Long-term oral effects in patients treated with radiochemotherapy for head and neck cancer

[Physical long-term consequences of cancer]

The number of long-term survivors of malignant diseases is steadily increasing, which is due to the further development and optimization of multimodal therapy strategies and the mechanisms of new substance classes. These can now be combined with classical treatment methods or used sequentially. At the same time the number of patients who suffer from physical and psychosocial long-term consequences of cancer therapies or have to live with chronic side effects under the long-term therapies increases. Every therapy, whether radiation, chemotherapy, targeted therapy, or operation, has undesirable long-term side effects that contribute to the decrease of one's quality of life. These affect all parts of the body. As a result, patients can be heavily burdened. In oncology and in other disciplines involved in aftercare, these consequences must therefore be increasingly addressed and clarified and treatment strategies further developed. Unfortunately, there is still a considerable need for research in this area; moreover, there is a lack of clinical studies examining the evidence of a wide variety of holistic therapy methods.

External validation of OroGrams as a predictive model for overall and progression-free survival in Scottish patients with oropharyngeal squamous cell carcinoma: a retrospective cohort study

The aims of this study were to externally validate the OroGrams (oropharyngeal cancer survival calculator) nomogram in a Scottish cohort with high endemic smoking rates, and to compare survival rates with the original validation cohort. A retrospective cohort study in Greater Glasgow and Clyde ENT and OMFS departments was performed to investigate survival outcomes of patients with oropharyngeal squamous cell carcinoma (OPSCC) from January 2012 - December 2017. The main outcome measures were progression-free (PFS) and overall survival (OS), and Kaplan Meier curves. The predictive accuracy of OroGrams was investigated for survival probabilities at one, three, and five years. Smoking and HPV-negative cancer rates were significantly higher in Scottish patients than in the UK consortium cohort. A greater proportion of Scottish patients had advanced UICC8 stages. PFS in patients with HPV-negative cancer appeared better in the Scottish cohort than in the original cohort. Calculated mean standardised Brier scores for PFS and OS were below 0.2 at all three follow-up points, suggesting good overall prognostic accuracy, but there was wide variation between predictive accuracy in individual patients. OroGrams shows prognostic accuracy at one-year follow up in Scotland. The accuracy decreases with longer follow-up periods.

Quality of Life in Orthodontic Cancer Survivor Patients-A Prospective Case-Control Study

Background: The aim of the study was to compare the quality of life (QoL) of cancer survivors with a control group of healthy subjects before, during, and after the orthodontic treatment. Methods: Consecutive cancer survivors (40 people) who were looking for orthodontic treatment between 2008 and 2015 were enrolled into the study. Healthy orthodontic patients matched for age (±4 years), sex, and malocclusion served as controls. The 14-item version of the Oral Health Impact Profile was used to assess the effect of orthodontic treatment on QoL before, during, and after the orthodontic treatment. Results: There were no significant differences between both groups regarding the cast model, cephalometric analysis, and photographic documentation analysis. There was a significant worsening of QoL after the onset of the orthodontic treatment with a significant improvement after the treatment. Male cancer survivor patients reported significantly lower QoL during the treatment time, which was not observed in the male control group. Conclusions: The outcome of orthodontic treatment in cancer survivors did not differ from the healthy orthodontic patients. The orthodontic treatment had an impact on the oral health quality of life both in the cancer and the control groups with a significantly higher impact in male cancer survivor patients.

Late Oral Complications Caused by Head and Neck Radiotherapy: Clinical and Laboratory Study

Objectives

The aim of presented cross-sectional and observational study was to determine the prevalence of late oral complications of patients with head and neck cancer who underwent radiotherapy, by clinical and laboratory analyses.

Material and Methods

Fifty-five patients, 43 (78.2%) men and 12 (21.8%) women, mean age 60; range 38 to 87 years, who have completed radiotherapy for head and neck cancer for at least 6 months were enrolled. The presence of xerostomia, hyposalivation, oral candidiasis, and type of oral yeasts were correlated with post-radiotherapy period. A control group, age and gender matched, was used for comparisons. The Pearson’s Chi-square or Fischer’s exact test was used at a significance level of 5%.

Results

The mean post-radiotherapy period was 32 months. The oral complications found were xerostomia (45/55, [81.8%]), hyposalivation (44/55 [80%]) and oral candidiasis (15/55 [27.2%]). Xerostomia and hyposalivation was statistically higher in the study group when compared to the control group (P < 0.05). The presence of yeast occurred in 39 (70.9%) of the patients in the study group, and Candida albicans was the most prevalent etiological agent in 25 (64.1%) of those patients (P < 0.05).

Conclusions

Xerostomia and hyposalivation were the more prevalent late oral complications related to radiotherapy. Oral candidiasis was also observed, although its prevalence was lower. The need for long-term dental follow-up of patients who underwent radiotherapy of the head and neck cancer is mandatory.

Variations in odontological care routines for patients undergoing treatment for head and neck cancer in county councils/regions of Sweden

OBJECTIVE

To investigate current odontological care routines for patients treated for head and neck cancers in the county councils/regions (C/Rs) of Sweden.

METHODS

An invitation to fill in a web-based questionnaire was sent to dentists/dental hygienists working in dental clinics in the 12 C/Rs, treating and responsible for the odontological care of patients undergoing treatment for cancer of the head and neck. The questionnaire started with two mandatory and one non-mandatory questions, followed by questions regarding routines before (n = 28), during (n = 23), and after (n = 9) treatment, plus two additional questions, totalling 65 questions.

RESULTS

Four dental hygienists and six dentists in 10 of the 12 C/Rs answered the questionnaire. Three C/Rs stated that they measure both the unstimulated and stimulated salivary secretion rate, and another C/R stated that they measure the stimulated secretion rate only. Similar recommendations were given regarding oral hygiene, salivary stimulants and substitutes, and extra fluoride. However, great variations were seen regarding recommendations for preventing and relieving oral mucositis. There were also discrepancies regarding information about the importance of avoiding smoking and alcohol. In seven C/Rs, patients visited the dental hygienist once a week during cancer treatment.

CONCLUSION

The results suggests that there are great variations in odontological care given to patients undergoing treatment for cancer of the head and neck region in different county councils/regions in Sweden. There is a need to develop and implement evidence-based guidelines to decrease the risk of oral complications and increase both the quality of life and the quality of care.

Hyposalivation due to chemotherapy exacerbates oral ulcerative mucositis and delays its healing

OBJECTIVES

Cancer therapy including chemotherapy causes gland atrophy, resulting in low salivary secretion in cancer patients. Since saliva plays an important role in oral health, the dysfunction may exacerbate oral ulcerative mucositis (OUM), which is another side effect. Here, we investigated the effect of hyposalivation on OUM using sialoadenectomized rats and examined the effects of anticancer drugs on the salivary glands.

DESIGN

As models for hyposalivation, the bilateral submandibular and sublingual glands except (2EXT) or together with (3EXT) the parotid glands were extracted. At 16 days after the procedure, OUM was experimentally developed by topical acetic acid treatment on the labial fornix region of the inferior incisors, and the severity and bacterial loading level were evaluated. The salivary gland weights and histology were analyzed after administration of the representative anticancer drugs 5-fluorouracil or cisplatin.

RESULTS

The severity of OUM was greater in both the 3EXT and 2EXT rats and delayed the healing process compared with that in sham rats without salivary gland extraction. The healing process in the 3EXT rats was longer than that in the 2EXT rats. The number of colony-forming units in the ulcerative region from the 3EXT rats was 10-fold greater than that in the sham rats. Both 5-fluorouracil and cisplatin reduced glands weights and damaged the salivary glands.

CONCLUSIONS

These results suggest that chemotherapy-induced hyposalivation exacerbates OUM and delays healing, most likely due to loss of salivary clearance and antimicrobial functions. This study illustrates the significance of oral health care for cancer patients undergoing chemotherapy.

Explorative study on quality of life in relation to salivary secretion rate in head and neck cancer patients treated with radiotherapy up to 2 years post treatment

OBJECTIVE

The aim of this study was to analyse quality of life (QoL) pretreatment and up to 24 months post radiation therapy (RT) in patients with head and neck (H&N) cancer.

METHODS

Twenty-nine patients (19 men and 10 women) with a mean age of 59 ± 8 years were included. The stimulated salivary secretion was measured and the patients completed the European Organisation for Research and Treatment of Cancer Quality of Life questionnaires (EORTC QLQ-C30 and H&N35) and the Hospital Anxiety and Depression scale (HADS) pretreatment and at 6, 12 and 24 months post RT.

RESULTS

At all time-points after RT (6, 12, and 24 months), patients with hyposalivation (stimulated secretion rate ≤0.7 mL/min) reported clinically significant differences (> 10 points) regarding insomnia, swallowing, social eating, dry mouth, and sticky saliva. Statistically significant differences were found for emotional functioning and insomnia at 12 months (P < 0.05 for both) and for sticky saliva at both 12 and 24 months (P < 0.05 and P < 0.01). The number of clinically significant differences increased from 10 at both 6 and 12 months post-RT to 14 functioning/symptom scales and single items at the 24 months follow-up. At 24 months post RT, 21% of patients with hyposalivation had HADS scores suggesting anxiety problems compared to 7% for those with stimulated salivary secretion rates >0.7 mL/min.

CONCLUSION

Patients with hyposalivation showed deterioration in health related quality of life (QoL) at 24 months compared with 12 months post RT. Most pronounced were problems with insomnia, swallowing, social eating, dry mouth, and sticky saliva.

A novel method to evaluate salivary flow rates of head and neck cancer patients after radiotherapy: a pilot study

Introduction

The procedure used to evaluate salivary flow rate is called sialometry. It can be performed through several techniques, but none appears to be really efficient for post-radiotherapy patients.

Objective

To adequate sialometry tests for head and neck cancer patients submitted to radiotherapy.

Methods

22 xerostomic patients post-radiotherapy (total radiation dose ranging from 60 to 70 Gy) were included in this study. Ten patients were evaluated using sialometries originally proposed by the Radiation Therapy Oncology Group and twelve were assessed by our modified methods. Unstimulated and stimulated sialometries were performed and the results were classified according a grading scale and compared between both groups.

Results

There was no statistically significant difference between the salivary evaluations of both groups (p = 0.4487 and p = 0.5615). Also, most of these rates were classified as very low and low.

Conclusion

This novel method seems to be suitable for patients submitted to radiotherapy.

An evaluation of nutrition intervention during radiation therapy in patients with locoregionally advanced nasopharyngeal carcinoma

Purpose

To evaluate the effectiveness of nutrition intervention during radiation for patients with locoregionally advanced (III-IVa) nasopharyngeal carcinoma (NPC).

Materials and Methods

We retrospectively reviewed 117 patients with locoregionally advanced (III-IVa) NPC treated between December 2015 and March 2016 in Zhejiang Cancer Hospital. All the patients underwent radical chemo-radiotherapy. First, all the patients were divided into the nutrition intervention group and the control group, depending on whether they accepted nutrition intervention. Repeated measures were used to analyze the change of nutritional indicators before, during, and after radiation therapy and to simultaneously compare the difference in nutritional status between the two groups at the same time point. Subsequently, the 117 patients were divided into the malnourished group (weight loss > 5%) and the non-malnourished group (weight loss ≤ 5%) according to whether their weight loss was over 5% of their body weight during radiotherapy. Chi-square tests and logistic regression analysis were used to explore the influence factors for the weight loss.

Results

The repeated measures showed that all indicators including weight, body mass index (BMI), albumin, pre-albumin(PA), and prognostic nutritional index (PNI) dramatically declined in both groups compared with their levels before radiation therapy (All p < 0.001). However, there was no significant difference between the intervention and non-intervention groups regarding the mean values of nutritional indicators at the same time point, that before, during, and after radiation therapy, except BMI (All p > 0.05). Logistic regression analysis revealed grade ≥ 3 radiation-induced oral mucositis as the prognostic factor for a poor nutrition status (odds ratio, OR = 3.232, p = 0.021, confidence interval, CI [1.198, 8.820]). Besides this, patients with a decrease of >15% in pre-albumin level were more likely to be malnourished (OR = 2.442, p = 0.041, CI [1.036, 5.757]). Similar to that observed in our former analysis, we did not find that existing nutrition intervention can significantly improve nutritional status (OR = 1.217, p = 0.704, CI [0.042, 3.348]).

Conclusions

Our study shows that the nutritional status of the patients gradually declined during treatment. We concluded that grade ≥ 3 radiation-induced oral mucositis would aggravate the extent of malnutrition during radiation therapy in patients with locoregionally advanced NPC. Pre-albumin level was a predictive marker for weight loss in patients with NPC. However, current nutrition intervention during radiation therapy can't significantly reverse nutritional status.

Beneficial Effects of Adjuvant Melatonin in Minimizing Oral Mucositis Complications in Head and Neck Cancer Patients Receiving Concurrent Chemoradiation

OBJECTIVES

Oral mucositis is a major cause of pain and delayed cancer treatment leading to poor survival in head and neck cancer patients receiving concurrent chemoradiation. The study evaluated the effect of adjuvant melatonin on minimizing oral mucositis complications to reduce these treatment delays and interruptions.

DESIGN

A randomized, double-blind, double dummy, placebo-controlled clinical trial.

SETTING

Ubon Ratchathani Cancer Hospital, Thailand.

PARTICIPANTS

Thirty-nine head and neck cancer patients receiving concurrent chemoradiation (5 days/week of radiation plus chemotherapy three or six cycles).

METHODS

Patients were randomized to receive 20 mg melatonin gargle (or matched placebo) before each irradiation, and 20 mg melatonin capsules (or matched placebo) taken nightly during 7 weeks of concurrent chemoradiation. Endpoints were oral mucositis events (incidence and time to grade 3 mucositis or grade 2 xerostomia), pain medication consumption and quality of life (QOL).

RESULTS

Melatonin group reported lower incidence of grade 3 oral mucositis (42% vs. 55%) and grade 2 xerostomia (20% vs. 21%); no statistical significance was detected. Melatonin regimen delayed onset of grade 3 mucositis (median 34 days vs. 50 days; p = 0.0318), allowing median time of 16 more patient visits before its onset and fewer interrupted treatments due to oral mucositis were reported (n = 1 vs. n = 5). There was no difference of grade 2 xerostomia (median 32 days vs. 50 days; p = 0.624). Morphine consumption was also reduced (median 57 mg vs. 0 mg; p = 0.0342), while QOL was comparable during the study period.

CONCLUSION

Adjuvant melatonin delayed the onset of oral mucositis, which enables uninterrupted cancer treatment and reduced the amount of morphine used for pain treatment.

HPV Associated Head and Neck Cancer

Head and neck cancers (HNCs) are a highly heterogeneous group of tumours that are associated with diverse clinical outcomes. Recent evidence has demonstrated that human papillomavirus (HPV) is involved in up to 25% of HNCs; particularly in the oropharyngeal carcinoma (OPC) subtype where it can account for up to 60% of such cases. HPVs are double-stranded DNA viruses that infect epithelial cells; numerous HPV subtypes, including 16, 18, 31, 33, and 35, drive epithelial cell transformation and tumourigenesis. HPV positive (HPV+) HNC represents a distinct molecular and clinical entity from HPV negative (HPV-) disease; the biological basis for which remains to be fully elucidated. HPV positivity is strongly correlated with a significantly superior outcome; indicating that such tumours should have a distinct management approach. This review focuses on the recent scientific and clinical investigation of HPV+ HNC. In particular, we discuss the importance of molecular and clinical evidence for defining the role of HPV in HNC, and the clinical impact of HPV status as a biomarker for HNC.

Topical application of Aloe vera and vitamin E on induced ulcers on the tongue of rats subjected to radiation: clinical and histological evaluation

OBJECTIVE

The aim of this study is to assess the effect of two types of antioxidants, vitamin E (VE) and Aloe vera (AV), on healing of induced oral lesions after radiation in a murine model by clinical and histological analysis.

METHODS

The animals were randomly divided into three groups of 12 animals each (400 mg VE, 70 % AV and control) and two time periods (5 and 7 days). They were irradiated with a single dose of 30 Gy, and after 24 h, a lesion was produced on the ventral tongue of each animal. The products were applied daily in their respective group until euthanasia.

RESULTS

On clinical analysis, there was a higher frequency of lesions in the animals of the control group at both periods. The area of the lesions was also greater in the control group compared with the groups AV and VE (5 days p = 0.006; 7 days p = 0.002). On microscopic analysis, the degree of inflammation differed between the study groups and experimental periods. At 5 days, the statistical difference was not significant among the groups evaluated, but at 7 days, animals in the control group showed intense inflammation, while those in groups VE and AV exhibited mild to moderate inflammation (p = 0.002).

CONCLUSION

The results suggest that VE and AV contributed to the decrease in inflammatory response and healing of the lesions induced on the tongue of rats subjected to radiation.

Modulation of therapeutic sensitivity by human papillomavirus

Human papillomaviruses (HPVs) are small double-stranded DNA viruses that pose significant public health concerns as the causative agent of approximately 5% of worldwide cancers. The HPV oncogenes E6 and E7 play key roles in carcinogenesis. In the last 15years there has been a significant increase in the incidence of HPV-related head and neck cancers arising primarily in the oropharynx. Patients with HPV-positive head and neck cancers (HNCs) have a significantly improved prognosis compared to those with HPV-negative disease. In this review we will discuss data suggesting how HPV oncogenes modulate both the intrinsic radiation sensitivity of HNCs and also have important effects upon the tumor microenvironment. Together, these findings contribute to the improved outcomes seen in patients with HPV-positive HNC.

Development of tools for the oral health and panoramic radiograph evaluation of head and neck cancer patients: a methodological study

PURPOSE

Describe the methodology used to construct tools for standardized data collection of head and neck cancer patients (HNCP).

METHODS

We constructed the Oral Health Evaluation Tool (OHET) and Panoramic Radiograph Evaluation Tool (PRET) for systematic collection of long-term oral clinical/radiographical complications, prevalence, and severity. Tools were pilot-tested in 50 chemoradiation-treated HNCP >6 months post-therapy.

RESULTS

Tools allowed for collection of extensive clinical and radiographical data. A medium of 1.9 years had elapsed since chemoradiation completion. Patients had a median of 6 missing teeth, 32.7% had no decay and a medium of 30% had filled surfaces; 42.9% had moderate-to-severe decay. Reduced/thickened saliva was noted in 85.4% and dry mucosa in 93.9%. Gingival bleeding was present in 75.5% HNCP and attachment loss in 86%. Four patients had trismus.

CONCLUSIONS

Tools were user friendly and provided comprehensive, reproducible, and inexpensive means to evaluate post-therapy oral health of HNCP. Validation testing is ongoing.

The interplay between HPV and host immunity in head and neck squamous cell carcinoma

Persistent infection with human papillomavirus (HPV) type 16 is a major risk factor for the development of head and neck squamous cell carcinoma (HNSCC), in particular oropharyngeal squamous cell carcinoma (OPSCC). The oropharyngeal epithelium differs from the mucosal epithelium at other commonly HPV16-infected sites (i.e., cervix and anogenital region) in that it is juxtaposed with the underlying lymphatic tissue, serving a key immunologic function in the surveillance of inhaled and ingested pathogens. Therefore, the natural history of infection and immune response to HPV at this site may differ from that at other anatomic locations. This review summarizes the literature concerning the adaptive immune response against HPV in the context of HNSCC, with a focus on the T-cell response. Recent studies have shown that a broad repertoire of tumor-infiltrating HPV-specific T-cells are found in nearly all patients with HPV-positive tumors. A systemic response is found in only a proportion of these. Furthermore, the local response is more frequent in OPSCC patients than in cervical cancer patients and HPV-negative OPSCC patients. Despite this, tumor persistence may be facilitated by abnormalities in antigen processing, a skewed T-helper cell response, and an increased local prevalence of T-regulatory cells. Nonetheless, the immunologic profile of HPV-positive vs. HPV-negative HNSCC is associated with a significantly better outcome, and the HPV-specific immune response is suggested to play a role in the significantly better response to therapy of HPV-positive patients. Immunoprofiling may prove a valuable prognostic tool, and immunotherapy trials targeting HPV are underway, providing hope for decreasing treatment-related toxicity.

Changes in parotid gland morphology and function in patients treated with intensity-modulated radiotherapy for nasopharyngeal and oropharyngeal tumors

OBJECTIVE

To evaluate the morphological changes of the parotid glands in patients treated with intensity-modulated radiotherapy (IMRT) for nasopharyngeal and oropharyngeal tumors and the correlations with parotid function.

METHODS

Ten patients with nasopharyngeal and oropharyngeal tumors treated with IMRT between May 2009 and January 2010 at Hokkaido University Hospital were included in this study. In the morphological assessment of the parotid glands, the sizes and computed tomography (CT) numbers of the bilateral parotid glands before and after IMRT with CT were calculated. For functional assessment of the parotid glands, we conducted the Saxon test and used a visual analog scale (VAS) for xerostomia evaluation.

RESULTS

Reductions in saliva secretion were observed in the patients treated with IMRT for nasopharyngeal and oropharyngeal tumors, and there was a significant correlation between the reduction in saliva secretion and the VAS. The reductions in the parotid gland size and CT number were larger on the ipsilateral side than on the contralateral side. The reduction in saliva secretion was not significantly correlated with the reduction in parotid gland size, but was significantly correlated with the reduction in CT number.

CONCLUSIONS

Morphological and functional changes of the parotid glands were observed after IMRT for nasopharyngeal and oropharyngeal tumors, and preservation of the contralateral parotid glands was only partly achieved. Among the morphological changes of the parotid glands, the CT number may be considered a predictor of parotid function after radiotherapy.