Timing matters: gastrostomy placement and outcomes in patients with head and neck cancer undergoing chemoradiotherapy

Patients with head and neck cancer (HNC) undergoing chemoradiotherapy (CRT) are at high risk of malnutrition. The optimal timing of gastrostomy [percutaneous endoscopic gastrostomy (PEG) or radiologically inserted gastrostomy (RIG)] placement remains controversial.

To compare survival, nutritional outcomes, and gastrostomy-related complications between prophylactic and later gastrostomy placement.

In this retrospective TriNetX US Collaborative Network cohort, prophylactic gastrostomy (within ±14 days of CRT initiation) was compared with early-reactive (15-90 days), late-reactive (91-180 days), and very-late (>180 days) placement using 1:1 propensity-score matching on demographic, clinical, and laboratory characteristics. Survival was measured from index gastrostomy; therefore, comparisons with later placement were conditional on survival until gastrostomy and considered exploratory rather than estimates of the effect of placement timing.

The prophylactic-versus-very-late comparison included 2,251 matched pairs, analyzed at 1-2 and 2-5 years. Post-gastrostomy survival was similar between prophylactic and early-reactive placement at both intervals [hazard ratio (HR) 0.94 and 0.95; both nonsignificant]. Compared with very-late placement, survival did not differ at 1-2 years (HR 0.90, 95% CI 0.65-1.25) but was higher at 2-5 years (88.4% vs. 83.2%; HR 0.69, 95% CI 0.48-0.98); adjusted HRs were 0.72 (0.54-0.96) and 0.61 (0.45-0.83), respectively. Survival was higher with prophylactic versus late-reactive placement at 1-2 years (84.2% vs. 77.8%; HR 0.70, 95% CI 0.54-0.90), but not at 2-5 years (HR 0.64, 95% CI 0.32-1.26). Prophylactic placement was associated with fewer gastrostomy-related complications than very-late placement (1.8% vs. 3.1% at 1-2 years; 1.3% vs. 2.6% at 2-5 years), less aspiration pneumonia at 1-2 years (1.0% vs. 1.9%), and higher serum albumin (3.89 vs. 3.70 g/dL; all p < 0.05), while malnutrition (p = 0.10) and body mass index (p = 0.45) did not differ.

Prophylactic and early-reactive placement had comparable post-gastrostomy survival, supporting early-reactive placement as a reasonable alternative in appropriately monitored patients. Poorer outcomes with late and very-late placement may identify a clinically higher-risk population rather than demonstrate a benefit of earlier placement. Prospective target-trial emulation studies are needed to define optimal timing.