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210 CHAPTER 11 poorly predicts plasma drug concentrations of most cytotoxic drugs in individual patients, including cisplatin. 29,30 Currently, a prospective study investigating this relationship in HNSCC patients is ongoing. It may also be that low SMM reflects an overall poorer physical functioning in patients, which is not as distinctly found as using other routinely used risk stratification methods. In recent years, there has been increased interest in the supportive care of cancer patients undergoing chemotherapy, including increased interest in guided exercise and nutritional support during cancer treatment. A randomized controlled trial in breast cancer patients undergoing several physical activity programs showed a positive effect on treatment tolerance and fatigue. 31 A recently published randomized controlled trial in rectal cancer patients undergoing neoadju- vant CRT showed a significant increase in SMM in patients who followed an exercise program during neoadjuvant chemotherapy, compared to patients who did not. 32 A recent study in breast cancer patients undergoing adjuvant chemotherapy did not show a difference in che - motherapy completion in patients participating in an exercise intervention, but it did show a significant decrease in hospitalization during treatment. 33 Besides exercise and nutritional support during cancer treatment, ‘prehabilitation’ with exercise and nutritional support prior to start of treatment are likely to increase treatment tolerance. However, limited time between diagnosis and start of treatment may decrease the ability to effectively implement a preha - bilitation program in patients undergoing primary CRT. Feasibility studies in patients with HNSCC have shown that muscle resistance training pro - grams in patients undergoing chemoradiotherapy or radiotherapy are feasible and show high patient satisfaction. 34,35 Whether such interventions also provide benefit in terms of overall survival is unknown, but low SMM prior to start of treatment may be an indicator that a patient may benefit from intensified supportive care in terms of physical exercise and nutritional support. Pre-treatment low SMMmay also be used as an argument for an intended treatment de-escalation choice, such as weekly low-dose cisplatin, to maximize treatment adherence and cumulative cisplatin dose administered. Several limitations to this study need to be addressed. Due to the retrospective nature of the research, not all relevant research parameters for body composition or nutritional status were measured or documented during normal clinical practice. Because of the academic nature of the tertiary referral center this study was conducted in, a relatively large percentage of patients was excluded because of a trial-based treatment regimen (weekly or daily cisplatin). In the present study CDLT was defined as any toxicity resulting in a cumulative cisplatin dose of less than 200mg/m 2 ; it is generally accepted that at least a dose of 200mg/m 2 should be administered to be sufficiently effective. 3,4 In the previous study of Wendrich et al, CDLT was defined as any toxicity resulting in any chemotherapy dose-reduction of ≥50% (e.g. due to neutropenia or nephrotoxicity), a postponement of treatment of ≥4 days (e.g. in the case of