Retrospective analysis of the impact of HPV status and smoking on mucositis in patients with oropharyngeal squamous cell carcinoma treated with concurrent chemotherapy and radiotherapy

Prevalence and risk factors of chronic oral complications in head and neck cancer therapies: A retrospective study

BACKGROUND

Oncological therapy can trigger various complications and side effects in certain tissues, such as the oral cavity, inducing a direct or indirect impact on basic functions and the patient's quality of life. The aim of the study is to determine the prevalence of chronic oral complications of oncological treatments in patients with head and neck cancer and assess their possible relationship with risk indicators associated with the patient, the tumor, and the treatment.

MATERIAL AND METHODS

A retrospective, single-center, observational pilot cohort study was designed at the Dental Hospital of the University of Barcelona, involving patients with head and neck cancer who underwent surgery, non-surgical oncological therapy (radiotherapy/chemotherapy/immunotherapy), or combined therapy. Medical histories were analyzed, and data related to demographics, toxic, hygienic, and dietary habits, systemic and oral health status, characteristics of cancer and its treatment, and registered chronic oral complications were collected. The results were expressed in descriptive measures (means, standard deviations, counts, prevalence, and 95% confidence intervals), and for statistical associations, parametric and non-parametric tests were used.

RESULTS

The overall prevalence of chronic oral complications was 92.57%. Dental disease (81.14%), periodontal disease (65.14%), and hyposalivation/xerostomia (62.86%) showed the highest prevalence. Advanced age, certain cancer locations, advanced cancer stages, and oncological therapy including radiotherapy were significantly associated with the presence and number of complications.

CONCLUSIONS

The elevated noticed prevalence necessitates rigorous monitoring and preventive care. The combination of risk factors can significantly contribute to oral complications. Understanding these factors services dentists establish protocols for preventing, diagnosing, and treating oncology patients.

Oral Mucositis in Adult Cancer Patients Undergoing Chemotherapy: Six-Month On-Treatment Follow-Up

Objectives. Oral mucositis (OM) is a common adverse reaction associated with chemotherapy. We conducted a six-month longitudinal study to estimate the cumulative incidence of OM during the first six months of chemotherapy in adult patients with cancer other than head and neck cancer. Secondary objectives were as follows: (a) to scrutinize the oral health status of these patients and its evolution during chemotherapy, as assessed by oral health indices; (b) to estimate adherence to prescribed oral hygiene protocol during chemotherapy; and (c) to analyze ulceration-free survival in these patients. Methods. Sixty-four patients participated. Dental health and oral hygiene were assessed at baseline and at the end. Every month, blood tests were performed and oral lesions were recorded. This study was observational, with the only intervention being instruction in the hygiene protocol. The cumulative incidence of OM was estimated with the patient as the unit of analysis. A repeated measures ANOVA was applied to analyze the monthly blood test results. Ulceration-free survival analysis was conducted with adherence to the oral hygiene protocol as a grouping factor, followed by Cox proportional-hazards regression. Results. The six-month cumulative incidence rate was 43.75%, 95%CI (31.58-56.67%) for OM grade 2 or higher. The hazard ratio of ulceration associated with adherence to the hygiene protocol was 0.154, 95%CI (0.049-0.483), adjusted for age, sex, baseline hygiene index, and class of treatment. Conclusions. Compliance with hygiene recommendations would decrease the OM risk by more than six times, compared to non-compliance.

The prevalence of oral mucositis after radiotherapy in patients with Head and Neck Cancer and its associated factors: a meta-analysis

OBJECTIVES

Although the discussion about oral mucositis in Head and Neck Cancer (HNC) patients has become a prominent issue, its incidence and influencing factors have not been thoroughly synthesized. This meta-analysis aims to integrate the prevalence and associated factors of radiation-induced oral mucositis among HNC patients.

METHODS

This study searched the following electronic databases: PubMed, the Cochrane Database, the Web of Science, EMBASE, CNKI, the Wanfang Database, and the VIP Database. The publication timeframe for the included studies ranged from January 2005 until January 2024. Two investigators used the NOS scale and AHRQ evaluation criteria for quality evaluation. All qualified studies and statistical analyses were conducted using RevMan 5.2 and Stata 17.0.

RESULTS

Thirty eligible studies were included in the analysis. The results show that the prevalence of radiation-induced oral mucositis in HNC patients was 94% [95% CI (89%, 98%)]. Furthermore, the prevalence of severe radiation-induced oral mucositis in HNC patients is 37% [95%CI (29%, 45%)]. Chemotherapy, smoking history, diabetes, oral PH ≤ 7.0, and alcohol consumption are the main risk factors for radioactive oral mucositis. In addition, BMI > 24.0 kg/m2, no use of antibiotics, and no use of oral mucosal protective agents are associated with radioactive oral mucositis.

CONCLUSIONS

This meta-analysis underscores a significantly high prevalence of radiation-induced oral mucositis in HNC patients. Establishing healthy lifestyle habits and maintaining a healthy oral environment are pivotal in preventing radiation-induced oral mucositis.

Adverse drug reactions and drug-related problems with supportive care medications among the oncological population

AIM

The current study emphasizes the impact of adverse drug reactions (ADRs) and Drug-Related Problems (DRPs) caused by supportive care medications administered with chemotherapy.

METHOD

This is a longitudinal observational study carried out at the Ramaiah Medical College Hospital in Bengaluru, Karnataka, India, at the Department of Oncology. The data was recorded using a specifically created data collecting form. Based on the PCNE (Pharmaceutical Care Network Europe), DRPs are identified. The WHO probability scale, Modified Hartwig and Siegel for ADR severity assessment, Naranjo's algorithm for causality assessment, Rawlins and Thompson for predictability assessment, and Modified Shumock and Thornton for preventability assessment were all utilized. The OncPal guideline was considered in terms of the precision of supportive care medications regarding the reduction of ADRs in cancer patients.

RESULT

We enrolled 302 patients,166 (55%) female and 136 (45%) male (SD 14.378) (mean 49.97), patients with one comorbidity 59(19.6%) and multimorbidity (two or more) 45(14.9%), the DRPs identified were found to be 153 (50.6%); only P2 (safeties of drug therapy PCNE) were considered in this study. ADRs which are identified 175(57.9%) contributed/caused by the supportive care medications. WHO probability scale: 97 (32.1%) possible and 60 (19.9%) unlikely; Naranjo's algorithm: 97 (32.1%) unlikely and 69 (22.8%) possible; ADR severity assessment scale (Modified Hartwig and Siegel): 95 (31.5%) mild and 63 (20.9%) moderates; Rawlins and Thompson for determining predictability of an ADR: 33 (10.9%) predictable and 137 (45.5%) non-predictable; and Modified Shumock and Thornton for determining preventability of an ADR: 81 (26.8%) probably preventable and 90 (29.8%) non-preventable. The statistical comparison through preforming t-test and measuring Chi-Square between group with ADRs and without ADRs shows in some variables, significantly (Alcohol consumption status, P = .019) and Easter Cooperative Oncology Group (ECOG) performance status P < 0.001.

CONCLUSION

Comprehensive assessment of supportive medications in cancer patients would enhance the patient management and therapeutic outcome. The potential adverse drug reactions (ADRs) caused by supportive care medications can contribute to longer hospital stays and interact with the systemic anti-cancer treatment. The health care professionals should be informed to monitor the patients clinically administered with supportive medications.

Prospective comparison of acute severe toxicities between smokers and non-smokers during radiotherapy for head and neck cancers

BACKGROUND AND PURPOSE

The association between smoking and acute radiation toxicities of head and neck cancer (HNC) is currently unproven. The aim of the study was to compare the occurrence of acute severe toxicity between active and non-active smokers treated for HNC by radiotherapy.

MATERIALS AND METHODS

A prospective monocentric cohort study included patients treated by (chemo)radiotherapy for HNC from January 2021 to January 2023. Smoking status was recorded. Patients underwent a medical exam weekly during the radiotherapy to report acute toxicities according to the Common Terminology Criteria for Adverse Effects system version 5.0. Primary endpoint was the occurrence of at least one grade ≥ 3 acute toxicity among mucositis, dysphagia and dermatitis.

RESULTS

Among the 102 patients included, 27.4 % were active smokers, 58.8 % were former smokers and 13.7 % had never smoked. Regarding toxicity, 23.5 % (n = 24) patients experienced severe mucositis, 37.2 % (n = 38) severe dysphagia, 13.7 % (n = 14) severe dermatitis and 54.9 % (n = 56) experienced at least one of them. Occurrence of severe acute toxicity was not statistically associated with smoking during radiotherapy (64.3 % among active smokers versus 51.3 % among non-active smokers; p = 0.24). On multivariate analysis, concurrent chemotherapy (87.5 % vs 65.2 %; OR = 5.04 [1.64-15.52]; p = 0.004) and 2.12 Gy versus 2 Gy fractionation schedule (64.3 % vs 41.3 %; OR = 2.53 [1.09-5.90]; p = 0.03) were significantly associated with severe acute toxicity.

CONCLUSION

This study did not find an association between smoking during radiotherapy for HNC and occurrence of severe acute toxicities.

Association of Insomnia and Obstructive Sleep Apnea with Worse Oral Mucositis and Quality of Life in Head and Neck Cancer Patients Undergoing Radiation Therapy

BACKGROUND

Patients with head and neck cancer (HNC) undergoing radiation therapy (RT) often experience sleep disturbances that may contribute to oral mucositis (OM) and quality of life (QOL).

METHODS

Patients with HNC treated with RT at a single institution were examined. Sleep questionnaires were given on the first day of RT to assess for insomnia and obstructive sleep apnea (OSA). Patient-reported QOL and oral mucositis were assessed during RT. Associations between insomnia and OSA with QOL were assessed using the Mann-Whitney U test. Linear mixed models assessed associations with OM.

RESULTS

Among 87 patients, 34 patients (39%) had subthreshold or greater insomnia and 47 patients (54%) screened positive for OSA. Upon RT completion, patients with subthreshold or greater insomnia had worse physical function (p = 0.005), fatigue (p = 0.01), insomnia (p < 0.001), and sticky saliva (p = 0.002). Patients screening positive for OSA had worse physical function (p = 0.01), sticky saliva (p = 0.02), fatigue (p = 0.007), insomnia (p = 0.009), and pain (p = 0.005). Upon linear mixed model evaluation, subthreshold or greater insomnia (p = 0.01) and positive OSA screen (p = 0.002) were associated with worse OM.

CONCLUSION

Insomnia and OSA are highly prevalent in patients with HNC undergoing RT. These sleep disturbances are associated with worse QOL and OM during treatment.

The Trajectory of Oral Mucositis in Head and Neck Cancer Patients Undergoing Radiotherapy and its Influencing Factors

BACKGROUND

Oral mucositis (OM) is a common and severe side effect of radiotherapy in head and neck cancer (HNC). The study aimed to investigate the longitudinal changes in OM and its influencing factors in patients with HNC during radiotherapy.

METHODS

This was a retrospective longitudinal observational study. From July 2022 to March 2023, patients with HNC undergoing radiation therapy were enrolled. OM, oral hygiene, oral infections, oral pain, feeding route, and laboratory indicators were measured at 7 times. The influencing factors of OM were analyzed using generalized estimation equations (GEEs).

RESULTS

A total of 160 patients were included in this study. The prevalence of severe OM at T0, T1, T2, T3, T4, T5, and T6 was 0, 0, 2.5%, 9.4%, 26.9%, 24.4%, and 26.9%, respectively. The prevalence of grade 1-2 OM at T0, T1, T2, T3, T4, T5, and T6 was 0, 16.3%, 53.1%, 65.1%, 61.9%, 70.7%, and 71.3%, respectively. Duration of diagnosis, clinical stage, N stage, M stage, surgery, diabetes, radiotherapy dose, oral hygiene, oral infection, oral pain, feeding route, and lymphocyte impacted OM significantly in the GEEs multivariate model.

CONCLUSIONS

OM occurs in almost all patients with HNC who undergo radiotherapy. Changes in the severity of OM are a dynamic process, with the severity increasing with the cumulative radiotherapy dose. Specialist oral evaluation and oral care are needed to alleviate the severity of OM in HNC patients.

Mitochondrial metabolism: a predictive biomarker of radiotherapy efficacy and toxicity

INTRODUCTION

Radiotherapy is a mainstay of cancer treatment. Clinical studies revealed a heterogenous response to radiotherapy, from a complete response to even disease progression. To that end, finding the relative prognostic factors of disease outcomes and predictive factors of treatment efficacy and toxicity is essential. It has been demonstrated that radiation response depends on DNA damage response, cell cycle phase, oxygen concentration, and growth rate. Emerging evidence suggests that altered mitochondrial metabolism is associated with radioresistance.

METHODS

This article provides a comprehensive evaluation of the role of mitochondria in radiotherapy efficacy and toxicity. In addition, it demonstrates how mitochondria might be involved in the famous 6Rs of radiobiology.

RESULTS

In terms of this idea, decreasing the mitochondrial metabolism of cancer cells may increase radiation response, and enhancing the mitochondrial metabolism of normal cells may reduce radiation toxicity. Enhancing the normal cells (including immune cells) mitochondrial metabolism can potentially improve the tumor response by enhancing immune reactivation. Future studies are invited to examine the impacts of mitochondrial metabolism on radiation efficacy and toxicity. Improving radiotherapy response with diminishing cancer cells' mitochondrial metabolism, and reducing radiotherapy toxicity with enhancing normal cells' mitochondrial metabolism.

Associations between Human Papillomavirus Status, Weight Change, and Survival of Oropharyngeal Cancer Patients

This study examined associations between HPV status and weight change in oropharyngeal cancer (OPC). OPC patients receiving concurrent chemoradiotherapy in Toronto, Canada were included. Relationships were assessed between HPV status and weight loss grade (WLG, combining weight loss and current body mass index); weight change during treatment; and HPV status and WLG/weight change on overall (OS) and cancer-specific (CSS) survival. Of 717 patients, WLG pre-radiation was less severe among HPV-positive compared to HPV-negative, though weight loss during treatment was greater. The adjusted odds ratio for greater WLG among HPV-positive versus HPV-negative was 0.47 (95%CI 0.28-0.78). Grade-4 WLG (worst category) experienced poorer OS and CSS (OS adjusted hazard ratio (aHR) 4.08; 95%CI 1.48-11.2, compared to Grade-0); and was non-significant for HPV-negative (aHR 2.34; 95%CI 0.69-7.95). Relationships between weight change before/during treatment and survival had similar direction between HPV-positive and HPV-negative, but of greater magnitude in HPV-positive patients.

Enteral Nutrition during Radiotherapy for Oropharyngeal Cancers: Prevalence and Prognostic Factors Based on HPV Status (A GETTEC Study)

Nutritional support during radiotherapy is crucial to tolerating and completing oropharyngeal squamous cell carcinoma (OPSCC) treatment. The impact of HPV status on nutritional support is debated. The objective was to evaluate the rate of Reactive Feeding Tube (RFT) use and determine its prognostic factors during definitive radiotherapy for OPSCC. All OPSCC patients treated from 2009 to 2014 were included in this multicentric retrospective study. The impact of tumor p16 status on the risk of RFT was assessed through multivariate analyses. Among the 543 patients, 103 patients required an RFT (19.0%). The use of RFT differed between centers (5% to 32.4%). In multivariate analysis, only tongue base involvement and concurrent chemotherapy were significantly associated with RFT (OR = 2.18 and 3.7, respectively). Tongue base involvement and concomitant chemotherapy were prognostic factors for RFT. HPV status was not a prognostic factor for enteral nutrition during radiotherapy for OPSCC.

[Impact of HPV status on nutritional status during radio chemotherapy for oropharyngeal cancer]

PURPOSE

Patients with oropharyngeal cancer are at high nutritional risk before and during treatment. Little is known about the influence of human papillomavirus (HPV) infection on nutritional status and its evolution during treatment.

MATERIALS AND METHODS

A single-center retrospective study was conducted between August 2017 and December 2020 including 48 patients (14 HPV-induced: HPV+ and 34 non-HPV-induced: HPV-) with oropharyngeal squamous cell carcinoma treated by radiotherapy±chemotherapy (RT/CT). Nutritional risk at the time of tumor assessment (TA) was assessed by weight loss, swallowing ability, and the presence of digestive disorders in 4 stages of increasing severity. Nutritional status was assessed by weight and nutrition risk index (NRI) at the time of TA, before the start and at 3 months from the end of RT±CT. During RT±CT, the NRI and the systemic inflammatory response index (SIRI=neutrophils * monocytes/lymphocytes) were assessed weekly.

RESULTS

HPV+patients were at lower nutritional risk at TA (50% grade ≥2 vs 85%, P=0.02), lost more weight (6% of their body weight vs 3%, P=0.05), and increased their SIRI by 7.5 points more than HPV- patients (P=0.04) during RT/CT.

CONCLUSION

HPV+ oropharyngeal cancer patients are at high nutritional risk even in the absence of undernutrition at the outset of management.

The changing face of head and neck cancer: are patients with human papillomavirus-positive disease at greater nutritional risk? A systematic review

PURPOSE

Human papillomavirus (HPV) is now the primary cause of oropharyngeal head and neck cancer (OPC) worldwide; yet limited research has examined the effect of HPV-positive status (OPC+) on nutrition outcomes. This study aims to determine the impact of HPV status on nutritional outcomes for adult patients with OPC undergoing any treatment modality.

METHODS

A systematic literature review was conducted up to and including July 2021 of PubMed, Embase, CENTRAL, CINAHL, and Web of Science to identify studies conducted in adults (>18 years) with known OPC reporting on any outcome(s) related to nutrition, according to HPV status (OPC+ versus OPC-). Bias was assessed using QUIPS tool, with certainty of evidence assessed using GRADE system.

RESULTS

Six studies (total n = 635) all at moderate-high risk of bias were included. Three studies reported on weight change (n = 255), three feeding tube dependency (n = 380), three feeding tube timing of placement (prophylactic or reactive) and/or utilisation (n = 255), two nutritional (energy and/or protein) intake (n = 230), and one nutritional status (n = 83). Patients with OPC+ may experience greater weight loss, may have higher utilisation of reactive feeding tubes (both GRADE low certainty, downgraded due to serious bias and imprecision), and may have lower feeding tube dependency rates (GRADE low certainty, downgraded due to serious bias and inconsistency) versus OPC- . It is uncertain whether nutritional intake and nutritional status differed between populations (GRADE very low certainty, downgraded due to serious bias and very serious imprecision).

CONCLUSION

Further, high-quality research is needed to understand optimal nutritional care practices for patients with OPC + to achieve positive health outcomes into survivorship.

Precision medicine for risk prediction of oral complications of cancer therapy–The example of oral mucositis in patients receiving radiation therapy for cancers of the head and neck

Oral complications of cancer therapy are common, markedly symptomatic, negatively impact patients' quality of life, and add significantly to the cost of care. Patients' risk of treatment-related toxicities is not uniform; most patients suffer at least one side effect, while others tolerate treatment without any. Understanding those factors which impact risk provides opportunities to customize cancer treatment plans to optimize tumor kill and minimize regimen-related toxicities. Oral mucositis (OM) is an iconic example of a clinically significant and common complication of head and neck radiotherapy. Individuals' OM risk is governed by the cumulative impact of factors related to treatment, the tumor, and the patient. In addition to OM risk prediction, a second opportunity to apply precision medicine will evolve as viable treatment options become available. Patients vary widely in how well or poorly they respond to specific treatments. What works well in one individual, might fail in another. Prospective determination of the likelihood of a patient's response or non-response is based on a range of biological interactions. Coupled with risk determination, the application of precision medicine will allow caregivers, patients, and payers to integrate risk/benefit to optimize the probability that the best treatment is be given to the most appropriate patients.

Confounding factors in the assessment of oral mucositis in head and neck cancer

Treatment of locally advanced head and neck carcinoma not amenable for surgical resection or resected with high-risk features is usually based on (chemo-)radiation treatment. Oral mucositis represents one of the main side effects of (chemo-)radiation, with an important impact on quality of life and causing approximately 20% of early interruption of treatment, leading to a suboptimal dose administered. Treatment and prevention of oral mucositis have a central role in the therapeutic pathways of head and neck cancer patients but remains quite challenging. Although extensive research is conducted to identify interventions for the management of mucositis, very few interventions had sufficient evidence to generate an international expert consensus. This may be partially explained by confounding factors that could influence the development and assessment of oral mucositis. Little is known about the confounding factors of oral mucositis, which, if not well balanced in an experimental study, could lead to non-solid results. The current paper aims to review the main oral mucositis confounding factors related to head and neck cancer patients.

Analysis of Selected Nutritional Parameters in Patients with HPV-Related and Non-HPV-Related Oropharyngeal Cancer before and after Radiotherapy Alone or Combined with Chemotherapy

Background: Radiotherapy plays an essential role in the treatment of oropharyngeal carcinoma (OPC). The aim of this study was to assess and compare the nutritional status (NS) of patients with HPV-related (HPV+) and non-HPV-related (HPV-) OPC before and after radiotherapy (RT) or chemoradiotherapy (CRT). Methods: The analysis included 127 patients with OPC who underwent radiotherapy (RT) alone, or in combination with chemotherapy (CRT), in the I Radiation and Clinical Oncology Department of Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice Branch, Poland. Patients were divided according to HPV status. Confirmation of HPV etiology was obtained from FFPE (formalin-fixed, paraffin-embedded) tissue material and/or extracellular circulating HPV DNA. Basic anthropometric and biochemical parameters before and after RT/CRT were compared between the HPV- and HPV+ groups. The effect of NS on survival was also analyzed. Results: In both groups, a significant decrease in all analyzed nutritional parameters was noted after RT/CRT (p < 0.01). CRT caused significant weight loss and decreases in BMI, albumin, total lymphocyte count (TLC), and hemoglobin concentration, as well as an increase in the Nutritional Risk Score (NRS) 2002, in HPV- and HPV+ patients. A significant decrease in prealbumin levels after CRT was noted only in HPV+ patients. RT caused a significant decrease in hemoglobin concentration and TLC in HPV- patients. There were no significant differences regarding other nutritional parameters after RT in either group. RT did not have negative impact on body mass index (BMI), weight, NRS, CRP, Alb, Prealb, or PNI. Overall survival (OS) and disease-free survival (DFS) were significantly better in patients with a higher BMI in the HPV- group (OS, p = 0.011; DFS, p = 0.028); DFS was significantly better in patients with C-reactive protein (CRP) < 3.5 g/dL in the HPV- (p = 0.021) and HPV+ (p = 0.018) groups, and with total lymphocyte count (TLC) >1.28/mm3 in the HPV+ group (p = 0.014). Higher NRS 2002 was an independent adverse prognostic factor for OS and DFS in HPV-, but not in the HPV+ group. Kaplan−Meier analysis showed that both OS and DFS were significantly better in HPV- patients with lower NRS 2002 scores. However, this relationship was not observed in the HPV+ group. Conclusions: Regardless of HPV status, patients with OPC can develop malnutrition during RT/CRT. Therefore, nutritional support during RT/CRT is required in patients with HPV- and HPV+ OPC.

Evaluating predictive factors for toxicities experienced by head & neck cancer patients undergoing radiotherapy

Purpose

The purpose of this study was to evaluate if HPV status serves as an independent predictor of early and late dysphagia outcomes when considered alongside standard patient characteristics and dose metrics for head and neck cancer patients treated with radiotherapy.

Methods and materials

The age, sex, smoking history, cancer type (oropharyngeal vs non-oropharyngeal), HPV status, and early and late dysphagia outcomes were obtained for 99 retrospective head and neck cancer patients treated at our clinic with radiotherapy. Additionally for each patient, the mean radiation dose to the pharynx, superior/middle/inferior pharyngeal constrictor muscles, and cricopharyngeus was calculated. The predictive power of these clinical characteristics and radiation metrics was evaluated using chi-square tests for categorical variables and t-tests for continuous variables. Then multi-variate logistic models were built for each outcome using a single dose metric at a time, and either HPV status, cancer type, or both. Multi-variate models were built using both top-down and bottom-up technique to establish the most predictive independent covariates.

Results

In the univariate analysis for early dysphagia, cancer type (p = 0.04) and four dose metrics (p ≤ 0.02) were significantly associated with outcome, while for late dysphagia, only cancer type (p = 0.04) was associated with outcome. In the multivariate analysis for early dysphagia, cancer type, smoking history, and mean dose to the five structures were consistently selected as covariates. For late dysphagia, either HPV status or cancer type was selected in each model and the mean dose to the cricopharyngeus was selected in one model.

Conclusion

While HPV is a known contributing factor for tumor prognosis in oropharyngeal cancers, its role in normal tissue toxicities for head and neck cancers has not previously been evaluated. Our results indicate having an oropharyngeal cancer may increase a patient’s risk of high-grade early and late dysphagia while HPV status was seldom selected.

Dysphagia, trismus and speech impairment following radiation-based treatment for advanced stage oropharyngeal carcinoma: a one-year prospective evaluation

OBJECTIVE

The objective was to assess swallowing, mouth opening and speech function during the first year after radiation-based treatment (RT(+)) after introduction of a dedicated preventive rehabilitation program for stage III-IV oropharyngeal carcinoma (OPC).

METHODS

Swallowing, mouth opening and speech function were collected before and at six- and twelve-month follow-up after RT(+) for OPC as part of ongoing prospective assessments by speech-language pathologists .

RESULTS

Objective and patient-perceived function deteriorated until 6 months and improved until 12 months after treatment, but did not return to baseline levels with 25%, 20% and 58% of the patients with objective dysphagia, trismus and speech problems, respectively. Feeding tube dependency and pneumonia prevalence was low.

CONCLUSION

Despite successful implementation, a substantial proportion of patients still experience functional limitations after RT(+) for OPC, suggesting room for improvement of the current rehabilitation program. Pretreatment sarcopenia seems associated with worse functional outcomes and might be a relevant new target for rehabilitation strategies.

The Impact of Human Papillomavirus (HPV) Associated Oropharyngeal Squamous Cell Carcinoma (OPSCC) on Nutritional Outcomes

Background: Patients undergoing (chemo) radiotherapy for oropharyngeal squamous cell carcinoma (OPSCC) are at high risk of malnutrition during and after treatment. Malnutrition can lead to poor tolerance to treatment, treatment interruptions, poor quality of life (QOL) and potentially reduced survival rate. Human papillomavirus (HPV) is now known as the major cause of OPSCC. However, research regarding its effect on nutritional outcomes is limited. The aim of this study was to examine the relationship between HPV status and nutritional outcomes, including malnutrition and weight loss during and after patients’ (chemo) radiotherapy treatment for OPSCC. Methods: This was a longitudinal cohort study comparing the nutritional outcomes of HPV-positive and negative OPSCC patients undergoing (chemo) radiotherapy. The primary outcome was nutritional status as measured using the Patient Generated-Subjective Global Assessment (PG-SGA). Secondary outcomes included loss of weight, depression, QOL and adverse events. Results: Although HPV-positive were less likely to be malnourished according to PG-SGA at the beginning of treatment, we found that the difference between malnutrition rates in response to treatment was not significantly different over the course of radiotherapy and 3 months post treatment. HPV-positive participants had significantly higher odds of experiencing >10% weight loss at three months post-treatment than HPV-negative participants (OR = 49.68, 95% CI (2.7, 912.86) p ≤ 0.01). Conclusions: The nutritional status of HPV positive and negative patients were both negatively affected by treatment and require similarly intense nutritional intervention. In acute recovery, HPV positive patients may require more intense intervention. At 3- months post treatment, both groups still showed nutritional symptoms that require nutritional intervention so ongoing nutritional support is essential.

Evidence for different molecular parameters in head and neck squamous cell carcinoma of nonsmokers and nondrinkers: Systematic review and meta-analysis on HPV, p16, and TP53

BACKGROUND

The goal of this review was to present an overview of the currently identified molecular parameters in head and neck squamous cell carcinoma (HNSCC) of nonsmokers and nondrinkers (NSND).

METHODS

Following the PRISMA guidelines, a systematic search was performed using the electronic databases PubMed, Embase, and Google Scholar.

RESULTS

Of the 902 analyzed unique studies, 74 were included in a quantitative synthesis and 24 in a meta-analysis. Human papillomavirus (HPV) was reported as a molecular parameter in 38 studies, followed by p16 and TP53 (23 and 14 studies, respectively). The variety of other molecular parameters concerned sporadic findings in small numbers of NSND.

CONCLUSIONS

HNSCC in NSND is more often related to HPV and p16 overexpression compared to tumors of smokers-drinkers. In a third of virus-negative tumors, TP53 mutations were detected with a mutational profile associated with aging and ultraviolet light exposure rather than to tobacco consumption.

Prediction of mucositis risk secondary to cancer therapy: a systematic review of current evidence and call to action

PURPOSE

Despite advances in personalizing the efficacy of cancer therapy, our ability to identify patients at risk of severe treatment side effects and provide individualized supportive care is limited. This is particularly the case for mucositis (oral and gastrointestinal), with no comprehensive risk evaluation strategies to identify high-risk patients. We, the Multinational Association for Supportive Care in Cancer/International Society for Oral Oncology (MASCC/ISOO) Mucositis Study Group, therefore aimed to systematically review current evidence on that factors that influence mucositis risk to provide a foundation upon which future risk prediction studies can be based.

METHODS

We identified 11,018 papers from PubMed and Web of Science, with 197 records extracted for full review and 113 meeting final eligibility criteria. Data were then synthesized into tables to highlight the level of evidence for each risk predictor.

RESULTS

The strongest level of evidence supported dosimetric parameters as key predictors of mucositis risk. Genetic variants in drug-metabolizing pathways, immune signaling, and cell injury/repair mechanisms were also identified to impact mucositis risk. Factors relating to the individual were variably linked to mucositis outcomes, although female sex and smoking status showed some association with mucositis risk.

CONCLUSION

Mucositis risk reflects the complex interplay between the host, tumor microenvironment, and treatment specifications, yet the large majority of studies rely on hypothesis-driven, single-candidate approaches. For significant advances in the provision of personalized supportive care, coordinated research efforts with robust multiplexed approaches are strongly advised.

Polymorphism of TNFRSF1 A may act as a predictor of severe radiation-induced oral mucositis and a prognosis factor in patients with head and neck cancer

OBJECTIVE

The aim of this study was to evaluate the relationship between single nucleotide polymorphism (SNP) (-135 T>C) of TNFRSF1 A and the frequency of occurrence and severity of oral mucositis (OM) in patients with head and neck cancer (HNC) treated with radiotherapy (RT).

STUDY DESIGN

This retrospective, cohort study included 60 patients with HNC treated with intensity-modulated radiation therapy (IMRT). TNFRSF1 A SNP analysis (-135 T>C) was performed by using molecular probes (TaqMan, ThermoFisher Scientific, Waltham, MA) in DNA isolated from peripheral blood (QIAamp DNA MiniKit; Qiagen, Germantown, MD).

RESULTS

CC genotype was related to 4.5-fold higher risk of grade 2 OM after the second week of RT. Similarly, CC carriers had a significantly higher risk of severe (grade 3) OM after the fourth (6-fold) and fifth (7.5-fold) weeks of RT. The CC genotype of the TNFRSF1 A gene was significantly correlated with a higher risk of shorter overall survival (OS) (> 37 months follow-up period; hazard ratio [HR] = 2.78).

CONCLUSIONS

SNP (-135 T>C) of the TNFRSF1 A gene may act as a predictor of OM occurrence in patients with HNC treated with IMRT. The studied SNP may also serve as a prognostic factor in such cases.

Disease-induced and treatment-induced alterations in body composition in locally advanced head and neck squamous cell carcinoma

BACKGROUND

Chemoradiation or bioradiation treatment (CRT/BRT) of locally advanced head and neck squamous cell carcinoma (LAHNSCC) comes with high toxicity rates, often leading to temporary tube feeding (TF) dependency. Cachexia is a common problem in LAHNSCC. Yet changes in body composition and muscle weakness during CRT/BRT are underexplored. Strong evidence on the effect of TF on body composition during treatment is lacking. The aim of this cohort study was to assess (i) the relationship of fat-free mass index (FFMI) and handgrip strength (HGS) with CRT/BRT toxicity and outcome, (ii) body composition in patients treated with chemoradiation (cisplatin) vs. bioradiation (cetuximab), and (iii) the effect of the current TF regime on body composition and muscle strength.

METHODS

Locally advanced head and neck squamous cell carcinoma patients treated with CRT/BRT between January 2013 and December 2016 were included (n = 137). Baseline measurements of body composition (bioelectrical impedance analysis) and HGS were performed. Toxicity grades (Common Terminology Criteria for Adverse Events) were scored. In a subset of 69 patients, weight loss, body composition, and HGS were additionally assessed during and after CRT/BRT. TF was initiated according to the Dutch guidelines for malnutrition.

RESULTS

In this cohort (68% male, mean age 59 ± 8 years), the incidence of baseline muscle wasting, defined as FFMI < P₁₀ , was 29%. Muscle wasting was present in 23 of 100 (23%) chemoradiation patients and 17 of 37 (46%) bioradiation patients (P = 0.009). Muscle-wasted patients required more unplanned hospitalizations during CRT (P = 0.035). In the chemoradiation subset, dose-limiting toxicity was significantly higher in wasted vs. non-wasted patients (57% vs. 25%, P = 0.004). Median follow-up was 32 months. Multivariate Cox regression analysis identified muscle wasting as independent unfavourable prognostic factor for overall survival [hazard ratio 2.1 (95% CI 1.1-4.1), P = 0.022] and cisplatin as favourable prognostic factor [hazard ratio 0.3 (95% CI 0.2-0.6), P = 0.001]. Weight and HGS significantly decreased during CRT/BRT, -3.7 ± 3.5 kg (P < 0.001) and -3.1 ± 6.0 kg (P < 0.001), respectively. Sixty-four per cent of the patients required TF 21 days (range 0-59) after CRT/BRT initiation. Total weight loss during CRT/BRT was significantly (P = 0.007) higher in the total oral diet group (5.5 ± 3.7 kg) compared with the TF group (3.0 ± 3.2 kg). Loss of FFM and HGS was similar in both groups.

CONCLUSIONS

In LAHNSCC patients undergoing CRT/BRT, FFMI < P₁₀ is an unfavourable prognostic factor for overall survival, treatment toxicity, and tolerance. Patients experience significant weight and FFM loss during treatment. Current TF regime attenuates weight loss but does not overcome loss of muscle mass and function during therapy. Future interventions should consider nutritional intake and additional strategies specifically targeting metabolism, loss of muscle mass, and function.

Human papillomavirus-associated squamous cell carcinoma of the larynx or hypopharynx: Clinical outcomes and implications for laryngeal preservation

OBJECTIVES

Human papillomavirus (HPV) can be detected in approximately 25% of squamous cell carcinomas (SCC) of the larynx and hypopharynx. Though HPV is associated with improved survival and disease control in patients with oropharyngeal SCC, the role of HPV as a marker of favorable treatment outcomes in laryngeal and hypopharyngeal cancer is unclear.

MATERIALS AND METHODS

Patients treated for laryngeal or hypopharyngeal SCC were reviewed. HPV status detected by p16 and/or HPV DNA PCR were abstracted from the medical record. A subset of samples (stage III-IV treated with primary radiotherapy) was retrospectively tested for p16 and HPV DNA. Overall survival (OS), disease-free survival (DFS), and locoregional control (LRC) were determined and compared between HPV-positive (p16+, PCR+ or both) and HPV-negative (p16- or PCR-) patients.

RESULTS

In total, 279 patients were identified, 94 of which were tested for HPV. Eighty-two (87%) were negative and 12 (13%) were positive for HPV. At 3 years, there were no significant differences in OS (72% v. 83%), DFS (60% v. 71%) and LRC (80% v. 89%). Performance status, smoking history and stage predicted for OS, while performance status and stage predicted for DFS. Analysis of patients treated with primary radiotherapy revealed non-significantly higher rates of laryngeal preservation at 3 years (75% v. 100%).

CONCLUSION

HPV was detected in 13% of tested laryngeal/hypopharyngeal cancers. HPV does not appear to significantly impact survival or disease control in patients with SCC of the larynx or hypopharynx. Non-significant improvements in laryngeal preservation were observed in HPV-positive patients.

Afatinib as second-line treatment in patients with recurrent/metastatic squamous cell carcinoma of the head and neck: Subgroup analyses of treatment adherence, safety and mode of afatinib administration in the LUX-Head and Neck 1 trial

OBJECTIVES

Patients with head and neck squamous cell carcinoma (HNSCC) can experience severe symptom burden and/or difficulty swallowing, leading to problems with treatment adherence/administration. In LUX-Head and Neck 1 (LH&N1; NCT01345682), second-line afatinib improved progression-free survival (PFS) versus methotrexate in patients with recurrent/metastatic HNSCC. We report adherence and safety across pre-specified and additional subgroups potentially linked to afatinib PFS benefit in LH&N1 (p16 status, smoking history), and afatinib adherence, safety and efficacy by administration (oral versus feeding tube; post-hoc analysis).

METHODS

Patients were randomized (2:1) to afatinib (40 mg/day) or intravenous methotrexate (40 mg/m²/week).

RESULTS

Among 320 afatinib-treated and 160 methotrexate-treated patients, 83-92% and 76-92% (of patients with data available) across all subgroups took ≥80% of treatment. Across p16 status and smoking history subgroups, the most common treatment-related adverse events (AEs) were diarrhea (70-91%), rash/acne (72-84%), stomatitis (34-73%) with afatinib; and included stomatitis (39-100%), fatigue (22-50%), nausea (19-36%) with methotrexate. Dose reduction decreased AE incidence/severity. Baseline characteristics were generally similar between oral/feeding tube (n = 276/n = 46) groups. 89%/89% (of patients with data available) took ≥80% of assigned afatinib. Median PFS was 2.6 versus 2.7 months (hazard ratio: 0.997; 95% confidence interval: 0.72-1.38). The most common afatinib-related AEs were: rash/acne (74% versus 74%), diarrhea (73% versus 65%), stomatitis (40% versus 30%).

CONCLUSION

Subgroup analyses of LH&N1 demonstrate that afatinib has predictable and manageable safety across patient subgroups, with high treatment adherence, and is effective via oral and feeding tube administration.

HPV-related oropharyngeal cancer: a review on burden of the disease and opportunities for prevention and early detection

The incidence of oropharyngeal cancer (OPC) related to infection with human papillomavirus (HPV) is rising, making it now the most common HPV-related malignancy in the United States. These tumors present differently than traditional mucosal head and neck cancers, and those affected often lack classic risk factors such as tobacco and alcohol use. Currently, there are no approved approaches for prevention and early detection of disease, thus leading many patients to present with advanced cancers requiring intense surgical or nonsurgical therapies resulting in significant side effects and cost to the health-care system. In this review, we outline the evolving epidemiology of HPV-related OPC. We also summarize the available evidence corresponding to HPV-related OPC prevention, including efficacy and safety of the HPV vaccine in preventing oral HPV infections. Finally, we describe emerging techniques for identifying and screening those who may be at high risk for developing these tumors.

Predictors of Patient-Reported Dysphagia Following IMRT Plus Chemotherapy in Oropharyngeal Cancer

The aim of this cross-sectional study is to evaluate the factors associated with patient-reported dysphagia in patients affected by locally advanced oropharyngeal cancer (OPC) treated with definitive intensity-modulated radiation therapy (IMRT) and concurrent chemotherapy (CHT), with or without induction CHT. We evaluated 148 OPC patients treated with IMRT and concurrent CHT, without evidence of disease and who had completed their treatment since at least 6 months. At their planned follow-up visit, patients underwent clinical evaluation and completed the M.D. Anderson dysphagia inventory (MDADI) questionnaire. The association between questionnaire composite score (MDADI-CS) and different patients' and tumor's characteristics and treatments (covariates) was investigated by univariable and multivariable analyses, the latter including only covariates significant at univariable analysis. With a median time from treatment end of 30 months [range 6-74 months, interquartile range (IQR) 16-50 months], the median (IQR) MDADI-CS was 72 (63-84). The majority of patients (82.4%) had a MDADI-CS ≥ 60. At multivariable analysis, female gender, human papilloma virus (HPV)-negative status, and moderate and severe clinician-rated xerostomia were significantly associated with lower MDADI-CS. Patient-perceived dysphagia was satisfactory or acceptable in the majority of patients. HPV status and xerostomia were confirmed as important predictive factors for swallowing dysfunction after radiochemotherapy. Data regarding female gender are new and deserve further investigation.

Burden of Oral Mucositis: A Systematic Review and Implications for Future Research

BACKGROUND

Surprisingly little is known about the burden of oral mucositis (OM). We provide a systematic review of studies on the burden of OM (incidence, economic impact, health-related quality of life (HRQoL)).

METHODS

Systematic literature searches were made in BIOSIS, EMBASE, and MEDLINE. Inclusion criteria were studies on OM in hematology/oncology patients of ≥ 18 years, journal articles, English language, and published between 2000 and 2016; OM treatment studies were excluded. Quality assessment was performed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

We screened 4,996 hits, and identified 68 studies of which 13 were without transparency on OM grading. The evidence level of 65 studies was rated 'low' or 'very low' in 58.5%, 'moderate' in 20% and 'high' in 21.5%. Mean value of incidence (7 studies) was 83.5% for all grades of OM with hematopoietic stem cell transplantation. OM incidence for all grades in head and neck cancer patients was 59.4-100%. Considering the economic impact, 16 studies showed highly variable numbers. HRQoL was measured in 16 studies using 13 different instruments. Statistically significant changes in HRQoL scores were demonstrated.

CONCLUSION

OM is common, burdensome, costly and imposes major reductions in HRQoL. However, from a quality standpoint, the level of current evidence in OM is disappointing. The field needs continued attention to address methodological challenges.

The impact of HPV status on weight loss and feeding tube use in oropharyngeal carcinoma

OBJECTIVES

It has been well established that patients with oropharyngeal carcinoma are at high nutritional risk, with significant weight loss and tube feeding common. Human papillomavirus (HPV)-associated disease has led to a change in the "typical" presentation and nutritional profile of this population. The aim of our study was to determine whether the need for a feeding tube, and weight loss during radiotherapy (RT) in patients with oropharyngeal carcinoma differed with HPV status.

MATERIALS AND METHODS

Patients who received curative RT ± chemotherapy from January 2011 to January 2016 were included (n = 100). We retrospectively evaluated feeding tube use and timing of insertion (prophylactic vs reactive), percentage weight loss during RT and the prevalence of critical weight loss (CWL) ≥5%.

RESULTS

HPV-positive patients had significantly higher weight loss during RT compared to the rest of the cohort (8.4% vs 6.1%, 95%CI 0.8-3.9, p = 0.003). CWL was observed in 86% and in a higher proportion with HPV-positive disease (93%, p = 0.011). Conditional probability modelling analysis revealed, with 74% accuracy, concurrent chemoradiotherapy and HPV-positive status were predictors of CWL when comparing HPV-positive patients to HPV-negative (96%, p = 0.001 and 98%, p = 0.012 respectively). More HPV-positive patients required feeding tubes (n = 43, 63%, p = 0.05), most being reactive (n = 27, 63%). All patients with reactive tubes experienced CWL.

CONCLUSION

The high incidence of CWL in patients with HPV-positive oropharyngeal carcinoma is of concern. Tube feeding continues to be a necessary nutritional intervention in this population and predicting who will require a tube is challenging. Larger, prospective cohort studies are required.

FDG uptake in normal tissues assessed by PET during treatment has prognostic value for treatment results in head and neck squamous cell carcinomas undergoing radiochemotherapy

BACKGROUND AND PURPOSE

Pronounced early side effects have been suggested to be a positive prognostic factor in patients undergoing chemo-radio-therapy (CRT) for head and neck squamous cell carcinomas (HNSCC). We assessed the utility of positron emission tomography (PET) during treatment to analyze the correlation of 18F-fluorodeoxyglucose (FDG) uptake in off target structures within the irradiated volume with outcome.

MATERIAL AND METHODS

Two independent cohorts of patients with locally advanced HNSCC, both treated within prospective clinical imaging trials with curatively intended CRT were retrospectively analyzed. The exploratory cohort included 50, the independent validation cohort 26 patients. Uptake of FDG in mucosa and submucosal soft tissues (MST) as well as in other structures was assessed at week 4 during treatment. Considered endpoints were local tumor control (LC) and overall survival (OS). The prognostic value of FDG uptake on the endpoints was measured by the concordance index (ci) using univariate and multivariate Cox regression analyses based on the continuous variables of the exploratory cohort.

RESULTS

In the exploratory cohort FDG uptake in MST was prognostic for LC (hazard ratio HR=0.23, p=0.025) and OS (HR=0.30, p=0.003) in univariate analyses. These findings remained significant upon multivariate testing (LC HR=0.14, p=0.011; OS HR=0.20, p=0.001) and were confirmed in the validation cohort for LC (HR=0.15, p=0.034) and OS (HR=0.17, p=0.003). Also the SUV_mean threshold of MST that was generated within the exploratory cohort (2.375) yielded significant differences in OS (p=0.006) and a statistical trend for LC (p=0.078) when applied to the validation cohort.

CONCLUSIONS

FDG uptake in normal tissues within the irradiated volume measured by PET during treatment has significant prognostic value in HNSCC. This effect may potentially be of use for personalized treatment adaptation.

Temporal course and predictive factors of analgesic opioid requirement for chemoradiation-induced oral mucositis in oropharyngeal cancer

BACKGROUND

Oral mucositis (OM)-related pain affects most patients with head and neck cancer during treatments, but its management is not standardized.

METHODS

We retrospectively collected data about the opioid therapy used for OM-induced pain in all patients with oropharyngeal cancer treated with chemoradiotherapy (CRT) between 2009 and 2013. To compare the different opioids, a conversion into oral morphine equivalent daily dose (OMEDD) was performed. The highest OMEDD (h-OMEDD) and the opioids' weekly increase were associated with patient, tumor, or treatment-related characteristics in order to identify predictive factors of opioid consumption.

RESULTS

Ninety-seven percent of patients received opioids. The h-OMEDD was significantly correlated with a higher OM-grade and a lower smoking history. The weekly opioids' increase was higher in patients with lower smoking history and human papillomavirus (HPV) positivity.

CONCLUSION

Opioid therapy remains the mainstay for OM-related pain management during CRT. The role of previous smoking and HPV on opioid use needs further confirmations. © 2016 Wiley Periodicals, Inc. Head Neck 38: E1521-E1527, 2016.

Morbidity, mortality and cost from HPV-related oropharyngeal cancer: Impact of 2-, 4- and 9-valent vaccines

OBJECTIVE

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) related to human papillomavirus (HPV) is increasing at a dramatic rate, with men affected more commonly than women. Individuals who develop this disease suffer significant morbidity and potential mortality from their cancer and its associated treatment. We aim to evaluate the possible impact that the currently available HPV vaccines will have on this group of cancers.

DATA SOURCES

Available peer-reviewed literature, practice guidelines, and statistics published by the Center for Disease Control and Prevention.

REVIEW METHODS

Contemporary peer-reviewed medical literature was selected based on its scientific validity and relevance to the impact HPV vaccination may have on the morbidity, mortality and cost resulting from HPV-related OPSCC in the United States.

CONCLUSIONS

The incidence of HPV-related OPSCC is increasing at a near epidemic rate in the United States. The cost of treatment of HPV-related OPSCC is high, and the disease and its therapy result in significant morbidity and potential mortality to individuals. Using a cut-off of $50,000/Quality-Adjusted Life Year, expansion of current HPV vaccine indications to include prevention of OPSCC in both men and women should be recommended.

The impact of smoking on the clinical outcome of locoregionally advanced nasopharyngeal carcinoma after chemoradiotherapy

Background

Cigarette smoking is a common risk factor for developing nasopharyngeal carcinoma. However, the relationship between smoking and clinical outcomes remains uncertain.

Methods

The patients who participated in this study were drawn from a randomized clinical trial, for which the purpose was to compare the efficacy of induction chemotherapy plus concurrent chemoradiotherapy with that of induction chemotherapy plus radiotherapy in patients with locoregionally advanced nasopharyngeal carcinoma. The patients who ever smoked were divided into the following categories of cumulative smoking exposure based on the duration of smoking and the quantity of cigarettes smoked: light, short-term smokers; light, long-term smokers; heavy, short-term smokers; and heavy, long-term smokers. A log-rank test and Cox models were used to assess the association between smoking and the clinical outcomes of overall survival (OS), failure-free survival (FFS), locoregional recurrence failure-free survival (LRFFS) and distant failure-free survival (DFFS).

Results

We found that ever-smokers experienced significantly shorter LRFFS times than never-smokers (5-year LRFFS rates: 85.8% vs. 88.5%, P = 0.022). The amount of smoking was significantly associated with FFS (P = 0.046) and LRFFS (P = 0.001) in the different ever-smoker groups. The amount of smoking was associated with LRFFS [P = 0.002, HR = 2.069 (95% confident interval (CI), 1.298-3.299)] even after a multivariable adjustment.

Conclusions

Smoking increases the risk of locoregional recurrence. Furthermore, the amount of smoking influences the prognosis of smokers, and these effects are dose-dependent.