Prophylactic vs. reactive percutaneous endoscopic gastrostomy (PEG) tubes in head and neck cancer: a meta-analysis of survival and supportive care outcomes.

purposeThe optimal timing of percutaneous endoscopic gastrostomy (PEG) tube insertion in head and neck cancer (HNC) remains controversial. While prophylactic PEG placement may prevent treatment-related malnutrition, its true clinical value compared with a reactive strategy is unclear. This systematic review and meta-analysis aimed to evaluate whether prophylactic PEG offers advantages in PEG tube dependence, hospitalization rates, and overall survival among patients undergoing chemoradiotherapy for HNC.

methodsA comprehensive search of PubMed, Scopus, and Web of Science was conducted through September 2025. Two independent reviewers screened and selected studies comparing prophylactic and reactive PEG placement. PEG dependence and survival data were pooled using random-effects meta-analytic models for time-dependent dependency estimates. Hospitalization outcomes were synthesized narratively.

resultsNine studies involving 1279 patients met the inclusion criteria. Longitudinal analysis of PEG tube dependence showed that the odds of a tube remaining in situ decreased by 0.5% for each passing month (0.995; p = 0.002). Reactive placement was associated with a nonsignificant 1.0% increase in the odds of dependence compared to the prophylactic group (p > 0.9). Milestone analyses confirmed these findings, with no significant differences in the odds of tube retention at 6 months (OR 1.15; p = 0.72) or 12 months (OR 0.95; p = 0.92). Overall survival showed a nonsignificant 8.8% reduction in median survival time for the reactive group (pooled median survival ratio 0.912; p = 0.6). Pairwise survival odds did not differ significantly at 12 months (OR 1.60; p = 0.19) or 24 months (OR 1.15; p = 0.64). Prophylactic PEG placement resulted in consistently fewer hospitalizations and a more stable nutritional status during treatment.

conclusionNo significant differences in survival were observed between prophylactic and reactive PEG strategies; however, these findings should be interpreted with caution due to the methodological limitations of the available data. They do offer meaningful supportive care benefits, including reduced hospitalizations and nutritional decline. These findings support individualized PEG timing based on patient risk factors and anticipated treatment toxicity.