PEG timing in head and neck cancer: Is there a sweet spot? A real world study.

Abstract

e18116 Background: Malnutrition and dysphagia are common during chemoradiation for head and neck cancer, with 30–50% of patients malnourished at diagnosis and over 60% losing ≥5% body weight during treatment. Percutaneous endoscopic gastrostomy (PEG) tubes are widely used to support nutrition, yet the optimal timing of placement remains unclear. Prior studies have shown mixed results with no consistent impact on pneumonia, unplanned care, treatment completion, or survival. Current guidelines reflect this uncertainty and do not recommend an uniform approach to PEG timing. Methods: We conducted a retrospective cohort study using the TriNetX Network. Adults with oral cavity, oropharyngeal, or laryngeal cancers receiving definitive radiation therapy with or without cisplatin or carboplatin were included. Radiation start defined the index date. PEG placement was classified as timely if within 7 days of radiation initiation and untimely if after 7 days and up to 3 months. Outcomes within 90 days included aspiration pneumonia, IV hydration, acute kidney injury (AKI), and syncope or orthostatic events. Overall survival was assessed at 12 months. Propensity score matching was performed 1:1 using age, sex, cancer site grouping, gastrointestinal comorbidities, and other baseline characteristics, yielding two balanced cohorts of 267 patients. Results: Aspiration pneumonia occurred in 10.5% of patients with timely PEG placement and 11.6% with untimely placement (p=0.73). IV hydration was lower in the timely PEG cohort (44.9% vs 62.9%, p<0.001). AKI occurred in 15.3% of the timely cohort and 30.5% of the untimely cohort (RR 0.50, 95% CI 0.37–0.68). Syncope or orthostatic events occurred in 6.5% and 12.1%, respectively (RR 0.54, 95% CI 0.32–0.89). One-year overall survival was 77.1% with timely PEG and 82.1% with untimely placement (HR 1.34, p=0.57). Conclusions: This analysis shows that PEG timing acts as an important supportive care measure in treating patients with definitive intent concurrent chemoRT. Earlier PEG placement did not influence aspiration pneumonia or one year survival but was associated with fewer dehydration related complications, including IV fluid use, acute kidney injury, and syncope, suggesting improved tolerance of chemoradiation when nutritional access is established early. These findings move the PEG timing discussion toward objective outcomes that reflect day to day treatment tolerance. Early PEG placement should be considered for patients at higher risk of nutritional and volume compromise, while delayed placement appears reasonable for patients able to maintain intake. Assessment of treatment interruptions as a function of time from radiation initiation was not feasible in this dataset, though deeper evaluation of treatment continuity in relation to PEG timing represents an important area for future study. Residual confounding from unmeasured factors influencing PEG selection remains possible.