Radiotherapy-related quality of life in patients with head and neck cancers: a meta-analysis

Improved quality of life in head and neck cancer patients treated with modern arc radiotherapy techniques - A prospective longitudinal analysis

Purpose

The present longitudinal study aimed to evaluate the potential impact of modern radiotherapy (RT) techniques on quality of life (QOL) in patients with head and neck (HNC) cancer.

Materials and methods

In this single-center prospective study, participants were asked to complete QOL questionnaires that included the EORTC QLQ-C30, QLQ-H&N 35 and utility score by time trade-off (TTO) at three time points (2 weeks, 3 months and 6 months) after completion of RT. All patients were treated by modern RT techniques [volumetric modulated arc therapy (VMAT) or helical tomotherapy (HT)]. Patients who developed recurrence or died before the 6-month follow-up were excluded. Linear mixed models with random intercepts for participants and restricted maximum likelihood estimates were used to assess the effect of our study variables (age, sex, primary site, cancer stage, treatment, radiation dose and radiation method). Overall changes in QOL, utility scores and symptom burdens at different time points were tested using paired t tests.

Results

A total of 45 patients were recruited from 2022 to 2023. Those who completed the surveys at 2 weeks with at least 1 follow-up (30 patients, 67%) were enrolled in the final analysis. The majority of these 30 patients were men (76.7%), had oral cancer (40%), had stage III or IV disease (60%), received surgical intervention (63%) and were treated with chemoradiation (80%). A curative total dose of 66 to 70 Gy was delivered to 23 (76.7%) patients, half of whom received HT. Patients who received chemotherapy had significantly lower global QoL scales (mean difference, 27.94; 95% CI, 9.33-46.55; p=0.005). Global QOL, physical function, symptoms of sticky saliva, cough, feelings of illness and weight loss improved significantly between 2 weeks and 3 months. There was no significant difference between 3 and 6 months. Interestingly, improvements in social function, social contact, pain and nutrition reached significance at 6 months. Subgroup analysis revealed greater pain relief over time for patients who underwent HT (p=0.030). Moreover, patients who participated in swallowing rehabilitation programs had a greater decrease in nausea and vomiting (p=0.036).

Conclusion

HNC patients treated with modern RT techniques experience improved QOL and physical function over time. The most significant improvement occurs between 2 weeks and 3 months, after which the improvement plateaus. However, social function, social contact, pain and nutrition may require longer recovery intervals after treatment. HT with daily image guidance could provide a therapeutic opportunity for improving pain relief in patients with HNC.

Radiotherapy-Related Quality of Life in Nasopharyngeal Carcinoma Patients: A Systematic Review and Meta-Analysis

INTRODUCTION

This systematic review and meta-analysis evaluated the quality of life (QoL) for nasopharyngeal carcinoma (NPC) patients with radiotherapy.

METHODS

A systematic literature search was performed to identify relevant studies published until March 2022. Quality evaluation and data extraction were performed for the included studies, and meta-analysis was performed using Stata.

RESULTS

Nine studies, including 1,659 patients, were eligible. Most QoL scales developed at the end of the treatment course and then followed by a gradual recovery to 1 year and more than 1 year after treatment. However, some items have not changed significantly and have a deteriorating trend. Items of cognitive functioning and constipation in EORTC QLQ-C30, and sexuality, felt ill, and weight gain in EORTC QLQ-H&N35 showed that scales with follow-up of more than 1 year were worse than those within 1 year but still better than those after treatment. In the intensity-modulated radiotherapy (IMRT) subgroup in EORTC QLQ-C30, cognitive functioning was similar to those before, and there was no significant change in insomnia. There was no significant change in the teeth item in EORTC QLQ-H&N35. In the IMRT subgroup, scales of swallowing, felt ill, and weight gain with follow-up of more than 1 year were worse than those within 1 year.

CONCLUSION

The QoL of patients with NPC is significantly impaired after radiotherapy-treated compared to baseline, and most of these items will gradually improve.

Effect of different approaches of direct radiation on the surface structure and caries susceptibility of enamel

It is not clear whether different radiation methods have different effects on enamel. The purpose of this study was to compare the effects of single and fractionated radiation on enamel and caries susceptibility and to provide an experimental basis for further study of radiation‑related caries. Thirty-six caries-free human third molars were collected and randomly divided into three groups (n = 12). Group1 (control group) was not exposed to radiation. Group 2 received single radiation with a cumulative dose of 70 Gy. Group 3 underwent fractionated radiation, receiving 2 Gy/day for 5 days followed by a 2-day rest period, for a total of 7 weeks with a cumulative dose of 70 Gy. Changes in microhardness, roughness, surface morphology, bacterial adhesion and ability of acid resistance of each group were tested. Scanning electron microscope revealed that the enamel surface in both radiation groups exhibited unevenness and cracks. Compared with the control group, microhardness and acid resistance of enamel decreased, while roughness and bacterial adhesion increased in both the single radiation and fractionated radiation groups. Compared with the single radiation group, the enamel surface microhardness and acid resistance decreased in the fractionated radiation group, while roughness and bacterial adhesion increased. Both single radiation and fractionated radiation resulting in changes in the physical and biological properties of enamel, with these changes being more pronounced in the fractionated radiation group. Therefore, fractionated radiation is recommended as a more suitable method for constructing a radiation‑related caries model in vitro.

Evaluation of photobiomodulation therapy (PBMT) on salivary flow and composition in head and neck cancer patients undergoing radiation therapy

OBJECTIVE

Assess the impact of photobiomodulation therapy (PBMT) on xerostomia, salivary flow rate (SFR) and composition in patients undergoing radiotherapy (RT) for head and neck cancer (HNC).

STUDY DESIGN

Thirty patients undergoing RT (65 Gy) for HNC were enrolled. Saliva and xerostomia evaluations collected pre- and post-PBMT-RT. PBMT involved irradiation of extra and intraoral points, 15-20 sessions, 2-3 times/week. SFR, trace elements, total protein, alkaline phosphatase, xerostomia, and pH were analyzed.

RESULTS

The average age was 60.7 years. After treatment, there was not a significant reduction in SFR and there was no difference on xerostomia. Significant reductions in Al, Cd, Fe, Ni, P, and Sb concentrations were observed, along with a significant increase in Mg concentration. Sample data were organized into 3 groups based on a self-organizing map. Low concentrations of Al, As, Co, Cr, Cu, Fe, Mn, Mo, S, Sr, and Zn were the primary discriminatory factors for group A, while group B consisted of post-PBMT-RT samples with high concentrations of Ca, K, Mg, Na, and S.

CONCLUSIONS

PBMT prevented a significant reduction in SFR and xerostomia induced by radiation therapy. These findings suggest that PBMT prevents salivary gland damage minimizing the decline in salivary flow.

Predictive value of delta radiomics in xerostomia after chemoradiotherapy in patients with stage III-IV nasopharyngeal carcinoma

BACKGROUND

Xerostomia is one of the most common side effects in nasopharyngeal carcinoma (NPC) patients after chemoradiotherapy. To establish a Delta radiomics model for predicting xerostomia secondary to chemoradiotherapy for NPC based on magnetic resonance T1-weighted imaging (T1WI) sequence and evaluate its diagnostic efficacy.

METHODS

Clinical data and Magnetic resonance imaging (MRI) data before treatment and after induction chemotherapy (IC) of 255 NPC patients with stage III-IV were collected retrospectively. Within one week after CCRT, the patients were divided into mild (92 cases) and severe (163 cases) according to the grade of xerostomia. Parotid glands in T1WI sequence images before and after IC were delineated as regions of interest for radiomics feature extraction, and Delta radiomics feature values were calculated. Univariate logistic analysis, correlation, and Gradient Boosting Decision Tree (GBDT) methods were applied to reduce the dimension, select the best radiomics features, and establish pretreatment, post-IC, and Delta radiomics xerostomia grading predictive models. The receiver operating characteristic (ROC) curve and decision curve were drawn to evaluate the predictive efficacy of different models.

RESULTS

Finally, 15, 10, and 12 optimal features were selected from pretreatment, post-IC, and Delta radiomics features, respectively, and a xerostomia prediction model was constructed with AUC values of 0.738, 0.751, and 0.843 in the training set, respectively. Only age was statistically significant in the clinical data of both groups (P < 0.05).

CONCLUSION

Delta radiomics can predict the degree of xerostomia after chemoradiotherapy for NPC patients and it has certain guiding significance for clinical early intervention measures.

Oral-Functioning Questionnaires in Patients with Head and Neck Cancer: A Scoping Review

Background: Oral-functioning impairment can negatively affect the quality of life (QoL) of head and neck cancer (HNC) patients after receiving radiotherapy (RT). Assessment of patient-reported oral functioning throughout treatment can improve patient care. This scoping review aims to propose a definition for oral functioning for HNC patients and to map out the available questionnaires measuring patient-reported oral functioning in RT-treated HNC patients. Methods: A literature search in relevant databases was performed. Each questionnaire was scored on the domains validity, reliability, and responsiveness. Furthermore, the items from the questionnaires were analyzed to define the common denominators for oral functioning in HNC patients. Results: Of the 6434 articles assessed, 16 met the inclusion criteria and employed 16 distinct instruments to evaluate QoL. No questionnaire covered all oral-health-related QoL items nor assessed all aspects of validity, reliability, and responsiveness. Chewing, speaking, and swallowing were the common denominators for oral functioning. Conclusions: Based on the included studies, we suggest using the VHNSS 2.0 questionnaire to assess oral functioning in HNC patients. Furthermore, we suggest to more clearly define oral functioning in HNC patients by focusing on masticatory function (chewing and grinding), mouth opening, swallowing, speaking, and salivation.

Noninvasive Systemic Modalities for Prevention of Head and Neck Radiation-Associated Soft Tissue Injury: A Narrative Review

BACKGROUND

 Radiation-associated soft tissue injury is a potentially devastating complication for head and neck cancer patients. The damage can range from minor sequelae such as xerostomia, which requires frequent daily maintenance, to destructive degenerative processes such as osteoradionecrosis, which can contribute to flap failure and delay or reverse oral rehabilitation. Despite the need for effective radioprotectants, the literature remains sparse, primarily focused on interventions beyond the surgeon's control, such as maintenance of good oral hygiene or modulation of radiation dose.

METHODS

 This narrative review aggregates and explores noninvasive, systemic treatment modalities for prevention or amelioration of radiation-associated soft tissue injury.

RESULTS

 We highlighted nine modalities with the most clinical potential, which include amifostine, melatonin, palifermin, hyperbaric oxygen therapy, photobiomodulation, pentoxifylline-tocopherol-clodronate, pravastatin, transforming growth factor-β modulators, and deferoxamine, and reviewed the benefits and limitations of each modality. Unfortunately, none of these modalities are supported by strong evidence for prophylaxis against radiation-associated soft tissue injury.

CONCLUSION

 While we cannot endorse any of these nine modalities for immediate clinical use, they may prove fruitful areas for further investigation.

Diagnosis, Prevention, and Treatment of Radiotherapy-Induced Xerostomia: A Review

In patients with head and neck cancer, irradiation (IR)-sensitive salivary gland (SG) tissue is highly prone to damage during radiotherapy (RT). This leads to SG hypofunction and xerostomia. Xerostomia is defined as the subjective complaint of dry mouth, which can cause other symptoms and adversely affect the quality of life. In recent years, diagnostic techniques have constantly improved with the emergence of more reliable and valid questionnaires as well as more accurate equipment for saliva flow rate measurement and imaging methods. Preventive measures such as the antioxidant MitoTEMPO, botulinum toxin (BoNT), and growth factors have been successfully applied in animal experiments, resulting in positive outcomes. Interventions, such as the new delivery methods of pilocarpine, edible saliva substitutes, acupuncture and electrical stimulation, gene transfer, and stem cell transplantation, have shown potential to alleviate or restore xerostomia in patients. The review summarizes the existing and new diagnostic methods for xerostomia, along with current and potential strategies for reducing IR-induced damage to SG function. We also aim to provide guidance on the advantages and disadvantages of the diagnostic methods. Additionally, most prevention and treatment methods remain in the stage of animal experiments, suggesting a need for further clinical research, among which we believe that antioxidants, gene transfer, and stem cell transplantation have broad prospects.

Oral Health Management and Rehabilitation for Patients with Oral Cancer: A Narrative Review

Surgery is the current first choice for oral cancer treatment. Intensity-modulated radiation therapy, molecular targeted drugs, and immune checkpoint inhibitors are still used as adjuvant therapy for advanced cancer. In addition, postoperative rehabilitation and multidisciplinary treatment have also been developed in recent years. Multidisciplinary team approaches and supportive care in oral cancer treatment reportedly shorten the time to treatment and improve outcomes. Although there is enough evidence confirming the role of oral and maxillofacial surgeons, dentists, and dental hygienists in supportive care in oral cancer treatment, there are very few systematic studies. In particular, oral health management is a concept that encompasses oral function management, oral hygiene management, and oral care during oral cancer treatment. We provide a narrative review focusing on oral health management from a multidisciplinary and supportive care perspective, applicable in oral cancer treatment.

Prognostic factor analysis of definitive radiotherapy using intensity-modulated radiation therapy and volumetric modulated arc therapy with boluses for scalp angiosarcomas

Cutaneous angiosarcomas is a rare cancer with poor prognoses. The common radiotherapy techniques that have been reported so far are two pairs of lateral X-ray and electron fields. However, it is quite difficult to irradiate scalp angiosarcomas (SAs) homogeneously with this technique. In this study, safety, effectiveness, and risk factors were assessed for localized SAs ≥ 5 cm treated with intensity-modulated radiotherapy (IMRT) or volumetric modulated arc therapy (VMAT) with boluses. Sixty-eight angiosarcoma patients who had received radiotherapy in our institution between January 2007 and November 2020 were retrieved from our radiotherapy database. Of these patients, 27 localized SA patients were included in the retrospective analysis. The 2-year overall survival, local progression-free rate, and distant metastases-free survival were 41.8%, 48.4%, and 33.1%. All the patients experienced acute radiation dermatitis ≥ grade 2, with18 (66.7%) ≥ grade 3. No nodule lesion was a significant unfavorable predictive factor of acute radiation dermatitis ≥ grade 3. Tumor bleeding at the initiation of radiotherapy and tumor invasion to the face were significant predictive factors of overall survival, and tumor bleeding at the initiation of radiotherapy was also a significant predictive factor of local progression-free rate.

Prevalence of occult nodal metastases in squamous cell carcinoma of the temporal bone: a systematic review and meta-analysis

PURPOSE

Primary: To determine the rate of occult cervical metastases in primary temporal bone squamous cell carcinomas (TBSSC). Secondary: to perform a subgroup meta-analysis of the risk of occult metastases based on the clinical stage of the tumour and its risk based on corresponding levels of the neck.

METHODS

A systematic review and meta-analysis of papers searched through Medline, Cochrane, Embase, Scopus and Web of Science up to November 2021 to determine the pooled rate of occult lymph node/parotid metastases. Quality assessment of the included studies was assessed through the Newcastle-Ottawa scale.

RESULTS

Overall, 13 out of 3301 screened studies met the inclusion criteria, for a total of 1120 patients of which 550 had TBSCC. Out of the 267 patients who underwent a neck dissection, 33 had positive lymph nodes giving a pooled rate of occult metastases of 14% (95% CI 10-19%). Occult metastases rate varied according to Modified Pittsburg staging system, being 0% (0-16%) among 12 pT1, 7% (2-20%) among 43 pT2 cases, 21% (11-38%) among 45 pT3, and 18% (11-27%) among 102 pT4 cases. Data available showed that most of the positive nodes were in Level II.

CONCLUSION

The rate of occult cervical metastases in TBSCC increases with pathological T category with majority of nodal disease found in level II of the neck.

Radiation necrosis of the bone, cartilage or cervical soft-tissues following definitive high-precision radio(chemo)therapy for head-neck cancer: uncommon and under-reported phenomenon

Background

The impact of modern high-precision conformal techniques on rare but highly morbid late complications of head and neck radiotherapy, such as necrosis of the bone, cartilage or soft-tissues, is not well described.

Method

Medical records of head and neck cancer patients treated in prospective clinical trials of definitive high-precision radiotherapy were reviewed retrospectively to identify patients with necrosis.

Results

Twelve of 290 patients (4.1 per cent) developed radiotherapy necrosis at a median interval of 4.5 months. There was no significant difference in baseline demographic (age, gender), disease (primary site, stage) and treatment characteristics (radiotherapy technique, total dose, fractionation) of patients developing radiotherapy necrosis versus those without necrosis. Initial management included antibiotics or anti-inflammatory agents, tissue debridement and tracheostomy as appropriate followed by hyperbaric oxygen therapy and resective surgery for persistent symptoms in selected patients.

Conclusion

Multidisciplinary management is essential for the prevention, early diagnosis and successful treatment of radiotherapy necrosis of bone, cartilage or cervical soft tissues.

SPM Receptor Expression and Localization in Irradiated Salivary Glands

Radiation therapy-mediated salivary gland destruction is characterized by increased inflammatory cell infiltration and fibrosis, both of which ultimately lead to salivary gland hypofunction. However, current treatments (e.g., artificial saliva and sialagogues) only promote temporary relief of symptoms. As such, developing alternative measures against radiation damage is critical for restoring salivary gland structure and function. One promising option for managing radiation therapy-mediated damage in salivary glands is by activation of specialized proresolving lipid mediator receptors due to their demonstrated role in resolution of inflammation and fibrosis in many tissues. Nonetheless, little is known about the presence and function of these receptors in healthy and/or irradiated salivary glands. Therefore, the goal of this study was to detect whether these specialized proresolving lipid mediator receptors are expressed in healthy salivary glands and, if so, if they are maintained after radiation therapy-mediated damage. Our results indicate that specialized proresolving lipid mediator receptors are heterogeneously expressed in inflammatory as well as in acinar and ductal cells within human submandibular glands and that their expression persists after radiation therapy. These findings suggest that epithelial cells as well as resident immune cells represent potential targets for modulation of resolution of inflammation and fibrosis in irradiated salivary glands.

Randomized Trial Assessing the Impact of Routine Assessment of Health-Related Quality of Life in Patients with Head and Neck Cancer

Simple Summary

The purpose of this research was to investigate the impact of routine assessment of health-related quality of life (HRQoL) on quality of life and satisfaction with care in patients with head and neck cancer (HNC). A randomized controlled open-label clinical trial with 200 patients with HNC managed in four cancer centers in Eastern France was performed. In the intervention arm (regularly completed HRQoL questionnaires), HRQoL mean change was significantly improved at 2 years from baseline. Compared with the control arm, differences were not statistically significant, but minimal clinically important differences in favor of the intervention arm were found for HRQoL, satisfaction with waiting times, and satisfaction with accessibility. In patients with head and neck cancer undergoing treatments, routine assessment of HRQoL is a simple practice and may have HRQoL and satisfaction benefits.

Abstract

The impact of routine assessment of health-related quality of life (HRQoL) on satisfaction with care and the HRQoL of patients with head and neck cancer (HNC) treated with radiotherapy was assessed. Patients with HNC were randomly assigned to two arms, with stratification on sex, cancer localization, and stage of the disease. In the intervention arm, the patients completed the EORTC QLQ-C30 and EORTC QLQ-H&N35 questionnaires first before randomization, then before each medical appointment during radiotherapy (7 weeks), and then every 3 months until 1 year and at 2 years thereafter. In the control arm, the EORTC QLQ-C30 and EORTC QLQ-H&N35 questionnaires were completed before randomization and at 1 year and 2 years thereafter. The primary endpoint was mean change in HRQoL at score at 2 years from baseline assessed by EQ VAS from the EuroQol questionnaire. The secondary endpoint was mean change in satisfaction with care at 2 years from baseline assessed by QLQ-SAT32. Two hundred patients with head and neck cancers were involved in this study (mean age, 58.83 years (range, 36.56–87.89)), of whom 100 were assigned to the intervention arm and 100 to the control arm. Patients in the intervention arm were reported to have a statistically significant increase in EQ VAS at 2 years (p < 0.0001) and exceeded the minimal clinically important difference (mean change at 2 years from baseline = 10.46). In the two arms, mean differences between arms were not statistically significant, but minimal clinically important differences in favor of the intervention arm were found for EQ VAS (mean change difference (MD) = 5.84), satisfaction with care, in particular waiting times (MD = 10.85) and satisfaction with accessibility (MD = 6.52). Routine assessment of HRQoL improves HRQoL and satisfaction with care for patients with HNC treated with radiotherapy.

Validation of the German-language version of the Liverpool Oral Rehabilitation Questionnaire version 3 and evaluation of oral-health-related quality of life among patients with squamous cell carcinoma of the head and neck

The aim of this study was to translate the Liverpool Oral Rehabilitation Questionnaire version 3 (LORQv3) into German and validate this version in order to assess oral-health-related quality of life (OHRQoL) among head and neck cancer patients. This study was conducted at a German university clinic among patients who had completed therapy for squamous cell carcinoma of the head and neck (HNSCC). The original English-language LORQv3 was translated into German according to the forward-backward approach. Validity and reliability were evaluated using further questionnaires related to OHRQoL and psychological impairments. Subgroups were built with reference to oral rehabilitation status and type of cancer therapy. Furthermore, OHRQoL was evaluated. Test-retest reliability was assessed by weighted kappa with a 10-14 day interval. Data were analysed by using Spearman's correlation and the following tests: Shapiro-Wilk, Kruskal-Wallis, Mann-Whitney U and Cronbach's alpha. The level of significance was set at α = 0.05. Analysis of the LORQv3 evaluations revealed excellent Cronbach's alpha and high test-retest reliability. Construct validity were supported by the data. LORQv3 summary score and domains were significantly affected by status of oral rehabilitation (p = 0.003, p = 0.008, p = 0.024) and treatment approach (p < 0.001, p = 0.025, p = 0.035). The German version of the LORQv3 showed high reliability and validity and an impaired OHRQoL of HNSCC patients. It can therefore be recommended for the assessment of OHRQoL.

The impact of radiotherapy on the quality of life in patients with early-stage clinical head and neck cancer

Radiotherapy (RT) for patients with head and neck squamous cell carcinoma (HNSCC) affects vital functions related to the irradiation volume of the head and neck region and, in addition, has a negative impact on social functioning, thereby significantly impairing patients' quality of life (QoL). The aim of this study was to assess changes in the quality of life in patients with head and neck cancer treated with curative RT at 12 months after completion of RT. The aim of this study was to assess the differences between the baseline QoL of patients with early clinical stage HNSCC and at 12 months after curative/radical RT. The prospective clinical study included 92 patients in good general condition (ECOG 0-1 - Eastern Cooperative Oncology Group performance status), without regional or distant metastases, diagnosed with pathomorphologically confirmed early-stage head and neck squamous cell carcinoma treated with definitive RT. All patients participating in the study signed an informed consent form. QoL was assessed using the standard EORTC QLQ-C30 and QLQH&amp;N35 questionnaires. In addition, information on clinical aspects and data relating to socio-demographic factors were obtained from each patient. Statistical analysis was performed using a statistical package (SPSS 17.0). T-test was used for dependent and independent samples. A general linear model was used for repeated measures. Patients' QoL deteriorated significantly after definitive RT. Worse QoL Core-30 scores in patients 12 months after the end of RT, compared with baseline QoL, before the start of RT, were observed in domains such as physical performance, fulfillment of life roles, cognitive functioning, loss of appetite, fatigue and constipation. For the QLQ-H&amp;N35 questionnaires, patients 12 months after the end of RT reported problems in relation to aspects of life such as senses, mouth opening, dry mouth, thick saliva, pain, and weight loss. RT, even in early clinical stage head and neck cancer, has a negative impact on QoL, despite modern treatment techniques.

Locally Advanced Oral Cavity Cancers: What Is The Optimal Care?

Patients with oral cavity cancers often present late to seek medical care. Surgery is usually the preferred upfront treatment. However, surgical resection cannot be achieved in many cases with advanced disease without major impact on patient’s quality of life. On the other hand, radiotherapy (RT) and chemotherapy (CT) have not been employed routinely to replace surgery as curative treatment or to facilitate surgery as neoadjuvant therapy. The optimal care of these patients is challenging when surgical treatment is not feasible. In this review, we aimed to summarize the best available evidence-based treatment approaches for patients with locally advanced oral cavity cancer. Surgery followed by RT with or without CT is the standard of care for locally advanced oral cavity squamous cell carcinoma. In the case of unresectable disease, induction CT prior to surgery or chemoradiotherapy (CRT) can be attempted with curative intent. For inoperable patients or when surgery is expected to result in poor functional outcome, patients may be candidates for possibly curative CRT or palliative RT with a focus on quality of life.

Intensity-modulated radiation therapy versus three-dimensional conformal radiotherapy in head and neck squamous cell carcinoma: long-term and mature outcomes of a prospective randomized trial

Purpose

To compare long-term disease-related outcomes and late radiation morbidity between intensity-modulated radiation therapy (IMRT) and three-dimensional conformal radiotherapy (3D-CRT) in head and neck squamous cell carcinoma (HNSCC) in the setting of a prospective randomized controlled trial.

Methods

Previously untreated patients with early to moderately advanced non-metastatic squamous carcinoma of the oropharynx, larynx, or hypopharynx (T1-T3, N0-N2b, M0) planned for comprehensive irradiation of primary site and bilateral neck nodes were randomly assigned to either IMRT or 3D-CRT after written informed consent. Patients were treated with 6MV photons to a total dose of 70Gy/35 fractions over 7 weeks (3D-CRT) or 66Gy/30 fractions over 6 weeks (IMRT). A sample size of 60 patients was estimated to demonstrate 35% absolute difference in the incidence of ≥grade 2 acute xerostomia between the two arms. All time-to-event outcomes were calculated from date of randomization until the defined event using the Kaplan-Meier method.

Results

At a median follow-up of 140 months for surviving patients, 10-year Kaplan-Meier estimates of loco-regional control (LRC); progression-free survival (PFS); and overall survival (OS) with 95% confidence interval (95%CI) were 73.6% (95%CI: 61.2–86%); 45.2% (95%CI: 32–58.4%); and 50.3% (95%CI: 37.1–63.5%) respectively. There were no significant differences in 10-year disease-related outcomes between 3D-CRT and IMRT for LRC [79.2% (95%CI: 62.2–96.2%) vs 68.7% (95%CI: 51.1–86.3%), p = 0.39]; PFS [41.3% (95%CI: 22.3–60.3%) vs 48.6% (95%CI: 30.6–66.6%), p = 0.59]; or OS [44.9% (95%CI: 25.7–64.1%) vs 55.0% (95%CI: 37–73%), p = 0.49]. Significantly lesser proportion of patients in the IMRT arm experienced ≥grade 2 late xerostomia and subcutaneous fibrosis at all time-points. However, at longer follow-up, fewer patients remained evaluable for late radiation toxicity reducing statistical power and precision.

Conclusions

IMRT provides a clinically meaningful and sustained reduction in the incidence of moderate to severe xerostomia and subcutaneous fibrosis compared to 3D-CRT without compromising disease-related outcomes in long-term survivors of non-nasopharyngeal HNSCC.