Because of study heterogeneity, it was impossible to pool data between studies and conduct a meta-analysis to determine the estimates of the effects of each risk factor. However, the evidence synthesis method is also a useful method for arriving at clinical recommendations. In the present systematic review, we included only observational studies, which might result in an incomplete detection of a higher bias of risk. In addition, heterogeneity of the included studies was induced, to a certain degree, by study population, RT technique, nutritional supplementation, and follow-up periods. Accordingly, although the results of this systematic review should be considered valid, these methodological quality considerations should be taken into account when interpreting the findings.
This study also showed that a higher BMI before treatment was a strong risk factor for weight loss in HNC patients undergoing RT. Patients with overweight or obesity according to the BMI classification demonstrated significantly greater weight loss than did patients with normal weight.23,31,33,37 One previous study had conflicting results when considering pretreatment BMI as a predictor for weight loss and use of nutritional support during RT.42 Tube feeding is often initiated for patients with a low BMI before treatment. The reason patients with a low BMI experienced less weight loss may be that these patients were more likely to receive tube feeding.23 Both healthcare professionals and patients need to reconsider their belief that patients with a higher BMI might be in better nutritional balance than patients with a lower BMI. We suggest that using nutritional supplementation for higher BMI patients undergoing RT is equally important to using it with lower BMI patients.
We also identified 8 moderate-evidence predictors and 30 limited-evidence predictors. Although some of these potential risk factors (eg, multimodal therapy, QoL issues, and metabolic indictors) are not strong evidence factors, a better understanding of these risk factors still contributes to identify patients at different degrees of risk for weight loss and helps to develop preventative measures.
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