Radiation therapy is well tolerated and produces excellent control rates in elderly patients with locally advanced head and neck cancers

Evaluation of oral mucositis, candidiasis, and quality of life in patients with head and neck cancer treated with a hypofractionated or conventional radiotherapy protocol: a longitudinal, prospective, observational study

BACKGROUND

Due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, recently, Radiotherapy (RT) protocols requiring fewer sessions (hypofractionated) have been used to shorten RT treatment and minimize patient exposure to medical centers, and decrease the risk of SARS-CoV-2 infection.

METHODS

This longitudinal, prospective, observational study aimed to compare the quality of life (QoL) and the incidence of oral mucositis and candidiasis in 66 patients with head and neck cancer (HNC) who undergo a hypofractionated RT protocol (GHipo), total of 55 Gy for 4 weeks, or a conventional RT protocol (GConv), total of 66 - 70 Gy for 6 - 7 weeks.

PURPOSE

To assess the incidence and severity of oral mucositis, the incidence of candidiasis, and QoL were evaluated using the World Health Organization scale, clinical evaluation, and the QLC-30 and H&N-35 questionnaires, respectively, at the beginning and the end of RT.

RESULTS

The incidence of candidiasis did not show differences between the two groups. However, at the end of RT, mucositis had a higher incidence (p < 0.01) and severity (p < 0.05) in GHipo. QoL was not markedly different between the two groups. Although mucositis worsened in patients treated with hypofractionated RT, QoL did not worsen for patients on this regimen.

CONCLUSIONS

Our results open perspectives for the potential use of RT protocols for HNC with fewer sessions in conditions that require faster, cheaper, and more practical treatments.

Tolerance of Radical Radiotherapy Among Elderly Head and Neck Cancer Patients

Head and neck cancers usually occur in the elderly age group and about half of the cases occur at the age > 60 years with majority detected in an advanced stage with increased morbidity and decreasing compliance to therapy. Since there are limited data available for the adequate treatment of elderly head and neck cancer patients, we proposed a study to analyze tolerance and response based on age, site, modality of treatment received, and implication of nutrition vs weight loss during treatment. Fifty-five patients were enrolled in this study, which was conducted between November 2015 and April 2017, and those who met the eligibility criteria were evaluated with a detailed history and physical examination, and biochemical, pathological, and radiological investigations. Patients were staged based on TNM staging and treated as per the standard guidelines. Patients were assessed with the weekly routine blood investigation, weight loss, and toxicity. The response was assessed after 6 weeks and documented as per RECIST criteria. 52/55 (94.5%) patients completed the treatment, and 48/55 (92.3%) had a complete response at 6 weeks (p value 0.000) with a mean treatment duration of 46.67 days and mean weight loss of 5.44 kg with 55.4% having GR-II mucositis, 40% having GRIII mucositis at the time of completion of treatment. Sixty-eight percent having GRII and 38.2% having GR I dermatitis and 80% had moderate pain. Subgroup analysis was done based on age, site, and treatment modality. Patients were also assessed for nutrition vs weight loss. We concluded that elderly patients tolerate and respond well to radical treatment with acceptable toxicities; hence, age should not be a barrier to decide treatment.

Managing older patients with head and neck cancer: The non-surgical curative approach

Managing older patients with head and neck cancers poses a challenge due to the often reduced levels of physiological reserve, the frequent comorbidities and treatment related toxicity. These factors have implications on speech, breathing and swallowing functions. Treatment management plans in these patients may result in de-intensification strategies and as a result of this, use of non-standard treatments is increasing. There have been published reports that indicate the addition of concurrent systemic therapy to radiation in selected older patients is feasible, and produces outcomes comparable with younger patients. However, some other studies including meta-analyses suggest a lack of real survival benefit with the addition of chemotherapy. So, the key point appears to be the optimal patient selection. Appropriate geriatric and frailty assessments are required to help determine the optimal treatment for older patients with head and neck cancer. Treatment for this population still needs to be well defined and optimized in both modality and intensity. Qualitative studies are also required to address short and long-term post-treatment quality-of-life and survivorship issues in this specific patient population. This review summarizes the evidence available regarding the non-surgical management of older patients with head and neck cancers.

Tumour boards in geriatric oncology

Multidisciplinary tumour board is an integral part of cancer treatment planning. Although no definite survival benefits have yet been shown by mostly observational studies, other benefits of multidisciplinary tumour board have been identified. Traditionally the multidisciplinary tumour board involves participation of treating clinicians-medical, radiation and surgical oncologists. They tend to focus on the cancer alone. There is an increasing awareness that the treatment goal for cancer in older adults is not primarily on prolonging survival, with functional preservation and quality of life being particularly important for this population. The use of Comprehensive Geriatric Assessment and the input of the geriatrician in informing the oncologists regarding treatment decision have increasingly been shown to be beneficial. The integration of the geriatrician into the multidisciplinary tumour board should be urgently explored.

Assessment and management of radiotherapy induced toxicity in older patients

Radiotherapy is an attractive treatment option for older adults, especially where surgery and chemotherapy pose too great a risk. Radiotherapy toxicity may be divided into acute/early and late effects of treatment. The latter may have limited relevance to an older patient with competing causes of mortality due to significant comorbidity. Altered fractionation regimes have been employed in numerous sites, with no significant toxicity impact. These offer greater convenience in the elderly, especially those with limited social support or in active caregiving roles. As radiotherapy toxicity is site specific, it's important to assess baseline function via Comprehensive Geriatric Assessment (CGA), and any pre-existing comorbidities that may influence toxicity. With modern radiotherapy technology and capabilities, these are less of an issue and radiotherapy is a very suitable treatment option for the older adult. When evaluating the literature on toxicity in older patients, it's important to recognise that older studies do not represent modern day radiotherapy techniques and capabilities. Advanced technology may simultaneously deliver enhanced target coverage and reduced toxicity. More research is required related to the predictive power of CGA in linking radiotherapy toxicity to frailty. What little evidence exists shows that CGA has a role in treatment of older patients with radiotherapy and that, in general, radiotherapy appears to be well tolerated in older adults. The purpose of this review is to provide a broad overview of the mechanisms of normal tissue reactions to radiotherapy and how radiation induced toxicity may affect older patients.