Matched case-control study of quality of life and xerostomia after intensity-modulated radiotherapy or standard radiotherapy for head-and-neck cancer: initial report

Normal tissue complication probability model parameter estimation for xerostomia in head and neck cancer patients based on scintigraphy and quality of life assessments

BACKGROUND

With advances in modern radiotherapy (RT), many patients with head and neck (HN) cancer can be effectively cured. However, xerostomia is a common complication in patients after RT for HN cancer. The purpose of this study was to use the Lyman-Kutcher-Burman (LKB) model to derive parameters for the normal tissue complication probability (NTCP) for xerostomia based on scintigraphy assessments and quality of life (QoL) questionnaires. We performed validation tests of the Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) guidelines against prospectively collected QoL and salivary scintigraphic data.

METHODS

Thirty-one patients with HN cancer were enrolled. Salivary excretion factors (SEFs) measured by scintigraphy and QoL data from self-reported questionnaires were used for NTCP modeling to describe the incidence of grade 3+ xerostomia. The NTCP parameters estimated from the QoL and SEF datasets were compared. Model performance was assessed using Pearson's chi-squared test, Nagelkerke's R2, the area under the receiver operating characteristic curve, and the Hosmer-Lemeshow test. The negative predictive value (NPV) was checked for the rate of correctly predicting the lack of incidence. Pearson's chi-squared test was used to test the goodness of fit and association.

RESULTS

Using the LKB NTCP model and assuming n=1, the dose for uniform irradiation of the whole or partial volume of the parotid gland that results in 50% probability of a complication (TD50) and the slope of the dose-response curve (m) were determined from the QoL and SEF datasets, respectively. The NTCP-fitted parameters for local disease were TD50=43.6 Gy and m=0.18 with the SEF data, and TD50=44.1 Gy and m=0.11 with the QoL data. The rate of grade 3+ xerostomia for treatment plans meeting the QUANTEC guidelines was specifically predicted, with a NPV of 100%, using either the QoL or SEF dataset.

CONCLUSIONS

Our study shows the agreement between the NTCP parameter modeling based on SEF and QoL data, which gave a NPV of 100% with each dataset, and the QUANTEC guidelines, thus validating the cut-off values of 20 and 25 Gy. Based on these results, we believe that the QUANTEC 25/20-Gy spared-gland mean-dose guidelines are clinically useful for avoiding xerostomia in the HN cohort.

[Intensity modulated radiotherapy for head and neck cancers: ethics and patients selection]

PURPOSE

Intensity modulated radiotherapy (IMRT) allows a better coverage of the target volume and a better saving of organs at risk with a decrease of toxicity in head and neck cancers. It requires more human labor and materials compared to conformational radiotherapy. If they are insufficient, a selection of the patients receiving IMRT may be necessary, raising an ethical problem.

MATERIAL AND METHODS

We collected the motives guiding the choice of the technique of radiotherapy for head and neck cancers during a month of physicists' shortage.

RESULTS

Nineteen patients received IMRT and eight conformational radiotherapy. Conformational irradiation was chosen in palliative and postsurgery treatments, to reduce delay, in laryngeal tumors and re-irradiation. IMRT was preferred for complex target volumes and the localizations at risk of important xerostomia following conformational radiotherapy. These choices were confronted with the bioethics criteria of Beauchamp and Childress. The beneficence justified the use of IMRT or conformational radiotherapy depending on the circumstances. The non-maleficence attempted to decrease the toxicity with IMRT. Justice was questioned by the selection. The autonomy of patients was not totally respected in the choice.

CONCLUSION

To help in the choice of the patients receiving an IMRT in a crisis situation, we proposed a hierarchical organization of selection criteria: complex volumes close to critical organs at risk, localization with high risk of xerostomia, long life expectancy and postoperative delay constraints.

Toxicities affecting quality of life after chemo-IMRT of oropharyngeal cancer: prospective study of patient-reported, observer-rated, and objective outcomes

PURPOSE

To test the hypothesis that intensity modulated radiation therapy (IMRT) aiming to spare the salivary glands and swallowing structures would reduce or eliminate the effects of xerostomia and dysphagia on quality of life (QOL).

METHODS AND MATERIALS

In this prospective, longitudinal study, 72 patients with stage III-IV oropharyngeal cancer were treated uniformly with definitive chemo-IMRT sparing the salivary glands and swallowing structures. Overall QOL was assessed by summary scores of the Head Neck QOL (HNQOL) and University of Washington QOL (UWQOL) questionnaires, as well as the HNQOL "Overall Bother" question. Quality of life, observer-rated toxicities (Common Toxicity Criteria Adverse Effects scale, version 2), and objective evaluations (videofluoroscopy assessing dysphagia and saliva flow rates assessing xerostomia) were recorded from before therapy through 2 years after therapy. Correlations between toxicities/objective evaluations and overall QOL were assessed using longitudinal repeated measures of analysis and Pearson correlations.

RESULTS

All observer-rated toxicities and QOL scores worsened 1-3 months after therapy and improved through 12 months, with minor further improvements through 24 months. At 12 months, dysphagia grades 0-1, 2, and 3, were observed in 95%, 4%, and 1% of patients, respectively. Using all posttherapy observations, observer-rated dysphagia was highly correlated with all overall QOL measures (P<.0001), whereas xerostomia and mucosal and voice toxicities were significantly correlated with some, but not all, overall QOL measures, with lower correlation coefficients than dysphagia. Late overall QOL (≥6 or ≥12 months after therapy) was primarily associated with observer-rated dysphagia, and to a lesser extent with xerostomia. Videofluoroscopy scores, but not salivary flows, were significantly correlated with some of the overall QOL measures.

CONCLUSION

After chemo-IMRT, although late dysphagia was on average mild, it was still the major correlate of QOL. Further efforts to reduce swallowing dysfunction are likely to yield additional gains in QOL.

Interobserver variation in parotid gland delineation: a study of its impact on intensity-modulated radiotherapy solutions with a systematic review of the literature

OBJECTIVES

This study evaluates the interobserver variation in parotid gland delineation and its impact on intensity-modulated radiotherapy (IMRT) solutions.

METHODS

The CT volumetric data sets of 10 patients with oropharyngeal squamous cell carcinoma who had been treated with parotid-sparing IMRT were used. Four radiation oncologists and three radiologists delineated the parotid gland that had been spared using IMRT. The dose-volume histogram (DVH) for each study contour was calculated using the IMRT plan actually delivered for that patient. This was compared with the original DVH obtained when the plan was used clinically.

RESULTS

70 study contours were analysed. The mean parotid dose achieved during the actual treatment was within 10% of 24 Gy for all cases. Using the study contours, the mean parotid dose obtained was within 10% of 24 Gy for only 53% of volumes by radiation oncologists and 55% of volumes by radiologists. The parotid DVHs of 46% of the study contours were sufficiently different from those used clinically, such that a different IMRT plan would have been produced.

CONCLUSION

Interobserver variation in parotid gland delineation is significant. Further studies are required to determine ways of improving the interobserver consistency in parotid gland definition.

Intensity-modulated radiotherapy for nasopharyngeal carcinoma: improvement of the therapeutic ratio with helical tomotherapy vs segmental multileaf collimator-based techniques

OBJECTIVES

The aim of the study was to compare differences in dosimetric, clinical and quality-of-life end points among patients treated with helical tomotherapy (HT) and segmental multileaf collimator (SMLC)-based intensity-modulated radiotherapy (IMRT) for nasopharyngeal carcinoma.

METHODS

From June 2005 to August 2009, 30 consecutive patients were treated with IMRT for nasopharyngeal carcinoma to a dose of 70 Gy. 14 patients (47%) were treated using HT and 16 (53%) were treated using SMLC-based IMRT. 28 patients (93%) received concurrent chemotherapy. The patients were evenly balanced between the two radiotherapy groups with respect to clinical and pathological characteristics. Median follow-up was 30 months (range, 6-62 months).

RESULTS

The 2-year estimates of overall survival, local-regional control and progression-free survival were 81%, 87% and 82%, respectively. There were no significant differences in any of these end points with respect to IMRT technique (p>0.05 for all). Dosimetric analysis revealed that patients treated by HT had significantly improved salivary sparing with respect to mean dose (27.3 vs 34.1 Gy, p=0.03) and volume receiving greater than or equal to 30 Gy (31.7% vs 47.3%, p=0.01) to the contralateral (spared) parotid gland. The incidence of Grade 3+ late xerostomia was 13 and 7% among patients treated with SMLC-based IMRT and HT, respectively (p=0.62). The corresponding proportion of patients who subjectively reported "too little" or "no" saliva at final follow-up was 38% and 7%, respectively (p=0.04).

CONCLUSION

The superior dosimetric outcome observed with HT appeared to translate into moderately improved clinical outcomes with respect to salivary sparing. Prospective trials are needed to validate this gain in the therapeutic ratio.

Scintigraphic assessment of salivary function after intensity-modulated radiotherapy for head and neck cancer: correlations with parotid dose and quality of life

OBJECTIVE

We investigated salivary function using quantitative scintigraphy and sought to identify functional correlations between parotid dose and quality of life (QoL) for head and neck cancer (HNC) patients receiving intensity-modulated radiotherapy (IMRT).

MATERIALS AND METHODS

Between August, 2007 and June, 2008, 31 patients treated IMRT for HNC were enrolled in this prospective study. Salivary excretion function (SEF) was previously measured by salivary scintigraphy at annual intervals for 2 years after IMRT. A dose-volume histogram of each parotid gland was calculated, and the normal tissue complication probability (NTCP) was used to determine the tolerance dose. QoL was longitudinally assessed by the EORTC QLQ-C30 and H&N35 questionnaires prior to RT, and at one, three, 12 and 24 months after RT.

RESULTS

A significant correlation was found between the reduction of SEF and the mean parotid dose measured at 1 year (correlation coefficient, R(2)=0.651) and 2 years (R(2)=0.310) after IMRT (p<0.001). The TD(50) of the parotid gland at 1 year after IMRT is 43.6 Gy, comparable to results from western countries. We further found that contralateral parotid and submandibular gland function preservation was correlated with reduced sticky saliva and a better QoL compared to the functional preservation of both parotid glands, as determined by the EORTC QLQ-H&N35 questionnaire.

CONCLUSION

A significant correlation was found between the reduction of SEF and the mean parotid dose. Preservation of contralateral parotid and submandibular gland function predicts a better QoL compared to preservation of the function of both parotid glands.

Intensity-modulated radiotherapy in the treatment of head and neck cancer

Intensity-modulated radiotherapy (IMRT) is a newer method of radiotherapy that uses intensity-modulated beams that can provide multiple intensity levels for any single-beam direction and any single-source position, allowing concave dose distributions and dose gradients with narrower margins than those possible using conventional methods. IMRT is ideal for treating complex treatment volumes and avoiding close proximity organs at risk that may be dose limiting and provides increased tumour control through an escalated dose and reduces normal tissue complications through organ at risk sparing. Given the potential advantages of IMRT and the availability of IMRT-enabled treatment planning systems and linear accelerators, IMRT has been introduced in a number of disease sites, including head and neck cancer. This systematic review examined the evidence for IMRT compared with two-dimensional external beam radiotherapy (EBRT) in the treatment of head and neck cancer in order to quantify the potential benefits of this new technology and made recommendations for radiation treatment programmes considering adopting this technique. Findings were in favour of IMRT compared with two-dimensional EBRT where avoidance of the adverse outcomes xerostomia, osteoradionecrosis and blindness are the main outcomes of interest, based on a review of 15 papers including 1555 patients. There are insufficient data to recommend IMRT over two-dimensional EBRT if treatment-related outcomes are the main outcomes of interest. Future research should focus on additional normal tissue preservation, and the role of IMRT in the treatment of recurrent head and neck cancer, as well as its use in combination with surgery, chemotherapy and/or brachytherapy.

Quality-of-life among head and neck cancer survivors at one year after treatment--a systematic review

BACKGROUND

The importance of quality-of-life (QoL) research has been recognised over the past two decades in patients with head and neck (H&N) cancer. The aims of this systematic review are to evaluate the QoL status of H&N cancer survivors one year after treatment and to identify the determinants affecting their QoL.

METHODS

Pubmed, Medline, Scopus, Sciencedirect and CINAHL (2000-2011) were searched for relevant studies, and two of the present authors assessed their methodological quality. The characteristics and main findings of the studies were extracted and reported.

RESULTS

Thirty-seven studies met the inclusion criteria, and the methodological quality of the majority was moderate to high. While patients of the group in question recover their global QoL by 12 months after treatment, a number of outstanding issues persist - deterioration in physical functioning, fatigue, xerostomia and sticky saliva. Age, cancer site, stage of disease, social support, smoking, feeding tube placement and alcohol consumption are the significant determinants of QoL at 12 months, while gender has little or no influence.

CONCLUSIONS

Regular assessments should be carried out to monitor physical functioning, degree of fatigue, xerostomia and sticky saliva. Further research is required to develop appropriate and effective interventions to deal with these issues, and thus to promote the patients' QoL.

A phase II study of submandibular gland transfer prior to radiation for prevention of radiation-induced xerostomia in head-and-neck cancer (RTOG 0244)

PURPOSE

We report the results of a phase II study to determine the reproducibility of a submandibular salivary gland transfer (SGT) surgical technique for prevention of radiation (XRT)-induced xerostomia in a multi-institutional setting and to assess severity of xerostomia.

METHODS AND MATERIALS

Eligible patients had surgery for primary, neck dissection, and SGT, followed by XRT, during which the transferred salivary gland was shielded. Intensity modulated radiation therapy, amifostine, and pilocarpine were not allowed, but postoperative chemotherapy was allowed. Each operation was reviewed by 2 reviewers and radiation by 1 reviewer. If 13 or more (of 43) were "not per protocol," then the technique would be considered not reproducible as per study design. The secondary endpoint was the rate of acute xerostomia, grade 2 or higher, and a rate of ≤ 51% was acceptable.

RESULTS

Forty-four of the total 49 patients were analyzable: male (81.8%), oropharynx (63.6%), stage IV (61.4%), median age 56.5 years. SGT was "per protocol" or within acceptable variation in 34 patients (77.3%) and XRT in 79.5%. Nine patients (20.9%) developed grade 2 acute xerostomia; 2 had grade 0-1 xerostomia (4.7%) but started on amifostine/pilocarpine. Treatment for these 11 patients (25.6%) was considered a failure for the xerostomia endpoint. Thirteen patients died; median follow-up for 31 surviving patients was 2.9 years. Two-year overall and disease-free survival rates were 76.4% and 71.7%, respectively.

CONCLUSIONS

The technique of submandibular SGT is reproducible in a multicenter setting. Seventy-four percent of patients were prevented from XRT-induced acute xerostomia.

[Oropharyngeal candidiasis and radiotherapy]

The oropharyngeal candidiasis is a common condition in cancer patients treated by irradiation, during and after their treatment. For example, almost 70% of patients treated with chemoradiation for head and neck cancer are colonized, and 40% of symptomatic patients have an oropharyngeal candidiasis. Furthermore, we noticed an increase in non-albicans Candida strains, which are present in almost 50% of samples. Cancer treatments, especially radiation therapy, and comorbidities are risk factors of oropharyngeal candidiasis. Oropharyngeal candidiasis has substantial effects on quality of life, and may limit treatment. Epidemiologic data, physiopathology, clinical diagnosis criteria, consequences and treatment of oropharyngeal candidiasis will be discussed in this article.

Intensity-modulated radiotherapy is associated with improved global quality of life among long-term survivors of head-and-neck cancer

PURPOSE

To compare the long-term quality of life among patients treated with and without intensity-modulated radiotherapy (IMRT) for head-and-neck cancer.

METHODS AND MATERIALS

The University of Washington Quality of Life instrument scores were reviewed for 155 patients previously treated with radiation therapy for locally advanced head-and-neck cancer. All patients were disease free and had at least 2 years of follow-up. Eighty-four patients (54%) were treated with IMRT. The remaining 71 patients (46%) were treated with three-dimensional conformal radiotherapy (3D CRT) by use of initial opposed lateral fields matched to a low anterior neck field.

RESULTS

The mean global quality of life scores were 67.5 and 80.1 for the IMRT patients at 1 and 2 years, respectively, compared with 55.4 and 57.0 for the 3D CRT patients, respectively (p < 0.001). At 1 year after the completion of radiation therapy, the proportion of patients who rated their global quality of life as "very good" or "outstanding" was 51% and 41% among patients treated by IMRT and 3DCRT, respectively (p = 0.11). At 2 years, the corresponding percentages increased to 73% and 49%, respectively (p < 0.001). On multivariate analysis accounting for sex, age, radiation intent (definitive vs. postoperative), radiation dose, T stage, primary site, use of concurrent chemotherapy, and neck dissection, the use of IMRT was the only variable independently associated with improved quality of life (p = 0.01).

CONCLUSION

The early quality of life improvements associated with IMRT not only are maintained but apparently become more magnified over time. These data provide powerful evidence attesting to the long-term benefits of IMRT for head-and-neck cancer.

Posttreatment quality-of-life assessment in patients with head and neck cancer treated with intensity-modulated radiation therapy

OBJECTIVES

To evaluate patient-reported quality-of-life (QOL) domains in patients with head and neck cancer (HNC) treated with intensity-modulated radiotherapy (IMRT); specifically time-based QOL changes compared with baseline and correlation with independent variables.

METHODS

Between January 2002 and August 2006, we prospectively administered the University of Washington Quality of Life-Revised assessment to 143 patients with primary HNC treated with IMRT to investigate the impact of treatment on 12 QOL domains. We analyzed 108 patients with more than 6 months follow-up for correlation between QOL domains and independent variables.

RESULTS

Patients were divided into 2 groups based on mean parotid gland dose with a 26-Gy threshold. We saw in general, an acute drop in all scores after starting treatment regardless of the degree of parotid sparing. If the parotid received a mean dose ≥26 Gy, then the acute decrease was larger than if the parotid received less than 26 Gy. Higher radiation dose to the parotid resulted in significantly lower QOL scores over 9 months (pain) and often more than 2 years (chewing and taste). No significance was found between the domains and the independent variables assessed.

CONCLUSIONS

Patients with HNC treated with IMRT experienced an acute decrement in QOL across many domains despite parotid sparing. Lower radiation doses to the parotid corresponded to a smaller decrease in QOL and an earlier return to baseline compared with higher doses. Self-reported QOL and functional outcomes are important determinants of patient satisfaction and should be evaluated in future studies.

Submandibular salivary gland transfer for the prevention of radiation-induced xerostomia in patients with nasopharyngeal carcinoma: 5-Year outcomes

BACKGROUND

Our aim in this study was to investigate the value of the submandibular salivary gland transfer procedure in prevention of radiation-induced xerostomia in patients with nasopharyngeal carcinoma (NPC).

METHODS

In all, there were 70 patients, consisting of a test group (36 patients) and a control group (34 patients) in a nonrandomized fashion. In the test group, the submandibular salivary gland was transferred to submental space before radiotherapy (XRT) and shielded. Salivary gland functions were evaluated by the amount of saliva and a quality of life questionnaire before and after XRT and 3 and 60 months after XRT.

RESULTS

At 5 years, the trapping and excretion functions of salivary gland were significantly better in the test group (p = .000 and p = .000). The mean weight of saliva after XRT was heavier (1.65 g vs 0.73 g, p = .000), and the incidence of xerostomia was lower in the test group, with no difference in 5-year survival and neck nodal recurrence between the 2 groups.

CONCLUSIONS

Salivary gland transfer procedure prevents XRT-induced xerostomia and improves quality of life of patients with NPC.

Comparison of IMRT techniques in the radiotherapeutic management of head and neck cancer: is tomotherapy "better" than step-and-shoot IMRT?

Currently, the most common method of delivering intensity-modulated radiotherapy (IMRT) is through step-and-shoot, segmental multi-leaf collimator (SMLC)-based techniques. Although rotational delivery methods such as helical tomotherapy (HT) have been proposed as offering advantages in the treatment of head and neck cancer, a lack of clinical data exists on its potential utility. This study compared dosimetric, clinical, and quality-of-life endpoints among 149 patients treated by HT and SMLC-IMRT for head and neck cancer. Dosimetric analysis revealed that the use of HT resulted in significant improvements with respect to mean dose (23.5 versus 27.9 Gy, p = 0.03) and V30 (30.1 versus 43.9 Gy, p = 0.01) to the contralateral (spared) parotid gland. However, the incidence of grade 3+ xerostomia in the late setting was 10% and 8% among patients treated by HT and SMLC-IMRT, respectively (p = 0.46). There were no significant differences in any of the quality of life endpoints among patients treated by HT and SMLC-IMRT (p > 0.05, for all). Acknowledging the biases inherent in this retrospective analysis, we found that the dosimetric advantages observed with HT compared to SMLC-IMRT failed to translate into significant improvements in clinical outcome. Prospective studies are needed to further evaluate how HT may affect the therapeutic ratio.

Recovery of salivary epidermal growth factor in parotid saliva following parotid sparing radiation therapy: a proof-of-principle study

BACKGROUND

Although radiation therapy (RT) causes permanent xerostomia, parotid-sparing radiation therapy (PSRT) ensures recovery of saliva quantity over time. Salivary epidermal growth factor (EGF) is produced primarily by parotid glands.

OBJECTIVES

The aim of this study was to determine whether salivary EGF can be detected in parotid saliva after PSRT and whether protein secretion is time dependent.

STUDY DESIGN

Salivary EGF concentration (pg/mL) was determined by enzyme-linked immunosorbent assay in stimulated parotid saliva before RT and at 3, 6, and 12 months after RT from 22 patients with head and neck cancer treated with PSRT.

RESULTS

Saliva samples were from 17 men and 5 women (age ranges 23-70 years and 46-71 years, respectively). At 6 months after RT, EGF concentration was 407 pg/mL lower than at baseline (P = .045). Twelve months after PSRT, parotid glands produce substantial amounts of EGF and other proteins, eventually approximating pre-RT levels, with recovery of salivary function.

CONCLUSIONS

This proof-of-principle study shows that even proteins in picogram quantities, such as EGF, can be detected in saliva after PSRT.

Cervical lymph node metastases from unknown primary cancer: a single-institution experience with intensity-modulated radiotherapy

PURPOSE

To determine the effectiveness and rate of complications of intensity-modulated radiotherapy (IMRT) in the treatment of cervical lymph node metastases from unknown primary cancer.

METHODS AND MATERIALS

Between February 2005 and November 2008, 25 patients with an unknown primary cancer underwent IMRT, with a median radiation dose of 70 Gy. The bilateral neck and ipsilateral putative pharyngeal mucosa were included in the target volume. All patients had squamous cell carcinoma, except for 1 patient who had adenosquamous differentiation. They were all treated with curative intent. Of the 25 included patients, 20 were men and 5 were women, with a median age of 54 years. Of these patients, 3 had Stage III, 18 had Stage IVa, and 4 had Stage IVb. Of the 25 patients, 18 (72%) received platinum-based chemotherapy in a combined-modality setting. Neck dissection was reserved for residual disease after definitive IMRT. Overall survival, disease-free survival, and locoregional control were calculated using the Kaplan-Meier method.

RESULTS

With a median follow-up of 38 months, the overall survival, disease-free survival, and locoregional control rates were all 100% at 3 years. No occurrence of primary cancer was observed during the follow-up period. The reported rates of xerostomia reduced with the interval from the completion of treatment. Nine patients (36%) reported Grade 2 or greater xerostomia at 6 months, and only 2 (8%) of them reported the same grade of salivary function toxicity after 24 months of follow-up.

CONCLUSION

In our institution, IMRT for unknown primary cancer has provided good overall and disease-free survival in all the patients with an acceptable rate of complications. IMRT allowed us to address the bilateral neck and ipsilateral putative pharyngeal mucosa with minimal late salivary function toxicity. The use of concurrent chemotherapy and IMRT for more advanced disease led to good clinical results with reasonable toxicities.

Evidence-based review: quality of life following head and neck intensity-modulated radiotherapy

Inverse planned Intensity modulated radiotherapy (IMRT) can minimize the dose to normal structures and therefore can reduce long-term radiotherapy-related morbidity and may improve patients' long-term quality of life. Despite overwhelming evidence that IMRT can reduce late functional deficits in patients with head and neck cancer, treated with radiotherapy, a review of the published literature produced conflicting results with regard to quality of life outcomes. Following a critical appraisal of the literature, reasons for the discrepant outcomes are proposed.

Influence of intensity-modulated radiation therapy technique on xerostomia and related quality of life in patients treated with intensity-modulated radiation therapy for nasopharyngeal cancer

BACKGROUND

The purpose of this study was to compare 5-field and 7-field intensity-modulated radiation therapy (IMRT) techniques in terms of xerostomia and related quality of life in patients with nasopharyngeal cancer.

METHODS

Eight and 23 patients were treated with 5-field (group I) and 7-field (group II) techniques, respectively. The xerostomia was evaluated using the Radiation Therapy Oncology Group (RTOG) scale, stimulated and unstimulated salivary flow (SSF/USF), and xerostomia-related questionnaires (XQs). The assessments were done before and at 3, 6, 12, 18, and 24 months after radiotherapy.

RESULTS

The mean parotid dose was 45.7 Gy and 29.9 Gy and the ≥G3 toxicity at 24 months was 25% and 19% in group I and II, respectively. Sixty-three percent and 93% of patients recovered at least 25% of SSF pretherapy values. The XQ scores of both groups improved over time but more so in group II.

CONCLUSION

The 7-field technique decreases the mean parotid dose, reducing xerostomia assessed by the RTOG/XQ score.

Intensity-modulated radiotherapy versus conventional and 3D conformal radiotherapy in patients with head and neck cancer: is there a worthwhile quality of life gain?

BACKGROUND

Intensity-modulated radiotherapy (IMRT) is a technique that allows delivery of lower doses of radiation to normal tissue, while maintaining or increasing the tumour dose, compared with two-dimensional radiotherapy (2DRT) or three-dimensional conformal radiotherapy (3DCRT). This review of published data was undertaken to assess whether IMRT is associated with quality of life (QoL) benefits versus 2DRT and 3DCRT.

DESIGN

English-language literature published between January 2005 and August 2010 was searched for studies comparing IMRT versus 2DRT or 3DCRT in head and neck cancers that included QoL evaluation. Fourteen studies (five prospective and nine retrospective) were identified, two in abstract form only. Only one study was randomised. Studies included patients with nasopharyngeal cancer only, oropharyngeal cancer only and mixed populations.

RESULTS

The EORTC QLQ-C30 was the most widely used instrument, generally supplemented with the head and neck cancer module H&N35. IMRT was associated with statistically significant improvements in certain QoL domains versus 2DRT and 3DCRT, particularly those relating to xerostomia, including dry mouth, sticky saliva and eating-related domains. Improvements in global QoL were also observed in the IMRT groups in some studies.

CONCLUSION

Based on the studies reviewed, patients treated with IMRT experience statistically significant improvements in several important QoL domains versus 2DRT and 3DCRT. However, studies included heterogeneous populations, different timepoints for measurements and a variety of instruments for QoL assessment. Accepting the difficulties in execution, IMRT should be compared with 3DCRT in prospective randomised studies in homogeneous patient populations, using appropriate QoL assessments and clinical end points, to establish if IMRT provides enough value for the additional resources involved.

Simultaneous integrated boost using intensity-modulated radiotherapy compared with conventional radiotherapy in patients treated with concurrent carboplatin and 5-fluorouracil for locally advanced oropharyngeal carcinoma

PURPOSE

To compare, in a retrospective study, the toxicity and efficacy of simultaneous integrated boost using intensity-modulated radiotherapy (IMRT) vs. conventional radiotherapy (CRT) in patients treated with concomitant carboplatin and 5-fluorouracil for locally advanced oropharyngeal cancer.

METHODS AND MATERIALS

Between January 2000 and December 2007, 249 patients were treated with definitive chemoradiation. One hundred patients had 70 Gy in 33 fractions using IMRT, and 149 received CRT at 70 Gy in 35 fractions. Overall survival, disease-free survival, and locoregional control were estimated using the Kaplan-Meier method.

RESULTS

Median follow-up was 42 months. Three-year actuarial rates for locoregional control, disease-free survival, and overall survival were 95.1% vs. 84.4% (p = 0.005), 85.3% vs. 69.3% (p = 0.001), and 92.1% vs. 75.2% (p < 0.001) for IMRT and CRT, respectively. The benefit of the radiotherapy regimen on outcomes was also observed with a Cox multivariate analysis. Intensity-modulated radiotherapy was associated with less acute dermatitis and less xerostomia at 6, 12, 24, and 36 months.

CONCLUSIONS

This study suggests that simultaneous integrated boost using IMRT is associated with favorable locoregional control and survival rates with less xerostomia and acute dermatitis than CRT when both are given concurrently with chemotherapy.

Parotid-sparing intensity modulated versus conventional radiotherapy in head and neck cancer (PARSPORT): a phase 3 multicentre randomised controlled trial

Background

Xerostomia is the most common late side-effect of radiotherapy to the head and neck. Compared with conventional radiotherapy, intensity-modulated radiotherapy (IMRT) can reduce irradiation of the parotid glands. We assessed the hypothesis that parotid-sparing IMRT reduces the incidence of severe xerostomia.

Methods

We undertook a randomised controlled trial between Jan 21, 2003, and Dec 7, 2007, that compared conventional radiotherapy (control) with parotid-sparing IMRT. We randomly assigned patients with histologically confirmed pharyngeal squamous-cell carcinoma (T1–4, N0–3, M0) at six UK radiotherapy centres between the two radiotherapy techniques (1:1 ratio). A dose of 60 or 65 Gy was prescribed in 30 daily fractions given Monday to Friday. Treatment was not masked. Randomisation was by computer-generated permuted blocks and was stratified by centre and tumour site. Our primary endpoint was the proportion of patients with grade 2 or worse xerostomia at 12 months, as assessed by the Late Effects of Normal Tissue (LENT SOMA) scale. Analyses were done on an intention-to-treat basis, with all patients who had assessments included. Long-term follow-up of patients is ongoing. This study is registered with the International Standard Randomised Controlled Trial register, number ISRCTN48243537.

Findings

47 patients were assigned to each treatment arm. Median follow-up was 44·0 months (IQR 30·0–59·7). Six patients from each group died before 12 months and seven patients from the conventional radiotherapy and two from the IMRT group were not assessed at 12 months. At 12 months xerostomia side-effects were reported in 73 of 82 alive patients; grade 2 or worse xerostomia at 12 months was significantly lower in the IMRT group than in the conventional radiotherapy group (25 [74%; 95% CI 56–87] of 34 patients given conventional radiotherapy vs 15 [38%; 23–55] of 39 given IMRT, p=0·0027). The only recorded acute adverse event of grade 2 or worse that differed significantly between the treatment groups was fatigue, which was more prevalent in the IMRT group (18 [41%; 99% CI 23–61] of 44 patients given conventional radiotherapy vs 35 [74%; 55–89] of 47 given IMRT, p=0·0015). At 24 months, grade 2 or worse xerostomia was significantly less common with IMRT than with conventional radiotherapy (20 [83%; 95% CI 63–95] of 24 patients given conventional radiotherapy vs nine [29%; 14–48] of 31 given IMRT; p<0·0001). At 12 and 24 months, significant benefits were seen in recovery of saliva secretion with IMRT compared with conventional radiotherapy, as were clinically significant improvements in dry-mouth-specific and global quality of life scores. At 24 months, no significant differences were seen between randomised groups in non-xerostomia late toxicities, locoregional control, or overall survival.

Interpretation

Sparing the parotid glands with IMRT significantly reduces the incidence of xerostomia and leads to recovery of saliva secretion and improvements in associated quality of life, and thus strongly supports a role for IMRT in squamous-cell carcinoma of the head and neck.

Funding

Cancer Research UK (CRUK/03/005).

A review of the clinical evidence for intensity-modulated radiotherapy

AIMS

Intensity-modulated radiotherapy (IMRT) is a development of three-dimensional conformal radiotherapy that offers improvements in dosimetry in many clinical scenarios. Here we review the clinical evidence for IMRT and present ongoing or unpublished randomised controlled trials (RCTs).

METHODS

We identified randomised and non-randomised comparative studies of IMRT and conventional radiotherapy using MEDLINE, hand-searching Radiotherapy and Oncology and the International Journal of Radiation Oncology, Biology and Physics and the proceedings of the American Society for Therapeutic Radiology and Oncology and the European Society for Therapeutic Radiology and Oncology annual meetings. The metaRegister of Controlled Trials was searched to identify completed-unpublished, ongoing and planned RCTs.

RESULTS

Sixty-one studies comparing IMRT and conventional radiotherapy were identified. These included three RCTs in head and neck cancer (205 patients) and three in breast cancer (664 patients) that had reported clinical outcomes; these were all powered for toxicity-related end points, which were significantly better with IMRT in each trial. There were 27 additional non-randomised studies in head and neck (1119 patients), 26 in prostate cancer (>5000 patients), four in breast cancer (875 patients) and nine in other tumour sites. The results of these studies supported those of the RCTs with benefits reported in acute and late toxicity, health-related quality of life and tumour control end points. Twenty-eight completed-unpublished, ongoing or planned RCTs incorporating IMRT were identified, including at least 12,310 patients, of which 15 compared conventional radiotherapy within IMRT as a randomisation or pre-planned stratification.

DISCUSSION

Inverse-planned IMRT maintains parotid saliva production and reduces acute and late xerostomia during radiotherapy for locally advanced head and neck cancer, reduces late rectal toxicity in prostate cancer patients allowing safe dose escalation and seems to reduce toxicity in several other tumour sites. Forward-planned IMRT reduces acute toxicity and improves late clinician-assessed cosmesis compared with conventional tangential breast radiotherapy.

Phase II trial of hyperfractionated intensity-modulated radiation therapy and concurrent weekly cisplatin for Stage III and IVa head-and-neck cancer

PURPOSE

To investigate a novel chemoradiation regimen designed to maximize locoregional control (LRC) and minimize toxicity for patients with advanced head-and-neck squamous cell carcinoma (HNSCC).

METHODS AND MATERIALS

Patients received hyperfractionated intensity modulated radiation therapy (HIMRT) in 1.25-Gy fractions b.i.d. to 70 Gy to high-risk planning target volume (PTV). Intermediate and low-risk PTVs received 60 Gy and 50 Gy, at 1.07, and 0.89 Gy per fraction, respectively. Concurrent cisplatin 33 mg/m(2)/week was started Week 1. Patients completed the Quality of Life Radiation Therapy Instrument pretreatment (PRE), at end of treatment (EOT), and at 1, 3, 6, 9, and 12 months. Overall survival (OS), progression-free (PFS), LRC, and toxicities were assessed.

RESULTS

Of 39 patients, 30 (77%) were alive without disease at median follow-up of 37.5 months. Actuarial 3-year OS, PFS, and LRC were 80%, 82%, and 87%, respectively. No failures occurred in the electively irradiated neck and there were no isolated neck failures. Head and neck QOL was significantly worse in 18 of 35 patients (51%): mean 7.8 PRE vs. 3.9 EOT. By month 1, H&N QOL returned near baseline (mean 6.2, SD = 1.7). The most common acute Grade 3+ toxicities were mucositis (38%), fatigue (28%), dysphagia (28%), and leukopenia (26%).

CONCLUSIONS

Hyperfractionated IMRT with low-dose weekly cisplatin resulted in good LRC with acceptable toxicity and QOL. Lack of elective nodal failures despite very low dose per fraction has led to an attempt to further minimize toxicity by reducing elective nodal doses in our subsequent protocol.

A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: management strategies and economic impact

PURPOSE

This systematic review aimed to assess the literature for management strategies and economic impact of salivary gland hypofunction and xerostomia induced by cancer therapies and to determine the quality of evidence-based management recommendations.

METHODS

The electronic databases of MEDLINE/PubMed and EMBASE were searched for articles published in English since the 1989 NIH Development Consensus Conference on the Oral Complications of Cancer Therapies until 2008 inclusive. For each article, two independent reviewers extracted information regarding study design, study population, interventions, outcome measures, results, and conclusions.

RESULTS

Seventy-two interventional studies met the inclusion criteria. In addition, 49 intensity-modulated radiation therapy (IMRT) studies were included as a management strategy aiming for less salivary gland damage. Management guideline recommendations were drawn up for IMRT, amifostine, muscarinic agonist stimulation, oral mucosal lubricants, acupuncture, and submandibular gland transfer.

CONCLUSIONS

There is evidence that salivary gland hypofunction and xerostomia induced by cancer therapies can be prevented or symptoms be minimized to some degree, depending on the type of cancer treatment. Management guideline recommendations are provided for IMRT, amifostine, muscarinic agonist stimulation, oral mucosal lubricants, acupuncture, and submandibular gland transfer. Fields of sparse literature identified included effects of gustatory and masticatory stimulation, specific oral mucosal lubricant formulas, submandibular gland transfer, acupuncture, hyperbaric oxygen treatment, management strategies in pediatric cancer populations, and the economic consequences of salivary gland hypofunction and xerostomia.

A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: prevalence, severity and impact on quality of life

PURPOSE

This systematic review aimed to assess the literature for prevalence, severity, and impact on quality of life of salivary gland hypofunction and xerostomia induced by cancer therapies.

METHODS

The electronic databases of MEDLINE/PubMed and EMBASE were searched for articles published in English since the 1989 NIH Development Consensus Conference on the Oral Complications of Cancer Therapies until 2008 inclusive. Two independent reviewers extracted information regarding study design, study population, interventions, outcome measures, results and conclusions for each article.

RESULTS

The inclusion criteria were met by 184 articles covering salivary gland hypofunction and xerostomia induced by conventional, 3D conformal radiotherapy or intensity-modulated radiotherapy in head and neck cancer patients, cancer chemotherapy, total body irradiation/hematopoietic stem cell transplantation, radioactive iodine treatment, and immunotherapy.

CONCLUSIONS

Salivary gland hypofunction and xerostomia are induced by radiotherapy in the head and neck region depending on the cumulative radiation dose to the gland tissue. Treatment focus should be on optimized/new approaches to further reduce the dose to the parotids, and particularly submandibular and minor salivary glands, as these glands are major contributors to moistening of oral tissues. Other cancer treatments also induce salivary gland hypofunction, although to a lesser severity, and in the case of chemotherapy and immunotherapy, the adverse effect is temporary. Fields of sparse literature included pediatric cancer populations, cancer chemotherapy, radioactive iodine treatment, total body irradiation/hematopoietic stem cell transplantation, and immunotherapy.

Evidence-based organ-sparing radiotherapy in head and neck cancer

Intensification of radiotherapy treatment for locally advanced head and neck cancer by use of altered fractionation schedules or concomitant chemotherapy has resulted in substantially improved locoregional control and survival. However, these improvements have come at the cost of increased acute, and late, toxic effects. The application of technological advances, such as intensity-modulated radiotherapy, is expected to further improve the therapeutic index of radiotherapy for head and neck cancer, by limiting toxicity and possibly by increasing locoregional control. However, the organ-sparing potential of such highly conformal radiotherapy techniques relies heavily on the appropriate selection and accurate delineation of the crucial organs at risk, with the application of rigorous dose constraints during planning. Because xerostomia and dysphagia are the main causes of decreased quality of life after radiotherapy for head and neck cancer, the prevention of these two complications will form the focus of this review.

Standard chemoradiation versus intensity-modulated chemoradiation: a quality of life assessment in oropharyngeal cancer patients

This study is based on the context that many patients with advanced oropharyngeal carcinoma are being treated with primary chemoradiation. The aims of this study are to identify differences in quality of life (QOL) between patients with advanced oropharyngeal cancer following traditional chemoradiation versus chemotherapy with intensity-modulated radiation therapy (CIMRT). This research is designed on a cohort study from an academic tertiary referral center. Fifty patients were identified from an institutional database of patients who had undergone primary chemotherapy and radiation (traditional or IMRT) for advanced oropharyngeal carcinoma. Patients responded via mail using the University of Washington quality of life instrument version 4. Statistical analysis of data was performed using Chi-square and Wilcoxon tests. The results comprise the responses of 17 CRT (57%) and 14 CIMRT (70%) patients. The patients completed the survey between 9 and 44 months following end of treatment. When adjusted for tumor stage and time since treatment, CIMRT patients reported improved appearance (p = 0.05), chewing (p = 0.02), and mood (p = 0.01). There was a trend toward significance for improved activity (p = 0.07), recreation (p = 0.07), and anxiety (p = 0.08). There were no differences between the two groups for saliva, taste, shoulder function, speech, and swallowing. But there was a trend for significance for improved overall QOL in patients who had undergone CIMRT (p = 0.06). In conclusion, CIMRT results in improved QOL for some domains but surprisingly not for swallowing or saliva. Patients undergoing CIMRT also report slightly better QOL overall when compared to patients receiving more traditional forms of radiation therapy.

IMRT quality assurance using a second treatment planning system

We used a second treatment planning system (TPS) for independent verification of the dose calculated by our primary TPS in the context of patient-specific quality assurance (QA) for intensity-modulated radiation therapy (IMRT). QA plans for 24 patients treated with inverse planned dynamic IMRT were generated using the Nomos Corvus TPS. The plans were calculated on a computed tomography scan of our QA phantom that consists of three Solid Water slabs sandwiching radiochromic films, and an ion chamber that is inserted into the center slab of the phantom. For the independent verification, the dose was recalculated using the Varian Eclipse TPS using the multileaf collimator files and beam geometry from the original plan. The data was then compared in terms of absolute dose to the ion chamber volume as well as relative dose on isodoses calculated at the film plane. The calculation results were also compared with measurements performed for each case. When comparing ion chamber doses, the mean ratio was 0.999 (SD 0.010) for Eclipse vs. Corvus, 0.988 (SD 0.020) for the ionization chamber measurements vs. Corvus, and 0.989 (SD 0.017) for the ionization chamber measurements vs. Eclipse. For 2D doses with gamma histogram, the mean value of the percentage of pixels passing the criteria of 3%, 3 mm was 94.4 (SD 5.3) for Eclipse vs. Corvus, 85.1 (SD 10.6) for Corvus vs. film, and 93.7 (SD 4.1) for Eclipse vs. film; and for the criteria of 5%, 3 mm, 98.7 (SD 1.5) for Eclipse vs. Corvus, 93.0 (SD 7.8) for Corvus vs. film, and 98.0 (SD 1.9) for Eclipse vs. film. We feel that the use of the Eclipse TPS as an independent, accurate, robust, and time-efficient method for patient-specific IMRT QA is feasible in clinic.

Radiation therapy for head and neck cancers

OBJECTIVES

To provide an overview of the state of the art in the management of head and neck cancers with radiation therapy (RT) and review issues concerning dose-fractionation, concurrent systemic treatment as well as acute and chronic toxicity.

DATA SOURCES

Published peer-reviewed research articles, technical documents, and patient management guidelines.

CONCLUSION

Modern RT techniques can use technical advances to precisely target regions involved by the tumor, while sparing normal structures. This has significant implications for treatment decisions and anticipated treatment toxicities. Our understanding of radiation effects on tumor and normal tissues and their optimal care are continuously evolving.

IMPLICATIONS FOR NURSING PRACTICE

Nurses need to be aware of the basic principles underlying the technical advances in RT in order to be able to counsel patients during their decision-making and treatment. They also need to stay updated on the pathophysiology and current management of acute and chronic toxicities of radiation treatment in order to provide optimal supportive care.

Intensity-modulated radiotherapy in the treatment of oropharyngeal cancer: clinical outcomes and patterns of failure

PURPOSE

To report outcomes, failures, and toxicities in patients treated with intensity-modulated radiotherapy (IMRT) for squamous cell carcinoma of the oropharynx.

METHODS AND MATERIALS

Between Aug 2001 and Oct 2007, 107 patients were treated with IMRT with curative intent at Stanford University. Twenty-two patients were treated postoperatively, and 85 were treated definitively. Concurrent platinum-based chemotherapy was administered to 86 patients (80%) and cetuximab to 8 patients (7%). The prescribed dose was 66 Gy at 2.2 Gy/fraction for definitively treated cases and 60 Gy at 2 Gy/fraction for postoperative cases. Median follow-up was 29 months among surviving patients (range, 4-105 months).

RESULTS

Eight patients had persistent disease or local-regional failure at a median of 6.5 months (range, 0-9.9 months). Six local failures occurred entirely within the high-risk clinical target volume (CTV) (one with simultaneous distant metastasis). One patient relapsed within the high- and intermediate-risk CTV. One patient had a recurrence at the junction between the IMRT and low-neck fields. Seven patients developed distant metastasis as the first site of failure. The 3-year local-regional control (LRC), freedom from distant metastasis, overall survival, and disease-free survival rates were 92%, 92%, 83%, and 81%, respectively. T stage (T4 vs. T1-T3) was predictive of poorer LRC (p = 0.001), overall survival (p = 0.001), and disease-free survival (p < 0.001) rates. Acute toxicity consisted of 58% grade 3 mucosal and 5% grade 3 skin reactions. Six patients (6%) developed grade >or=3 late complications.

CONCLUSIONS

IMRT provides excellent LRC for oropharyngeal squamous cell carcinoma. Distant metastases are a major failure pattern. No marginal failures were observed.

A predictive model for swallowing dysfunction after curative radiotherapy in head and neck cancer

INTRODUCTION

Recently, we found that swallowing dysfunction after curative (chemo) radiation (CH) RT has a strong negative impact on health-related quality of life (HRQoL), even more than xerostomia. The purpose of this study was to design a predictive model for swallowing dysfunction after curative radiotherapy or chemoradiation.

MATERIALS AND METHODS

A prospective study was performed including 529 patients with head and neck squamous cell carcinoma (HNSCC) treated with curative (CH) RT. In all patients, acute and late radiation-induced morbidity (RTOG Acute and Late Morbidity Scoring System) was scored prospectively. To design the model univariate and multivariate logistic regression analyses were carried out with grade 2 or higher RTOG swallowing dysfunction at 6 months as the primary (SWALL(6months)) endpoint. The model was validated by comparing the predicted and observed complication rates and by testing if the model also predicted acute dysphagia and late dysphagia at later time points (12, 18 and 24 months).

RESULTS

After univariate and multivariate logistic regression analyses, the following factors turned out to be independent prognostic factors for SWALL(6months): T3-T4, bilateral neck irradiation, weight loss prior to radiation, oropharyngeal and nasopharyngeal tumours, accelerated radiotherapy and concomitant chemoradiation. By summation of the regression coefficients derived from the multivariate model, the Total Dysphagia Risk Score (TDRS) could be calculated. In the logistic regression model, the TDRS was significantly associated with SWALL(6months) ((p<0.001). Subsequently, we defined three risk groups based on the TDRS. The rate of SWALL(6months) was 5%, 24% and 46% in case of low-, intermediate- and high-risk patients, respectively. These observed percentages were within the 95% confidence intervals of the predicted values. The TDRS risk group classification was also significantly associated with acute dysphagia (P<0.001 at all time points) and with late swallowing dysfunction at 12, 18 and 24 months (p<0.001 at all time points).

CONCLUSION

The TDRS is a simple and validated measure to predict swallowing dysfunction after curative (CH) RT for HNC. This classification system enables identification of patients who may benefit from strategies aiming at prevention of swallowing dysfunction after curative (CH) RT such as preventive swallowing exercises during treatment and/or emerging IMRT techniques aiming at sparing anatomical structures that are involved in swallowing.