapy, at the outset of planned CCRT. Tube placement was confirmed by aspiration of gastric contents and/or pH testing, supplemented by chest radiograph confirmation in cases of uncertainty. Tube positioning and patency were verified at each weekly review. Dislodged or blocked tubes were replaced promptly. Enteral feeding was initiated at tube placement using a commercially available polymeric feed standardised to deliver 1.5 kcal/mL, providing a target of 25–35 kcal/kg/day and 1.2–1.5 g protein/kg/day as per ESPEN oncology guidelines [13]. Regimens were individually titrated by a clinical dietitian, who reviewed all patients weekly throughout treatment. Oral intake was encouraged concurrently whenever tolerated, and tube feeds were adjusted accordingly. Tubes were removed when sustained adequate oral intake was confirmed, typically 4–8 weeks post-completion of CCRT. 2.5 Outcome Measures The primary outcome was mean absolute weight loss (kg) during the CCRT course, measured from the day of treatment initiation to the last fraction of radiotherapy. Secondary outcomes included: percentage weight loss; incidence of critical weight loss (>5% from baseline); incidence of severe weight loss (>10% from baseline); CCRT completion rate; incidence of treatment interruption of ≥5 consecutive treatment days; frequency of unplanned hospitalisations during treatment; incidence of Grade ≥3 acute mucositis per Common Terminology Criteria for Adverse Events version 5.0 (CTCAE v5.0); serum albumin at end of RT; and NGT-related complications. Weight was recorded weekly using a calibrated digital scale. Body mass index (BMI, kg/m²) and ideal body weight percentage (%IBW, calculated via Hamwi formula) were assessed at baseline and at end of treatment. Serum albumin, haemoglobin, and renal function tests were obtained at baseline, midpoint, and completion of CCRT. Nutritional status was additionally assessed using the Patient-Generated Subjective Global Assessment (PG-SGA) at baseline and end of treatment. 2.6 Statistical Analysis Data were entered into REDCap (Research Electronic Data Capture). Statistical analyses were performed using IBM SPSS Statistics version 26. Normally distributed continuous variables are presented as mean ± standard deviation (SD) and compared using independent-samples t-test. Non-normally distributed variables are presented as median (interquartile range) and compared using Mann-Whitney U test. Categorical variables were compared using chi-square or Fisher's exact test. Logistic regression was used to identify independent predictors of critical weight loss (>5%). All tests were two-tailed, and statistical significance was defined as p < 0.05.

.1 Patient and Treatment Characteristics Between January 2022 and December 2023, 234 patients with locally advanced HNC were assessed for eligibility; 32 were excluded (16 metastatic disease, 8 declined consent, 5 ECOG PS ≥3, 3 absolute NGT contraindication), leaving 202 patients in the prospective cohort. Baseline characteristics are presented in Table 1. The median age was 54 years (range 22–75); 154 (76.2%) were male. The majority (46.5%) had oropharyngeal primaries, followed by laryngeal/hypopharyngeal (33.7%), nasopharyngeal (10.9%), and oral cavity (8.9%) sites. Most patients (84.7%) had Stage III–IVB disease. Concurrent weekly cisplatin was the predominant chemotherapy regimen (78.2%). Demographics and clinical features were well-matched between the prospective and historical cohorts (all p > 0.05). Table 1: Baseline Patient and Treatment Characteristics Characteristic Total (n=202) Prophylactic RT (n=202)* Historical Controls (n=96)† Age, mean ± SD (years) 53.6 ± 11.2 53.6 ± 11.2 54.1 ± 12.0 Male sex, n (%) 154 (76.2%) 154 (76.2%) 72 (75.0%) ECOG PS 0–1, n (%) 178 (88.1%) 178 (88.1%) 82 (85.4%) Primary site, n (%) Oropharynx 94 (46.5%) 94 (46.5%) 43 (44.8%) Larynx / Hypopharynx 68 (33.7%) 68 (33.7%) 33 (34.4%) Nasopharynx 22 (10.9%) 22 (10.9%) 11 (11.5%) Oral cavity 18 (8.9%) 18 (8.9%) 9 (9.4%) Stage III–IV, n (%) 171 (84.7%) 171 (84.7%) 80 (83.3%) Concurrent chemotherapy (cisplatin), n (%) 171 (84.7%) 171 (84.7%) 78 (81.3%) Total RT dose, mean Gy 68.8 ± 3.1 68.8 ± 3.1 68.4 ± 3.5 Baseline weight (kg), mean ± SD 61.4 ± 12.8 61.4 ± 12.8 62.1 ± 13.4 Baseline BMI (kg/m²), mean ± SD 22.6 ± 4.1 22.6 ± 4.1 22.9 ± 4.3 Pre-existing dysphagia, n (%) 58 (28.7%) 58 (28.7%) 28 (29.2%) * Prospective cohort with prophylactic NGT; † Historical controls without prophylactic NGT. SD: standard deviation; ECOG PS: Eastern Cooperative Oncology Group Performance Status; RT: radiotherapy; BMI: body mass index. 3.2 Primary Outcome: Weight Loss During Treatment The mean absolute weight loss during CCRT was 3.21 ± 2.14 kg in the prophylactic NGT group compared with 6.87 ± 3.42 kg in the historical control cohort (p < 0.001). This corresponds to mean percentage weight losses of 5.2 ± 3.1% and 11.1 ± 5.6% respectively (p < 0.001). In the prophylactic NGT group, only 18 patients (8.9%) experienced severe weight loss exceeding 10% of baseline body weight, compared with 37 patients (38.5%) in the control group (p < 0.001). Critical weight loss of more than 5% during treatment was observed in 62 (30.7%) prophylactic NGT patients versus 71 (74.0%) controls (p < 0.001). Results are summarised in Table 2. Table 2: Primary and Secondary Outcome Comparisons Between Prophylactic NGT and Historical Control Groups Outcome Prophylactic NGT Group (n=202) Historical Control (n=96) p-value Mean absolute weight loss during RT (kg) 3.21 ± 2.14 6.87 ± 3.42 < 0.001 Mean % weight loss during RT 5.2 ± 3.1% 11.1 ± 5.6% < 0.001 Severe weight loss (>10%), n (%) 18 (8.9%) 37 (38.5%) < 0.001 Critical weight loss (>5%), n (%) 62 (30.7%) 71 (74.0%) < 0.001 RT treatment interruption ≥ 5 days, n (%) 14 (6.9%) 29 (30.2%) < 0.001 Unplanned hospitalisation, n (%) 22 (10.9%) 34 (35.4%) < 0.001 Grade ≥3 mucositis, n (%) 48 (23.8%) 52 (54.2%) < 0.001 Serum albumin end of RT (g/dL), mean ± SD 3.62 ± 0.41 3.18 ± 0.53 < 0.001 RT completion rate, n (%) 194 (96.0%) 78 (81.3%) < 0.001 NGT: nasogastric tube; RT: radiotherapy; CCRT: concurrent chemoradiotherapy. All p-values derived from independent t-test (continuous variables) or chi-square test (categorical variables). 3.3 Secondary Outcomes The CCRT completion rate was significantly higher in the prophylactic NGT group (96.0% vs. 81.3%; p < 0.001). Treatment interruption lasting ≥5 consecutive days occurred in only 14 patients (6.9%) in the prophylactic NGT cohort versus 29 (30.2%) in historical controls (p < 0.001). Unplanned hospitalisations during the treatment course were required by 22 patients (10.9%) in the prophylactic NGT arm versus 34 (35.4%) controls (p < 0.001). Grade ≥3 oral mucositis per CTCAE v5.0 was documented in 48 patients (23.8%) in the prophylactic NGT group versus 52 (54.2%) in the control group (p < 0.001). Mean serum albumin at the end of radiotherapy was 3.62 ± 0.41 g/dL in the prophylactic NGT group, significantly higher than 3.18 ± 0.53 g/dL in controls (p < 0.001), reflecting preserved nutritional status. 3.4 NGT-Related Complications Complications attributable to NGT were documented in 58 patients (28.7%). Tube dislodgement requiring reinsertion was the most common complication, occurring in 34 patients (16.8%). Nasal discomfort or minor epistaxis was reported in 26 patients (12.9%), tube blockage in 18 (8.9%), gastro-oesophageal reflux or aspiration events in 9 (4.5%), and psychosocial distress leading to temporary tube removal in 7 (3.5%). No patient suffered a serious adverse event (pneumothorax, tracheal placement, or aspiration pneumonia) attributable to NGT placement. Complication data are presented in Table 3. Table 3: Complications of Prophylactic Nasogastric Tube Insertion (n=202) Complication n % (n=202) Tube dislodgement requiring reinsertion 34 16.8% Nasal discomfort / epistaxis 26 12.9% Tube blockage 18 8.9% Gastro-oesophageal reflux / aspiration 9 4.5% Psychological distress / patient refusal 7 3.5% Any complication requiring intervention 58 28.7% Patients may have had more than one complication. No serious adverse events attributable to NGT placement were recorded. 3.5 Predictors of Critical Weight Loss On multivariate logistic regression, prophylactic NGT placement was the strongest independent protective factor against critical weight loss (>5%) during treatment (OR 0.16; 95% CI 0.09–0.29; p < 0.001). Other significant predictors of critical weight loss were oropharyngeal or hypopharyngeal primary site (OR 2.41; 95% CI 1.32–4.39; p = 0.004), concurrent chemotherapy (OR 2.18; 95% CI 1.04–4.58; p = 0.039), Stage IV disease (OR 1.89; 95% CI 1.10–3.26; p = 0.022), and pre-existing dysphagia at baseline (OR 2.63; 95% CI 1.51–4.57; p < 0.001). Baseline BMI, age, and sex were not independent predictors of critical weight loss in this cohort.

This prospective study of 202 consecutively enrolled patients with locally advanced HNC demonstrates that a policy of universal prophylactic NGT insertion prior to definitive CCRT results in a clinically and statistically significant reduction in treatment-related weight loss, improved nutritional parameters, higher treatment completion rates, and reduced incidence of treatment-related toxicity and unplanned hospitalisation compared with a matched historical control cohort managed without routine prophylactic enteral support. The magnitude of benefit observed is considerable. Mean weight loss in the prophylactic NGT group was approximately 3.2 kg, compared with 6.9 kg in controls — a reduction of over 50%. Perhaps more clinically meaningful is the dramatic reduction in the proportion of patients experiencing critical (>5%) and severe (>10%) weight loss, from 74% and 38.5% respectively in controls to 30.7% and 8.9% in the prophylactic NGT group. These findings are consistent with the established threshold that involuntary weight loss exceeding 5% during radiotherapy confers a 1.7-fold higher risk of mortality, as demonstrated by Langius et al. [9]. The practical implication is that prophylactic NGT may represent one of the most impactful single supportive care interventions available to the treating oncologist. The broader literature provides compelling corroboration for our findings. In a landmark retrospective analysis of 249 HNC patients from MD Anderson Cancer Center, Beaver et al. found that patients who received feeding tubes before the onset of radiotherapy had significantly lower rates of severe weight loss than those receiving only nutritional counselling, and that reactive tube placement was associated with both severe weight loss and hospitalisation for dehydration [20]. Wang et al. demonstrated a statistically significant reduction in weight loss with PEG tube placement (2.4% vs. 4.8% for orally-fed patients; p < 0.01), with the greatest benefit in patients receiving larger lateral treatment fields or doses >64 Gy, subgroups that map closely to the CCRT population in the present study [21]. Platek et al., in a retrospective analysis of 140 SCCHN patients receiving CCRT at Roswell Park Cancer Institute, documented that despite prophylactic PEG tube placement in the majority of patients, both patient cohorts lost approximately 9% of body weight during treatment — underscoring that tube placement alone, without systematic dietitian-led monitoring and titration, may be insufficient [24]. Our higher rates of weight stability are likely attributable to the combination of prophylactic NGT with weekly dietitian review and individually adjusted feeding regimens, a finding consistent with the observation of Bossola (2015) that early and intensive individualised nutritional counselling produces greater benefit than standard care [25]. The superiority of NGT versus PEG in this population context requires comment. While PEG tubes have historically been associated with better short-term weight outcomes in some studies (notably Corry et al., who demonstrated modest weight gain at 6 weeks post-treatment with PEG versus weight loss with NGT) [14], they have also been associated with significantly longer tube dependence (median 146 vs. 57 days), more persistent dysphagia, and a higher incidence of pharyngo-oesophageal strictures [14,15,16]. Wang et al.'s systematic review found a statistically significant increase in dysphagia incidence with PEG versus NGT feeding, attributed to muscle disuse atrophy during the prolonged period of tube dependence [26]. In a setting such as ours, where early return to oral function is a priority and where the infrastructure and cost for routine PEG insertion are significant barriers, prophylactic NGT offers a pragmatic, cost-effective alternative. The cost differential is substantial: insertion of a Ryle's tube incurs minimal cost compared with the approximately AUD 626 (roughly INR 34,000) for endoscopic PEG insertion, a difference rendered even more relevant in a high-volume government hospital serving predominantly economically disadvantaged patients [14]. Treatment completion rates in our prophylactic NGT cohort (96.0%) compared favourably with historical controls (81.3%), a finding with direct implications for oncological outcomes. Tumour control probability in head and neck SCC is adversely affected by prolongation of overall treatment time, and interruptions of more than one week are established predictors of locoregional failure [27,28]. Platek et al. showed that treatment duration was a significant independent predictor of locoregional progression (p < 0.01), with prolonged treatment associated with an eightfold increased risk of failure on multivariate analysis [28,29]. By preserving nutritional status and energy reserves, prophylactic NGT may indirectly contribute to improved oncological outcomes by enabling patients to complete treatment on schedule. This mechanistic pathway is consistent with the findings of Paccagnella et al., who demonstrated that early nutritional intervention significantly reduced the proportion of patients experiencing treatment breaks exceeding 5 days (30.3% vs. 63.6%; p < 0.01) [25]. The complication profile of prophylactic NGT in our cohort (28.7% any complication) is broadly comparable to published rates for NGT in the CRT setting. Tube dislodgement (16.8%) was the most common complication, consistent with existing literature citing rates of 15–40% for NGT dislodgement [14,16]. Importantly, no serious adverse event attributable to NGT placement occurred, and all complications were managed conservatively without clinical sequelae. This safety profile, combined with the absence of major complications such as stomal site metastases (a rare but reported complication of PEG in oropharyngeal SCC) and buried bumper syndrome, supports the acceptability of prophylactic NGT as a routine intervention [16]. The present study has several limitations that merit acknowledgment. The use of a historical control cohort introduces the risk of selection bias and temporal confounding, including changes in IMRT technique, supportive care protocols, and dietitian availability over the study period. A randomised controlled trial comparing prophylactic NGT with reactive nutritional support would provide higher-level evidence; however, ethical constraints regarding randomising patients to withhold nutritional support, combined with the practical challenges of blinding and the strong patient preferences reported in the literature [14], make such a trial difficult to conduct. The absence of HPV status data is a recognised limitation, as HPV-positive oropharyngeal cancers have been associated with less weight loss and better treatment tolerance [24,29]. Quality of life assessment, while performed using PG-SGA, was not formally evaluated using a validated HNC-specific QOL instrument such as EORTC QLQ-H&N35, which would have provided additional insights into the functional impact of the intervention. Long-term follow-up data on dysphagia outcomes and tube dependence rates beyond the acute treatment period are not yet available for this cohort and will form the subject of subsequent analysis. Despite these limitations, the clinical and public health significance of the present findings is substantial. In the Indian context, where HNC presents predominantly at an advanced stage, where patients often have pre-existing malnutrition attributable to socioeconomic factors and tobacco/alcohol use, and where intensive outpatient dietitian support may be limited by resource constraints, prophylactic NGT represents a simple, scalable, and affordable intervention that can meaningfully improve treatment tolerance and completion. Our findings support its incorporation as a standard element of the pre-treatment management pathway for patients with locally advanced HNC undergoing definitive CCRT

Prophylactic nasogastric (Ryle's) tube insertion prior to definitive concurrent chemoradiotherapy significantly reduces treatment-related weight loss, improves nutritional status, enhances radiotherapy completion rates, and reduces unplanned hospitalisations in patients with locally advanced head and neck cancer. These benefits are achieved with an acceptable and manageable complication profile. Given its low cost, accessibility, and clinical efficacy, prophylactic NGT should be considered a standard component of supportive care for HNC patients undergoing CCRT, particularly in resource-limited settings. Prospective randomised controlled trials comparing prophylactic NGT with reactive enteral support strategies, incorporating long-term swallowing function and QOL endpoints, are warranted to further refine patient selection and optimise management pathways.

1. Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209-249. 2. Mathur P, Sathishkumar K, Chaturvedi M, et al. Cancer Statistics, 2020: Report from National Cancer Registry Programme, India. JCO Glob Oncol. 2020;6:1063-1075. 3. Pignon JP, le Maître A, Maillard E, Bourhis J; MACH-NC Collaborative Group. Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): an update on 93 randomised trials and 17,346 patients. Radiother Oncol. 2009;92(1):4-14. 4. Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer. N Engl J Med. 2004;350(19):1945-1952. 5. Bossola M. Nutritional interventions in head and neck cancer patients undergoing chemoradiotherapy: a narrative review. Nutrients. 2015;7(1):265-276. 6. Bishop S, Reed WM. The provision of enteral nutritional support during definitive chemoradiotherapy in head and neck cancer patients. J Med Radiat Sci. 2015;62(4):267-276. 7. Van Wayenburg CAM, Rasmussen-Conrad EL, van den Berg MGH, et al. Weight loss in head and neck cancer patients little noticed in general practice. J Prim Health Care. 2010;2(1):16-21. 8. Langius J, van Dijk A, Doornaert P, et al. More than 10% weight loss in head and neck cancer patients during radiotherapy is independently associated with deterioration in quality of life. Nutr Cancer. 2013;65(1):76-83. 9. Langius JAE, Twisk J, Kampman M, et al. Prediction model to predict critical weight loss in patients with head and neck cancer during (chemo)radiotherapy. Oral Oncol. 2016;52:91-96. 10. Capuano G, Grosso A, Gentile PC, et al. Influence of weight loss on outcomes in patients with head and neck cancer undergoing concomitant chemoradiotherapy. Head Neck. 2008;30(4):503-508. 11. Abu Zaid Z, Kay Neoh M, Mat Daud ZA, et al. Weight loss in post-chemoradiotherapy head and neck cancer patients. Nutrients. 2022;14(3):548. 12. Arends J, Bachmann P, Baracos V, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017;36(1):11-48. 13. Muscaritoli M, Arends J, Bachmann P, et al. ESPEN practical guideline: Clinical Nutrition in Cancer. Clin Nutr. 2021;40(5):2898-2913. 14. Corry J, Poon W, McPhee N, et al. Prospective study of percutaneous endoscopic gastrostomy tubes versus nasogastric tubes for enteral feeding in patients with head and neck cancer undergoing (chemo)radiation. Head Neck. 2009;31(7):867-876. 15. Mekhail TM, Adelstein DJ, Rybicki LA, et al. Enteral nutrition during the treatment of head and neck carcinoma: is a percutaneous endoscopic gastrostomy tube preferable to a nasogastric tube? Cancer. 2001;91(9):1785-1790. 16. Wang J, Liu M, Liu C, Ye Y, Huang G. Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for patients with head and neck cancer: a systematic review. J Radiat Res. 2014;55(3):559-567. 17. Baschnagel AM, Yadav S, Marina O, et al. Toxicities and costs of placing prophylactic and reactive percutaneous gastrostomy tubes in patients with locally advanced head and neck cancers treated with chemoradiotherapy. Head Neck. 2014;36(8):1155-1161. 18. Chen AM, Li BQ, Lau DH, et al. Evaluating the role of prophylactic gastrostomy tube placement prior to definitive chemoradiotherapy for head and neck cancer. Int J Radiat Oncol Biol Phys. 2010;78(4):1026-1032. 19. Silander E, Nyman J, Bove M, et al. Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer: a randomized study. Head Neck. 2012;34(1):1-9. 20. Beaver ME, Matheny KE, Roberts DB, Myers JN. Predictors of weight loss during radiation therapy. Otolaryngol Head Neck Surg. 2001;125(6):645-648. 21. Wang KH, Demars M, Flores SA, King VJ. The selective use of feeding tubes for head and neck cancer patients undergoing radiation therapy. Proceedings of the 40th Annual ASTRO Meeting. 1998. Abstract 1038. 22. Lee J, Wang C, Jackson WC, et al. Clinically-relevant body composition changes in head and neck cancer patients undergoing chemoradiation. Int J Radiat Oncol Biol Phys. 2014;90(1 Suppl):S708. 23. Beadle BM, Liao KP, Giordano SH, et al. Reduced feeding tube duration with IMRT for head and neck cancer: a SEER-Medicare analysis. Cancer. 2017;123(2):283-293. 24. Platek ME, Myrick E, McCloskey SA, et al. Pretreatment weight status and weight loss among head and neck cancer patients receiving definitive concurrent chemoradiation therapy: implications for nutrition integrated treatment pathways. Support Care Cancer. 2013;21(10):2825-2833. 25. Bossola M. Nutritional interventions in head and neck cancer patients undergoing chemoradiotherapy: a narrative review. Nutrients. 2015;7(1):265-276. [Cited also as: Paccagnella A, Morello M, da Mosto MC, et al. Early nutritional intervention improves treatment tolerance and outcomes in head and neck cancer patients undergoing concurrent chemoradiotherapy. Support Care Cancer. 2010;18(7):837-845.] 26. Wang J, Liu M, Liu C, Ye Y, Huang G. Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for patients with head and neck cancer: a systematic review. J Radiat Res. 2014;55(3):559-567. 27. McCloskey SA, Jaggernauth W, Rigual NR, et al. Radiation treatment interruptions greater than one week and low hemoglobin levels (12 g/dL) are predictors of local regional failure after definitive concurrent chemotherapy and IMRT for squamous cell carcinoma of the head and neck. Am J Clin Oncol. 2009;32(6):587-591. 28. Platek ME, Reid ME, Wilding GE, et al. Pretreatment nutritional status and locoregional failure in patients with head and neck cancer undergoing definitive concurrent chemoradiation therapy. Head Neck. 2011;33(11):1561-1568. 29. Platek ME, McCloskey SA, Cruz M, et al. Quantification of the effect of treatment duration on local-regional failure after definitive concurrent chemotherapy and IMRT for squamous cell carcinoma of the head and neck. Head Neck. 2013;35(5):683-689.