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

Long-term results of radio(chemo)therapy in metastatic carcinoma to cervical lymph nodes from an unknown primary. Adult Comorbidity Evaluation 27 score as a predictor of survival

PURPOSE

To evaluate the effectiveness and toxicity of curative (chemo)radiotherapy in patients with metastatic carcinoma to cervical lymph nodes from an unknown primary.

METHODS

Retrospective study of 90 consecutive patients, treated with curative radiotherapy from 2003 to 2018 (median age 59 years; current/former smokers 76%) was conducted. The distribution of nodal staging was as follows: N1: 12%, N2a: 21%, N2b: 43%, N2c: 10%, N3: 13%. In 62% of patients, neck dissection was performed before radiotherapy. Concomitant chemotherapy was given to 64% of patients.

RESULTS

The median follow-up of surviving patients was 86 months. The median total radiotherapy dose achieved was 70 Gy. The 5‑ and 10-year locoregional control were 84% in both cases, while 5‑ and 10-year distant control were 90% and 89%, respectively. A primary tumor in the head and neck area was detected in only 2 patients. No patient had an initial failure in the pharyngeal axis or contralateral cervical nodes. The 5‑ and 10-year overall survival were 55% and 42%, respectively. Severe early toxicity occurred in 71%; severe late toxicity in 33% of patients. Multivariate analysis demonstrated N‑status (hazard ratio [HR] 2.424; 95% confidence interval [CI] 1.121-5.241; p = 0.024) and comorbidity scores assessed by ACE-27 (Adult Comorbidity Evaluation; HR 3.058; 95% CI 1.489-6.281; p = 0.002) as two independent prognostic factors for overall survival.

CONCLUSION

The results of our work study demonstrate the high effectiveness of curative (chemo)radiotherapy on the pharyngeal axis and bilateral cervical nodes with long-term locoregional and distant control in 3/4 of the treated patients. N‑status and comorbidity scores were shown as strong prognostic factors influencing overall survival.

Unmet needs, quality of life and psychological distress: insights regarding head and neck cancer patients in a rural setting

OBJECTIVE

This study aimed to evaluate the perceived quality of life, unmet needs and psychological distress in patients with head and neck cancer in a rural setting in New Zealand.

METHOD

Patients presenting with head and neck cancer in Northland, New Zealand, were asked to complete questionnaires on quality of life, unmet needs, and anxiety or depression together with a free-text option.

RESULTS

About one quarter of respondents (27 per cent) scored high in the anxiety and depression scale, with corresponding diminished quality of life scores and increased needs. Over half of respondents (54 per cent) found it challenging to travel for treatment. Financial difficulties were encountered more frequently with indigenous patients. Rurality alone does not lead to significant differences in quality of life or needs.

CONCLUSION

After treatment for head and neck cancer, it is important to monitor and manage patients' psychological distress and ease of access to health services to improve quality of life.

The impact of head and neck radiotherapy on salivary flow and quality of life: Results of the ORARAD study

OBJECTIVES

Salivary hypofunction and xerostomia, are common side effects of radiotherapy, negatively impacting quality of life. The OraRad study presents results on the longitudinal impact of radiotherapy on salivary flow and patient-reported outcomes.

PATIENTS AND METHODS

Prospective, multicenter cohort study of 572 patients receiving curative-intent head and neck radiotherapy (RT). Stimulated salivary flow (SSF) rate and patient-reported outcomes were measured prior to RT and at 6- and 18-months post-RT. Linear mixed effects models examined the relationship between RT dose and change in salivary flow, and change in patient-reported outcomes.

RESULTS

544 patients had baseline salivary flow measurement, with median (IQR) stimulated flow rate of 0.975 (0.648, 1.417) g/min. Average RT dose to parotid glands was associated with change in salivary flow post-RT (p < 0.001). Diminished flow to 37% of pre-RT level was observed at 6 months (median: 0.358, IQR: 0.188 to 0.640 g/min, n = 481) with partial recovery to 59% of pre-RT at 18 months (median: 0.575, IQR: 0.338 to 0.884 g/min, n = 422). Significant improvement in patient-reported swallowing, senses (taste and smell), mouth opening, dry mouth, and sticky saliva (p-values < 0.03) were observed between 6 and 18 months post-RT. Changes in swallowing, mouth opening, dry mouth, and sticky saliva were significantly associated with changes in salivary flow from baseline (p-values < 0.04).

CONCLUSION

Salivary flow and patient-reported outcomes decreased as a result of RT, but demonstrated partial recovery during follow-up. Continued efforts are needed to improve post-RT salivary function to support quality of life.

A prospective study of patient-reported xerostomia-related outcomes after parotidectomy

OBJECTIVE

There is a paucity of data on patient-reported outcome measures regarding xerostomia after parotidectomy surgery. Although salivary flow rates after parotidectomy have been previously studied, they do not correlate with subjective xerostomia. This study was designed to evaluate if unilateral parotidectomy increases patient-reported xerostomia.

METHODS

A prospective cohort of patients undergoing unilateral partial, superficial, or total parotidectomy for benign or low-grade malignant pathology without postoperative radiation at a tertiary care academic center was studied. We analyzed patient-reported outcome measures of xerostomia using the Xerostomia Questionnaire (XQ) preoperatively and postoperatively. We compared pre- and postoperative cumulative and individual XQ scores using Wilcoxon signed-rank tests. We stratified patients by the weight in grams (g) of the parotid tissue excised, pathology, smoking status, and xerostomia-related medication use.

RESULTS

Twenty-two adults with benign or low grade malignant unilateral parotid tumors were included. Postoperative questionnaires were completed at a median of 10.2 months (interquartile range [IQR] 8.6-11.9) after unilateral parotidectomy. Mean preoperative and postoperative cumulative XQ scores, on a 100-point scale, with higher scores representing worse symptoms, were 10.33 (95% CI: 4.46-16.20) and 10.54 (95% CI: 5.10-15.98), respectively, with a mean change of +0.21 (p = 0.472). There were no statistically significant changes in individual XQ symptom scores. Neither type of parotidectomy, resection specimens weighing over 10 g, smoking habits, xerostomia-related medication use, nor malignant pathology were associated with worse symptom scores.

CONCLUSION

Based on these data, unilateral parotidectomy does not appear to definitely, or at least consistently, increase xerostomia per patient reporting. More extensive parotid resections are not associated with worse symptom scores. These data can help guide preoperative counseling and postoperative expectations for parotidectomy.

LEVEL OF EVIDENCE

2b.

Accuracy of automatic structure propagation for daily magnetic resonance image-guided head and neck radiotherapy

BACKGROUND AND PURPOSE

Deformable image registration (DIR) and contour propagation are used in daily online adaptation for hybrid MRI linac (MRL) treatments. The accuracy of the propagated contours may vary depending on the chosen workflow (WF), affecting the amount of required manual corrections. This study investigated the impact of three different WFs of contour propagations produced by a clinical treatment planning system for a high-field MRL on head and neck cancer patients.

METHODS

Seventeen patients referred for curative radiotherapy for oropharyngeal cancer underwent standard CT-based dose planning and MR scans in the treatment position for planning (pMR), and at the 10th (MR10), 20th (MR20) and 30th (MR30) fraction (±2). The primary tumour, a metastatic lymph node and 8 organs at risk were manually delineated on each set of T2 weighted images. Delineations were repeated one month later on the pMR by the same observer to determine the intra-observer variation (IOV). Three WFs were used to deform images in the treatment planning system for the high-field MRL: In WF1, only the planning image and contours were used as a reference for DIR and propagation to MR_10,20,30. The most recently acquired image set prior to the daily images was deformed and uncorrected (WF2) versus manually corrected (WF3) structures propagated to the session image. Dice similarity coefficient (DSC), mean surface distance (MSD) and Hausdorff distance (HD) were calculated for each structure in each model.

RESULTS

Population median DSC, MSD and HD for WF1 and WF3 were similar and slightly better than for WF2. WF3 provided higher accuracy than WF1 for structures that are likely to shrink. All DIR workflows were less accurate than the IOV.

CONCLUSIONS

WF1 and WF3 provide higher accuracy in structure propagation than WF2. Manual revision and correction of propagated structures are required for all evaluated workflows.

Intensity-modulated proton therapy for oropharyngeal cancer reduces rates of late xerostomia

BACKGROUND AND PURPOSE

To determine rates of xerostomia after intensity-modulated radiotherapy (IMRT) or intensity-modulated proton therapy (IMPT) for oropharyngeal cancer (OPC) and identify dosimetric factors associated with xerostomia risk.

MATERIALS AND METHODS

Patients with OPC who received IMRT (n = 429) or IMPT (n = 103) from January 2011 through June 2015 at a single institution were studied retrospectively. Every 3 months after treatment, each patient completed an eight-item self-reported xerostomia-specific questionnaire (XQ; summary XQ score, 0-100). An XQ score of 50 was selected as the demarcation value for moderate-severe (XQs ≥ 50) and no-mild (XQs < 50) xerostomia. The mean doses and percent volumes of organs at risk receiving various doses (V5-V70) were extracted from the initial treatment plans. The dosimetric variables and xerostomia risk were compared using an independent-sample t-test or chi-square test.

RESULTS

The median follow-up time was 36.2 months. The proportions of patients with moderate-severe xerostomia were similar in the two treatment groups up to 18 months after treatment. However, moderate-severe xerostomia was less common in the IMPT group than in the IMRT group at 18-24 months (6% vs. 20%; p = 0.025) and 24-36 months (6% vs. 20%; p = 0.01). During the late xerostomia period (24-36 months), high dose/volume exposures (V25-V70) in the oral cavity were associated with high proportions of patients with moderate-severe xerostomia (all p < 0.05), but dosimetric variables regarding the salivary glands were not associated with late xerostomia.

CONCLUSION

IMPT was associated with less late xerostomia than was IMRT in OPC patients. Oral cavity dosimetric variables were related to the occurrence of late xerostomia.

Parotid sparing and quality of life in long-term survivors of locally advanced head and neck cancer after intensity-modulated radiation therapy

PURPOSE

Intensity-modulated radiation therapy (IMRT) enables radiation oncologists to optimally spare organs at risk while achieving homogeneous dose distribution in the target volume. Despite great advances in technology, xerostomia is one of the most detrimental long-term side effects after multimodal therapy in patients with locally advanced head and neck cancer (HNC). This prospective observational study examines the effect of parotid sparing on quality of life in long-term survivors.

PATIENTS AND METHODS

A total of 138 patients were grouped into unilateral (n = 75) and bilateral (n = 63) parotid sparing IMRT and questioned at 3, 24, and 60-month follow-up using the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-H&N35 questionnaires. Treatment-related toxicity was scored according to the RTOG/EORTC toxicity criteria. Patients' QoL 24 and 60 months after IMRT was analyzed by ANCOVA using baseline QoL (3 months after IMRT) as a covariate.

RESULTS

Patients with bilateral and unilateral parotid-sparing IMRT surviving 60 months experience similar acute and late side effects and similar changes in QoL. Three months after IMRT, physical and emotional function as well as fatigue, nausea and vomiting, pain, dyspnea, and financial problems are below (function scales) or above (symptom scales) the threshold of clinical importance. In both groups, symptom burden (EORTC H&N35) is high independent of parotid sparing 3 months after IMRT and decreases over time in a similar pattern. Pain and financial function remain burdensome throughout.

CONCLUSION

Long-term HNC survivors show a similar treatment-related toxicity profile independent of unilateral vs. bilateral parotid-sparing IMRT. Sparing one or both parotids had no effect on global QoL nor on the magnitude of changes in function and symptom scales over the observation period of 60 months. The financial impact of the disease and its detrimental effect on long-term QoL pose an additional risk to unmet needs in this special patient population. These results suggest that long-term survivors need and most likely will benefit from early medical intervention and support within survivorship programs.

Does Dose Volume Histogram of Parotid Glands Correlate with Xerostomia Radiation Therapy Oncology Group Scores in Locoregionally Advanced Head and Neck Cancer Patients Treated with Intensity-Modulated Radiation Therapy?

Introduction Xerostomia is an imminent complication of head and neck radiotherapy best assessed subjectively. This study aimed to evaluate the effects of sparing parotid glands with intensity-modulated radiation therapy (IMRT) on subjective xerostomia scores in patients with locoregionally advanced head and neck cancer.

Subjects and Methods This is a prospective longitudinal study conducted in an outpatient department setting. A total of 43 patients with head and neck cancer were planned with IMRT as per the ICRU 62 (International Commission on Radiation Units and Measurement Report 62). The constraints to ipsilateral and contralateral parotid glands were 35 and 25 Gy, respectively. Treatment plan was assessed for doses to 100, 67, 50, and 33% volume of individual parotid glands. Patients were subjectively assessed using the Amosson’s Questionnaire and graded as per Eisbruch’s xerostomia Radiation Therapy Oncology Group scores. Dose volume histogram (DVH) was plotted and correlated with grades of xerostomia postradiation at 1, 3, 6, 9 and 12 months follow-ups. Statistical analysis was performed suing SPSS version 16, chi-square test, and one-way analysis of variance test.

Results No statistically significant correlation between mean dose of radiation, volume of the parotid glands, and grades of xerostomia was noted postradiation. A statistically significant improvement in grades of xerostomia between 3 and 6 months (p = 0.0), 3 and 9 months (p = 0.020), 6 and 9 months (p = 0.009), 6 and 12 months (p = 0.05), and 9 and 12 months (p = 0.00) was noted. Recovery in grades was noted at 9 months.

Conclusion There is no statistically significant direct correlation between DVH of the parotid glands and grades of xerostomia, although recovery in grades was statistically significant at 9 months.

Impact of xerostomia on the quality of life of patients submitted to head and neck radiotherapy

Background

The aim of the present work was to evaluate the impact of xerostomia on the quality of life of patients who underwent radiotherapy in the head and neck region.

Material and Methods

This was a cross-sectional, quantitative study. The sample comprised 40 patients whose xerostomia was classified through the xerostomia inventory and the quality of life evaluated through the oral health impact profile questionnaire (OHIP).

Results

The majority of participants were male (75%), mean age 58.7 years. According to the degree of severity of the xerostomia, the average score among the participants was 36 points, this being considered moderate xerostomia. A significant impact was observed, with the median score 11 points, with the highest scores in the domains related to functional limitation, physical pain and physical disability. The majority of the participants (97.5%) had reduced salivary flow after the end of radiotherapy. There was a significant positive correlation between the degree of xerostomia and reduced quality of life, Pearson correlation 0.5421, (p< 0.05).

Conclusions

Based upon the results it is concluded that xerostomia has a negative impact on the quality of life of patients who undergo radiotherapy in the head and neck region.

Key words:Head and neck neoplasms, radiotherapy, xerostomia, quality of life.

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

OBJECTIVES

To compare effects of intensity-modulated radiotherapy (IMRT) with those of conventional radiotherapy on quality of life (QoL) and severity of xerostomia in patients with head and neck cancer.

MATERIAL AND METHODS

PubMed, Cochrane, and Embase databases were searched to July 1, 2019, to identify relevant studies, using the following terms: radiotherapy, head and neck cancer, quality of life, cognition, xerostomia, two-/three-dimensional conformal radiation therapy, IMRT, conformal proton beam radiation therapy, stereotactic radiosurgery, and volumetric modulated arc therapy. The outcomes of interest were QoL measured by global health status; emotional, social, and cognitive function; and severity of xerostomia.

RESULTS

Seven studies with a total of 761 patients (n = 369 with IMRT; n = 392 with conventional RT) were included in this study. Median patient age was 18-65 years. IMRT group patients had better global health status (pooled standardized mean difference [SMD] = 0.80, 95% CI 0.26 to 1.35, P = 0.004) and cognitive function (pooled SMD = 0.30, 95% CI 0.06 to 0.54, P = 0.013) than the conventional RT group. Patients receiving IMRT also had significantly lower scores for xerostomia than those receiving conventional RT (pooled SMD = - 0.60, 95% CI - 0.97 to - 0.24, P = 0.001). No differences were found in emotional function (P = 0.531) and social function (P = 0.348) between the two groups.

CONCLUSION

IMRT significantly improves QoL and reduces the severity of xerostomia in patients with head and neck cancer. Results of this study provide clinicians with guidelines for decisions on the use of IMRT versus conventional RT.

Gastrostomy Utilization by Oropharyngeal Cancer Patients Is Partially Driven by Swallowing Function

OBJECTIVE

Oropharyngeal squamous cell carcinoma (OPSCC) incidence is rapidly increasing, as are survival rates, in large part due to the human papillomavirus (HPV). Treatment intensity, however, has remained unchanged, making treatment-related toxicity (i.e., dysphagia) a critical problem for an increasing number of patients. The primary objective of this study was to determine whether pretreatment objective swallowing measures can predict percutaneous fluoroscopic guided gastrostomy tube (PFG) utilization during OPSCC treatment.

METHODS

Forty-one newly diagnosed OPSCC patients treated with radiation underwent evaluation of swallow function with modified barium swallow study (MBSS) prior to and at completion of radiation treatment using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST); a subset of patients were evaluated using the MD Anderson Dysphagia Inventory (MDADI).

RESULTS

Patients were male (100%), primarily Caucasian (85.4%) and p16 positive (85.4%) with mean age of 65.7 years. PFG were placed in 70.7% patients (n = 29) and used by 63.4% (n = 26). Pre- and post-treatment DIGEST scores were associated with T-classification (t = -2.9, p = .001, t = -2.7, p = .01) and indicated deteriorating swallow function during treatment (mean change = 0.46 [t = -2.7, p = .01]). DIGEST and MDADI scores were generally not associated with patient PFG utilization. DIGEST and MDADI scores were significantly correlated prior to, but not following completion of treatment.

CONCLUSION

Pre-treatment DIGEST and patient reported swallowing outcomes (MDADI) can be useful in identifying patients with unsafe and/or grossly inefficient swallowing function. However, objectively measured swallow function was not associated with PFG utilization. Development of PFG placement algorithms (reactive vs. prophylactic) therefore require additional inputs/metrics.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:2153-2159, 2020.

Target Coverage in Head and Neck Cancer Treated with Intensity-Modulated Radiotherapy: A Comparison between Conventional and Conformal Techniques

Aims and background

We designed a comparative planning study aimed at quantifying the advantages of intensity-modu-lated radiotherapy (IMRT) over the conventional 3-field technique (3FT) and a 5-field conformal technique (5FCT) for head and neck (HN) cancer.

Methods

We selected 9 patients treated at our institution with curative radiotherapy for a HN cancer. For all cases 4 plans were generated: 2 plans using the “standard” techniques (3FT and 5FCT), a third plan using IMRT, and a fourth “mixed” plan using IMRT followed by a conventional boost.

Results

Our study confirmed literature data on the ability of IMRT to significantly decrease the dose received by organs at risk, compared with previous techniques. Target coverage was systematically better with 5FCT and IMRT than with 3FT. However, the increase in coverage of both PTV2 and PTV1 was only about 3-5% and this was achieved at the price of a similar increase in maximum dose (D1%). Volumetric parameters (V100%, V95%) were much more sensitive in detecting the improvement with IMRT.

Conclusions

The improvement of target coverage attained by IMRT, as compared with conventional and conformal techniques, might be overestimated by data currently available in the medical literature. If treatment with conventional techniques is planned using all tools provided by currently available fully 3-D planning systems, excellent target coverage can be obtained.

Dental condition and salivary characteristics in Vietnamese patients with chronic kidney disease

OBJECTIVES

To determine the dental status and salivary characteristics and to analyse the correlation between creatinine clearance with DMFT index and salivary flow rate in Vietnamese patients with chronic kidney disease (CKD).

METHODS

This study was conducted on 111 CKD and 109 non-CKD patients. The socio-demographic characteristics associated with dental habits and xerostomia status were recorded from a self-administered questionnaire. Dental status (DT, MT, FT) and salivary characteristics (flow rate; pH; buffering capacity; urea and creatinine concentrations) were examined. The multivariate regression models were used to assess the correlation of creatinine clearance with DMFT index and salivary flow rate with adjustment for confounders.

RESULTS

Patients with CKD made MT and DMFT indices significantly higher than non-CKD subjects. Chronic kidney disease patients had reduced salivary flow rate; but higher xerostomia level, salivary pH and buffering capacity than those in non-CKD subjects. Results of multivariate regression models showed that with lower creatinine clearance 1 mL/min, DMF index was higher 0.02 teeth, and salivary flow rate lower 0.003 mL/min.

CONCLUSIONS

There were no differences in dental status between patients with CKD and those without CKD, except that poor renal function is directly related with a higher DMFT index and lower salivary flow rate. Dental professionals should pay greater attention to oral problems during the progression of CKD to prevent deterioration of oral health.

Evaluation of Salivary Gland Function Using Diffusion-Weighted Magnetic Resonance Imaging for Follow-Up of Radiation-Induced Xerostomia

Objective

To investigate the value of diffusion-weighted magnetic resonance imaging (DW-MRI) as a noninvasive tool to assess salivary gland function for follow-up of patients with radiation-induced xerostomia.

Materials and Methods

This study included 23 patients with nasopharyngeal carcinoma who had been treated with parotid-sparing radiotherapy (RT). Salivary function was assessed by DW-MRI pre-treatment and one week and one year post-RT, respectively. The maximum apparent diffusion coefficient (ADC) of parotid glands (pADCmax) and the time to peak ADC of parotid glands (pTmax) during stimulation were obtained. Multivariate analysis was used to analyze factors correlated with the severity of radiation-induced xerostomia.

Results

The ADCs of parotid and submandibular glands (1.26 ± 0.10 × 10⁻³ mm²/s and 1.32 ± 0.07 × 10⁻³ mm²/s pre-RT, respectively) both showed an increase in all patients at one week post-RT (1.75 ± 0.16 × 10⁻³ mm²/s, p < 0.001 and 1.70 ± 0.16 × 10⁻³ mm²/s, p < 0.001, respectively), followed by a decrease in parotid glands at one year post-RT(1.57 ± 0.15 × 10⁻³ mm²/s, p < 0.001) but not in submandibular glands (1.69 ± 0.18 × 10⁻³ mm²/s, p = 0.581). An improvement in xerostomia was found in 13 patients at one year post-RT. Multivariate analysis revealed 4 significant predictors for the improvement of xerostomia, including dose to parotid glands (p = 0.009, odds ratio [OR] = 0.639), the ADC of submandibular glands (p = 0.013, OR = 3.295), pADCmax (p = 0.024, OR = 0.474), and pTmax (p = 0.017, OR = 0.729) at one week post-RT.

Conclusion

The ADC value is a sensitive indicator for salivary gland dysfunction. DW-MRI is potentially useful for noninvasively predicting the severity of radiation-induced xerostomia.

Salivary flow rate after conventional and intensity-modulated radiation therapy

BACKGROUND

Conventional 3-dimensional conformal radiation therapy (3DCRT) for head and neck cancer (HNC) can cause hyposalivation, leading to caries and tooth extraction-related osteoradionecrosis. Intensity-modulated radiation therapy (IMRT) delivers more focused radiation than does 3DCRT. To reduce hyposalivation, the Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) guidelines limit salivary gland radiation dose. In this study, the authors compared the salivary flow rate in patients receiving 3DCRT and those receiving IMRT and evaluated the effect of their treatment satisfying the QUANTEC guidelines on hyposalivation.

METHODS

The authors evaluated findings in 96 patients with HNC who received radiation therapy (RT); 20 received unilateral 3DCRT, 17 received bilateral 3DCRT, and 59 received IMRT. The authors measured stimulated whole saliva before radiation and 3 and 12 months after radiation. The authors defined hyposalivation as stimulated whole saliva less than 3.5 grams per 5 minutes.

RESULTS

At 12 months, 50% and 54% of patients receiving unilateral 3DCRT and IMRT, respectively, exhibited nonstatistically significant hyposalivation compared with 71% of patients receiving bilateral 3DCRT (P = .2). A lower proportion of patients receiving IMRT (27%) and unilateral 3DCRT (5%) had decreased salivary flow (< 25% of baseline) than did those receiving bilateral 3DCRT (59%; P < .004); fewer patients whose treatment satisfied the QUANTEC guidelines exhibited hyposalivation than patients whose treatment did not fullfill QUANTEC guidelines (39% versus 71%; P < .002).

CONCLUSIONS

Twelve months after RT for HNC, treatment satisfying the QUANTEC guidelines resulted in decreased hyposalivation. Unilateral 3DCRT and IMRT may result in less hyposalivation than does bilateral 3DCRT.

PRACTICAL IMPLICATIONS

Patients with HNC treated with modern RT techniques have a lower risk of developing hyposalivation, particularly if the QUANTEC guidelines are met, which also may result in decreased dental caries, tooth extractions, and postextraction osteoradionecrosis. Management of HNC requires a multidisciplinary team, including dentists and radiation oncologists.

Partner's survivorship care needs: An analysis in head and neck cancer patients

PURPOSE

To determine the number, type and predictors of unmet needs for head and neck cancer (HNC) survivors' partner's.

METHODS

Partners of HNC patients were invited to complete the Cancer Survivors' Partners Unmet Needs Survey (CaSPUN). Analysis determined number, proportion and factors associated with greater unmet needs using linear regression. Agreement between the unmet needs of patients and their partners was determined.

RESULTS

Among the 44 partners participated 29 reported ≥1 unmet need and 4 had a very high number of needs (31-35). The most common unmet needs were related to concerns about cancer returning, coping with supporting someone with cancer, and the changes cancer has caused. The highest reported needs were in the Relationships domain. Increasing patient unmet needs was significantly associated with increasing partner unmet needs (p<0.01).

CONCLUSIONS

A significant proportion of head and neck cancer partners experience unmet needs, which often differ from the patient's needs.

Impact on quality of life of IMRT versus 3-D conformal radiation therapy in head and neck cancer patients: A case control study

Objective

The purpose of this study was to prospectively and longitudinally compare the health-related quality of life (HRQOL) outcomes between head and neck (HN) cancer patients treated with parotid-sparing intensity modulated radiation therapy (IMRT) and patients treated with 3-dimensional conventional radiation therapy (3D-CRT).

Methods and materials

Before and up to 12 months after treatment, HRQOL was recorded in patients with HN cancer who were referred to the Department of Oncology at Sahlgrenska University Hospital for curative IMRT. The study group's HRQOL was compared with a matched group of patients from previous descriptive HRQOL studies treated with 3D-CRT. Both groups' HRQOL was measured by the European Organization for Research and Treatment for Cancer QLQ-C30 and European Organization for Research and Treatment for Cancer QLQ-HN35 at 6 time points in the first year after diagnosis.

Results

Two hundred and seven patients were included, 111 treated with IMRT and 96 matched controls treated with 3D-CRT. Both groups' HRQOL deteriorated during and after treatment. Just after treatment, worse HRQOL scores were observed in the IMRT group regarding insomnia (38 vs 27; P = .032), appetite loss (64 vs 50; P = .019), senses (54 vs 41; P = .017), and coughing (39 vs 26, P = .009). At 12 months, however, significantly better HRQOL scores were observed in the IMRT group regarding problems with dry mouth (72 vs 62; P = .018), pain (28 vs 20; P = .018), sexuality (37 vs 23; P = .016), social contacts (10 vs 6; P = .026), cognitive functioning (79 vs 87; P = .0057), and financial difficulties (12 vs 20; P = .0019).

Conclusions

This study further supports the hypothesis that the introduction of IMRT has improved the long-term quality of life of HN cancer patients who have been treated with radiation therapy, but might cause more acute side effects. Longer follow-up is needed to study late complications.

Assessment of xerostomia and its impact on quality of life in head and neck cancer patients undergoing radiation therapy

Xerostomia in head and neck (H&N) cancer patients significantly affects their quality of life (QoL). The aim of the present study was to investigate the associations among QoL, xerostomia and quantity of saliva in a sample of H&N cancer patients who had received conventional radiotherapy (RT). A total of 60 H&N adult patients were enrolled in this prospective study. The patients completed the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (QLQ-C30), the Quality of Life Questionnaire Head and Neck Module (QLQ-H&N35) and the Greek version of the XQ questionnaire at 4 timepoints: At the beginning of RT, at the end of RT, 6 months after RT completion and 1 year after RT completion. Patients with distant metastases or serious comorbidities were excluded from the study. Salivary pH, and stimulated and unstimulated salivary flow rate were assessed. All functional scales and symptom scales, apart from cognitive functioning in QLQ-C30 and feeding tube in H&N35 exhibited an abrupt deterioration at timepoint 3 and were then gradually restored over time. The difference was statistically significant (P<0.001). XQ scores at different timepoints exhibited a statistically significant negative correlation with salivary flow rates. Salivary flow rate and XQ scores almost parallelled one another. Flow rates recovered at a mean level of 20% below baseline values at the end of the follow-up period. The subjective symptom of xerostomia parallelled salivary flow and QoL. Despite receiving conventional RT, the participants exhibited a considerable preservation of salivary gland function after 12 months, allowing some optimism regarding the course of xerostomia in selected patients.

Patterns of care of IMRT usage in postoperative management of uterine cancer

OBJECTIVE

To analyze the patterns of care regarding intensity modulated radiation therapy (IMRT) usage in the postoperative management of uterine cancer.

METHODS

The National Cancer Database was queried to identify women with endometrial adenocarcinoma who underwent hysterectomy followed by external beam radiation between 2004-2012. Descriptive statistics were used to analyze IMRT usage with comparison via the Chi Square test. Overall survival was also compared between IMRT and three dimensional conformal radiation therapy. Multivariable logistic regression and multivariable Cox Regression were used to identify covariables that impact IMRT usage and improved survival respectively.

RESULTS

7839 women were included in this study. IMRT utilization increased from 1.9% in 2004 to 32.4% in 2012 (p<0.001). The adjusted odds ratio (OR) for IMRT in 2012 compared with 2004 was 24.90, 95% CI 15.24-40.67 (p<0.001). Aside from year, other predictors of IMRT usage on multivariate analysis were positive nodes, higher dose, private insurance and higher income. Black race was associated with lower IMRT usage compared to Whites with an OR of 0.60, 95% CI 0.44-0.81 (p=0.001). IMRT was not associated with significantly increased survival (HR 0.86, 95% CI 0.73-1.01, p=0.06). Black race and positive nodes were associated with decreased survival within the group studied whereas private insurance and higher income were associated with improved survival.

CONCLUSIONS

In this hospital-based registry, IMRT has significantly increased in utilization for postoperative radiation in uterine cancer between 2004-2012 although not resulting in significantly improved survival. Socioeconomic and racial disparities exist in the allocation of IMRT usage.

Long-term disease-specific and cognitive quality of life after intensity-modulated radiation therapy: a cross-sectional survey of nasopharyngeal carcinoma survivors

BACKGROUND

There is a lack of data on quality of life in long-term survivors of nasopharyngeal carcinoma (NPC) who have been treated with intensity-modulated radiation therapy (IMRT). We characterized long-term disease-specific and cognitive QoL in NPC survivors after IMRT.

METHODS

We conducted a cross-sectional study of surviving patients diagnosed and treated for NPC at our center with curative-intent IMRT, with or without chemotherapy. Patients who were deceased, still undergoing treatment, with known recurrent disease, or treated with RT modality other than IMRT were excluded. QoL was measured by FACT-NP and FACT-Cog.

RESULTS

Between May and November 2013, 44 patients completed cognitive (FACT-Cog), general (FACT-G), and NPC-specific (NPCS) QoL assessments. Patients were categorized into 4 cohorts based on duration since IMRT (≤2.5, >2.5-6, >6-10, and >10-16 years). There was no significant difference in age (p = 0.20) or stage ((I/II vs III/IV: p = 0.78) among the cohorts. The 4 cohorts differed overall for all QoL measures (ANOVA: p < 0.02 for each), due to improved scores >2.5-6 years post-IMRT compared with ≤2.5 years post-IMRT (post hoc tests: p ≤ 0.04 for each). No differences were observed between >2.5-6 and >6-10 years post-IMRT, but lower mean FACT-Cog and NPCS scores were observed for >10 years compared to >2.5-6 years post-IMRT (post hoc: p < 0.05 for each).

CONCLUSIONS

All QoL measures were low during the initial recovery period (≤2.5 years) and were higher by 6 years post-IMRT. At >10 years post-IMRT, lower scores were observed in the domains of NPC-specific and cognitive QoL. Survivors of NPC, even if treated with IMRT, are at risk for detriment in domain-specific QoL measures at very long-term follow-up.

Prevalence and nature of survivorship needs in patients with head and neck cancer

BACKGROUND

The purpose of this study was to determine the number, type, and predictors of patients with head and neck cancer unmet survivorship needs.

METHODS

This study accrued patients with head and neck cancer at any time point in their survivorship course, and they completed a survey, including demographic information and the Cancer Survivors' Unmet Needs Measure (CaSUN).

RESULTS

The median age of the 158 participants was 64 years. Ninety-six patients (61%) reported at least one unmet need on the CaSUN and 6 patients had a very high number of needs between 31 and 35. The mean number of unmet needs was 5.8 ± 8.9. Comprehensive Cancer Care was the most common domain of unmet need (n = 69; 45%). Younger age, earlier survivorship phase, and worse quality of life were associated with increased survivorship unmet needs on multivariable analysis.

CONCLUSION

A high proportion of patients with head and neck cancer have unmet needs. These data can guide the development of head and neck survivorship programs. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1097-1103, 2016.

Long-term late toxicities and quality of life for survivors of nasopharyngeal carcinoma treated with intensity-modulated radiotherapy versus non-intensity-modulated radiotherapy

BACKGROUND

The purpose of this study was to investigate late toxicities and quality of life (QOL) of patients with nasopharyngeal carcinoma (NPC) with long-term survival after treatment by intensity-modulated radiotherapy (IMRT) versus non-IMRT.

METHODS

An observational, cross-sectional study of QOL and late toxicities was conducted in 242 patients with NPC with survival of >5 years after treatment with IMRT (n = 100) or non-IMRT (n = 142) by using physician-assessed toxicities (Common Terminology Criteria for Adverse Events [CTCAE] version 4) and the patient-reported European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30-questions (EORTC QLQ-C30) and the Head and Neck 35-questions (EORTC QLQ-C30-H&N35) module.

RESULTS

The IMRT group had both statistically (p < .05) and clinically (difference of predicted mean scores ≥10 points) better outcome in global QOL, cognitive functioning, social functioning, fatigue, and 11 scales of the head and neck module. Late toxicities, including neuropathy, hearing loss, dysphagia, xerostomia, and neck fibrosis were significantly less severe in the IMRT group. Multivariate analysis revealed that the radiotherapy (RT) technique was statistically significantly associated with late toxicities and QOL outcome after adjusting for other clinical and demographic variables.

CONCLUSION

The use of the IMRT technique was associated with the improvement of physician-assessed late toxicities and patient-reported QOL in NPC survivors. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1026-E1032, 2016.

Intensity-modulated radiotherapy for early-stage glottic cancer

BACKGROUND

The purpose of this study was to report on treatment outcome of intensity-modulated radiotherapy (IMRT) for early-stage (cT1-2 cN0 M0) squamous cell carcinoma of the glottis, as compared with patients treated with conventional radiotherapy.

METHODS

Between November 2007 and December 2011, 40 consecutive patients were treated with IMRT with daily cone-beam CT position verification. The median prescription to the planning target volume (PTV) was 63 Gy/28 fractions and 67.5 Gy/30 fractions for T1 and T2 tumors, respectively. The historical control comprised 81 consecutive patients treated with conventional radiotherapy to total doses of 66 Gy/33 fractions (66 patients) and 70 Gy/35 fractions (15 patients) for T1 and T2 tumors, respectively.

RESULTS

The median follow-up of living patients was 3.8 years (range, 1.0-5.0 years) in the IMRT group and 9.0 years, (range, 5.2-12.7 years) in the conventional group. Five-year actuarial local control was equal compared to the conventional group: 83% versus 74% (p = .64). Five-year actuarial ultimate local control was 100% in the IMRT group and 95% in the conventional group (p = .17). Five-year actuarial overall and disease-specific survival was 85% after IMRT versus 65% after conventional radiotherapy (p = .15) and 97% versus 89% (p = .31), respectively. Incidence and severity of acute dermatitis was significantly less during IMRT than in the control group (p < .001). Two patients receiving IMRT had late grade 3 hoarseness.

CONCLUSION

IMRT is as efficient as conventional radiotherapy in terms of disease control and overall survival. It has the potential to reduce toxicity as compared to conventional radiotherapy. © 2015 Wiley Periodicals, Inc. Head Neck 38: E179-E184, 2016.

Long-term quality of life after swallowing and salivary-sparing chemo-intensity modulated radiation therapy in survivors of human papillomavirus-related oropharyngeal cancer

PURPOSE

To evaluate long-term health-related quality of life (HRQOL) in 2 prospective studies of chemo-intensity modulated radiation therapy (chemo-IMRT) for oropharyngeal cancer (OPC).

METHODS AND MATERIALS

Of 93 patients with stage III/IV OPC treated on prospective studies of swallowing and salivary organ-sparing chemo-IMRT, 69 were eligible for long-term HRQOL assessment. Three validated patient-reported instruments, the Head and Neck QOL (HNQOL) questionnaire, the University of Washington quality of life (UWQOL) questionnaire, and the Xerostomia Questionnaire (XQ), previously administered from baseline through 2 years in the parent studies, were readministered at long-term follow-up, along with the Short-Form 36. Long-term changes in HRQOL from before treatment and 2 years were evaluated.

RESULTS

Forty patients (58%) with a median follow-up of 6.5 years participated, 39 of whom (97.5%) had confirmed human papillomavirus-positive OPC. Long term, no clinically significant worsening was detected in mean HRQOL scores compared with 2 years, with stable or improved HRQOL from before treatment in nearly all domains. "Moderate" or greater severity problems were uncommon, reported by 5% of patients for eating, 5% for swallowing, and 2.5% and 5% by HNQOL and UWQOL summary scores, respectively. Freedom from percutaneous endoscopic gastrostomy tube dependence and stricture dilation beyond 2 years was 97.5% and 95%, respectively. Eleven percent and 14% of patients reported "moderate" or "severe" long-term worsening in HNQOL Pain and Overall Bother domains, respectively, which were associated with mean dose to the cervical esophagus, larynx, and pharyngeal constrictors.

CONCLUSIONS

At more than 6 years' median follow-up, OPC patients treated with swallowing and salivary organ-sparing chemo-IMRT reported stable or improved HRQOL in nearly all domains compared with both before treatment and 2-year follow-up. New late toxicity after 2 years was uncommon. Further emphasis on sparing the swallowing organs may yield additional HRQOL gains for long-term OPC survivors.

Impact of Node Negative Target Volume Delineation on Contralateral Parotid Gland Dose Sparing Using IMRT in Head and Neck Cancer

There is considerable practice variation in treatment of the node negative (N0) contralateral neck in patients with head and neck cancer. In this study, we examined the impact of N0 neck target delineation volume on radiation dose to the contralateral parotid gland. Following institutional review board approval, 12 patients with head and neck cancer were studied. All had indications for treatment of the N0 neck, such as midline base of tongue or soft palate extension or advanced ipsilateral nodal disease. The N0 neck volumes were created using the Radiation Therapy Oncology Group head and neck contouring atlas. The physician-drawn N0 neck clinical target volume (CTV) was expanded by 25% to 200% to generate volume variation, followed by a 3-mm planning target volume (PTV) expansion. Surrounding organs at risk were contoured and complete intensity-modulated radiation therapy plans were generated for each N0 volume expansion. The median N0 target volume drawn by the radiation oncologist measured 93 cm(3) (range 71-145). Volumetric expansion of the N0 CTV by 25% to 200% increased the resultant mean dose to the contralateral parotid gland by 1.4 to 8.5 Gray (Gy). For example, a 4.1-mm increase in the N0 neck CTV translated to a 2.0-Gy dose increase to the parotid, 7.4 mm to a 4.5 Gy dose increase, and 12.5 mm to an 8.5 Gy dose increase, respectively. The treatment volume designated for the N0 neck has profound impact on resultant dose to the contralateral parotid gland. Variations of up to 15 mm are routine across physicians in target contouring, reflecting individual preference and training expertise. Depending on the availability of immobilization and image guidance techniques, experts commonly recommend 3 to 10 mm margin expansions to generate the PTV. Careful attention to the original volume of the N0 neck CTV, as well as expansion margins, is important in achieving effective contralateral gland sparing to reduce the resultant xerostomia and dysguesia that may ensue after radiotherapy.

Improving target dose coverage and organ-at-risk sparing in intensity-modulated radiotherapy of advanced laryngeal cancer by a simple optimization technique

OBJECTIVE

To evaluate a simple optimization technique intended to improve planning target volume (PTV) dose coverage and organ-at-risk (OAR) sparing in intensity-modulated radiotherapy (IMRT) of advanced laryngeal cancer.

METHODS

Generally acceptable initial IMRT plans were generated for 12 patients and were improved individually by the following two techniques: (1) base dose function-based (BDF) technique, in which the treatment plans were reoptimized based on the initial IMRT plans; (2) dose-controlling structure-based (DCS) technique, in which the initial IMRT plans were reoptimized by adding constraints for hot and cold spots. The initial, BDF and DCS IMRT plans and additionally generated volumetric modulated arc therapy (VMAT) plans were compared concerning homogeneity index (HI) and conformity index (CI) of PTVs prescribed at 70 Gy/60 Gy (PTV70/PTV60), OAR sparing, monitor units (MUs) per fraction and total planning time.

RESULTS

Compared with the initial IMRT and DCS IMRT plans, the BDF technique provided superior HI/CI, by approximately 19-37%/4-11%, and lower doses to most OARs, by approximately 1-7%, except for the comparable HI of PTV60 to DCS IMRT plans. Compared with VMAT plans, the BDF technique provided comparable HI, CI and most-OAR sparing, except for the superior HI of PTV70, by approximately 13%. The BDF technique produced more MUs and reduced the planning time.

CONCLUSION

The BDF optimization technique for IMRT of advanced laryngeal cancer can improve target dose homogeneity and conformity, spare most OARs and is efficient.

ADVANCES IN KNOWLEDGE

A novel optimization technique for improving IMRT was assessed and found to be effective and efficient.

Dosimetric Evaluation of a Simple Planning Technique for Improving Intensity-Modulated Radiotherapy for Nasopharyngeal Cancer

PURPOSE

To evaluate the dosimetric outcomes of a simple planning technique for improving intensity-modulated radiotherapy (IMRT) for nasopharyngeal cancer (NPC).

METHODS

For 39 NPC cases, generally acceptable original plans were generated and were improved by the two planning techniques, respectively: (1) a basal-dose-compensation (BDC) technique, in which the treatment plans were re-optimized based on the original plans; (2) a local-dose-control (LDC) technique, in which the original plans were re-optimized with constraints for hot and cold spots. The BDC, original, and LDC plans were then compared regarding homogeneity index (HI) and conformity index (CI) of planning target volumes (PTVs), organ-at-risk (OAR) sparing and monitor units (MUs) per fraction. The whole planning times were also compared between the BDC and LDC plans.

RESULTS

The BDC plans had superior HIs / CIs, by 13-24% / 3-243%, respectively, over the original plans. Compared to the LDC plans, the BDC plans provided better HIs only for PTVnx (the PTV of nasopharyngeal primary tumor) by 11% and better CIs for all PTVs by 2-134%. The BDC technique spared most OARs, by 1-9%. The average MUs of the BDC, original, and LDC plans were 2149, 2068 and 2179, respectively. The average whole planning times were 48 and 69 minutes for the BDC and LDC plans, respectively.

CONCLUSIONS

For the IMRT of nasopharyngeal cancer, the BDC planning technique can improve target dose homogeneity, conformity and OAR sparing, with better planning efficiency.

Changes in health related quality of life in women and men undergoing radiation treatment for head and neck cancer and the impact of smoking status in the radiation treatment period

PURPOSE

The aim of this study was to evaluate health-related quality of life (HRQOL) in women and men undergoing radiation treatment for head and neck cancer through the intervention period and examine if age, body mass index (BMI) and smoking status at baseline may modify changes in HRQOL.

METHODS

HRQOL was examined by the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and the EORTC QLQ-H&N35, in the beginning and end of the treatment period in 65 patients at the University Hospital in Northern Norway. Changes in HRQOL were calculated and compared by paired sample T-tests. Linear multiple regression analyses were used to examine if baseline characteristics had any influence towards HRQOL changes.

RESULTS

Most aspects of HRQOL declined substantially and significantly (p < 0.001) with a magnitude of more than one standard deviation during the radiation treatment period irrespective of sex and age. Smoking status at baseline had some, albeit minor, influence on changes in HRQOL. Patients who continued smoking during therapy had significantly higher decline in several aspects of HRQOL, compared to patients who stopped smoking.

CONCLUSIONS

HRQOL declined with substantial magnitude in patients undergoing radiation treatment for head and neck cancer, but smoking cessation may modify the declining quality of life.

XRCC3 polymorphisms are associated with the risk of developing radiation-induced late xerostomia in nasopharyngeal carcinoma patients treated with intensity modulation radiated therapy

OBJECTIVE

The incidence of radiation-induced late xerostomia varies greatly in nasopharyngeal carcinoma patients treated with radiotherapy. The single-nucleotide polymorphisms in genes involved in DNA repair and fibroblast proliferation may be correlated with such variability. The purpose of this paper was to evaluate the association between the risk of developing radiation-induced late xerostomia and four genetic polymorphisms: TGFβ1 C-509T, TGFβ1 T869C, XRCC3 722C>T and ATM 5557G>A in nasopharyngeal carcinoma patients treated with Intensity Modulation Radiated Therapy.

METHODS

The severity of late xerostomia was assessed using a patient self-reported validated xerostomia questionnaire. Polymerase chain reaction-ligation detection reaction methods were performed to determine individual genetic polymorphism. The development of radiation-induced xerostomia associated with genetic polymorphisms was modeled using Cox proportional hazards, accounting for equivalent uniform dose.

RESULTS

A total of 43 (41.7%) patients experienced radiation-induced late xerostomia. Univariate Cox proportional hazard analyses showed a higher risk of late xerostomia for patients with XRCC3 722 TT/CT alleles. In multivariate analysis adjusted for clinical and dosimetric factors, XRCC3 722C>T polymorphisms remained a significant factor for higher risk of late xerostomia.

CONCLUSIONS

To our knowledge, this is the first study that demonstrated an association between genetic polymorphisms and the risk of radiation-induced late xerostomia in nasopharyngeal carcinoma patients treated with Intensity Modulation Radiated Therapy. Our findings suggest that the polymorphisms in XRCC3 are significantly associated with the risk of developing radiation-induced late xerostomia.

Review of the complications associated with treatment of oropharyngeal cancer: a guide for the dental practitioner

OBJECTIVES

Oropharyngeal cancer (OPC) is the sixth most common cancer worldwide. Focus on risk factors, improved diagnostic methods and effective management strategies have made it possible to successfully treat OPC. However, the 5-year survival rate has not improved for several years due to multiple treatment complications, tissue morbidity, loss of function, and diminished quality of life. Survivors are faced with complications like oral mucositis, hyposalivation, osteoradionecrosis, tissue fibrosis, morbidity from jaw resection, disfigurement, and loss of function that further diminish quality of life. The aim of this review is to highlight major complications associated with treatment of OPC via a literature search and review of available options for identification and management of these complications.

DATA SOURCES

Relevant publications on oral complications of OPC therapy were thoroughly reviewed from the literature published between the years 1988 and 2012. We evaluated reported incidence, prevalence, and risk factors for oral complications of chemotherapy and radiotherapy for OPC. The authors conducted an electronic search using English language databases, namely PubMed Plus, Medline (Pre-Medline and Medline), Cochrane Database of Systematic Reviews (evidence-based medicine), Dentistry & Oral Sciences Source, A ccessScience, Embase, Evidence-Based Medicine Reviews Multifile, Google Scholar, ISI Journal Citation Reports, and Ovid Multi-Database.

CONCLUSION

We identified the most common complications associated with the treatment of oral cancers. Based on the information gathered, there is evidence that survival of OPC extends beyond eradication of the diseased tissue. Understanding the potential treatment complications and utilizing available resources to prevent and minimize them are important. Caring for OPC survivors should be a multidisciplinary team approach involving the dentist, oncologist, internist, and social worker to improve the currently stagnant 5-year survival rate of OPC. More emphasis on improved quality of life after elimination of the cancer will ultimately improve OPC survivorship.

Hazards and risks in oncology: radiation oncology

Adverse effects and hazards which have their origin from radiation using conventional techniques like 3-D conformal radiotherapy and total radiation doses are well known. However little is known about the sprectum of especially late toxicity after radiation using new technologies like intensity modulated radiotherapy (IMRT) combined with novel target volume and dose concepts. Since IMRT allows for selective protection of the large salivary glands this technique improves the intermediate term quality of life and is the standard of care despite many details need further prospective evaluation. Combining cytotoxic drugs and radiotherapy yield improved survival in well-defined high risk patients. However morbidity and mortality of these protocols are high and deserve special expertise and supportive therapy. EGF-receptor antibodies have gained well defined indications, albeit specific toxicities in combination with irradiation deserve prospective studies and special attention.

Two-year and lifetime cost-effectiveness of intensity modulated radiation therapy versus 3-dimensional conformal radiation therapy for head-and-neck cancer

PURPOSE

To assess the cost-effectiveness of intensity modulated radiation therapy (IMRT) versus 3-dimensional conformal radiation therapy (3D-CRT) in the treatment of head-and neck-cancer (HNC).

METHODS AND MATERIALS

We used a Markov model to simulate radiation therapy-induced xerostomia and dysphagia in a hypothetical cohort of 65-year-old HNC patients. Model input parameters were derived from PARSPORT (CRUK/03/005) patient-level trial data and quality-of-life and Medicare cost data from published literature. We calculated average incremental cost-effectiveness ratios (ICERs) from the US health care perspective as cost per quality-adjusted life-year (QALY) gained and compared our ICERs with current cost-effectiveness standards whereby treatment comparators less than $50,000 per QALY gained are considered cost-effective.

RESULTS

In the first 2 years after initial treatment, IMRT is not cost-effective compared with 3D-CRT, given an average ICER of $101,100 per QALY gained. However, over 15 years (remaining lifetime on the basis of average life expectancy of a 65-year-old), IMRT is more cost-effective at $34,523 per QALY gained.

CONCLUSION

Although HNC patients receiving IMRT will likely experience reduced xerostomia and dysphagia symptoms, the small quality-of-life benefit associated with IMRT is not cost-effective in the short term but may be cost-effective over a patient's lifetime, assuming benefits persist over time and patients are healthy and likely to live for a sustained period. Additional data quantifying the long-term benefits of IMRT, however, are needed.

Efficacy of intensity-modulated radiotherapy combined with chemotherapy or surgery in locally advanced squamous cell carcinoma of the head-and-neck

Objectives

Long-term locoregional control following intensity-modulated radiotherapy (IMRT) for locally advanced squamous cell carcinoma of the head-and-neck (SCCHN) remains challenging. This study aimed to assess the efficacy and toxicity of IMRT with and without chemotherapy or surgery in locally advanced SCCHN.

Materials and methods

Between January 2007 and January 2011, 61 patients with locally advanced SCCHN were treated with curative IMRT in the Department of Radiation Oncology, Xijing Hospital, Fourth Military Medical University; 28% underwent definitive IMRT and 72% postoperative IMRT, combined with simultaneous cisplatin-based chemotherapy in 58%. The mean doses of definitive and postoperative IMRT were 70.8 Gy (range, 66–74 Gy). Outcomes were analyzed using Kaplan–Meier curves. Acute and late toxicities were graded according to Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer radiation morbidity scoring criteria.

Results

At a median follow-up of 35 months, 3-year local recurrence-free survival (LRFS), regional recurrence-free survival (RRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS) were 83.8%, 86.1%, 82.4%, 53.2%, and 62%, respectively. Postoperative IMRT (n = 44, 72%) had significantly higher LRFS/OS/DMFS than definitive IMRT (n = 17, 28%; P < 0.05). IMRT combined with chemotherapy (n = 35, 58%) had significantly higher LRFS/OS/DMFS than IMRT alone (n = 26, 42%; P < 0.05). One year after radiotherapy, the incidence of xerostomia of grade 1, 2, or 3 was 13.1%, 19.7%, and 1.6%, respectively. No grade 4 acute or late toxicity was observed.

Conclusion

IMRT combined with surgery or chemotherapy achieved excellent long-term locoregional control and OS in locally advanced SCCHN, with acceptable early toxicity and late side-effects.

Outcomes and xerostomia after postoperative radiotherapy for oral and oropharyngeal carcinoma

BACKGROUND

We compared outcomes and xerostomia grade after postoperative intensity-modulated radiation therapy (IMRT) and conventional radiotherapy (RT) in patients with oral and oropharyngeal carcinoma.

METHODS

Eighty-eight patients with oral cavity (n = 77) and oropharyngeal (n = 11) carcinoma underwent postoperative IMRT (n = 44) or conventional RT (n = 44). Outcomes, failure patterns, volume, doses, salivary gland V30, and xerostomia grade were evaluated. The median follow-up was 53 months (range, 48-58 months). The median interval from surgery to RT was 4 weeks (range, 3-6 weeks).

RESULTS

Twenty-one patients (7 and 14 for the IMRT and conventional RT groups, respectively) experienced local-regional failure. For the IMRT group, all 7 local-regional failures occurred in the high-dose target volumes. For the conventional RT group, there were 12 in-field failures, 1 at the margin, and 1 out-of-field. Nine patients experienced distant failure (5 and 4 for the IMRT and conventional RT groups, respectively). The 4-year local-regional control, disease-free survival (DFS), overall survival (OS), and distant-metastasis rates for the IMRT and conventional RT groups were 84.1% versus 68.2% (p = .055), 68.2% versus 52.3% (p = .091), 70.5% versus 56.8% (p = .124), and 11.4% versus 9.1% (p = .927), respectively. Xerostomia grade after RT was lower for IMRT compared to conventional RT (p < .001).

CONCLUSION

Postoperative IMRT for oral and oropharyngeal carcinoma significantly improves mean dose, salivary gland V30, and xerostomia grade when compared to conventional RT. The predominant failure pattern was local. No differences were found in survival outcomes between both groups. There was a marginal difference in local-regional control.

Development and evaluation of a Perspex anthropomorphic head and neck phantom for three dimensional conformal radiation therapy (3D-CRT)

Purposes

To design, construct and evaluate an anthropomorphic head and neck phantom for the dosimetric evaluation of 3D-conformal radiotherapy (3D-CRT) dose planning and delivery, for protocols developed by the Radiation Therapy Oncology Group (RTOG).

Materials and methods

An anthropomorphic head and neck phantom was designed and fabricated using Perspex material with delineated planning target volumes (PTVs) and organs at risk (OARs) regions. The phantom was imaged, planned and irradiated conformally by a 3D-CRT plan. Dosimetry within the phantom was assessed using thermoluminescent dosimeters (TLDs). The reproducibility of phantoms and TLD readings were checked by three repeated identical irradiations. Subsequent three clinical 3D-CRT plans for nasopharyngeal patients have been verified using the phantom. Measured doses from each dosimeter were compared with those acquired from the treatment planning system (TPS).

Results

Phantom's measured doses were reproducible with <3·5% standard deviation between the three TLDs’ repeated measurements. Verification of three head and neck 3D-CRT patients’ plans was implemented, and good agreement between measured values and those predicted by TPS was found. The percentage dose difference for TLD readings matched those corresponding to the calculated dose to within 4%.

Conclusion

The good agreement between predicted and measured dose shows that the phantom is a useful and efficient tool for 3D-CRT technique dosimetric verification.

Dosimetric predictors of dysphonia after intensity-modulated radiotherapy for oropharyngeal carcinoma

AIMS

To investigate dosimetric predictors of voice changes after whole-field intensity-modulated radiotherapy (IMRT).

MATERIALS AND METHODS

Patients treated with whole-field IMRT for oropharyngeal/unknown primary tumours were selected for the present retrospective study having grossly uninvolved larynx at the time of radiotherapy and at least one follow-up visit. Voice changes were prospectively scored at each follow-up examination according to the Common Terminology Criteria for Adverse Events (CTCAE) v3.0 scale and self-reported by two items (HN4 and HN10) of the Functional Assessment of Cancer Therapy-Head and Neck Scale (FACT-HN) questionnaire. Predictors of toxicity were investigated at logistic regression, including various patient and tumour characteristics, as well as individual dosimetric data.

RESULTS

With a median follow-up of 18 months (range 3-46 months), peak CTCAE dysphonia was graded as 2 in 13 patients (10.5%), whereas 45 patients (36.3%) reported peak grade 0-1 voice changes according to FACT-HN4. Communication (FACT-HN10) was barely affected. At multivariate analysis, the mean laryngeal dose was an independent predictor of both grade 2 CTCAE dysphonia (odds ratio = 1.10, 95% confidence interval 1.01-1.20, P = 0.025) and grade 0-1 FACT-HN4 voice changes (odds ratio = 1.11, 95% confidence interval 1.04-1.18, P = 0.001). Further stratification optimised by a receiver operating characteristic (ROC) analysis showed that, to minimise the risk of grade 0-1 FACT-HN4 voice changes, the mean dose to the larynx has to be kept ≤ 49.4 Gy.

CONCLUSION

Voice changes after whole-field IMRT are common, but mild, and are strictly correlated to the dose received by the uninvolved larynx; in order to minimise the risk of side-effects, the mean dose to the larynx should be kept ≤ 50 Gy.

A bridge between academic and community radiation oncology treatment planning

PURPOSE

To evaluate Telesynergy (TS) as a method of interactive treatment planning between academic and community radiation oncology departments.

METHODS

Through a grant from the National Cancer Institute to improve cancer outcomes for underserved populations, community radiation oncologists at New Hanover Regional Medical Center (NHRMC) in Wilmington, North Carolina, partnered with those at the University of North Carolina (UNC) in Chapel Hill, North Carolina. TS suites were installed at both sites to facilitate teleconferencing and review of treatment planning for intensity-modulated radiation therapy (IMRT). Patients with locally advanced head and neck cancer at NHRMC who were enrolled on a clinical trial of chemoirradiation underwent IMRT planning utilizing commercial software. NHRMC physicians contoured tumor targets and adjacent healthy organs. Physics staff at NHRMC generated an initial IMRT plan for each patient. Radiation oncologists at UNC then reviewed individual IMRT plans via TS conferences.

RESULTS AND CONCLUSION

Between August 2004 and August 2005, seven IMRT plans were reviewed in eight TS conferences. Physician contours of tumor targets and healthy organs, dose volume histograms, IMRT beams, and isodose distributions were shared during each TS conference successfully. Median time for each session was 35 minutes (range, 30 to 75). Physician satisfaction with the interactive planning process was high at both NHRMC and UNC. A cycle would likely evolve of initial intensive use of TS conferences, to gradual use for ongoing quality control, then greater use as the treatment planning technology undergoes its next change. Complex IMRT treatment planning review was feasible between an academic and community hospital via TS with a high level of physician participant satisfaction.

[Constraints of the dentist are consistent with the results of an optimal irradiation with modulated intensity in N0 oropharyngeal cancer]

PURPOSE

We compared intensity-modulated radiotherapy and 3D-conformal irradiation in oropharyngeal cancers according to the requirement of dentists.

MATERIAL AND METHODS

From the files of seven patients with cancer of the oropharynx, two dosimetry plannings for 3D-conformal radiotherapy and intensity-modulated radiotherapy with tomotherapy were performed. The dose distributions in the target volumes and organs at risk in relation to the dental sphere were compared.

RESULTS

For the planning target volume of the primitive tumour sites, average values of V95%, D2%, D98% and of the conformal index were statistically in favour of tomotherapy. For the planning target volume of node areas, averages values of V95%, D2%, D98% were statistically in favour of tomotherapy. For ipsi- and controlateral parotide glands, average values of V15Gy, V26Gy, V30Gy, V40Gy were significantly lower for tomotherapy. For the submaxillary glands, average values of mean doses and V40Gy were statistically in favour of tomotherapy. For the buccal cavity, the average values of V45Gy were statistically in favour of tomotherapy. For ipsi- and controlateral masseter muscles, the average values of mean doses were statistically in favour of tomotherapy. For the ipsi- and controlateral temporomandibular joints, average values of mean doses and V60Gy were statistically in favour of tomotherapy. For mandibular bone, average values of mean doses and V40Gy, V50Gy, V60Gy and V70Gy were statistically in favour of tomotherapy. For maxillary bone, average values of V40Gy, V50Gy and V60Gy were statistically in favour of tomotherapy.

CONCLUSION

The radiation oncologist can constrain the intensity-modulated radiotherapy dosimetry to the needs of dentists to prevent or improve dental care and quality of life.

Dose-response analysis of parotid gland function: what is the best measure of xerostomia?

PURPOSE

To describe the dose-response relationships for the different measures of salivary gland recovery following radical radiotherapy for locally advanced head and neck squamous cell cancers (LA-HNSCC).

METHODS AND MATERIALS

Dosimetric analysis of data from the PARSPORT trial, a Phase III study of conventional RT (RT) and intensity modulated radiotherapy (IMRT) for LA-HNSCC was undertaken to determine the relationship between parotid gland mean dose and toxicity endpoints: high-grade subjective and objective xerostomia and xerostomia-related quality of life scores. LKB-NTCP parameters (TD50, m and n) were generated and tolerance doses (D50) reported using non-linear logistic regression analysis.

RESULTS

Data were available on 63 patients from the PARSPORT trial. Parotid saliva flow rate provided the strongest association between mean dose and recovery, D50=23.4 Gy (20.6-26.2) and k=3.2 (1.9-4.5), R(2)=0.85. Corresponding LKB parameters were TD50=26.3 Gy (95% CI: 24.0-30.1), m=0.25 (0.18-1.0 and n=1). LENTSOMA subjective xerostomia also demonstrated a strong association D50=33.3 Gy (26.7-39.8), k=2.8 (91.4-4.4), R(2)=0.77).

CONCLUSION

We recommend using the LENT SOMA subjective xerostomia score to predict recovery of salivation due to its strong association with dosimetry and ease of recording.

Quantitative analysis of normal tissue effects in the clinic (QUANTEC) guideline validation using quality of life questionnaire datasets for parotid gland constraints to avoid causing xerostomia during head-and-neck radiotherapy

PURPOSE

To perform a validation test of the quantitative analysis of normal tissue effects in the clinic (QUANTEC) guidelines against quality of life (QoL) questionnaire datasets collected prospectively from patients with head and neck (HN) cancers, including HN squamous cell carcinoma (HNSCC) and nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

QoL questionnaire datasets from 95 patients with NPC and 142 with HNSCC were analyzed separately. The European Organization for Research and Treatment of Cancer H&N35 QoL questionnaire was used as the endpoint evaluation. The primary endpoint (grade 3(+) xerostomia) was defined as moderate to severe xerostomia 3 and 12 months after the completion of RT, and excluded patients with grade 3(+) xerostomia at the baseline. The Lyman-Kutcher-Burman normal tissue complication probability (NTCP) model was used to describe the incidence of xerostomia. Negative predictive values (NPVs) were used to determine the rate of correctly predicting the lack of complications.

RESULTS

NTCP fitted parameters were TD₅₀=37.8 Gy (CI: 29.1-46.9 Gy), m=0.59 (CI: 0.48-0.80) and TD50=43.9 Gy (CI: 33.2-52.8 Gy), m=0.48 (CI: 0.37-0.76) at the 3-month and 12-month time points, respectively. For QUANTEC validation, HN and HNSCC data validation gave similar results at 3 months; at mean doses to the spared parotid of ≤20 and ≤25 Gy, the QoL dataset showed approximately 22% and 28% rates of xerostomia, respectively. At 12 months, the rates of xerostomia were approximately 13% and 19%, respectively. For NPC cases, the dataset showed approximately 0% and 33% (∼67% NPV) rates of xerostomia at 3 months. At 12 months, both rates of xerostomia were approximately 0% (∼100% NPV), which differed significantly from the results for the HNSCC cohort.

CONCLUSION

The QoL datasets validated the QUANTEC guidelines and suggested that the modified QUANTEC 20/20-Gy spared-gland guideline is suitable for clinical use in HNSCC cohorts to effectively avoid xerostomia, and the QUANTEC 25-Gy guideline is justified for NPC cohorts.

Global and health-related quality of life after intensity-modulated radiation therapy for head and neck cancer

This study aims to evaluate the current literature regarding the effects of conventional radiation therapy (CRT) versus intensity-modulated radiation therapy (IMRT) on global quality of life (QoL) among patients treated for head and neck cancer. A PubMed literature review was performed. Only articles comparing global QoL scores in head and neck cancer patients treated with CRT versus IMRT were included. Studies were scrutinized for methodology, level of evidence and limitations. Outcomes were evaluated for external validity, level of evidence and applicability. Between 2005 and 2012, 14 eligible studies (six prospective, two randomized controlled trials) were identified. Although all presented data comment on the advantages of IMRT, differences in study design made comparisons difficult. The vast majority of these were also limited by relatively small sample sizes and heterogeneity with respect to patient and treatment-related characteristics. Although more robust evidence is needed in the future, the published data reasonably support the benefits of IMRT as compared with CRT (either 2D or 3D) in improving QoL, beginning at approximately 3-6 months post-treatment, and possibly potentiating with time up to 2 and 3 years.