A functional evaluation of patients treated for oral cancer. A prospective study

Evaluation of the Effects of Radiation Therapy on Muscle Contractibility and Skin Healing: An Experimental Study of the Cancer Treatment Implications

BACKGROUND

Radiotherapy can affect healthy cells, resulting in side effects. This study aimed to assess the impact of radiotherapy on soft tissue in surgical wounds in rats.

METHODS

The animals were divided into four groups: control (S) group without irradiation, immediate irradiation (S-IIr) group receiving irradiation right after surgery, late irradiation (S-LIr) group receiving irradiation four weeks after surgery, and early irradiation (Ir-S) group receiving irradiation before surgery. The irradiated groups underwent two fractional stages of 15 Gy. Muscle contractibility (EMG) was evaluated at two different time points, and after 2 and 7 weeks, the animals were euthanized for histological analysis of the muscles and skin.

RESULTS

There was no significant difference between the EMG1 and EMG2 values of the S and S-LIr groups, but both S-IIr and Ir-S groups exhibited a statistically significant difference. The S group demonstrated a larger diameter of muscle fiber compared to other groups, showing a significant difference. In terms of skin analysis, the S-IIr group had the least inflammatory infiltrate and the highest amount of red fibers, differing significantly from the other groups.

CONCLUSIONS

Regardless of the duration, radiotherapy was found to have effects on the surrounding soft tissues, as concluded by this study.

Use of Kinesiography to Assess Mandibular Function Following Segmental Resection and Microvascular Reconstruction

Mandibular reconstruction has attained adequate morphological outcomes. However, some patients encounter difficulties in oral function and limited mandibular movements. An objective: evaluation has seldom featured actual kinetic measurements after mandibular reconstruction.Thirty patients who underwent mandibular reconstruction using bony free flap were enrolled in the study. Twenty-two patients were recruited after surgery and compared to a control group of 8 healthy subjects; 8 patients underwent both pre and postoperative evaluations. For each patient, a kinesiographic scan was obtained, recording maximum mouth opening, maximal laterality, and maximal protrusion.All postoperative kinesiographic evaluations were performed at least 6 months after surgery to ensure complete healing. In the first group of 22 patients, all measured movements were less than those of healthy controls, in particular maximum mouth opening. In the second study group (pre and postoperative evaluation), the postsurgical values did not achieve the control ones, but were no less than the preoperative values, granting adequate functional outcomes.The kinesiograph appears useful for objectively recording the functional outcomes in patients who have undergone mandibular reconstruction. The postoperative jaw movements were acceptable, ensuring a sufficient functional recovery.

Targeted Photodynamic Therapy of Human Head and Neck Squamous Cell Carcinoma with Anti-epidermal Growth Factor Receptor Antibody Cetuximab and Photosensitizer IR700DX in the Mouse Skin-fold Window Chamber Model

Targeted photodynamic therapy (PDT) in head/neck cancer patients with a conjugate of the anti-epidermal growth factor receptor (EGFR) antibody, Cetuximab and a phthalocyanine photosensitizer IR700DX is under way, but the exact mechanisms of action are still not fully understood. In this study, the EGFR-overexpressing human head/neck OSC-19-luc2-cGFP tumor with transfected GFP gene was used in a skin-fold window chamber model in BALB/c nude mice. The uptake and localization of the conjugate in the tumor and its surrounding normal tissues were studied by an intravital confocal laser scanning microscopy with image analyses. The tumor was also irradiated with 690 nm laser light 24 h after conjugate administration. The vascular and tumor responses were examined by morphological evaluation and immunohistochemistry (IHC). The amount of conjugate in the tumor peaked at 24-48 h after injection. Image analyses of colocalization correlation parameters demonstrated a high fraction of the conjugate IR700DX colocalized in the GFP-expressing tumor cells. PDT-treated tumors showed extensive necrotic/apoptotic destruction with little vascular damage, while IHC showed no HIF-1α expression and decreased EGFR and Ki67 expression with activated caspase-3 overexpression, indicating a direct killing of tumor cells through both necrotic and apoptotic cell death.

Evaluation of three-dimensional mandibular movements after reconstruction with free fibula flap

Seven patients who underwent mandibular reconstruction with a fibula free flap (one on the midline, six on either right or left side) and were rehabilitated with implant supported prostheses, performed free mandibular border movements (maximal mouth opening and closing, right and left lateral excursions, protrusion) that were recorded by a non-invasive motion analyser. Temporomandibular joint (TMJ) kinematic parameters were compared to those calculated in healthy control subjects using z-scores. Maximum mouth opening was reduced in all patients, with z-scores ranging from -2.742 to -0.106, and performed with a reduced sagittal plane mandibular rotation. Interincisal point forward movement during protrusion was reduced in all but one patient. Lateral mandibular movements (displacement of the interincisal point) and bilateral condylar movements during mouth opening were very variable and sometimes asymmetrical. Mandibular rotation was also variable, with z-scores ranging from -1.265 to 1.388. Together with mandibular range of motion, we investigated biomechanical characteristics of TMJ motion that can provide further information about the joint without submitting the patient to harmful procedures, and that can be followed-up during healing. The investigation indicates those areas that need to be given special attention in preoperative planning, patient information and rehabilitation.

Trismus in oral cancer patients undergoing surgery and radiotherapy

OBJECTIVE

The aim of this study was to determine the incidence of trismus before and after surgery and subsequent radiotherapy for patients of oral cancer and to determine the risk factors for the same.

METHODS

30 patients diagnosed with oral cancer were included. Maximum mouth opening was measured for each patient as the inter incisal distance and was measured on 4 occasions - preoperatively at the time of diagnosis, post-operatively at discharge from the hospital, post-radiotherapy and at 6 months follow-up. The site of cancer, staging and grading of the malignancy, the surgical treatment performed, method of reconstruction, details of radiotherapy and compliance to physiotherapy were recorded, to evaluate the risk factors for developing trismus.

RESULTS

Trismus was observed in 53.3% patients at the time of diagnosis which increased significantly post-surgery (86.7%) and post-radiotherapy (85.7%) and gradually decreased (65.4%) at 6 months. The use of flaps for reconstruction, delay in radiotherapy post-surgery and non-compliance of patients to physiotherapy were the risk factors for developing trismus, showing statistical significance (p < 0.05).

CONCLUSION

Trismus is a significant complication of oral malignancies or its surgical and radiotherapy treatment, or both. Consideration must be given to its early diagnosis, to help in timely intervention and planning of preventive strategies.

Comparison of health-related quality of life of patients with different precancer and oral cancer stages

OBJECTIVES

Health-related quality of life (HR-QoL) informations are becoming an important tool for the treatment concept for cancer patients. The purpose of this study was to evaluate how the quality of life depends on the disease severity of pre- and oral cancer patients and which factors influence their quality of life.

MATERIALS AND METHODS

During this study, 106 patients with a premalignant oral lesion, 174 patients with oral squamous cell carcinoma (OSSC) as well as 21 patients with a recurrence of OSSC were asked about their oral health-related quality of life. Additionally, the UW-QOLv4 was used to record the psychological and clinical symptoms from which the patients of the three groups are suffering.

RESULTS

Significant differences with respect to oral HR-QoL of life between the groups could be evaluated. Patients with a recurrence have the lowest and patients with precancer the highest HR-QoL. Within the groups, there is a difference regarding the significance of the psychological factors. The lowest values were achieved for mood within all three groups. Anxiety is of key importance for the precancer group whereas appearance and activity are of importance for the patients having a tumor. The patients of the recurrence group are heavily affected by all factors.

CONCLUSIONS

The quality of life differs depending on the disease. The patients of the recurrence group have the lowest oral health-related quality of life for all aspects analyzed, and they are suffering the most with respect to the psychological dimensions of the UW-QOLv4.

CLINICAL RELEVANCE

The present study examined the quality of life depending on the severity of the disease of pre- and oral cancer patients and which factors significantly influenced their quality of life. The evaluated findings of relevant variables may have therapeutic relevance for the multidisciplinary treatment of oral cancer patients in the future.

Speech production after glossectomy: methodological aspects

This article focuses on methodological issues related to quantitative assessments of speech quality after glossectomy. Acoustic and articulatory data were collected for 8 consonants from two patients. The acoustic analysis is based on spectral moments and the Klatt VOT. Lingual movements are recorded with ultrasound without calibration. The variations of acoustic and articulatory parameters across pre- and post-surgery conditions are analyzed in the light of perceptual evaluations of the stimuli. A parameter is considered to be relevant if its variation is congruent with perceptual ratings. The most relevant acoustic parameters are the skewness and the Center of Gravity. The Klatt VOT explains differences that could not be explained by spectral parameters. The SNTS ultrasound parameter provides information to describe impairments not accounted for by acoustical parameters. These results suggest that the combination of articulatory, perceptual and acoustic data provides comprehensive complementary information for a quantitative assessment of speech after glossectomy.

Assessment of the quality of life of patients with oral cancer after pectoralis major myocutaneous flap reconstruction with a focus on speech

PURPOSE

The aim of the present study was to evaluate the quality of life (QoL) of patients with oral cancer who had undergone resection of the tongue and floor of the mouth and reconstruction with the pectoralis major flap.

MATERIALS AND METHODS

The present study assessed 21 patients who had undergone pectoralis major flap reconstruction using the University of Washington QoL, version 4, questionnaire. A nonparametric Mann-Whitney U test was used to analyze the data.

RESULTS

Of the 12 disease-specific domains, the best 3 scores from the patients were for pain, saliva, and anxiety, and the worst 3 scores were for taste, chewing, and swallowing. The mean UW-QoL composite score was 73.4. Swallowing was considered to be the most important issue within the previous 7 days, followed by chewing and speech. Those patients who had undergone wider excision had poorer speech.

CONCLUSIONS

A significant effect was found on the QoL of patients with oral cancer who had undergone resection of the tongue and floor of the mouth with pectoralis major flap reconstruction.

Levels of scientific evidence of the quality of life in patients treated for oral cancer

Treatments used in cancer of the oral cavity have great impact on the physical, psychological and functional state of patients. There has been increasingly interest in evaluating the health-related quality of life using questionnaires among patients treated with oral cancer. Up to our knowledge no review on this theme has incorporated the level of evidence of the single identified studies. The objective of the present study is to determinate results and conclusions about the health-related quality of life of these patients, in view of scientific evidence. In general, the diversity of designs, level of evidence and questionnaires used for their assessment does not affect results, which indicate a decline in the health related quality of life after treatment. This decline is greater when the tumor is large in size, and when radiotherapy is used, though the situation is seen to improve over the span of a year. Questionnaires on health-related quality of life provide concrete information regarding the impact of cancer treatment on patients.

mTHPC mediated photodynamic therapy (PDT) of squamous cell carcinoma in the head and neck: a systematic review

OBJECTIVE

Photodynamic therapy (PDT) is used in curative and palliative treatment of head and neck squamous cell carcinoma (HNSCC). To evaluate available evidence on the use of mTHPC (Foscan®) mediated PDT, we conducted a review of the literature.

MATERIALS AND METHODS

A systematic review was performed by searching seven bibliographic databases on database specific mesh terms and free text words in the categories; "head and neck neoplasms", "Photodynamic Therapy" and "Foscan". Papers identified were assessed on several criteria by two independent reviewers.

RESULTS

The search identified 566 unique papers. Twelve studies were included for our review. Six studies reported PDT with curative intent and six studies reported PDT with palliative intent, of which three studies used interstitial PDT. The studies did not compare PDT to other treatments and none exceeded level 3 using the Oxford levels of evidence. Pooling of data (n=301) was possible for four of the six studies with curative intent. T1 tumors showed higher complete response rates compared to T2 (86% vs 63%). PDT with palliative intent was predominantly used in patients unsuitable for further conventional treatment. After PDT, substantial tumor response and increase in quality of life was observed. Complications of PDT were mostly related to non-compliance to light restriction guidelines.

CONCLUSION

The studies on mTHPC mediated PDT for HNSCC are not sufficient for adequate assessment of the efficacy for curative intent. To assess efficacy of PDT with curative intent, high quality comparative, randomized studies are needed. Palliative treatment with PDT seems to increase the quality of life in otherwise untreatable patients.

Dental Status and Quality of Life in Long-Term Head and Neck Cancer Survivors

OBJECTIVES

To analyze how the dental status of long-term head and neck cancer survivors affects their subjective quality of life.

STUDY DESIGN

Observational case series.

METHODS

A convenience sample of 5-year head and neck cancer survivors underwent the following battery of tests: 1) targeted head and neck examination, 2) updated medical history, 3) dental evaluation, 4) standardized quality of life questionnaires.

RESULTS

Eighty-six survivors were included in the study. The following associations were identified: 1) those who became edentulous secondary to cancer treatment and those without occlusion at time of the study demonstrated worse Pain, Activity, Recreation/Entertainment, Chewing, Swallowing, Speech, Eating in Public, Normalcy of Diet, Physical Well-Being, Social/Family Well-Being, Functional Well-Being, and Additional Concerns scores; 2) higher Decayed/Missing/Filled scores were associated with worse Pain, Disfigurement, Activity, Recreation/Entertainment, Employment, Chewing, Swallowing, Speech, Eating in Public, Understandability of Speech, Normalcy of Diet, Physical Well-Being, Additional Concerns scores, and weight loss; 3) decreased oral opening measurements were associated with worse Chewing, Swallowing, Eating in Public, Normalcy of Diet, Additional Concerns scores, and weight loss; 4) edentulous survivors who did not use dentures had worse Pain, Activity, Recreation/Entertainment, Understandability of Speech, and Eating in Public scores.

CONCLUSIONS

Although previous studies have shown that many of the effects of cancer treatment disappear between 1 and 3 years, this study shows that the dental status has a persistent impact on subjective quality of life.

Favourable impact of intensity-modulated radiation therapy on chronic dysphagia in patients with head and neck cancer

The aim of this study was to evaluate the impact of intensity-modulated radiation therapy (IMRT) on the incidence and severity of chronic dysphagia in patients with head and neck cancer. 62 evaluable patients with head and neck cancer who were treated with IMRT with or without concurrent chemotherapy were analysed. The majority of the patients (77.4%) had advanced locoregional disease. 45 patients underwent definitive IMRT and 17 received post-operative IMRT. Concurrent chemotherapy was given to 29 of the 45 patients treated with definitive IMRT. The average prescribed dose to clinical target volume (CTV)1 was 66-70 Gy (definitive IMRT) and 56-62 Gy (post-operative IMRT); 60 Gy to CTV2; 54 Gy to CTV3; and 50-52 Gy to the supraclavicular area. At a median follow-up of 19 months, 2-year actuarial locoregional control and survival was 77% and 74%, respectively. At 6 months after IMRT, chronic dysphagia was Grade 0 in 77.1% of patients, Grade 1 in 10.5% and Grade 2 in 12.3%. Acute mucositis showed no correlation with long-term dysphagia. The percutaneous endoscopic gastrostomy or nasogastric tube was removed in all of the patients within 8 weeks of completion of treatment. Xerostomia was Grade 0 in 61.4% of patients, Grade 1 in 31.5% and Grade 2 in 7% of patients. In conclusion, IMRT conferred a major favourable impact on chronic dysphagia in patients with locally advanced head and neck cancers, with satisfactory locoregional control.

Clinical outcome and patient satisfaction after mandibular reconstruction with free fibula flaps

This study evaluated the difference between female and male patients' perception of functional and aesthetic outcomes after mandibular reconstruction with free fibular flaps, the transplant of choice for defects exceeding the length of half a mandible or the simultaneous covering of a soft-tissue defect. Based on clinical records, 54 patients with a mean postoperative follow up of 63 months were reviewed retrospectively. In addition, each patient completed a 12-item scaled questionnaire to assess perception of pain, speech, mastication and deglutition on recipient site, as well as pain, oedema, gait disturbances, difficulties in going upstairs and spraining on donor site. Functional scores on mastication were low for both sexes. The male group showed a higher rating of permanent or frequent difficulties in deglutition and speech. Aesthetic outcome for the recipient region was judged as poor by 62% of the female and 34% of the male patients. Donor site morbidity was described as mild by both sexes with excellent cosmetic results. The perception of facial changes appears to be impacted by gender. Female patients view the aesthetic results of mandibular reconstruction more negatively than do men, but express greater satisfaction with functional outcome. Objective clinician-rated measurements of the donor and recipient region do not always correlate with patient perception of outcome.

Electromyographic evaluation of implant-supported prostheses in hemimandibulectomy-reconstructed patients

OBJECTIVES

To assess the clinical conditions, patient's satisfaction and functional outcomes in oral neoplasia patients with hemimandibulectomy, bone reconstruction and implant-supported prosthesis.

MATERIAL AND METHODS

Twelve patients after mandibular resection (with and without condyle), reconstruction and successful fixed implant-supported prosthesis rehabilitation were examined. Patients underwent clinical evaluation and filled in a questionnaire about their satisfaction toward oral functions. Surface electromyography (EMG) of the masticatory muscles was performed during a 15-s unilateral gum chewing test. EMG potentials were standardized as percentage of a maximum clench on cotton rolls and compared with reference data obtained from 20 healthy subjects.

RESULTS

Excellent clinical and radiological parameters were found. Patients stated a decreased post-rehabilitation satisfaction toward mastication and phonetics, but an increased attention to oral care. Only patients with condylar resection reported augmented esthetic scores. In both the resected and the remaining sides, chewing frequency was higher in the patients than in the reference group (Wilcoxon's rank-sum test, P<0.001). Pooled muscle activities (sum of the integrated areas of the EMG potentials over time) were larger in patients than in control subjects, particularly in the non-operated side (P=0.001). The percentage contribution of working-side muscular activity in the operated side was similar to reference values, but significantly inferior in the opposite side (P<0.001). The patterns of muscle contraction during unilateral chewing were more variable in the reconstructed patients than in control subjects; the difference was significant only in the non-operated side (P<0.01).

CONCLUSION

Post-rehabilitation median scores of the questionnaire indicated a positive judgment of the treatment. EMG analysis showed that functional recovery in hemimandibulectomy patients was satisfactory, although some alterations were observed in the non-operated side of mastication.

Restrictions of food intake in patients with oral cancer

Oral squamous cell carcinoma and its treatment are associated with facial disfigurement and functional inabilities that can lead patients to restrict food intake. The current study examined 80 patients undergoing treatment for the disease in a large Brazilian hospital setting, aiming at the appraisal of covariates with prognostic value for the prevalence of food restriction. Multivariate logistic regression analysis identified tumour size (adjusted odds ratio=19.32) and loss of tongue mobility (adjusted OR=5.51), controlled by the higher odds of females (adjusted OR=7.58) and patients living in crowded households (adjusted OR=4.01), as the most important clinical predictors of food restriction. These results are compatible with the hypothesis that an impaired functional status of the stomatognathic system is caused by large tumours and wide resections. The restriction of food intake in patients with oral cancer is multifactorial, and a complex causal pathway links it to the burden of disease. The knowledge of prognostic factors for nutritional depletion in cancer patients can instruct nutritional interventions in the context of planning treatment protocols aimed at improving quality of life.

Functional outcomes after organ preservation treatment in head and neck cancer: a critical review of the literature

The use of radiation therapy and/or chemotherapy in advanced head and neck cancer is increasing in popularity, driven by the notion that sparing the organs of speech and swallowing from surgical resection will also spare function. This critical review of the literature considered functional outcomes after organ preservation to assess the impact of such treatment on speech, swallowing and quality of life in patients with head and neck cancer. Literature searches were conducted on several library databases. A total of 50 relevant articles were identified and found to meet the inclusion criteria specified a priori. The majority of reports suggested that organ preservation techniques have the potential to result in swallowing disorders, often related to dysmotility of the oropharyngeal and laryngeal structures, and resulting in frequent episodes of aspiration. This may lead to the need for enteral feeding in the short term for some patients while, in others, this need is life long. Speech does not appear to be affected to the same degree as swallowing. These results suggest that organ preservation does not translate into function preservation for all patients with head and neck cancer.

Evaluations of quality of life and organ function

For advanced head and neck cancer (HNC) patients, aggressive radiation and chemoradiation treatments offer new therapy options. The aims of these regimens are increased survival and organ preservation, with the goals of preserving organ function, minimizing late effects, and improving quality of life (QOL). At the same time, the toxicities of these regimens are acknowledged as is the potential for long-term dysfunction. Thus, particularly now, with the increasing use of aggressive chemoradiation therapy (CRT) regimens, documentation of the QOL and functional outcomes of these treatments is critical. The implications for speech and swallowing are widely recognized and the broader effects of these impairments on overall QOL have received some attention. This article presents data on the performance, functional, and QOL results of radiation therapy (RT) and various CRT regimens in HNC.

mTHPC-mediated photodynamic therapy for early oral squamous cell carcinoma

Surgery and radiotherapy are standard treatments for early oral squamous cell carcinoma, both resulting in good tumour control. However, neither of these modalities is without consequent functional or cosmetic impairment, and there are patients in whom both are contraindicated. Furthermore, there is a significant risk of metachronous tumours developing in the oral cavity, and salvage or retreatment with either surgery or radiotherapy poses difficulties. Photodynamic therapy (PDT) offers the potential for improved functional and cosmetic outcomes, while achieving comparable tumour control. We conducted an open-label, multicentre study to assess the efficacy and safety of meta-tetrahydroxyphenylchlorin (mTHPC) in patients with early oral cancer. One hundred twenty-one patients received intravenously administered mTHPC, followed 96 hr later by illumination of the tumour surface with 652 nm laser light. Of these patients, 114 were protocol compliant. A complete tumour response was achieved in 85% of protocol-compliant patients (97 of 114 patients). A complete response was maintained in 85% of responders at 1 year and in 77% at 2 years. One- and 2-year actuarial survival rates were 89% and 75%, respectively. In the opinion of the investigators, tumour clearance was accompanied by excellent cosmetic and functional results, without impact on the patients' performance status. Mild-to-moderate pain at the treatment site, a recognised side effect of PDT in the oral cavity, was reported by 82% of patients but was manageable with appropriate analgesia. Mild-to-moderate skin photosensitivity reactions were reported for 13% of patients. mTHPC offers an effective alternative treatment for early oral squamous cell carcinoma. It is associated with excellent functional and cosmetic results and can be used in conjunction with other standard therapies.

Current treatment options in squamous cell carcinoma of the oral cavity

Oral cavity SCC remains a significant health problem and requires a multidisciplinary approach. Treatment with surgery alone or in combination with adjuvant radiotherapy for more advanced lesions is the standard of care. Major advances have been made in surgical approaches,reconstructive options, and the rehabilitation of patients who have oral cavity SCC. These advances have significantly improved disease-specific outcome and quality of life. The future may lie in the development of treatment regimes that combine early detection with organ preservation and result in improved cure rates and quality of life.

Perspectives on cancer therapy-induced mucosal injury: pathogenesis, measurement, epidemiology, and consequences for patients

BACKGROUND

A frequent complication of anticancer treatment, oral and gastrointestinal (GI) mucositis, threatens the effectiveness of therapy because it leads to dose reductions, increases healthcare costs, and impairs patients' quality of life. The Multinational Association of Supportive Care in Cancer and the International Society for Oral Oncology assembled an international multidisciplinary panel of experts to create clinical practice guidelines for the prevention, evaluation, and treatment of mucositis.

METHODS

The panelists examined medical literature published from January 1966 through May 2002, presented their findings at two separate conferences, and then created a writing committee that produced two articles: the current study and another that codifies the clinical implications of the panel's findings in practice guidelines.

RESULTS

New evidence supports the view that oral mucositis is a complex process involving all the tissues and cellular elements of the mucosa. Other findings suggest that some aspects of mucositis risk may be determined genetically. GI proapoptotic and antiapoptotic gene levels change along the GI tract, perhaps explaining differences in the frequency with which mucositis occurs at different sites. Studies of mucositis incidence in clinical trials by quality and using meta-analysis techniques produced estimates of incidence that are presented herein for what to our knowledge may be a broader range of cancers than ever presented before.

CONCLUSIONS

Understanding the pathobiology of mucositis, its incidence, and scoring are essential for progress in research and care directed at this common side-effect of anticancer therapies.

Oral functional outcome after intraoral reconstruction with nasolabial flaps

In this study, the functional and aesthetic outcome of patients with nasolabial flaps in the floor of the mouth was examined. Sixteen patients underwent reconstruction of the floor of the mouth with 19 nasolabial flaps after resection of a squamous cell carcinoma. Eight patients received postoperative radiotherapy. The patients were questioned concerning oral disabilities. Speech, mastication, deglutition, oral continence and the aesthetic result were evaluated. Two-point discrimination, temperature sensation and blunt-sharp discrimination of the intraoral flaps were tested. Speech and the wearing of dentures were hardly affected. Consumption of solid foods caused moderate problems in half of the patients. No sensibility problems were found. The aesthetic deformity was minimal. The use of nasolabial flaps in patients with limited defects of the anterior floor of the mouth after tumor resection showed adequate functional and aesthetic results.

Quality of life after parotid-sparing IMRT for head-and-neck cancer: a prospective longitudinal study

PURPOSE

Parotid-sparing intensity-modulated radiotherapy (IMRT) for head-and-neck cancer reduces xerostomia compared with standard RT. To assess potential improvements in broader aspects of quality of life (QOL), we initiated a study of patient-reported QOL and its predictors after IMRT.

MATERIALS AND METHODS

This was a prospective longitudinal study of head-and-neck cancer patients receiving multisegmental static IMRT. Patients were given a validated xerostomia questionnaire (XQ), and a validated head-and-neck cancer-related QOL questionnaire consisting of four multi-item domains: Eating, Communication, Pain, and Emotion. The Eating domain contains one question (total of six) asking directly about xerostomia. In both questionnaires, higher scores denote worse symptoms or QOL. The questionnaires and measurements of salivary output from the major glands were completed before RT started (pre-RT) and at 3, 6, and 12 months after RT. The association between the QOL scores and patient-, tumor-, and therapy-related factors was assessed using the random effects model.

RESULTS

Thirty-six patients participating in the study completed the questionnaires through 12 months. The XQ scores worsened significantly at 3 months compared with the pre-RT scores, but later they improved gradually through 12 months (p = 0.003), in parallel with an increase in the salivary output from the spared salivary glands. The QOL summary scores were stable between the baseline (pre-RT) and 3 months after RT scores. Patients receiving postoperative RT (whose pre-RT questionnaires were taken a few weeks after surgery) tended to have improved scores after RT, reflecting the subsidence of acute postoperative sequelae, compared with a tendency toward worsened scores in patients receiving definitive RT. After 3 months, statistically significant improvement was noted in the summary QOL scores for all patients, through 12 months after RT (p = 0.01). The salivary flow rates, tumor doses, mean oral cavity dose, age, gender, sites or stages of tumor, surgery, and use of chemotherapy were not associated with the QOL scores at any point. The mean dose to the parotid glands correlated with the QOL scores at 3 months (p = 0.05) but not at other post-RT periods. The XQ and QOL summary scores did not correlate before RT but were significantly correlated at each post-RT point (p < 0.01), with a linear correlation coefficient (r) of 0.59, 0.72, and 0.67 at 3, 6, and 12 months, respectively. At these points, the XQ scores also correlated significantly with the scores of each of the individual QOL domains (p < or = 0.01), including the domains Pain and Emotion, which did not contain any xerostomia-related question.

CONCLUSION

After parotid-sparing IMRT, a statistically significant correlation was noted between patient-reported xerostomia and each of the domains of QOL: Eating, Communication, Pain, and Emotion. Both xerostomia and QOL scores improved significantly over time during the first year after therapy. These results suggest that the efforts to improve xerostomia using IMRT may yield improvements in broad aspects of QOL.

Experiences of oral care in patients with haematological malignancies or head and neck cancer

The aim of the present study was to investigate cancer patients' experiences of oral hygiene information, oral care and self-care, information on oral complications, examination of the oral cavity, and ability to eat and drink during cancer treatment, and to explore patient attitudes to oral examination and oral hygiene. The sample consisted of 41 consecutive patients treated with radiotherapy for head and neck cancer (n = 18) or with chemotherapy for haematological malignancies (n = 23). Patients were interviewed at the end of radiotherapy or the second/third chemotherapy cycle. Compared with patients receiving chemotherapy, those who received radiotherapy had significantly more often visited hospital dentistry, been informed about oral complications and oral hygiene, received instructions in oral hygiene procedures, and been examined by hospital staff. More of the radiotherapy patients experienced oral symptoms and difficulties to eat and drink during treatment. There were no significant differences between the groups with regard to patient experiences of the oral hygiene procedures. Only one patient objected to having hospital staff discuss oral hygiene procedures, and three did not want hospital staff to examine their oral cavity. Patients undergoing radiotherapy or chemotherapy need to be monitored during treatment with regard to their oral status and oral symptoms and complications. There are no acceptable reasons for allowing patients to suffer from oral symptoms that can be reduced.

Clinical function after primary surgery for oral and oropharyngeal cancer: an 11-item examination

The aim of this study was to record clinical function using an 11-item clinical examination and identify the main postoperative functional deficits. Of 132 consecutive patients undergoing surgery for previously untreated disease between January 1995 and June 1997, 130 were recruited in the study. An 11-domain clinical examination was made on the day before operation, and at 6 and 12 months afterwards. This examination assessed lip competence, tongue movement, oral mucosa, dental state, mouth opening, speech, drooling, diet, appearance, oral sensation and shoulder movement. Preoperatively there were deficits in natural dentition, consistency of diet and tongue protrusion. Postoperatively functional scores fell particularly for tongue movements, mouth opening, mucosa, dentition, speech, diet, appearance, lip sensation and tongue sensation. At 1 year, dental status, sensation and oral mucosa were particularly defective. Patients with large tumours, free tissue transfer, or adjuvant radiotherapy had the worst levels of function.A simple clinical examination provides a rapid assessment of function that can be used in conjunction with validated questionnaires to provide a more comprehensive evaluation of outcome.

Health-related quality of life and clinical function after primary surgery for oral cancer

Clinical function and health-related quality of life (HRQoL) are both important outcome parameters following surgery for oral and oropharyngeal cancer. The aim of this project was to explore the relationship between an 11-point clinical examination and HRQoL. Of 132 consecutive patients undergoing surgery for previously untreated disease between January 1995 and June 1997, 130 were recruited into the study. The University of Washington Quality of Life Questionnaire (UW-QoL) was completed by each patient on the day before operation and 6 and 12 months later. On each occasion the first author made an 11-point clinical examination. The main predictors of cumulative UW-QoL scores were tumour size, clinical functional score and type of operation. The trend was for a fall from preoperative levels at 6 months and then for a slight improvement at 1 year. The differential in respect of baseline function was present at all three time points in each patient group. This suggests that functional deficits at presentation persist following treatment.

Functional status of patients with oral cancer and its relation to style of coping, social support and psychological status

Sixty-eight patients were evaluated 6 months to 6 years after treatment for oral cancer using standardized questionnaires to explore the influence of age, sex, site and stage of tumour, and primary treatment on their functional status measured by the University of Washington Quality of Life Questionnaire (UW-QoL), and the association between functional status and psychological outcome measured by the Hospital Anxiety and Depression Scale (HADS), style of coping measured by the Mental Adjustment to Cancer Questionnaire (MAC-Q), and social support measured by the Short-Form Social Support Questionnaire (SSQ-6). Young patients, women, patients with advanced tumours, those with oropharyngeal tumours and those who had been treated with both surgery and radiotherapy reported worse function. The worse the functional domain, the more likely it was to be associated with anxiety, depression and ineffective coping style, and better functional scores were weakly associated with fighting spirit, level of social support and satisfaction with that support. We have identified patients at need and highlighted their problems. Dealing with these problems may ultimately improve the perception of function after treatment of oral cancer.

Surgical treatment of early oral carcinoma-results of a prospective controlled multicenter study

PURPOSE OF THE STUDY

To assess whether early stage (pT1-2,pN0-1) oral cavity carcinoma is adequately treated by radical surgical resection alone.

MATERIAL AND METHODS

Prospective multicenter study. Of 105 patients with cT1-2 cN0-1 oral carcinoma treated in conformity with the study design, 12 had to be excluded because of tumor-positive margins or pN stage > N1. The remaining 93 patients were monitored for at least 2 years.

RESULTS

Seventeen patients had local or regional recurrence develop. In 12 of the 17 patients locoregional control was achieved by second treatment. Overall, the 4-year disease-specific survival probability was 94%. Patients treated initially without selective neck dissection had significantly higher recurrence rates than those with neck dissection, although the survival probability was not adversely affected.

CONCLUSIONS

Early (pT1-2, pN0-1) squamous cell carcinoma of the oral cavity is adequately treated by surgery alone, provided the resection margins are tumor free. On the basis of the presented data, we would also advocate routine selective neck dissection.

Pretreatment factors predicting quality of life after treatment for head and neck cancer

BACKGROUND

Quality of life (QOL) has become an important issue in head and neck cancer. Explanation of factors predicting QOL after treatment has important implications for patient management.

METHODS

In this prospective study we analyzed which pretreatment factors predicted QOL after surgery and/or radiotherapy with curative intent in a cohort of 153 patients with cancer of the oral cavity, oropharynx, hypopharynx, or larynx. The patients completed the EORTC Core Questionnaire, the EORTC Head and Neck Cancer module, and the Center for Epidemiologic Studies Depression scale before treatment and 6 and 12 months later. The influence of gender, age, performance status, and depressive symptoms at baseline, site, stage, and treatment on QOL (and its dimensions) and depressive symptoms after 6 and 12 months was studied, using linear regression analysis.

RESULTS

A high level of depressive symptoms and a low performance status at baseline and combination treatment were significant predictors of increased severity of symptoms and poor functioning after treatment. Treatment was a predictor of head and neck symptoms, whereas performance status and depressive symptoms were predictors of general symptoms and functioning. Gender and age had little predictive value.

CONCLUSIONS

Patients with depressive symptoms or a low performance status who receive combination treatment for cancer of the head and neck are at risk for physical and psychologic morbidity after treatment. Special attention should be given to these patients in rehabilitation programs.

Surgical management of head and neck cancer

Head and neck cancer surgery continues to evolve through the years and undergo improvement and refinement. In this article, the current state of head and neck cancer surgery is summarized in a site-by-site basis. The most important developments include organ-sparing surgery and microvascular free-tissue transfer for reconstruction.

Quality of life after surgical excision followed by radiotherapy for cancer of the tongue and floor of the mouth: evaluation of 78 patients

The aim of this study was to evaluate the quality of life of 78 patients treated for cancer of the tongue and the floor of the mouth, by subjective impressions and by objective assessment through different types of tests. Patients were divided into two groups according to the size of the post-excisional defect: (1) defect less than 5 cm (46); and (2) defect more than 5 cm (32). Patients were divided into three groups according to the type of reconstruction: 28 were partly reconstructed, 31 were reconstructed with local flaps and 19 with pectoralis major myocutaneous flaps. The following aspects were studied: overall well-being, food intake, speech intelligibility, dryness of mouth, willingness to undergo further surgery if necessary, tongue mobility, sensibility disturbances within the reconstructed region and oral competence. Overall results revealed that patients' quality of life was more or less disturbed. Among them, patients reconstructed with myocutaneous flaps and patients with larger post-excisional defects had a poorer quality of life.

Quality of life and performance in advanced head and neck cancer patients on concomitant chemoradiotherapy: a prospective examination

PURPOSE

To prospectively evaluate performance and quality of life (QOL) in advanced-stage head and neck cancer (HNC) patients on a curative-intent, concomitant-chemoradiotherapy (CT/XRT) (twice-daily radiation, fluorouracil, hydroxyurea, and cisplatin) regimen aimed at improving locoregional control, survival, and QOL.

PATIENTS AND METHODS

Sixty-four patients were assessed before, during, and at 3-month intervals after treatment. Standardized measures of QOL (Functional Assessment of Cancer Therapy-Head and Neck), performance (Performance Status Scale for Head and Neck Cancer Patients and Karnofsky Performance Status Rating Scale), and patient-reported symptoms (McMaster University Head and Neck Radiotherapy Questionnaire) were administered.

RESULTS

Acute treatment toxicities were severe, with declines in virtually all QOL and functional domains. Marked improvement was seen by 12 months; general functional and physical measures returned to baseline levels of good to excellent. Although up to a third of the patients continued to report problems with swallowing, hoarseness, and mouth pain, these difficulties were present in similar magnitudes before treatment. The following symptoms were more frequent at 12 months: dry mouth (58% v 17%), difficulties tasting (32% v 8%), and soft food diet (82% v 42%). Twelve-month diet was not related to pretreatment functioning, disease, treatment, or patient characteristics. Twelve-month QOL was best predicted by pretreatment QOL, with very little relationship to residual side effects or functional impairments. Small numbers of patients in four of the five disease sites precluded examination of outcome by site.

CONCLUSION

These data support the feasibility of intense CT/XRT as primary treatment for advanced HNC. Results confirm acute toxicity but indicate that many of the treatment-related performance and QOL declines resolve by 12 months. The persistent inability to eat a full range of foods warrants further attention and monitoring.

Pretherapy dental decisions in patients with head and neck cancer. A proposed model for dental decision support

OBJECTIVE

The proposed model was designed to function as a tool for the development and testing of evidence-based clinical guidelines for the pretherapy oral screening and dental management of patients with head and neck cancer.

STUDY DESIGN

Methods of clinical decision analysis were used to analyze the decision dilemma and construct a decision algorithm and decision tree. The robustness of the model was tested by means of a probabilistic sensitivity analysis with second-order Monte Carlo simulations (n = 10.000).

RESULTS

Clinical criteria for evaluating dental pathologic conditions and malignancy- and patient-related conditions were transformed in probability estimates. The tradeoffs between the benefits and drawbacks of the dental intervention were integrated into the model to identify the optimal option for dental intervention. The calculation process of "folding back and averaging out" the decision tree enabled the identification of the optimal options for dental intervention in four different pretherapy risk conditions.

CONCLUSIONS

A priori testing of the proposed model with 95% confidence intervals suggests that it has a great potential for solving clinical dilemmas associated with pretherapy dental decision-making. In addition, it seems a useful tool for the development of evidence-based clinical guidelines. A posteriori clinical testing should further validate the model before its assimilation into clinical practice takes place.

Speech, deglutition and life quality after intraoral tumour resection. A prospective study

The aim of the present prospective study was to evaluate the functional sequelae and postoperative development of quality of life after intraoral tumour surgery in 40 consecutive patients with a squamous cell carcinoma of the floor of the mouth. Immediate reconstruction of intraoral soft tissues after tumour resection was accomplished by local flaps (cheek and tongue) (n=27) and by revascularized transfer of small bowel grafts (n=5) and myocutaneous/fasciocutaneous flaps (n=8). Mobility of the tongue was assessed by ultrasound. Quality of speech was analysed using the Freiburg speech intelligibility test. Life quality was assessed by the functional living index-cancer preoperatively and six months postoperatively. A significant decrease in both mobility of the tongue and quality of speech was registered. The most substantial effect on quality of speech resulted from decreased movement of the base and the dorsum of the tongue. A significant increase in life quality at the end of the study period occurred only in the group of patients without substantial reduction of intelligibility of speech, while no significant improvement of postoperative life quality of patients with more severe deterioration of speech quality was found.

Complications following definitive irradiation for cancers of the oral cavity and the oropharynx (in a series of 1134 patients)

PURPOSE

To study the rate and severity of complications in a series of 1134 patients treated by definitive irradiation for tumors of the oral cavity (772 cases) or the oropharynx (361 cases).

METHODS AND MATERIALS

Patients were staged as 29.5% T1, 42% T2, 26% T3, 2.5% T4-Tx, and 74.5% N0 tumors. We treated 364 patients with brachytherapy only (192Ir) for the primary lesion. External irradiation and brachytherapy were combined for 770 patients.

RESULTS

The results included local control and survival. Out of 1134 patients, 330 had 376 complications. Grade 1 complications occurred in 20% of the patients, Grade 2 in 9%; Grade 3 in 4%; and Grade 4 in 0.2%. Of the Grade 1 complications, 78% were soft tissue and only 24% were bone complications. For the more severe grades (2, 3, and 4), there were 56 soft tissue complications and 90 bone complications out of 1340 patients. The statistical analysis included tumor-related factors and treatment-related factors. For the first two factors, only tumor location was significant. The treatment-related factors significant for complications were studied in univariate and multivariate study. This multivariate study confirmed that for soft tissue complications dose rate and volume treated were important (p < 0.001). It also confirmed that for bone complications, total dose > 80 Gy, dose rate > 0.7 Gy/h, and the absence of leaded protection of the mandible were all important factors.

CONCLUSION

This statistical study should allow future reduction of severe complications (Grades 2, 3, 4), if treatment factors inducing them can be taken into account. This is not always possible for very large tumors.

Comparative evaluation of function after surgery for cancer of the alveolobuccal complex

PURPOSE

The current study was undertaken to assess the functional deficit after hemiresection of the mandible and to determine whether lateral segment resection with reconstruction was a functionally superior alternative in the management of patients suffering from alveolobuccal cancer.

PATIENTS AND METHODS

Eighty-three patients were assigned to one of two main groups: Group I, hemiresection of the mandible (n = 47), and group II, lateral segment defects (n = 36). Functional assessment of patients included subjective evaluation of overall well-being, feeding, and cosmesis, as well as objective assessment of mastication, speech, and cosmesis. Mean scores for each of these categories were compared across groups using the Duncan Multiple Range Test with .01 confidence intervals.

RESULTS

Subjective assessment of overall well-being, feeding, and cosmesis did not yield statistically significant differences between groups. Objective evaluation of mastication showed significantly better function after hemiresection in dentate patients as compared with their edentulous counterparts. However, masticatory scores for hemimandibulectomy patients with intact residual dentition were not significantly different from those for patients whose lateral segmental defects had been reconstructed. Although objective cosmetic scores for reconstruction of lateral segment defects were significantly better than those for hemiresection of the mandible, most patients in the latter group accepted the resultant deformity as a consequence of their treatment and did not let it affect their routine activities.

CONCLUSION

Until functional results in patients undergoing lateral segmental resection for alveolobuccal cancer can be improved by better prosthetic techniques, hemiresection of the mandible remains a simple, safe, reliable, and cost-effective option that produces acceptable postoperative function.

Indications for and referrals to oral care for cancer patients in a county hospital

This retrospective study reports oral signs, symptoms, oral care and pattern of referrals to dentistry in 188 patients with haematological malignancies, head and neck cancer and small cell lung cancer in a Swedish county hospital in 1990-1992. Oral signs and symptoms were noted in 81% of the physicians' records and in 36% of the nurses' records for the 167 patients who received antineoplastic treatment. Notes on oral care were found in 14% of the nurses' records. Before the start of medical treatment, 73 patients (44%) were referred to dentistry and 19 patients (11%) were referred for acute problems. All patients receiving intensive cytotoxic treatment were referred to dentistry. A total of 16% of patients receiving moderate or mild cytotoxic treatment developed oral problems necessitating acute referral to dentistry. Dental personnel should be involved in the treatment of all patients who are scheduled to start cytotoxic treatment.

Head and neck cancer

This synthesis of the literature on radiotherapy for head and neck cancer is based on 424 scientific articles, including 3 meta-analyses, 38 randomized studies, 45 prospective studies, and 246 retrospective studies. These studies involve 79174 patients. The literature review shows that radiotherapy, either alone or in combination with surgery, plays an essential role in treating head and neck cancers. When tumors are localized, many tumor patients can be cured by radiotherapy alone and thereby maintain full organ function (1, 2). Current technical advancements in radiotherapy offer the potential for better local tumor control with lower morbidity (3). This, however, will require more sophisticated dose planning resources. To further improve treatment results for advanced tumors, other fractionation schedules, mainly hyperfractionation, should be introduced (5). This mainly increases the demands on staff resources for radiotherapy. The combination of radiotherapy and chemotherapy should be subjected to further controlled studies involving a sufficiently large number of patients (4, 5). Interstitial treatment (in the hands of experienced radiotherapists) yields good results for selected cancers. The method should be more generally accessible in Sweden. Intraoperative radiotherapy should be targeted for further study and development.

Cancer of the mobile tongue in Mexico. A retrospective study of 170 patients

Histological reports of 170 patients with cancer of the mobile tongue between 1977 and 1989 were identified at the Instituto Nacional de Cancerología (INCan), in Mexico City. Demographic, clinical and histological information was retrospectively reviewed. Chi-square, Student's t-test and Wilcoxon rank-sum test were applied for comparisons, and Kaplan-Meier curves, log-rank test and Cox proportional hazards for survival analysis. Of the 161 patients with mobile tongue squamous cell carcinoma (MTSCC), 104 (65%) were males and 57 (35%) were females. The mean age was 60 years old (range 19-91). T1 and T2 lesions comprised 35%, T3 and T4 lesions 65%. There was a statistically significant association between size of the tumour and lymph node involvement (P < 0.0001). The proportion of cases with advanced disease was 80% for males and 57% for females (P = 0.008). The 5-year survival rate was 16% (CI 10.2-22.8%). Cancer of the mobile tongue in Mexico still has a poor prognosis. Efforts should be made to reduce the delay in diagnosis of MTSCC, in order to increase the cure rates and improve the quality of life of the patients.