Quality of life of oropharyngeal cancer patients with respect to treatment strategy and p16-positivity

Temporal Trends in Clinician-Assessed and Patient-Reported Swallowing Outcomes in Oropharyngeal Cancer Patients

BACKGROUND

Dysphagia is a consequence of oropharyngeal squamous cell carcinoma (OPSCC) treatments and often results in a devastating reduction in quality of life (QoL; Nguyen et al., 2005; Pauloski, 2008).

OBJECTIVES

This study aimed to report temporal trends in swallowing outcomes using the Modified Barium Swallow Impairment Profile (MBSImP) and the M.D. Anderson Dysphagia Inventory (MDADI) and to study the relationship between these two measures.

METHOD

This was a retrospective review of clinical data collected in January 2013 to December 2017 from a tertiary care center. MBSImP PI scores and MDADI composite scores were collected pretreatment and 1, 6, and 12 months posttreatment. Data were analyzed in aggregate and stratified by treatment modality. To address the primary objective, descriptive statistics were used. To address the secondary objective, four Spearman tests were run between MBSImP PI and MDADI composite scores.

RESULTS

A total of 123 OPSCC participants were included. With respect to trends, MBSImP PI scores worsened 1 month posttreatment and remained impaired at 6 and 12 months. For MDADI composite scores, patient reports worsened 1 month posttreatment and subsequently improved at 6 and 12 months. MBSImP PI and MDADI composite scores were weakly negatively correlated (i.e., in agreement) at the pre- and 12-month posttreatment appointments.

CONCLUSIONS

Swallowing outcomes in OPSCC patients have distinct yet predictable trends for both clinician-assessed and patient-reported swallowing outcomes during the first year following cancer treatment. However, unlike previous findings, these two types of measures were in agreement at the pretreatment and 12 months posttreatment appointments.

Head and neck cancer biomarkers: Systematic review and meta-analysis

PURPOSE

To perform a systematic review and meta-analysis of the diagnostic capabilities of various biological markers in the plasma, serum, tissue, and saliva of patients with head and neck cancer (HNC).

METHODS

We performed manual and digital searches using specific keywords and found English-language literature published up to October 28, 2022. PubMed, ScienceDirect, Scopus, MEDLINE Complete, and EMBASE databases were used. Studies comparing biomarkers for the diagnosis of HNC versus healthy controls were evaluated.

RESULTS

Seventeen studies using varied sources of biomarkers, both individually and combined, were identified. The sensitivity and specificity of biomarkers ranged from 29.5% to 100% and 57.1% to 100%, respectively. The combined biomarkers demonstrated higher therapeutic applicability in terms of sensitivity and specificity than the individual biomarkers. Furthermore, the heterogeneity of the sensitivity/specificity for individual and combined biomarker was 534.45/1.66 and 247.41/14.62, respectively.

CONCLUSION

Combined biomarkers may aid in the diagnosis of HNC. Further studies are required to verify the accuracy of these biomarkers.

Association of post-treatment longitudinal symptom severity clusters with subsequent survival in oropharyngeal cancer

BACKGROUND

Patients with cancer often experience multiple symptoms concurrently. We identified patient clusters based on longitudinal symptom severity trajectories in oropharyngeal cancer (OPC) and evaluated the potential clinical utility of this approach.

METHODS

A retrospective OPC patient cluster analysis using 6 months of symptom severity data from radiotherapy initiation. The clinico-demographic characteristics and overall survival of patients were compared between clusters.

RESULTS

We identified four clusters of patients differing in longitudinal symptom severity. Cluster A (n = 168) included patients with the mildest longitudinal symptoms, cluster B (n = 59) and cluster C (n = 63) were intermediate, and cluster D (n = 30) included patients with the worst symptoms. The clusters differed in their HPV status, ECOG performance status, smoking history, drinking history, treatment modality, and 5-year survival. These clusters separated symptom severity trajectories more distinctly than individual clinico-demographic characteristics.

CONCLUSIONS

Early symptom severity trajectory clustering revealed distinct patient clusters that were prognostic of overall survival.

PET/CT versus triple endoscopy in initial workup of HPV+ oropharyngeal squamous cell carcinoma

BACKGROUND

Synchronous primary tumors (SPTs) are detected via triple endoscopy or positron emission tomography/computed tomography (PET/CT). Patients with human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV+ OPSCC) lack risk factors for SPTs.

METHODS

We performed a single institution retrospective review of the efficacy of triple endoscopy and PET/CT in HPV+ OPSCC patients.

RESULTS

Sixty-five HPV+ OPSCC patients underwent triple endoscopy and PET/CT. Patients were white (n = 48, 72.7%), male (n = 53, 81.5%), mean 58.7 ± 8.1 years old. SPT was detected in 1 (1.5%) patient via PET/CT. No SPTs were detected on triple endoscopy. PET/CT had 100% and 95.3% sensitivity and specificity, respectively. PET/CT positive predictive value (PPV) and negative predictive value (NPV) were 25.0% and 100%, respectively. Triple endoscopy specificity and NPV was 90.2% and 93.2%, respectively.

CONCLUSIONS

PET/CT is superior to triple endoscopy in ruling out SPTs. With negative PET/CT, only direct laryngoscopy with biopsy may be necessary.

Dysphagia, hypothyroidism, and osteoradionecrosis after radiation therapy for head and neck cancer

OBJECTIVES

To analyze the long-term side effects of radiation therapy (RT) for head and neck cancer (HNC).

METHODS

Retrospective chart analysis of all 688 HNC patients treated during 2010-2015 at Turku University Hospital, Finland. All patients who survived for more than a year after RT/chemoRT were included (n = 233). Intensity modulated RT (IMRT) with standard fractionation was applied in each case.

RESULTS

One hundred and six patients (45%) reported persisting dysphagia, for which neck RT increased risk. Definitive neck RT to high-risk volume did not increase late toxicity risks compared to elective neck RT. Radiation-induced hypothyroidism (29%, n = 67) was more common among younger patients and females. Osteoradionecrosis (12%, n = 29) was more common in the oral cavity cancer group (20.7%, n = 92) compared to all other subsites.

CONCLUSIONS

Late toxicities of RT for HNC are common. Age, gender, tumor subsite, and neck RT affect susceptibility to long-term side effects.

LEVEL OF EVIDENCE

4.

Evaluating dysphagia and xerostomia outcomes following transoral robotic surgery for patients with oropharyngeal cancer

BACKGROUND

We assessed long-term patient-reported dysphagia and xerostomia outcomes following definitive surgical management with transoral robotic surgery (TORS) in patients with oropharyngeal cancer (OPC) via a cross-sectional survey study.

METHODS

Patients with OPC managed with primary oropharyngeal surgery as definitive treatment at least 1 year ago between 2015 and 2019 were identified. The M. D. Anderson Dysphagia Inventory (MDADI) and Xerostomia Inventory (XI) scores were compared across treatment types (i.e., no adjuvant therapy [TORS-A] vs. adjuvant radiotherapy [TORS+RT] vs. adjuvant chemoradiotherapy [TORS+CT/RT]).

RESULTS

The sample had 62 patients (10 TORS-A, 30 TORS+RT, 22 TORS+CT/RT). TORS-A had clinically and statistically significantly better MDADI scores than TORS+RT (p = 0.03) and TORS+CT/RT (p = 0.02), but TORS+RT and TORS+CT/RT were not significantly different. TORS-A had clinically and statistically significantly less XI than TORS+RT (p < 0.01) and TORS+CT/RT (p < 0.01).

CONCLUSIONS

Patients with OPC who have undergone TORS+RT or TORS+CT/RT following surgery face clinically worse dysphagia and xerostomia outcomes relative to patients who undergo TORS-A.

A national study of health-related quality of life in patients with cancer of the base of the tongue compared to the general population and to patients with tonsillar carcinoma

BACKGROUND

This exploratory, registry-based, cross-sectional study aimed to evaluate patients' health-related quality of life (HRQOL) in a subsite of oropharyngeal cancer: cancer of the base of the tongue (CBT).

METHODS

CBT patients, treated with curative intent, completed the EORTC QLQ-C30 and QLQ-H&N35 questionnaires 15 months after diagnosis. The HRQOL of CBT patients was compared to reference scores from the general population and to that of tonsillar carcinoma patients.

RESULTS

The 190 CBT patients scored significantly worse than members of the general population on most scales. CBT patients with human papilloma virus (HPV)-positive tumors had significantly better HRQOL on 8 of 28 scales than HPV-negative patients. Compared to 405 tonsillar carcinoma patients, CBT patients had significantly worse HRQOL on 8 of the 28 scales, the majority local head and neck related problems.

CONCLUSION

One year after treatment, CBT patients' HRQOL was significantly worse in many areas compared to that of the general population and slightly worse than that of tonsillar carcinoma patients.

Patient-reported quality of life and symptom burden measures in human papillomavirus associated oropharyngeal cancer - A review of the literature and PRO methodology

The emergence of human papillomavirus-associated oropharyngeal cancer (HPVOPC) has resulted in an explosion of clinical research offering reduced toxicity and improved health-related quality of life (HRQL) through treatment de-escalation. At the heart of this objective are patient-reported outcomes (PROs) which aim to quantify the patient experience, usually through the measurement of HRQL or symptom burden. A number of PRO measures (PROMs) are available to HNC researchers and selection of the optimal instrument relies on a detailed understanding of their content and psychometric properties matched to the clinical endpoint of interest. As PROMs become increasingly favoured as the primary or co-primary endpoints of interest in HNC clinical trials, particularly those focussed on HPVOPC, future treatment paradigms will be determined by these measures and it is imperative that they are applied with sophistication and rigor. This review draws attention to the limitations and challenges our specialty faces in PRO application, analysis and reporting. These shortfalls typically include a reliance on statistical rather than clinically relevant differences, multiple hypothesis testing, a lack of evidence-based minimal clinically important differences for the commonly used tools, as well as variations in PROM selection. The aim of this review is to provide: (1) an overview of PRO/PROM terminology and methodology in the HNC setting; (2) to provide a summary of HRQL and symptom burden reports in the HPVOPC literature; and (3) to draw attention to the unmet research need of refining PROM development, application and interpretation to guide our treatment decisions based on what matters to patients.

Surviving Elderly Patients with Head-and-Neck Squamous Cell Carcinoma-What Is the Long-Term Quality of Life after Curative Radiotherapy?

The effects of radiotherapy on the long-term quality of life (QoL) of surviving elderly HNSCC patients are not well understood, therefore, we analyzed QoL in this population. A cross-sectional analysis was performed at a tertiary cancer center to assess long-term QoL in elderly HNSCC patients. Eligible patients were ≥65 years at the time of treatment who had to be alive for ≥1 year after radiotherapy and without current anti-cancer treatment. QoL and patient satisfaction were assessed using the EORTC QLQ-C30, QLQ-H&N35 and ZUF-8 questionnaires, respectively, and treatment-related toxicities were graded according to CTCAE (Common Terminology Criteria of Adverse Effects) v.5.0. Seventy-four patients met the inclusion criteria, of which 50 consented to participate. Median time between radiotherapy and QoL assessment was 32 months (range 12-113). The QLQ-C30 global QoL median amounted to 66.7 points (interquartile range (IQR) 50.0-83.3), which was comparable to the age- and gender-adjusted German population (median 65.3). Median global QoL was similar between patients undergoing definitive (75.0, IQR 50.0-83.3) and adjuvant (chemo)radiotherapy (66.7, IQR 41.7-83.3, p = 0.219). HPV-positive HNSCC patients had superior global QoL after radiotherapy than their HPV-negative counterparts (p < 0.05), and concomitant chemotherapy did not influence the long-term QoL (p = 0.966). Median global QoL did not correspond with physician-assessed highest-graded chronic toxicities (p = 0.640). The ZUF-8 ranged at 29 points in median (IQR 27-31), showing high patient satisfaction. Surviving elderly HNSCC patients treated by radiotherapy exhibit a relatively high long-term global QoL which is a relevant information for clinicians treating elderly HNSCC patients.

The course of health-related quality of life from diagnosis to two years follow-up in patients with oropharyngeal cancer: does HPV status matter?

Purpose

To investigate the course of health-related quality of life (HRQOL) from diagnosis to 2 years follow-up among patients with oropharyngeal cancer (OPSCC), in relation to human papilloma virus (HPV) status.

Methods

This study included 270 OPSCC patients. Age, sex, tumor sublocation, tumor stage, HPV status, treatment modality, comorbidity, smoking, and alcohol use were retrieved from medical records. HPV status was positive when p16 and HPV DNA tests were both positive. HRQOL was assessed using the EORTC QLQ-C30/QLQ-H&N35 pretreatment and at 6 weeks, 6, 12, 18, and 24 months after treatment. To compare the course of HRQOL between patients with an HPV-positive versus HPV-negative tumor, linear and logistic mixed models were used.

Results

Patients with an HPV-positive tumor (29%) were more often male, diagnosed with a tumor of the tonsil or base of the tongue, treated with single treatment, had fewer comorbidities, were less often current smokers and had lower alcohol consumption. Adjusted for confounders, the course of global quality of life, physical, role, and social functioning, fatigue, pain, insomnia, and appetite loss was significantly different: patients with an HPV-positive tumor scored better before treatment, worsened during treatment, and recovered better and faster at follow-up, compared to patients with an HPV-negative tumor. The course of emotional functioning and oral pain was also significantly different between the two groups, but with other trajectories.

Conclusion

The course of HRQOL is different in patients with an HPV-positive tumor versus an HPV-negative tumor, adjusted for sociodemographic, clinical, and lifestyle confounders.

Quality of Life Implications After Transoral Robotic Surgery for Oropharyngeal Cancers

Oropharyngeal cancers and their treatment can exquisitely affect a patient's quality of life and functional outcome. Transoral robotic surgery offers a minimally invasive surgical approach that mitigates injury from traditional open surgical approaches and offers a treatment more likely to have short-term side effects compared with nonsurgical treatment. Feeding tube dependence, oral intake, and swallowing questionnaires, in addition to swallowing evaluations provide a snapshot of a patient's current swallowing function. Investigation of patient-reported quality-of-life outcomes allows for understanding of their symptomatology and the comparison of different treatment strategies.

Correlations between long-term quality of life and patient needs and concerns following head and neck cancer treatment and the impact of psychological distress. A multicentric cross-sectional study

OBJECTIVES

To assess patient needs and concerns after head and neck squamous cell carcinoma (HNSCC) treatment and their possible correlations with long-term quality of life (QoL) and to examine the potential impact of psychological distress on these results.

METHODS

Alive and disease-free HNSCC patients at least 1 year after treatment were enrolled in this cross-sectional multicentric study and completed the EORTC QLQ-C30 and H&N35 QoL questionnaires, the head and neck cancer-specific patient concerns inventory (PCI-HN) questionnaire and the hospital anxiety and depression scale (HADS). Correlations between QoL outcomes and patient needs and concerns were investigated using Spearman's correlation tests.

RESULTS

Seventy-two patients were enrolled in the study. Fear of cancer recurrence was the main patient concern followed by dental, salivary, fatigue, speech, and eating problems. The leading patient needs in terms of consultation were to be referred to the surgeon, the speech, and swallow therapist and the oral rehabilitation team. The number of patient concerns correlated negatively (r < .40) with functioning scales score and positively (r > .40) with general and head and neck symptoms. Psychological distress was the main determinant of QoL outcomes (p < .0001). We found a significant impact of gender (p = .002) on the number of patient concerns, and of patient age (p = .003) on the number of staff members selected by patients.

CONCLUSION

Identification of patient needs and concerns along with multidisciplinary management of persistent symptoms and psychological distress seem essential steps towards improving QoL of HNSCC patients.

Long-term Quality of Life After Treatment of Oropharyngeal Squamous Cell Carcinoma

OBJECTIVES

To analyze the long-term quality of life (QOL) among oropharyngeal squamous cell carcinoma (OPSCC) survivors.

STUDY DESIGN

Retrospective chart analysis and patient response to European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, Core Module (EORTC QLQ-C30), Head and Neck Module (EORTC QLQ-H&N35), and M.D. Anderson Dysphagia Inventory (MDADI) survey questionnaires.

METHODS

All survivors of OPSCC diagnosed and treated between 2000 and 2009 in Finland were included. There were 263 survivors (44.2% of all curatively treated patients), of which a total of 164 participated in this study (62.4%). Median follow-up was 11.79 years (range = 8.59-18.53 years, interquartile range [IQR] = 4.64 years). The mean age of the participants was 67.9 years (standard deviation = 8.0 years) at QOL follow-up.

RESULTS

Most survivors reported a good QOL. The EORTC QLQ-C30 global health status median was 75.00 (IQR = 31.25). The single modality treatment group had significantly better QOL outcomes than the combined treatment group. Nonsmokers and previous smokers had significantly better QOL outcomes than patients who smoked at the time of diagnosis. A history of heavy alcohol use resulted in significantly worse QOL outcomes. The p16-positive cancer patients had significantly better QOL outcomes than p16-negative patients. Percutaneous endoscopic gastrostomy (PEG) tube-dependent patients reported a significantly worse QOL than patients without a PEG tube.

CONCLUSIONS

Long-term QOL in OPSCC survivors is generally good. In line with previous literature, single modality treatment was superior to combined treatment in long-term QOL outcomes, and it should be pursued whenever possible.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1172-E1178, 2021.

Association between human papillomavirus status and health-related quality of life in oropharyngeal and oral cavity cancer survivors

OBJECTIVES

The human papillomavirus (HPV) is a risk factor for a subgroup of head and neck cancers (HNC). HPV-positive and HPV-negative HNC patients encompass heterogeneous groups regarding risk factors, sociodemographic and clinical characteristics, which may influence health-related quality of life (HRQL) differently. Since this has been sparsely studied, our study investigated the association between HPV status and HRQL in HNC survivors in Denmark.

MATERIALS AND METHODS

This cross-sectional study included 179 recurrence-free oropharyngeal and oral cavity squamous cell carcinoma (OSCC) survivors. HRQL was assessed on the EORTC QLQ-C30 and QLQ-H&N35 questionnaires. Linear and logistic regression models were adjusted for sociodemographic, clinical and lifestyle factors.

RESULTS

Most unadjusted results showed better HRQL among HPV-positive (n = 119) compared to HPV-negative (n = 60) OSCC survivors (average 18 months since diagnosis). After adjustments, the HPV-positive survivors reported higher role functioning (mean difference [MD] 9.2, 95% confidence interval [CI] 0.1 to -18.4), and fewer problems with speech (MD -9.0, 95% CI -18.0 to -0.1), sexuality (MD -21.9, 95% CI -38.0 to -5.9) and opening mouth (MD -13.7, 95% CI -26.6 to -0.8) compared to HPV-negative survivors.

CONCLUSION

Our findings support that HPV-positive OSCC survivors experience better HRQL than HPV-negative survivors. However, results indicate that sociodemographic, clinical and lifestyle factors explain most of the association between HPV status and HRQL. Findings suggest increased focus on the HPV-negative OSCC survivors with deteriorated HRQL in rehabilitation programs and future research to investigate the long-term effects of treatment among HPV-positive OSCC survivors who may develop symptoms later in survivorship.

Knowledge Gaps among Patients and Providers in HPV-Related Oropharyngeal Cancer: A Systematic Review

Objective

To describe the level of knowledge of human papillomavirus (HPV) and HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) among the general population and health care providers.

Data Sources

Systematic search was performed on December 20, 2018, using MEDLINE (1966 to December 2018), EMBASE (1975 to December 2018), Web of Science (1900 to December 2018), and CENTRAL (1996 to December 2018) databases. English-language literature involving human subjects was used, and studies were limited to case series, case-control, cohort, and randomized controlled trial designs.

Review Methods

Studies were included if they assessed knowledge of HPV and HPV-associated OPSCC. The primary outcome measure was the knowledge of HPV-associated OPSCC among the general population and with health care providers. Meta-analysis of proportions was attempted using random-effects model. The PRISMA guidelines were used for accuracy of reporting.

Results

Thirty-two studies were included with 17,288 participants. There was a high degree of heterogeneity preventing completion of a meta-analysis. Knowledge of HPV and HPV-associated OPSCC varied between the general population and health care providers. The proportion of the general population and health care providers with knowledge of HPV ranged from 16% to 75% and 21% to 84%, respectively. Knowledge of HPV-associated OPSCC was greater in health care providers and ranged from 22% to 100% compared with the general population, which ranged from 7% to 57%.

Conclusion

There is a knowledge gap of HPV-associated OPSCC for both the general population and health care providers. Additional education may not only increase awareness but may also result in prevention and earlier detection.

Health-related quality of life among tonsillar carcinoma patients in Sweden in relation to treatment and comparison with quality of life among the population

BACKGROUND

The health-related quality of life (HRQOL) of tonsillar carcinoma survivors was explored to investigate any HRQOL differences associated with tumor stage and treatment. The survivors' HRQOL was also compared to reference scores from the population.

METHODS

In this exploratory cross-sectional study patients were invited 15 months after their diagnosis and asked to answer two quality of life questionnaires (EORTC QLQ- C30, EORTC QLQ- HN35), 405 participated.

RESULTS

HRQOL was associated with gender, with males scoring better than females on a few scales. Patients' HRQOL was more associated with treatment than tumor stage. Patients' HRQOL was worse than that in an age- and sex-matched reference group from the normal population, the largest differences were found for problems with dry mouth followed by problems with sticky saliva, senses, swallowing and appetite loss.

CONCLUSIONS

The tonsillar carcinoma patients had a worse HRQOL compared to the general population one year after treatment.

Factors associated with the quality of life for hospitalized patients with HPV-associated oropharyngeal squamous cell carcinoma

PURPOSE

Oropharynx squamous cell cancer (OPSCC) is a type of head and neck squamous cell carcinoma. The raising OPSCC incidence is mainly attributed to human papillomavirus (HPV). HPV-related OPSCC has a relatively good prognosis, the concerns are focused on the improvement of quality-of-life (QOL). We aimed to figure out the factors which may affect the QOL of HPV-related OPSCC patients after treatment.

METHODS

This study included patients with HPV-related OPSCC. The QOL of the patients were analyzed through the administration of European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30)-Chinese version, the European Organization for Research and Treatment of Cancer Head and Neck Cancer Module-35 (EORTC QLQ-H&N-35)-Chinese version, and Eating Assessment Tool-10 (EAT-10). Multivariable regression analysis was employed to detect the influence of predictor variables on the QOL of patients.

RESULTS

A total of 294 HPV-related OPSCC patients were involved in this research. The results of EORTC QLQ-C30, EORTC QLQ-H&N-35, and EAT-10 demonstrated that the treatment decreased the QOL of HPV-related OPSCC patients. Several different factors including marital status, consumption of tobacco and alcohol, tumor sites, clinical stages, therapeutic strategies, and neck dissection were proved to have influence on QOL of HPV-related OPSCC after treatment.

CONCLUSION

Based on the analyzation of the QOL at baseline and after treatment, we demonstrated several factors which influenced the QOL of HPV-associated OPSCC patients after treatment. These results can make a great contribution to the improvement of the QOL after treatment.

Intensity-modulated radiotherapy for stage I glottic cancer: a short-term outcomes compared with three-dimensional conformal radiotherapy

Purpose

To investigate the differences in treatment outcomes between two radiation techniques, intensity-modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3DCRT).

Materials and Methods

We retrospectively analyzed 160 (IMRT = 23, 3DCRT = 137) patients with stage I glottic cancer treated from January 2005 through December 2016. The IMRT was performed with TomoTherapy (16 patients), volumetric-modulated arc therapy (6 patients), and step-and-shoot technique (1 patient), respectively. The 3DCRT was performed with bilateral parallel opposing fields. The median follow-up duration was 30 months (range, 31 to 42 months) in the IMRT group and 65 months (range, 20 to 143 months) in the 3DCRT group.

Results

The 5-year overall survival and 3-year local control rates of the 160 patients were 95.7% and 91.4%, respectively. There was no significant difference in 3-year local control rates between the IMRT and 3DCRT groups (94.4% vs. 91.0%; p = 0.587). Thirteen of 137 patients in the 3DCRT group had recurrences. In the IMRT group, one patient had a recurrence at the true vocal cord. Patients treated with IMRT had less grade 2 skin reaction than the 3DCRT group, but this had no statistical significance (4.3% vs. 21.2%; p = 0.080).

Conclusion

IMRT had comparable outcomes with 3DCRT, and a trend of less acute skin reaction in stage I glottic cancer patients

Outcomes following TORS for HPV-positive oropharyngeal carcinoma: PEGs, tracheostomies, and beyond

OBJECTIVES

To review swallowing, airway and speech outcomes following transoral robotic surgery (TORS) ± adjuvant therapy for human papillomavirus associated oropharyngeal squamous cell carcinoma (HPV[+]OPSCC).

METHODS

Patients underwent TORS ± standard adjuvant therapy from 5/1/2007-5/31/2015. Clinical data were recorded and descriptive analysis was performed.

RESULTS

267 patients met criteria. All patients underwent surgery at Mayo, however, only 41/81 and 71/119 patients received RT and CRT at a Mayo Clinic site. A PEG was placed in 77 patients (3 prior to any treatment, 74 reactively during adjuvant therapy), with 3 PEG dependent and 3 partially PEG reliant at last follow-up. Tracheostomy was performed in 30 (11%) patients; 28 were decannulated. Swallow evaluations were completed for 20/81 undergoing RT and 50/119 undergoing CRT at a median of 3.8 and 7.6 months post-treatment, respectively. An unrestricted oral diet was reported by 5% following RT and 12% following CRT on the Functional Oral Intake Scale. HN-PSS normalcy of diet scores indicated a diet beyond soft chewable foods for 27% following RT and 46% following CRT. No restriction of place, food, or companion was reported for the HN-PSS for public eating in 13% after RT and 33% after CRT. Aspiration of thin liquid was present in 17% and 28% following RT and CRT, respectively. HN-PSS understandability of speech was "always understandable" in 60% and 63%, following RT and CRT, respectively. Hoarseness was reported in 56% and 45% following RT and CRT respectively.

CONCLUSION

Long-term PEG and tracheostomy dependence in this cohort is low. However, these outcomes under-represent the decrement in patient speech and swallowing following TORS ± standard adjuvant therapy for HPV(+)OPSCC.

Dosimetric comparison of intensity-modulated radiation therapy for early-stage glottic cancers with and without the air cavity in the planning target volume

For early-stage glottic cancers, intensity-modulated radiation therapy (IMRT) has been shown to have comparable local control to 3D-conformal radiotherapy with the advantage of decreased dose to the carotid arteries. The planning target volume (PTV) for early glottic cancers typically includes the entire larynx, plus a 3 to 5 mm uniform margin. The air cavity within the larynx creates a challenge for the inverse optimization process as the software attempts to "build up" dose within the air. This unnecessary attempt at dose build-up in air can lead to hot spots within the rest of the PTV and surrounding soft tissue. We hypothesized that removal of the air from the PTV would decrease hot spots and allow for a more homogeneous plan while still maintaining adequate coverage of the PTV. We analyzed 20 consecutive patients with early-stage glottic cancer, T1-2N0, who received IMRT at our institution from April 2015 to December 2016. Each patient received 63 to 65.25 Gy in 2.25 Gy per fraction. Two plans were created for each case: one in which the PTV included the laryngeal air cavity and one in which the air cavity was subtracted from the PTV to create a new PTV-air structure. Dosimetric variables were collected for PTV-air structure from both IMRT plans, including V100%, D98% D2%, and D0.2%. Dosimetric variables for spinal cord and the carotid arteries were also recorded. Homogeneity index (HI) defined as D98/D2 was calculated. Two-sided t-tests were used to compare dosimetric variables. The median PTV volume was 69.9 cc (standard deviation [SD] ± 28.7 cc) and the median air cavity volume removed was 11.0 cc (SD ± 3.4 cc). A 2-sided t-test revealed a statistically significant decrease in max dose (112.7% vs 108.8%, p value = 0.0002) and improvement of HI (0.93 vs 0.91, p value = 0.0023) for the PTV air in the IMRT plan optimized for PTV air, which had air excluded, compared to the IMRT plan optimized for PTV with air included. There was no significant worsening of PTV-air coverage or significant increase in doses to the organs at risk (OARs). The removal of the air cavity from the PTV for early-stage glottic cancers does not compromise PTV coverage or sparing of OARs and can result in a more homogeneous IMRT plan. A more homogeneous plan has the potential to reduce treatment morbidity, although further study is warranted to investigate the clinical impact of air cavity removal from the PTV.

Comparison of psychosocial factors over time among HPV+ oropharyngeal cancer and tobacco-related oral cavity cancer patients

INTRODUCTION

The role of human papilloma virus (HPV) in the pathogenesis of oropharyngeal squamous cell carcinoma (OPSCC) is well documented, as is the excellent prognosis of patients with HPV-associated disease; in contrast, oral cavity squamous cell carcinoma (OCSCC) is associated with tobacco and alcohol use and has a worse prognosis. While causative factors, staging, and treatment guidelines differ between these cancer subsets, few studies have compared psychosocial factors in these groups.

OBJECTIVE

To explore differences in psychosocial factors between HPV+ OPSCC patients versus OCSCC smokers.

METHODS

A prospective cohort study at a single multidisciplinary, tertiary care HNC center was completed with recruitment from 2010 to 2013 using self-administered questionnaires before treatment and at 12 months. Patients were included with a diagnosis of HPV+ OPSCC or OCSCC with a smoking history. 38 (21 HPV+ OPSCC/17 OCSCC) met criteria. The main outcomes included self-efficacy, symptom severity, cancer worry, and depression.

RESULTS

A total of 38 (21 HPV+ OPSCC/17 OCSCC) patients (mean age: 57 [32-76], 73.7% male, 78.9% Caucasian, 71% stage IV) met inclusion criteria. OPSCC patients tended to be of male sex, Caucasian race, and single. Furthermore, OPSCC patients were more likely than OCSCC patients to have private insurance, be employed, and use alcohol and tobacco less frequently. Regarding psychosocial factors, HPV+ OPSCC patients reported lower symptom severity (2.7 versus 3.3), depression (12.0 versus 14.0) and cancer worry (2.8 versus 3.2) at baseline compared to OCSCC patients. Depression decreased significantly over time in OPSCC patients (12.0 to 9.9; effect size: -3.2 (95% CI: -5.9 to -0.4)). Although not statistically significant, cancer worry decreased in both groups (2.8 to 2.4 and 3.2 to 2.7, respectively, effect sizes: -0.3 (95% CI: -0.7-0.08) and -0.6 (95% CI: -1.2-0.05), respectively). No statistically significant differences in patterns of change over time were noted between groups.

CONCLUSIONS AND RELEVANCE

This pilot study highlighted a pattern of reduced quality of life parameters in OCSCC patients at baseline with similar improvements over time compared to the OPSCC cohort. Although different in cancer etiology and treatment plans, HPV+ OPSCC and tobacco-related OCSCC patients both require multidisciplinary cancer care plans that address psychosocial concerns.

LEVEL OF EVIDENCE

2B.

Long-term quality of life in older patients with HPV-related oropharyngeal cancer

BACKGROUND

We explored if age affects quality of life (QOL) in survivors of locally advanced human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (SCC).

METHODS

In a cross-sectional survey of 185 patients, at least 12 months from radiation, we evaluated generic (EuroQOL-5D questionnaire [EQ-5D]) and head and neck specific (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Head and Neck 35-questions [EORTC-QLQ-H&N35]) QOL questionnaires and compared differences between younger (<65) and older (≥65) patients.

RESULTS

The median age was 57.0 years (range 25-77 years), and 31 patients (16.8%) were ≥65 years old. There was no significant difference in EQ-5D global QOL scores by age (P = .53). Patients ≥65 years reported more immobility (P < .01), problems with social eating (P < .0001), and coughing (P < .01). Patients ≥65 years were not more likely to ever require a gastrostomy (P = .24) but were more likely to remain gastrostomy-dependent at the time of the survey (P = .02).

CONCLUSION

Despite similar generic QOL, older survivors may have more mobility problems and issues with social eating compared with younger survivors deserving of further evaluation.

The impact of human papillomavirus (HPV) status on functional outcomes and quality of life (QOL) after surgical treatment of oropharyngeal carcinoma with free-flap reconstruction

Background

To determine the impact of Human Papillomavirus (HPV) status on speech, swallowing, and quality of life (QOL) outcomes after surgical treatment of oropharyngeal cancer (OPSCC).

Methods

A retrospective review of a prospectively collected database of all patients with OPSCC diagnosed and treated from 1998 to 2009. Speech, swallowing, and quality of life data were gathered at 3 different evaluation points. HPV status was determined using p16 positivity as a surrogate marker. Univariate and multivariate statistical analyses were performed to identify whether p16 status is a significant predictor of functional outcome and QOL.

Results

One hundred twelve patients with OPSCC and known p16 status were treated with primary surgery between 1998 and 2009, with mean age of 56 years. Out of those patients 63 (56%) were p16 positive. Speech intelligibility remained high at 1-year post operation (95.4%). Only 11.5% of the patients required a feeding tube at 1 year after surgery to maintain their daily caloric requirements and the risk of aspiration after surgery was not significant (p = 0.097). There was no statistically or clinically significant difference in speech, swallowing ability, swallowing safety and QOL outcomes between p16-positive and negative OPSCC.

Conclusions

Surgically treated OPSCC patients demonstrate excellent swallowing function and can achieve excellent speech perception. P16 status may not be predictive of functional outcomes or QOL in surgically treated OPSCC.

Quality of life in oropharyngeal cancer: a structured review of the literature

PURPOSE

To summarize the literature on quality of life (QoL) in patients with oropharyngeal squamous cell carcinoma (OPSCC).

METHODS

The PubMed database was searched using the inclusion criteria "oropharyngeal cancer," "quality of life," "human," and "English," the exclusion criterion "recurrent," and publication date between January 1, 2005 and October 26, 2015.

RESULTS

The search yielded 98 articles of which 17 fulfilled all selection criteria. Intensity-modulated radiotherapy (IMRT) showed a better outcome for several QoL domains and was superior to chemoradiotherapy (CRT) in some studies. At 12-month follow up, deterioration of QoL was seen in a smaller proportion of patients after surgery and postoperative radiotherapy (S&PORT) in comparison to CRT. For all treatment modalities, the most important worsening for several QoL domains was seen at 3 months. Stage III/IV patients experienced a greater deterioration of QoL scores for most scores. No consistent results were reported for the correlation between xerostomia assessed with QoL questionnaires and objective swallowing function assessed with modified barium swallow videofluoroscopy.

CONCLUSION

The different tools used for the assessment of patient-reported QoL and objective measurement of functional outcome make it difficult to evaluate the effect of different treatment modalities. In general, we can conclude that a non-surgical approach is associated with worse QoL scores. IMRT minimizes radiation to the surrounding tissue and therefore has a better outcome in several QoL domains in comparison to conventional RT.

Preservation of swallowing function with de-intensified chemoradiation therapy for HPV-associated oropharyngeal squamous cell carcinoma

Purpose

This study aimed to compare the swallowing function in patients with human papillomavirus–associated oropharyngeal squamous cell carcinoma treated with de-intensified chemoradiation therapy (6 weeks, 60 Gy) versus those receiving standard-of-care chemoradiation therapy (7 weeks, 70 Gy).

Methods and materials

A retrospective review was conducted of 78 patients with human papillomavirus–associated oropharyngeal squamous cell carcinoma with modified barium swallow studies pretreatment and 6 to 8 weeks posttreatment. The swallowing function was objectively scored for penetration, aspiration, and pharyngeal residue. Forty patients received de-intensified chemoradiation therapy (60 Gy image guided radiation therapy with weekly cisplatin 30 mg/m²) and 38 patients received standard-of-care chemoradiation therapy (70 Gy image guided radiation therapy with chemotherapy of the medical oncologist's choosing). Univariate and multivariate analyses were performed to detect differences between the cohorts with regard to laryngeal penetration, aspiration, and pharyngeal residue. A multivariate logistic regression was used to determine the overall effect of treatment on the swallowing function. Patient-reported swallowing outcomes in de-intensified cohort were assessed with the European Organisation for Research and Treatment of Cancer Quality of Life Module for Head and Neck Cancer and the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events questionnaires.

Results

Patients treated with de-intensified chemoradiation therapy were associated with a suggestion of lower risk of developing overall swallowing dysfunction (odds ratio [OR], 0.62; P = .07), laryngeal penetration (OR, 0.63; P = .12), and pharyngeal residue (OR, 0.61; P = .08). The mean pre- and 2-year post-European Organisation for Research and Treatment of Cancer Quality of Life scores pertaining to swallowing (1-4 scale, higher worse) in the de-intensified cohort were 1.4 and 1.2 for liquids; 1.2 and 1.1 for purees; 1.5 and 1.7 for solids, 1.0 and 1.3 for choked when swallowing; and 9.0 and 10.8 for composite score, respectively. The mean pre- and 2-year post-Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events swallowing difficulty scores (1-5 scale, with higher scores being worse) were 1.5 and 1.8, respectively.

Conclusions

Compared with 7 weeks of 70 Gy, 6 weeks of 60 Gy de-intensified chemoradiation therapy appears to better preserve the baseline swallowing function (per objective modified barium swallow assessment). Patients treated with de-intensified chemoradiation therapy reported minimal changes in swallowing function.

Trismus following different treatment modalities for head and neck cancer: a systematic review of subjective measures

The aim of this review was to compare systematically the subjective measure of trismus between different interventions to treat head and neck cancer, particularly those of the oropharynx. Using The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) Guidelines, Six databases were searched for the text using various terms which include “oropharyngeal/head and neck cancer”, “trismus/mouth opening” and the various treatment modalities. Included in the review were clinical studies (> or =10 patients). Three observers independently assessed the papers identified. Among the six studies reviewed, five showed a significantly worst outcome with regard to the quality-of-life questionnaire scores for a radiotherapy or surgery and radiotherapy (RT) ± chemotherapy or chemoradiotherapy when compared to surgery alone. Only one study showed no significant difference between surgery alone and other treatment modalities. Subjective quality-of-life measures are a concurrent part of modern surgical practice. Although subjective measures were utilised to measure post operative trismus successfully, there was no consensus as to which treatment modality had overall better outcomes, with conflicting studies in keeping with the current debate in this field. Larger and higher quality studies are needed to compare all three treatment modalities.

Intensity-modulated radiotherapy for early glottic cancer: transition to a new standard of care?

For decades, the standard of care for radiation treatment of early larynx cancers has been conventional treatment using opposed lateral fields encompassing the larynx and overlying neck structures, including the adjacent carotid arteries. While intensity-modulated radiotherapy (IMRT) has replaced conventional radiotherapy for all other head/neck cancer situations, the use of IMRT to treat early glottic cancers remains controversial. The article reviews the published experience with IMRT for this clinical situation and provides a detailed review of the literature on radiation-induced carotid toxicity and how it might apply to the controversy. Finally, we discuss whether the radiation oncology community should transition to IMRT as a new standard of care for the treatment of early glottic cancers.

Effect of p16 Status on the Quality-of-Life Experience During Chemoradiation for Locally Advanced Oropharyngeal Cancer: A Substudy of Randomized Trial Trans-Tasman Radiation Oncology Group (TROG) 02.02 (HeadSTART)

PURPOSE

Human papillomavirus-associated oropharyngeal cancer (OPC) has a favorable prognosis. Current research de-escalates treatment, aiming to improve quality of life (QOL). Understanding the QOL experience with current standard treatment (chemoradiation therapy) provides context for emerging data. We report the impact of p16 status on QOL for patients with stage III or IV OPC undergoing chemoradiation therapy in an international phase 3 trial (TROG 02.02 [HeadSTART]).

METHODS AND MATERIALS

A subgroup analysis by p16 status was conducted in patients with OPC treated in a phase 3 randomized trial. The study subset with OPC and known p16 status was mainly from Australasia, Western Europe, and North America. Of 861 participants, 200 had OPC, known p16 status, and baseline QOL data; 82 were p16 negative and 118 were p16 positive. Radiation therapy (70 Gy over a period of 7 weeks) was given concurrently with 3 cycles of either cisplatin (100 mg/m²) or cisplatin (75 mg/m²) plus tirapazamine. QOL was measured with the Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N) questionnaire at baseline and 2, 6, 12, 23, and 38 months. Because no significant difference in QOL score was observed between arms, results by p16 status are reported with arms combined.

RESULTS

The p16-positive patients were younger, had a better Eastern Cooperative Oncology Group performance status, and were less often current smokers. Our primary hypothesis that the change in FACT-H&N score from baseline to 6 months would be more favorable in the p16-positive cohort was not met (p16 positive, -6.3; p16 negative, -1.8; P=.14). The mean baseline FACT-H&N score was statistically and clinically significantly better in p16-positive patients (111 vs 102, P<.001); at 2 months, scores declined in both groups but more dramatically for p16-positive patients. By 12 months, p16-positive patients again had superior scores. A higher baseline FACT-H&N score and p16-positive status were independent predictors of overall survival.

CONCLUSIONS

Patients with p16-positive OPC exhibited better baseline QOL but showed a more dramatic QOL drop with concurrent chemoradiation. Given the favorable prognosis of p16-positive OPC, efforts to reduce the QOL burden of treatment are warranted.

Human Papillomavirus and Head and Neck Cancer: Psychosocial Impact in Patients and Knowledge of the Link - A Systematic Review

Head and neck cancer (HNC) currently affects approximately 11 200 people in the UK, with an increasing proportion known to be caused by the human papillomavirus (HPV). We undertook a systematic review of studies measuring the psychosocial impact of HPV-related HNC and also studies measuring knowledge about the link between HPV and HNC among different populations. Searches were conducted on MEDLINE, Embase, PsycINFO, CINAHL Plus and Web of Science, with reference and forward citation searches also carried out on included studies. Studies were selected if they (i) were original peer-reviewed research (qualitative or quantitative), (ii) mentioned HPV and HNC, (iii) measured an aspect of the psychosocial impact of the diagnosis of HPV-related HNC as the dependent variable and/or (iv) measured knowledge of the association between HPV and HNC. In total, 51 papers met the inclusion criteria; 10 measuring psychosocial aspects and 41 measuring knowledge of the link between HPV and HNC. Quality of life in those with HPV-positive HNC was found to be higher, lower or equivalent to those with HPV-negative HNC. Longitudinal studies found quality of life in patients was at its lowest 2–3 months after diagnosis and some studies found quality of life almost returned to baseline levels after 12 months. Knowledge of the link between HPV and HNC was measured among different populations, with the lowest knowledge in the general population and highest in medical and dental professionals. Due to the limited studies carried out with patients measuring the psychosocial impact of a diagnosis of HPV-positive HNC, future work is needed with the partners of HPV-positive HNC patients and health professionals caring for these patients. The limited knowledge of the association between HPV and HNC among the general population also indicates the need for research to explore the information that these populations are receiving.

Impact of Expression of CD44, a Cancer Stem Cell Marker, on the Treatment Outcomes of Intensity Modulated Radiation Therapy in Patients With Oropharyngeal Squamous Cell Carcinoma

PURPOSE

To investigate the significance of CD44 protein expression on the treatment outcomes of radiation therapy in patients with oropharyngeal squamous cell carcinoma (OPSCC) with or without p16 protein expression in the tumor tissue.

METHODS AND MATERIALS

We reviewed the medical records of 58 OPSCC patients who had undergone radiation therapy and examined the tumor tissue expressions of CD44 and p16 protein by immunohistochemical staining. The correlations between the expressions of these proteins and the patients' treatment outcomes were analyzed.

RESULTS

The data of 58 consecutive OPSCC patients who had undergone definitive intensity modulated radiation therapy were analyzed. The male/female ratio was 55:3, and the median age was 64 years. The clinical stage of the disease was stage II in 7 patients, stage III in 5 patients, stage IVA in 35 patients, and stage IVB in 11 patients. Of the patients, 79% received additional induction and/or concurrent chemotherapy. The median follow-up duration was 34 months. The 3-year overall survival, progression-free survival (PFS) and locoregional control (LRC) rates of all the patients, regardless of the results of immunohistochemistry, were 73%, 64% and 76%, respectively. The PFS and LRC rates in the CD44(-) patients (86% and 93%, respectively) were significantly higher than those in the CD44(+) patients (57% and 70%, respectively). The PFS and LRC rates in the p16(+) patients (83% and 90%, respectively) were significantly higher than those in the p16(-) patients (45% and 61%, respectively). Patients who were CD44(-)/p16(+) showed the best LRC rates, and those who were CD44(+)/p16(-) showed the worst PFS and LRC rates among all the groups.

CONCLUSIONS

Profiling of CD44 and p16 protein expressions by immunohistochemical staining is useful for predicting the treatment outcomes in patients with OPSCC undergoing definitive intensity modulated radiation therapy.

Human Papillomavirus-Negative Pharyngeal Cancer

Human papillomavirus-negative head and neck squamous cell carcinoma (HNSCC) carries a poor prognosis, and despite optimal treatment with chemoradiotherapy to the limit of tolerance, many patients will relapse. A number of methods for intensifying treatment of HNSCC have been investigated, leading to the current standards of care. Novel agents targeting tumor cell and stromal signaling, DNA damage response, and immune system are now reaching clinical trials in combination with chemoradiotherapy. In this review, we discuss the evidence for the current treatment of locally advanced human papillomavirus-negative HNSCC, as well as investigational therapies, such as hypoxia modification, molecular targeting of epidermal growth factor receptor family, vascular endothelial growth factor receptor or DNA damage response proteins in combination with radiation therapy.

Transoral laser microsurgery for the treatment of oropharyngeal cancer: the Dalhousie University experience

OBJECTIVE

The optimal treatment strategy for oropharyngeal squamous cell carcinoma is highly debated. However, growing evidence supports the use of minimally invasive techniques, such as transoral laser microsurgery (TLM), as a first-line treatment modality for these carcinomas. The purpose of our study was to assess the efficacy and safety of TLM for the treatment of primary and recurrent oropharyngeal carcinomas.

METHODS

All patients with oropharyngeal carcinoma undergoing TLM at the QEII Health Sciences Centre in Halifax, Nova Scotia were identified within a prospective database monitoring TLM outcomes. Kaplan-Meier survival analysis was used to evaluate the following end points at 36 months: local control (LC), disease-specific survival (DSS), and disease-free survival (DFS). Safety endpoints included complications following surgery and long term morbidity related to TLM.

RESULTS

Between 2003 and 2014, 39 patients with oropharyngeal carcinoma underwent TLM resection. Twenty-eight (72%) patients had primary carcinoma, nine (23%) were radiation/chemoradiation (RT/CRT) failures, and two (5%) had second primaries following previous RT/CRT. Three patients had stage I disease, 8 stage II, 5 stage III, and 23 stage IV disease. HPV status was available for 26 patients, of which 23 (88%) had HPV positive disease. Kaplan-Meier estimates of 36-month LC, DSS, and DFS for primary oropharyngeal carcinomas were 85.5% (SE 10.6%), 85.7% (SE 13.2%) and 77.7% (SE 12.5%) respectively. Thirty-six-month outcomes for RT/CRT failures were 66.76% (SE 15.7%) for LC and 55.6% (SE 16.6%) for DSS and DFS. Three patients developed complications following surgery.

CONCLUSIONS

Observed 36-month efficacy and safety outcomes support the use of TLM for the treatment of primary and recurrent oropharyngeal carcinoma.

Transoral robotic surgery vs. radiotherapy for management of oropharyngeal squamous cell carcinoma - A systematic review of the literature

BACKGROUND

Intensity-modulated radiation therapy (IMRT) with or without concurrent chemotherapy is widely utilized for the treatment of oropharyngeal squamous cell carcinoma (OPSCC). However, due to significant acute and late toxicities there has been increasing interest in minimally invasive surgical approaches, particularly transoral robotic surgery (TORS) in an attempt to preserve patient quality of life while maintaining oncologic outcomes. The aim of this study was to review the current literature in order to compare primary IMRT versus TORS in the management of OPSCC.

METHODS

A MEDLINE search was conducted to identify studies reporting on the outcomes of TORS or IMRT in the treatment of OPSCC. Reference lists were also reviewed for relevant articles. Oncologic, functional, and quality of life data is summarized and discussed.

RESULTS

One hundred-ninety papers were identified through the MEDLINE search. An additional 52 papers were retrieved by hand searching the reference lists. Ultimately, 44 papers were identified that discussed outcomes after IMRT or TORS for OPSCC. No outcomes from randomized trials were identified.

CONCLUSION

No randomized trials comparing TORS versus IMRT to each other were identified. Uncontrolled reports from the current literature suggest comparable oncologic outcomes with TORS compared to IMRT and functional outcomes may be superior. However, the median follow-up was relatively short and the TORS studies included patients with earlier stage OPSCC on average compared to IMRT studies. Prospective, randomized controlled trials and direct, well-matched comparisons are needed to further elucidate the role for TORS in the treatment of oropharyngeal squamous cell carcinoma.

Transoral Robotic Surgery in Oropharyngeal Carcinoma

Context

The incidence of oropharyngeal squamous cell carcinoma has increased during the past decade and is related primarily to the human papillomavirus. This change in etiology, from tobacco and alcohol to human papillomavirus, has resulted in improved survival for the disease. In the United States, open resection had largely been replaced by concurrent chemotherapy and/or radiotherapy by the early 2000s. The advent of transoral surgery has led to an increase in surgery as the primary treatment for both early- and advanced-stage oropharyngeal squamous cell carcinoma because it has potential advantages over open surgery and nonsurgical modalities.

Objective

To provide an overview of transoral robotic surgery for oropharyngeal squamous cell carcinoma and contrast it with other surgical and nonsurgical modalities.

Data Sources

Articles from 2000 to 2014 were accessioned on PubMed and reviewed for utility by the primary authors.

Conclusions

Transoral surgery has become more commonly used as a minimally invasive approach to treat oropharyngeal tumors. Other strategies, including radiation, chemotherapy with radiation, and open surgery, are still important treatment approaches. The treatment options for an individual patient rely on multiple factors, including the tumor location and size, features of the tumor, and patient comorbidities. The continued study of these techniques is important to match the patient with the most appropriate treatment.

A systematic review of quality of life in head and neck cancer treated with surgery with or without adjuvant treatment

Quality of life (QoL) is an important consideration in the management of head and neck cancers (HNC). We systematically reviewed the literature to assess the impact of curative surgical resection (+/- adjuvant therapy) of HNC on QoL. Eligible studies (participants>age 18 years, reported fully in English, and prospectively assessed QoL) were filtered using quality criteria, and classified according to the added value, using a published taxonomy. MEDLINE and EMBASE searching yielded 302 distinct reports, 49 met eligibility, and 26 met quality criteria. Among the eligible studies, achievement of certain quality criteria was poor: a priori hypothesis (8%), statistical accounting of missing data (8%), reporting of assessment interval (35%) and rationale for chosen measure (53%). The most frequent ways QoL added value were: understanding of treatment benefit and risk (100%), comparing treatments for QoL effect (92%) and advancing QoL research methodology (50%). QoL (physical/social functioning and various symptom domains) deteriorated with treatment, gradually recovering to baseline (cancer diagnosis) level. Swallowing, chewing, saliva, taste, eating disruption, and aesthetic deficits may persist. Advanced tumors, extensive surgical resection, need for flap reconstruction, neck dissection, and postoperative radiation are associated with worse QoL outcomes. Knowledge of these trends can be applied in shared decision making, identification of commonly faced QoL issues, and to develop and provide survivorship resources. Future research should focus on routinely incorporating QoL in randomized studies, reporting the result according to guidelines, and following knowledge translation principles to maximize the clinician's and patient's ability to use QoL data.

A meta-analysis of the relationship among impaired taste and treatment, treatment type, and tumor site in head and neck cancer treatment survivors

PROBLEM IDENTIFICATION

To understand how taste impairment caused by head and neck cancer treatment changes over time or varies with treatment site or type.

LITERATURE SEARCH

Ovid MEDLINE® database was searched for reports of health-related quality of life (HRQOL) in head and neck cancer treatment survivors (HNCTS), which included taste function in a HRQOL instrument from 1946-2013. Eligible studies compared taste scores from baseline to post-treatment, using two treatment types or two cancer sites.

DATA EVALUATION

247 reports were identified; 19 were suitable for meta-analysis.

DATA ANALYSIS

A series of dichotomous meta-analyses were conducted using comprehensive meta-analysis software .PRESENTATION OF FINDINGS: Taste scores were statistically significantly worse after treatment; the summary effect for the standard measure difference between pretreatment and post-treatment taste scores was 0.353 (p < 0.001). Patients treated with radiation therapy (RT) reported statistically significant worse taste function post-treatment than those who received no RT; the summary effect for the standard mean differences in taste scores was 0.77 (p = 0.001). Differences in tumor site were not significant.

IMPLICATIONS FOR NURSING

Taste dysfunction is a long-term complication for HNCTS, and nurses should screen survivors for this sensory dysfunction.

Human papilloma virus and survival of oropharyngeal cancer patients treated with surgery and adjuvant radiotherapy

Impact of p16 protein, a surrogate marker for human papilloma virus induced cancer, p53 and EGFR as well as clinical factors on survival in a patient cohort with oropharyngeal squamous cell carcinoma (OPSCC) treated by surgical resection and adjuvant radiotherapy (RT) ± concomitant chemotherapy (CT). This is a retrospective analysis of patient's charts and tumor tissue. 57 patients were consecutively included and their tumor tissue assembled on a tissue microarray following immunohistochemical analysis. Survival times were estimated by means of Kaplan-Meier analysis. The importance of clinical and immunohistochemical factors for outcome was estimated by cox proportional hazard models. With 88% 5-year overall survival, 91% 5-year disease-specific survival and 91% 5-year disease-free survival, respectively, we found excellent survival rates in this surgically treated patient cohort of mainly advanced OPSCC (93% AJCC stage III or IV). The only factors positively influencing survival were p16 overexpression as well as p53 negativity and even more pronounced the combination of those biomarkers. Survival analysis of patients classified into three risk categories according to an algorithm based on p16, smoking, T- and N-category revealed a low, intermediate and high-risk group with significant survival differences between the low and the high-risk group. Patients with OPSCC can be successfully treated by surgery and adjuvant RT ± CT with a clear survival benefit of p16 positive, p53 negative patients. We recommend considering a combination of immunohistochemical (p16, p53) and clinical factors (smoking, T- and N-category) for risk stratification.

Quality of life, shoulder range of motion, and spinal accessory nerve status in 5-year survivors of head and neck cancer

OBJECTIVE

To determine the association of neck dissection and radiation treatment for head and neck cancer (HNC) with subsequent shoulder range of motion (ROM) and quality of life (QOL) in 5-year survivors.

DESIGN

A cross-sectional convenience sample.

SETTING

Otolaryngology clinics at tertiary care hospital and Veterans Affairs medical center.

PATIENTS

Five-year, disease-free survivors of HNC.

METHODS

Demographic and cancer treatment information was collected, including type of neck dissection (none, spinal accessory "nerve sparing," and "nerve sacrificing") and radiation. QOL questionnaires were administered, and shoulder ROM was measured.

MAIN OUTCOME MEASUREMENTS

University of Washington Quality of Life (UWQOL), Functional Assessment of Cancer Therapy (FACT) Head and Neck, and Performance Status Scale for Head and Neck. Shoulder ROM measurements included abduction, adduction, flexion, extension, internal and external rotation.

RESULTS

One hundred and five survivors completed QOL surveys; 85 survivors underwent additional shoulder ROM evaluations. The nerve sacrifice group exhibited significantly poorer scores for UWQOL measures of disfigurement, level of activity, recreation and/or entertainment, speech and shoulder disability, and willingness to eat in public, FACT functional well-being, and FACT Head and Neck (P < .05). Shoulder ROM for flexion and abduction was poorest in the nerve sacrifice group (P < .05). Radiation was associated with significantly worse UWQOL swallowing (P < .05), but no other differences were found for QOL or ROM measurements. Decreased QOL scores were associated with decreased shoulder flexion and abduction (P < .05). Survivors with decreased shoulder abduction had significantly (P < .05) worse scores in disfigurement, recreation and/or entertainment, employment, shoulder disability, and FACT emotional well-being.

CONCLUSIONS

Sparing the spinal accessory nerve during neck dissection is associated with significantly less long-term shoulder disability in 5-year survivors of HNC. QOL measures demonstrated the highest level of function in the no dissection group, an intermediate level of functioning with nerve sparing, and poorest function when the nerve is sacrificed. Decreased shoulder flexion and abduction is associated with reduced QOL in long-term survivors of HNC.

Early stage oropharyngeal carcinomas: comparing quality of life for different treatment modalities

OBJECTIVE

To compare long-term quality of life outcomes after treating early stage oropharyngeal carcinoma either with surgery, surgery combined with radiotherapy, or surgery combined with chemoradiotherapy.

METHODS

Questionnaire based method: 111 eligible patients agreed to fill out a quality of life questionnaire.

RESULTS

Of the 32 scales contained in the EORTC's combined QLQ-C30 and HN35, 11 scales show significantly better results for the surgery-only treatment group when compared to either surgery combined with radiotherapy or surgery combined with any type of adjuvant therapy. These eleven scales are role function (P = 0.019/0.008), social function (P = 0.01/0.034), nausea (P = 0.017/0.025), pain (P = 0.014/0.023), financial problems (P = 0.030/0.012), speech (P = 0.02/0.015), social eating (P = 0.003/<0.001), mouth opening (P = 0.033/0.016), sticky saliva (P = 0.001/<0.001), swallowing (P < 0.001/<0.001), and dry mouth (P < 0.001/0.001).

CONCLUSION

Treatment of early stage oropharyngeal carcinoma with surgery alone has definite advantages over treatments including any form of adjuvant therapy when considering quality of life. Advantages manifest themselves especially in functional aspects of the head and neck realm; however general health aspects as well as psychosocial aspects show improvements as well. This study does not show any indication of QOL-related drawbacks of surgery-only treatment approaches.

Transoral robotic surgery for oropharyngeal cancer: long-term quality of life and functional outcomes

IMPORTANCE

Because treatment for oropharyngeal squamous cell carcinoma (OPSCC), especially in patients of older age, is associated with decreased patient quality of life (QOL) after surgery, demonstration of a less QOL-impairing treatment technique would improve patient satisfaction substantially.

OBJECTIVE

To determine swallowing, speech, and QOL outcomes following transoral robotic surgery (TORS) for OPSCC.

DESIGN, PARTICIPANTS, AND SETTING

This prospective cohort study of 81 patients with previously untreated OPSCC was conducted at a tertiary care academic comprehensive cancer center.

INTERVENTIONS

Primary surgical resection via TORS and neck dissection as indicated.

MAIN OUTCOMES AND MEASURES

Patients were asked to complete the Head and Neck Cancer Inventory (HNCI) preoperatively and at 3 weeks as well as 3, 6, and 12 months postoperatively. Swallowing ability was assessed by independence from a gastrostomy tube (G-tube). Clinicopathologic and follow-up data were also collected.

RESULTS

Mean follow-up time was 22.7 months. The HNCI response rates at 3 weeks and 3, 6, and 12 months were 79%, 60%, 63%, and 67% respectively. There were overall declines in speech, eating, aesthetic, social, and overall QOL domains in the early postoperative periods. However, at 1 year post TORS, scores for aesthetic, social, and overall QOL remained high. Radiation therapy was negatively correlated with multiple QOL domains (P < .05 for all comparisons), while age older than 55 years correlated with lower speech and aesthetic scores (P < .05 for both). Human papillomavirus status did not correlate with any QOL domain. G-tube rates at 6 and 12 months were 24% and 9%, respectively. Greater extent of TORS (>1 oropharyngeal site resected) and age older than 55 years predicted the need for a G-tube at any point after TORS (P < .05 for both).

CONCLUSIONS AND RELEVANCE

Patients with OPSCC treated with TORS maintain a high QOL at 1 year after surgery. Adjuvant treatment and older age tend to decrease QOL. Patients meeting these criteria should be counseled appropriately.