Effect of induction chemotherapy on speech and swallowing function in patients with oral tongue cancer

f25, a novel synthetic quinoline derivative, inhibits tongue cancer cell invasion and survival by the PPAR pathway in vitro and vivo

Tongue cancer has a very high incidence in China, and there is a need to develop new anti-tumour drugs against it. We synthesised 31 novel quinoline derivatives to test their anti-tumour activity. A compound referred to as "f25" was identified through screening for its high in vitro toxicity against an oral squamous carcinoma cell line (CAL-27). f25 exhibited significant cytotoxicity against CAL-27 cells (IC50 = 7.70 ± 0.58 μΜ). f25 also inhibited the migration and invasion of CAL-27 cells to a level comparable with that of the chemotherapy agent cisplatin. Moreover, f25 promoted the apoptosis of CAL-27 cells. Transcriptome sequencing and western blotting showed that the mechanism of action of f25 against CAL-27 cells involved the peroxisome proliferator-activated receptor (PPAR) signalling pathway. Specifically, f25 could bind to PPAR-α, PPAR-β, and PPAR-γ and increase their expression. In vivo experiments showed that treatment with f25 led to a reduction in tumour volume in nude mice without significant toxicity. Overall, this study highlights the potential of quinoline compounds (particularly f25) for the design and synthesis of anti-tumour drugs. It also underscores the importance of the PPAR signalling pathway as a target for potential cancer therapies.

Feasibility Outcomes of a Pilot Randomized Clinical Trial to Increase Cruciferous and Green Leafy Vegetable Intake in Posttreatment Head and Neck Cancer Survivors

BACKGROUND

Higher intakes of cruciferous vegetables (CVs) and green leafy vegetables (GLVs) in observational studies are associated with improvements in survival and cancer-related biomarkers in patients diagnosed with head and neck cancer (HNC). These results have yet to be corroborated in a randomized clinical trial (RCT).

OBJECTIVE

Determine the feasibility of implementing a 12-week RCT to increase CV and GLV intake in posttreatment HNC survivors.

DESIGN AND PARTICIPANTS

This was a two-arm RCT conducted among 24 posttreatment HNC survivors. Survivors were recruited from a southeastern, National Cancer Institute-designated Comprehensive Cancer Center between January 2015 and September 2016.

INTERVENTION

There were two groups: (1) an experimental group (n=12) receiving weekly 15- to 30-minute telephone dietary counseling from a registered dietitian nutritionist stressing 2.5 cups per week CVs and 3.5 cups per week GLVs, and (2) an attention control group (n=12) receiving weekly 15- to 30-minute telephone dietary counseling from a registered dietitian nutritionist focusing on general healthy eating for cancer survivors. Participants completed a baseline survey, three 24-hour dietary recalls, phlebotomy, and anthropometric measures prior to randomization and at the end of the 12-week study period. The experimental group also completed weekly vegetable record recalls.

MAIN OUTCOME MEASURES

Primary outcomes included feasibility, recruitment, retention, adherence, and safety. Secondary outcomes included inflammatory markers and carotenoids.

STATISTICAL ANALYSES PERFORMED

Descriptive statistics were generated for demographic, epidemiological, and clinical variables as well as the primary feasibility outcomes. Between- and within-group comparisons of mean serum cytokine and carotenoid levels were performed using appropriate statistical tests depending on their respective distributions for the purpose of generating preliminary effect sizes.

RESULTS

Overall, 350 incident HNC cases were screened for eligibility, and 98 were eligible for study participation. Reasons for ineligibility and exclusion included deceased (n=93); wrong or inactive telephone numbers, or unable to be reached, or lost to follow-up (n=93); not meeting inclusion criteria (n=39); and too ill to participate (n=27). Of the 98 eligible HNC cases, 24 agreed to participate, for an enrollment rate of 25%. The most common reason for nonparticipation was distance (n=48), as participants were asked to report for two on-site assignments. The retention rate was 96%. Mean intervention adherence rates for weekly goals were 67% CV, 74% GLV, and 71% overall. Completion rate of weekly counseling calls was 90%. The experimental group reported an overall mean increase of 5.5 cups GLV and 3.5 cups CV per week from baseline intake, respectively. No significant between- or within-arm differences were observed for inflammatory markers or carotenoids.

CONCLUSION

A posttreatment intervention aimed at increasing CV and GLV intake in HNC survivors is feasible. A larger RCT is needed to assess the efficacy of this intervention on disease outcomes.

Effect of induction chemotherapy on the quality-of-life in patients with advanced stage tongue cancer by a prospective study

Objective

To assess how induction chemotherapy affects the quality-of-life (QoL) in patients with advanced tongue cancer.

Methods

This prospective study included patients who were diagnosed with advanced tongue cancer. Each patient was asked to complete the University of Washington QoL (UW-QoL), version 4, questionnaire preoperatively and at 12 months after surgery. Patients were divided into two groups based on whether or not they received induction chemotherapy.

Results

Of the 192 patients included in the analysis, 145 patients had received induction chemotherapy. There were no significant differences regarding age, sex, tumour stage, node stage, flap reconstruction, tumour resection range and radiotherapy between the two groups. The mean total hospital cost was significantly higher in patients who underwent induction chemotherapy compared with those who did not (68 000 versus 44 000 Yuan Renminbi, respectively). The two groups had similar pre-treatment and post-treatment composite QoL scores and in the 12 individual domains.

Conclusion

Induction chemotherapy had a limited effect on postoperative QoL in patients with advanced tongue cancers, but it cost significantly more to administer.

The Value of Qualitative Research in Dysphagia in the Head and Neck Cancer Population: What Can We Learn From the Survivors' Perspective?

Dysphagia is a common acute and long-term side effect of curative, non-surgical treatment for head and neck cancer (HNC). Despite what is known about dysphagia associated with HNC treatment in terms of its prevalence, severity, physiological characteristics, and the associated effects on quality of life (QoL), our understanding of the key factors which impact on HNC survivors is only just emerging. Whilst quantitative research studies have demonstrated that most people experience dysphagia in the early post-treatment period, and that many people continue to have ongoing swallowing issues for months and years following treatment, emerging qualitative research in this field has provided insights into the extent to which the presence of dysphagia impacts on the everyday lives of people with HNC. By exploring issues from the perspectives of people living with dysphagia, qualitative research has highlighted those factors that have the greatest impact on oral intake, raised issues for service provision, and highlighted the need for additional professional involvement and better long term supportive care.

The lived experience of dysphagia following non-surgical treatment for head and neck cancer

The prevalence and severity of dysphagia in people treated non-surgically for primary head and neck cancer (HNC) is well documented. However, few studies have looked beyond the physiological impairment to explore the lived experience of dysphagia in the post-treatment period of HNC. The current study adopted a person-centred, qualitative approach to describe the experiences of people living with dysphagia in the months and years following non-surgical treatment for HNC. Using maximum variation sampling, 24 participants who had undergone radiotherapy treatment for HNC were recruited. Individual interviews were conducted to explore the impact of dysphagia on participants' everyday lives. The themes identified included: (1) physical changes related to swallowing; (2) emotions evoked by living with dysphagia; (3) altered perceptions and changes in appreciation of food; and (4) personal and lifestyle impacts. The data revealed the breadth and significance of the impact of dysphagia on the lives of people treated curatively for HNC. Assessment and management in the post-treatment period must be sufficiently holistic to address both the changing physical states and the psychosocial needs of people with dysphagia following HNC. Rehabilitation services which focus only on impairment-based management will fail to fully meet the support needs of this clinical population.

Effects of 2 different swallowing exercise regimens during organ-preservation therapies for head and neck cancers on swallowing function

BACKGROUND

This study investigated the effects of 2 different swallowing exercise regimens performed during radiation therapy with/without chemotherapy on swallowing function.

METHODS

Fifty patients were recruited prospectively to 2 groups (the exercise group, n = 26 and the repetitive swallow group, n = 24). Functional Oral Intake Scale (FOIS) scores and percutaneous endoscopic gastrostomy (PEG) placements were compared at posttreatment and at 3 months.

RESULTS

The exercise group eliminated significantly more PEG tubes at 3 months posttreatment compared to the swallow group (16% vs 50%). Among patients who received both radiation and chemotherapy, the exercise group had significantly less PEG tubes immediately posttreatment as well as 3 months posttreatment (35% and 10%), compared to the swallow group (69% and 50%).

CONCLUSION

Findings indicate significant benefits of the exercise group's exercise regimen in reducing PEG dependence and oral intake difficulties.

Long-term functional and survival outcomes after induction chemotherapy and risk-based definitive therapy for locally advanced squamous cell carcinoma of the head and neck

BACKGROUND

The purpose of this study was to evaluate long-term outcomes after induction chemotherapy followed by "risk-based" local therapy for locally-advanced squamous cell carcinoma of the head and neck (SCCHN).

METHODS

Forty-seven patients (stage IV; ≥N2b) were enrolled in a phase II trial. Baseline and 24-month functional measures included modified barium swallow (MBS) studies, oropharyngeal swallow efficiency (OPSE), and the MD Anderson Dysphagia Inventory (MDADI). Functional status was assessed at 5 years.

RESULTS

Five-year overall survival (OS) was 89% (95% confidence interval [CI], 81% to 99%). A nonsignificant 13% average reduction in swallowing efficiency (OPSE) was observed at 24 months relative to baseline (p = .191). MDADI scores approximated baseline at 24 months. Among 42 long-term survivors (median, 5.9 years), 3 patients (7.1%) had chronic dysphagia. The rate of final gastrostomy dependence was 4.8% (2 of 42).

CONCLUSION

Sequential chemoradiotherapy achieved favorable outcomes among patients with locally advanced SCCHN, mainly of oropharyngeal origin. MBS and MDADI scores found modest swallowing deterioration at 2 years, and chronic aspiration was uncommon in long-term survivors.

Gastrostomy tube placement in patients with oropharyngeal carcinoma treated with radiotherapy or chemoradiotherapy: factors affecting placement and dependence

BACKGROUND

Although many patients require nutritional support during radiotherapy or chemoradiotherapy for oropharyngeal cancer, little is known regarding the risk factors that predispose to gastrostomy tube (g-tube) placement and prolonged dependence, or the therapeutic interventions that may abrogate these effects.

METHODS

We performed a retrospective medical chart review of patients who were treated for primary oropharyngeal cancer at a tertiary care center from 2003 to 2008. Patients who had a complete response at the primary site at 1-year posttreatment were included. G-tube placement and dependence ≥6 months were evaluated in relationship to site and stage of primary tumor, baseline characteristics, treatment type, smoking status, and swallowing intervention.

RESULTS

We evaluated 474 patients (79%) with oropharyngeal cancer; 215 patients (40%) had concurrent chemotherapy, 73 patients (15%) had induction chemotherapy, and 69 patients (15%) had induction chemotherapy followed by concurrent chemotherapy. Two hundred ninety-three patients (62%) received g-tubes, of which 238 (81%) received the g-tube during radiation. At 1-year follow-up, 41 patients (9%) remained dependent on enteral feedings. Placement of g-tubes and prolonged g-tube dependence were significantly more likely in patients with T3 to 4 tumors (p < .001), baseline self-reported dysphagia (p < .001), odynophagia (p < .001), >10% baseline weight loss (p < .001), and in those treated with concurrent chemoradiotherapy. Patients who reported adherence to exercises had significantly lower rates of g-tube placement (p < .001), and duration of dependence was significantly shorter in those who reported adherence to swallowing exercises (p < .001).

CONCLUSION

Almost 40% of patients with oropharyngeal cancer treated with nonsurgical organ preservation modalities may avoid feeding tube placement. Factors that predispose to g-tube placement and prolonged dependence include T3 to T4 tumors, concurrent chemotherapy, current smoking status, and baseline swallowing dysfunction or weight loss. Adherence to an aggressive swallowing regimen may reduce long-term dependence on enteral nutrition and limit the rate of g-tube placement overall.

Phase II trial of induction chemotherapy followed by surgery for squamous cell carcinoma of the oral tongue in young adults

BACKGROUND

We conducted a phase II clinical trial of induction chemotherapy followed by surgery ± radiotherapy for squamous cell carcinoma of the oral tongue (SCCOT) in young adults.

METHODS

From September 2001 to October 2004, 23 patients aged 18 to 49 years with clinical T2-3 N0-2 M0 SCCOT and no prior radiotherapy, chemotherapy, or neck dissection underwent induction chemotherapy (paclitaxel, ifosfamide, and carboplatin) followed by glossectomy and neck dissection ± radiotherapy and chemotherapy.

RESULTS

On final surgical pathology, 9 patients (39%) had a complete/major (2 complete) histologic response at the primary tumor site; 8 patients (35%) had no response or progression. Similarly, 9 patients (39%) had a complete response in the neck or remained node negative; 6 patients (26%) had an increase in nodal category. No treatment-associated deaths occurred, and toxicity was modest. At a median follow-up from the end of treatment of 52 months (minimum, 23 months), 10 patients (43%) developed recurrence, and all 10 died of cancer. Crude recurrence/cancer death rates were associated with ≤ a partial response at the tongue (p = .029), poor histologic differentiation (p = .012), and multiple adverse features on final surgical pathology (p = .040).

CONCLUSION

Response rates and overall survival with this induction chemotherapy regimen were limited, but complete/major response at the tongue was associated with excellent prognosis. Additionally, improved patient selection and predictive tumor biomarkers will be needed for induction chemotherapy to be routinely incorporated into the treatment of oral tongue cancer in young adults.

Dysphagia after Nonsurgical Head and Neck Cancer Treatment

Objective. Assess patients’ perspectives on the severity, time course, and relative importance of swallowing deficit before and after (chemo)radiotherapy for head and neck cancer.

Study Design. Before-and-after cohort study.

Setting. Head and neck cancer UK multidisciplinary clinic.

Subjects and Methods. A total of 167 patients with a primary cancer, mostly laryngopharyngeal, completed the MD Anderson Dysphagia Index (MDADI) and the University of Washington Quality of Life Questionnaire (UWQOL) before treatment and at 3, 6, and 12 months. Pretreatment swallowing, age, gender, and tumor site and stage were assessed. Statistical methods used were Mann-Whitney, analysis of variance, and logistic regression.

Results. There was a sharp deterioration in swallowing on average by 18%, from before treatment to 3 months post treatment (mean difference in MDADI score = 14.5; P < .001). Treatment schedule, pretreatment score, and age accounted for 37% of the variance in 3-month posttreatment MDADI scores. There was then little improvement from 3 to 12 months. Patients treated with only 50-Gy radiotherapy reported significantly less dysphagia at 1 year than patients receiving higher doses or combined chemoradiation ( P < .001). Swallowing was the most commonly prioritized of the 12 UWQOL domains both before and after therapy. The MDADI and UWQOL scores were strongly correlated: ρ > 0.69.

Conclusion. Swallowing is a top priority before and after treatment for the vast majority of patients with head and neck cancer. Swallowing deteriorates significantly posttreatment ( P < .001). Treatment intensity, younger age, and lower pretreatment scores predict long-term dysphagia. After chemoradiation, there is little improvement from 3 to 12 months.

Efficacy survey of swallowing function and quality of life in response to therapeutic intervention following rehabilitation treatment in dysphagic tongue cancer patients

PURPOSE

This quasi-experimental parallel cluster study was carried out to investigate the utility of interdisciplinary swallowing therapy exercises in improving swallowing function and quality of life (QOL) in dysphagic cancer patients following tongue resection and subsequent rehabilitation treatment.

METHODS

All subjects in the experimental group underwent a structured swallowing training program. The subjects in the experimental group (n = 23) received 30 min of swallowing training each day, 6 days per week for 2 weeks. The control group (n = 23) received no training. Analysis of variance was used, and the M.D. Anderson Dysphagia Inventory (MDADI) discriminated between groups of subjects.

RESULTS

Patients who underwent structured swallowing training (n = 23) showed improvement in the overall MDADI score (P < 0.01) compared with the control population. Furthermore, a separate analysis of individual domains of the MDADI (global, emotional, functional, and physical) demonstrated improved QOL. Although the mean score for tongue rehabilitation indicated that ≥50% subjects in the functional subscale were improved compared with the control population, the difference was not statistically significant (P > 0.05).

CONCLUSIONS

This study used objectively timed swallowing tests, an interdisciplinary swallowing therapy protocol, and a swallowing questionnaire to evaluate the effects of swallowing training. We found that implementation of swallowing education and exercises improved dysphagia and QOL in cancer patients following tongue resection and rehabilitation. Furthermore, this study indicated that swallowing safety and dysphagia training for nursing professionals is effective.

Candidate dosimetric predictors of long-term swallowing dysfunction after oropharyngeal intensity-modulated radiotherapy

PURPOSE

To investigate long-term swallowing function in oropharyngeal cancer patients treated with intensity-modulated radiotherapy (IMRT), and to identify novel dose-limiting criteria predictive for dysphagia.

METHODS AND MATERIALS

Thirty-one patients with Stage IV oropharyngeal squamous carcinoma enrolled on a Phase II trial were prospectively evaluated by modified barium swallow studies at baseline, and 6, 12, and 24 months post-IMRT treatment. Candidate dysphagia-associated organs at risk were retrospectively contoured into original treatment plans. Twenty-one (68%) cases were base of tongue and 10 (32%) were tonsil. Stage distribution was T1 (12 patients), T2 (10), T3 (4), T4 (2), and TX (3), and N2 (24), N3 (5), and NX (2). Median age was 52.8 years (range, 42-78 years). Thirteen patients (42%) received concurrent chemotherapy during IMRT. Thirteen (42%) were former smokers. Mean dose to glottic larynx for the cohort was limited to 18 Gy (range, 6-39 Gy) by matching IMRT to conventional low-neck fields.

RESULTS

Dose-volume constraints (V30 < 65% and V35 < 35% for anterior oral cavity and V55 < 80% and V65 < 30% for high superior pharyngeal constrictors) predictive for objective swallowing dysfunction were identified by univariate and multivariate analyses. Aspiration and feeding tube dependence were observed in only 1 patient at 24 months.

CONCLUSIONS

In the context of glottic laryngeal shielding, we describe candidate oral cavity and superior pharyngeal constrictor organs at risk and dose-volume constraints associated with preserved long-term swallowing function; these constraints are currently undergoing prospective validation. Strict protection of the glottic larynx via beam-split IMRT techniques promises to make chronic aspiration an uncommon outcome.