Preserved salivary output and xerostomia-related quality of life in head and neck cancer patients receiving parotid-sparing radiotherapy

Cancer therapy-related salivary dysfunction

Salivary gland dysfunction is a common side effect of cancer treatments. Salivary function plays key roles in critical daily activities. Consequently, changes in salivary function can profoundly impair quality of life for cancer patients. We discuss salivary gland anatomy and physiology to understand how anticancer therapies such as chemotherapy, bone marrow transplantation, immunotherapy, and radiation therapy impair salivary function. We discuss approaches to quantify xerostomia in the clinic, including the advantages and limitations of validated quality-of-life instruments and approaches to directly measuring salivary function. Current and emerging approaches to treat cancer therapy-induced dry mouth are presented using radiation-induced salivary dysfunction as a model. Limitations of current sialagogues and salivary analogues are presented. Emerging approaches, including cellular and gene therapy and novel pharmacologic approaches, are described.

MASCC/ISOO Clinical Practice Statement: Clinical assessment of salivary gland hypofunction and xerostomia in cancer patients

PURPOSE

A MASCC/ISOO Clinical Practice Statement (CPS) is aimed at generating a concise tool for clinicians that concentrates practical information needed for the management of oral complications of cancer patients. This CPS is focused on the clinical assessment of salivary gland hypofunction and xerostomia in cancer patients.

METHODS

This CPS was developed based on a critical evaluation of the literature followed by a structured discussion of a group of leading experts, members of the Oral Care Study Group of MASCC/ISOO. The information is presented in the form of succinct bullets and tables to generate a short manual about the best standard of care.

RESULTS

The objective assessment of saliva secretion involves an extra- and intra-oral clinical examination while the subjective assessment involves eliciting information on the patient's complaint of xerostomia and its impact on daily functioning. This CPS summarizes the common investigator- and patient-reported instruments used in clinical practice for assessing salivary gland hypofunction and xerostomia in cancer patients.

CONCLUSION

There is a range of tools to assess salivary gland function in patients undergoing cancer therapy, patients recovering from cancer therapy, or cancer survivors. Clinicians should ideally conduct both objective and subjective measurements to ensure a clear understanding about the status of the patients in order to provide the most appropriate treatment.

Salivary toxicity from PSMA-targeted radiopharmaceuticals: What we have learned and where we are going

Clinical trials of prostate-specific membrane antigen (PSMA) targeted radiopharmaceuticals have shown encouraging results. Some agents, like lutetium-177 [177Lu]Lu-PSMA-617 ([177Lu]Lu-PSMA-617), are already approved for late line treatment of metastatic castration-resistant prostate cancer (mCRPC). Projections are for continued growth of this treatment modality; [177Lu]Lu-PSMA-617 is being studied both in earlier stages of disease and in combination with other anti-cancer therapies. Further, the drug development pipeline is deep with variations of PSMA-targeting radionuclides, including higher energy alpha particles conjugated to PSMA-honing vectors. It is safe to assume that an increasing number of patients will be exposed to PSMA-targeted radiopharmaceuticals during the course of their cancer treatment. In this setting, it is important to better understand and mitigate the most commonly encountered toxicities. One particularly vexing side effect is xerostomia. In this review, we discuss the scope of the problem, inventories to better characterize and monitor this troublesome side effect, and approaches to preserve salivary function and effectively palliate symptoms. This article aims to serve as a useful reference for prescribers of PSMA-targeted radiopharmaceuticals, while also commenting on areas of missing data and opportunities for future research.

Marrow-Derived Autologous Stromal Cells for the Restoration of Salivary Hypofunction (MARSH): A pilot, first-in-human study of interferon gamma-stimulated marrow mesenchymal stromal cells for treatment of radiation-induced xerostomia

BACKGROUND AIMS

Xerostomia, or the feeling of dry mouth, is a significant side effect of radiation therapy for patients with head and neck cancer (HNC). Preliminary data suggest that mesenchymal stromal/stem cells (MSCs) can improve salivary function. We performed a first-in-human pilot study of interferon gamma (IFNγ)-stimulated autologous bone marrow-derived MSCs, or MSC(M), for the treatment of radiation-induced xerostomia (RIX). Here we present the primary safety and secondary efficacy endpoints.

METHODS

A single-center pilot clinical trial was conducted investigating the safety and tolerability of autologous IFNγ-stimulated MSC(M). The study was conducted under an approved Food and Drug Administration Investigational New Drug application using an institutional review board-approved protocol (NCT04489732). Patients underwent iliac crest bone marrow aspirate and MSC(M) were isolated, cultured, stimulated with IFNγ and cryopreserved for later use. Banked cells were thawed and allowed to recover in culture before patients received a single injection of 10 × 106 MSC(M) into the right submandibular gland under ultrasound guidance. The primary objective was determination of safety and tolerability by evaluating dose-limiting toxicity (DLT). A DLT was defined as submandibular pain >5 on a standard 10-point pain scale or any serious adverse event (SAE) within 1 month after injection. Secondary objectives included analysis of efficacy as measured by salivary quantification and using three validated quality of life instruments. Quantitative results are reported as mean and standard deviation.

RESULTS

Six patients with radiation-induced xerostomia who had completed radiation at least 2 years previously (average 7.8 years previously) were enrolled in the pilot study. The median age was 71 (61-74) years. Five (83%) patients were male. Five patients (83%) were treated with chemoradiation and one patient (17%) with radiation alone. Grade 1 pain was seen in 50% of patients after submandibular gland injection; all pain resolved within 4 days. No patients reported pain 1 month after injection, with no SAE or other DLTs reported 1 month after injection. The analysis of secondary endpoints demonstrated a trend of increased salivary production. Three patients (50%) had an increase in unstimulated saliva at 1 and 3 months after MSC(M) injection. Quality of life surveys also showed a trend toward improvement.

CONCLUSIONS

Injection of autologous IFNγ-stimulated MSC(M) into a singular submandibular gland of patients with RIX is safe and well tolerated in this pilot study. A trend toward an improvement in secondary endpoints of salivary quantity and quality of life was observed. This first-in-human study provides support for further investigation into IFNγ-stimulated MSC(M) injected in both submandibular glands as an innovative approach to treat RIX and improve quality of life for patients with HNC.

Oral health outcomes in an HIV cohort with comorbidities- implementation roadmap for a longitudinal prospective observational study

BACKGROUND

Long-term antiretroviral therapy (ART) perpetually suppresses HIV load and has dramatically altered the prognosis of HIV infection, such that HIV is now regarded as a chronic disease. Side effects of ART in Patients With HIV (PWH), has introduced new challenges including "metabolic" (systemic) and oral complications. Furthermore, inflammation persists despite great viral load suppression and normal levels of CD4+ cell count. The impact of ART on the spectrum of oral diseases among PWH is often overlooked relative to other systemic complications. There is paucity of data on oral complications associated with ART use in PWH. This is in part due to limited prospective longitudinal studies designed to better understand the range of oral abnormalities observed in PWH on ART.

METHODS

We describe here the study design, including processes associated with subject recruitment and retention, study visit planning, oral health assessments, bio-specimen collection and preprocessing procedures, and data management and statistical plan.

DISCUSSION

We present a procedural roadmap that could be modelled to assess the extent and progression of oral diseases associated with ART in PWH. We also highlight the rigors and challenges associated with our ongoing participant recruitment and retention. A rigorous prospective longitudinal study requires proper planning and execution. A great benefit is that large data sets are collected and biospecimen repository can be used to answer more questions in future studies including genetic, microbiome and metabolome-based studies.

TRIAL REGISTRATION

National Institute of Health Clinical Trials Registration (NCT) #: NCT04645693.

Oral Health Outcomes In An HIV Cohort With Comorbidities- Implementation Roadmap For A Longitudinal Prospective Observational Study

Long-term antiretroviral therapy (ART) perpetually suppresses HIV load and has dramatically altered the prognosis of HIV infection, such that HIV is now regarded as a chronic disease. Side effects of ART in Patients With HIV (PWH), has introduced new challenges including "metabolic" (systemic) and oral complications. Furthermore, inflammation persists despite great viral load suppression and normal levels of CD4+ cell count. The impact of ART on the spectrum of oral diseases among PWH is often overlooked relative to other systemic complications. There is paucity of data on oral complications associated with ART use in PWH. This is in part due to limited prospective longitudinal studies designed to better understand the range of oral abnormalities observed in PWH on ART. Our group designed and implemented a prospective observational longitudinal study to address this gap. We present a procedural roadmap that could be modelled to assess the extent and progression of oral diseases associated with ART in PWH. We described here the processes associated with subject recruitment and retention, study visit planning, oral health assessments, bio-specimen collection and preprocessing procedures, and data management. We also highlighted the rigors and challenges associated with participant recruitment and retention.

Trehalose versus carboxymethylcellulose oral spray for relieving radiation-induced xerostomia in head and neck cancer patients: a randomized controlled trial

BACKGROUND

The aim of this study was to investigate the effect of trehalose oral spray to relieve radiation-induced xerostomia on a randomized controlled trial (RCT).

METHODS

Prior to RCT, the effect of trehalose (5-20%) on the epithelial growth of fetal mouse salivary gland (SG) explants was evaluated to confirm if 10% trehalose exerted the best epithelial outcomes. Participants who completed radiotherapy for head and neck cancer (HNC) treatment were enrolled in a double-blind RCT, according to inclusion and exclusion criteria as per the CONSORT statement. The experimental group (n = 35) received 10% trehalose spray, while the control group (n = 35) received carboxymethylcellulose (CMC) spray to apply intra-orally 4 times/day for 14 days. Salivary pH and unstimulated salivary flow rate were recorded pre- and post-interventions. The Xerostomia-related Quality of Life scale (XeQoLs) was filled, and scores assessed post-interventions.

RESULTS

In the SG explant model, pro-acinar epithelial growth and mitosis was supported by 10% topical trehalose. As for RCT outcomes, salivary pH and unstimulated salivary flow rate were significantly improved after use of 10% trehalose spray when compared to CMC (p < 0.05). Participants reported an improvement of XeQoLs dimension scores after using trehalose or CMC oral sprays in terms of physical, pain/discomfort, and psychological dimensions (p < 0.05), but not social (p > 0.05). When comparing between CMC and trehalose sprays, XeQoLs total scores were not statistically different (p > 0.05).

CONCLUSIONS

The 10% trehalose spray improved salivary pH, unstimulated salivary flow rate, and the quality-of-life dimensions linked with physical, pain/discomfort, and psychological signs. The clinical efficacy of 10% trehalose spray was equivalent with CMC-based saliva substitutes for relieving radiation-induced xerostomia; therefore, trehalose may be suggested in alternative to CMC-based oral spray.(Thai Clinical Trials Registry; https://www.thaiclinicaltrials.org/ TCTR20190817004).

Photobiomodulation for the management of xerostomia and oral mucositis in patients with cancer: a randomized clinical trial

To evaluate the applicability of photobiomodulation therapy (PBM-T) in the management of xerostomia and OM. Fifty-three patients with head and neck squamous cell carcinoma were randomized into two groups: Sham and PBM-T. The Sham group received artificial saliva and laser simulation, while the PBM-T group received artificial saliva and PBM-T. Xerostomia-related quality of life (QoL), the presence or absence of OM lesions, the decayed-missing-filled teeth (DMFT) index, and periodontal charts were evaluated. The results of the QoL questionnaire, DMFT index, and periodontal chart were analyzed with the Kruskal-Wallis test, followed by the Student-Newman-Keuls test, while OM findings were compared using the Mann-Whitney test. QoL scores significantly increased in the Sham group (p < 0.0001), denoting more severe xerostomia symptoms (p = 0.0074), and decreased in the PBM-T group, indicating no or very mild xerostomia. Higher grades of OM were found in the Sham group than the PBM-T group (p = 0.0001). There was no significant difference in DMFT index or periodontal charts between the groups (p > 0.05). PBM-T improved QoL in patients with head and neck cancer treated with radiotherapy, whether as radiation alone or as an adjunct to chemotherapy and surgery.

Quality of Life and Patient-Reported Outcomes Following Proton Therapy for Oropharyngeal Carcinoma: A Systematic Review

BACKGROUND

Complex anatomy surrounding the oropharynx makes proton therapy (PT), especially intensity-modulated PT (IMPT), a potentially attractive option due to its ability to reduce the volume of irradiated healthy tissues. Dosimetric improvement may not translate to clinically relevant benefits. As outcome data are emerging, we aimed to evaluate the evidence of the quality of life (QOL) and patient-reported outcomes (PROs) following PT for oropharyngeal carcinoma (OC).

MATERIALS AND METHODS

We searched PubMed and Scopus electronic databases (date: 15 February 2023) to identify original studies on QOL and PROs following PT for OC. We employed a fluid strategy in the search strategy by tracking citations of the initially selected studies. Reports were extracted for information on demographics, main results, and clinical and dose factor correlates. Quality assessment was performed using the NIH's Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The PRISMA guidelines were followed in the preparation of this report.

RESULTS

Seven reports were selected, including one from a recently published paper captured from citation tracking. Five compared PT and photon-based therapy, although none were randomized controlled trials. Most endpoints with significant differences favored PT, including xerostomia, cough, need for nutritional supplements, dysgeusia, food taste, appetite, and general symptoms. However, some endpoints favored photon-based therapy (sexual symptoms) or showed no significant difference (e.g., fatigue, pain, sleep, mouth sores). The PROs and QOL improve following PT but do not appear to return to baseline.

CONCLUSION

Evidence suggests that PT causes less QOL and PRO deterioration than photon-based therapy. Biases due to the non-randomized study design remain obstacles to a firm conclusion. Whether or not PT is cost-effective should be the subject of further investigation.

World Workshop on Oral Medicine VIII: Development of a Core Outcome Set for Dry Mouth: A Systematic Review of Outcome Domains for Xerostomia

OBJECTIVE

The purpose of this study was to identify all outcome domains used in clinical studies of xerostomia, that is, subjective sensation of dry mouth. This study is part of the extended project "World Workshop on Oral Medicine Outcomes Initiative for the Direction of Research" to develop a core outcome set for dry mouth.

STUDY DESIGN

A systematic review was performed on MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials databases. All clinical and observational studies that assessed xerostomia in human participants from 2001 to 2021 were included. Information on outcome domains was extracted and mapped to the Core Outcome Measures in Effectiveness Trials taxonomy. Corresponding outcome measures were summarized.

RESULTS

From a total of 34,922 records retrieved, 688 articles involving 122,151 persons with xerostomia were included. There were 16 unique outcome domains and 166 outcome measures extracted. None of these domains or measures were consistently used across all the studies. The severity of xerostomia and physical functioning were the 2 most frequently assessed domains.

CONCLUSION

There is considerable heterogeneity in outcome domains and measures reported in clinical studies of xerostomia. This highlights the need for harmonization of dry mouth assessment to enhance comparability across studies and facilitate the synthesis of robust evidence for managing patients with xerostomia.

An Updated Patient-Centered Sialadenitis Instrument: The Obstructive Salivary Problem Impact Test (SPIT)

OBJECTIVE

The Chronic Obstructive Sialadenitis Symptoms questionnaire (COSS) was created to assess chronic sialadenitis symptoms and treatment response, but its development lacked patient input and validation. We analyzed COSS responses and feedback from sialadenitis patients and physician experts to create the novel obstructive Salivary Problem Impact Test (SPIT), a new standardized measure of sialadenitis-associated symptoms.

METHODS

We analyzed COSS responses via exploratory factor analysis (EFA) to identify essential symptom domains and reduce overlap in questions. Sialadenitis patients evaluated the significance of index symptoms identified from the literature review. Expert physicians rated symptom relevance in clinical assessment. An updated questionnaire (SPIT) was piloted with both patient and expert interviews to optimize structure and readability. The SPIT was assessed for internal consistency, construct validity, and test-retest stability.

RESULTS

EFA of 310 COSS responses demonstrated 3 main symptom domains (functional impact, pain, swelling) that explained 58.4% of response variance. Results were not statistically different when collapsing from 11 to 5 question response options. Experts (n = 5) ranked gland swelling, mealtime pain, and foul taste as most clinically important, while patients (n = 12) ranked swelling, non-mealtime pain, and difficulty eating as most bothersome. Most patients experienced sialadenitis-related functional or psychosocial impairment. Following interviews for question refinement, a 25-question survey was finalized. SPIT responses from 50 sialadenitis patients demonstrated internal consistency (Cronbach's alpha = 0.96), 14-day stability (p < 0.001), and agreement with Oral Health Impact Profile-14 scores (p < 0.0001).

CONCLUSIONS

We developed the SPIT instrument to improve usability and content validity in chronic sialadenitis evaluation. The psychometric assessment demonstrated high construct validity and test-retest reliability. Further work will assess longitudinal changes with treatment.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:539-546, 2023.

Patient Reported Outcome Measures for Salivary Function: A Systematic Review

OBJECTIVE

A number of patient-reported outcome measures (PROMs) assess quality of life and symptom severity in patients with salivary gland dysfunction, but many vary in the extent of validation and domain types addressed. We identified PROMs validated to measure salivary gland function and analyzed key properties.

DATA SOURCES

PubMed, Web of Science, Embase, PsycInfo, and CINAHL.

REVIEW METHODS

A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Validated instruments with >1 item to assess salivary gland-related symptoms were included. PROMs were evaluated for developmental methodology, structure, validity, and reliability using Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) criteria.

RESULTS

A total of 2059 abstracts were retrieved, and 133 full-text articles were reviewed. Sixteen PROMs assessing xerostomia (n = 7), sialadenitis (n = 4), Sjogren's syndrome (n = 2), Parkinson's-associated sialorrhea (n = 2), and oral systemic sclerosis (n = 1) were identified. Most (n = 15) were developed de novo, one was adapted from a pre-existing questionnaire. Eleven PROMs demonstrated "very good" analysis of internal consistency per COSMIN criteria, and 10 included test-retest data. Regarding content validity, four PROMs were developed with both patient and physician input, but none were rated as "adequate." All included comparisons against other questionnaires (n = 7), salivary flow rate (n = 9), and/or healthy controls (n = 3). The most rigorously developed PROM, the Xerostomia Inventory, was rated adequate in 6 out of 7 domains.

CONCLUSIONS

Several PROMs evaluate salivary function. The abilties of these PROMs to meet design and validation standards were variable, with notable limitations in content validity for all tools. New and updated PROMs assessing obstructive and inflammatory salivary symptoms should  utilize patient and provider input.

LEVEL OF EVIDENCE

N/A Laryngoscope, 2023.

The Patient Experience of Thyroid Cancer

The 3 phases of thyroid cancer care are discussed: diagnosis, management, and survivorship. Drivers of quality of life (QOL) in each phase are described, and suggestions are made for mitigating the risk of poor QOL. Active surveillance is another emerging management strategy that has the potential to improve QOL by eliminating upfront surgical morbidity but will need to be studied prospectively.

Quantification of very late xerostomia in head and neck cancer patients after irradiation

Objective

Radiation therapy (RT) for head and neck cancer (HNC) can result in severe xerostomia, or the subjective feeling of dry mouth. Characterizing xerostomia is critical to designing future clinical trials investigating how to improve HNC patients' quality of life (QoL). Few studies have investigated the very late (>5 years post-RT) effects of RT for HNC. We undertook preliminary studies quantifying very late xerostomia.

Methods

Six adults who underwent RT for HNC at least 5 years prior and reported xerostomia were enrolled. Five healthy adults without a self-reported history of HNC or xerostomia were enrolled as controls. All participants completed three validated surveys to measure xerostomia-related QoL. Salivary production rates were measured and compositional analysis of the saliva and oral microbiome was completed.

Results

The QoL survey scores for the HNC participants were significantly worse as compared to the control participants. The HNC participants produced less unstimulated saliva (p = .02) but not less stimulated saliva. The median salivary mucin significantly higher in HNC participants than in control participants (p = .02). There was no significant difference between the pH, amylase, or total protein. Microbiome analysis revealed alpha diversity to be significantly lower in the HNC participants.

Conclusion

In the survivors of HNC who suffer from late toxicities, multiple means of measuring toxicity may be useful. We found that in patients with radiation-induced xerostomia over 5 years after therapy, not only were the QoL surveys significantly worse, as expected, but other measurements such as mucin and oral microbiome diversity were also significantly different.

Level of evidence

3.

Marrow-Derived Autologous Stromal Cells for the Restoration of Salivary Hypofunction (MARSH): Study protocol for a phase 1 dose-escalation trial of patients with xerostomia after radiation therapy for head and neck cancer

BACKGROUND

Xerostomia, or dry mouth, is a common side effect of head and neck radiation. Current treatment options for radiation-induced xerostomia are generally supportive in nature. Adult stem cells are the ultimate source for replenishment of salivary gland tissue. Bone marrow-derived mesenchymal stromal cells (BM-MSCs) are a viable cell-based therapy for xerostomia. We have undertaken studies enabling U.S. Food and Drug Administration Investigational New Drug status, demonstrating the normal phenotype, intact functionality, and pro-growth secretome of interferon-γ (IFNγ)-stimulated BM-MSCs taken from patients with head and neck cancer who have undergone radiation ± chemotherapy. Here we present the protocol of MARSH, a first-in-human clinical trial of bone marrow-derived, IFNγ-activated BM-MSCs for the treatment of radiation-induced xerostomia.

METHODS

This single-center phase 1 dose-escalation with expansion cohort, non-placebo-controlled study will assess the safety and tolerability of BM-MSCs for the treatment of radiation-induced xerostomia in patients who had head and neck cancer. The phase 1 dose-escalation study will be a 3 + 3 design with staggered enrollment. A total of 21 to 30 subjects (9 to 18 in phase 1 study, 12 in expansion cohort) will be enrolled. The primary endpoint is determining the recommended phase 2 dose (RP2D) of IFNγ-stimulated BM-MSCs to enable further studies on the efficacy of BM-MSCs. Patients' bone marrow will be aspirated, and BM-MSCs will be expanded, stimulated with IFNγ, and injected into the submandibular gland. The RP2D will be determined by dose-limiting toxicities occurring within 1 month of BM-MSC injection. Secondary outcomes of saliva amounts and composition, ultrasound of salivary glands, and quality of life surveys will be taken at 3-, 6-, 12-, and 24-month visits.

DISCUSSION

Autotransplantation of IFNγ-stimulated BM-MSCs in salivary glands after radiation therapy or chemoradiation therapy may provide an innovative remedy to treat xerostomia and restore quality of life. This is the first therapy for radiation-induced xerostomia that may be curative.

TRIAL REGISTRATION

World Health Organization International Clinical Trials Registry Platform: NCT04489732.

Oral health-related quality of life (OHRQoL) in cardiovascular patients referring to Fatima Zahra Hospital in Sari, Iran

Background

Cardiovascular Disease (CVD) is one of the leading causes of mortality and morbidity and significantly impacts the health-related quality of life. Oral infections have been linked to cardiovascular diseases such as thrombosis, cardiac infarction, stroke, and peripheral vascular disease. This study aims to evaluate the effects of oral health on the quality of life in cardiovascular patients.

Methods

The oral health-related quality of life was measured using the OHIP-14 questionnaire. Demographic information, questions regarding smoke consumption, wearing removable prostheses, nine questions regarding xerostomia, and the existence of other systemic diseases were asked from 240 participants with cardiovascular diseases. The DMFT index was clinically examined in each patient. Also, the Plaque, Gingival, and Sulcular Bleeding Indices were measured on the Ramfjord teeth. Data analysis was conducted using SPSS version 16. The independent t test, Mann–Whitney test, the variance analysis, and the Kruskal–Wallis test were used to compare variables in the present study. Also, regression models were used to eliminate the effect of confounding variables.

Results

Gender variables, removable prosthesis, xerostomia, DMFT, and SBI were the main determinants of quality of life in CVD patients. The mean ADD-OHIP14 of participants in the study was calculated at 21.34 ± 17.40, and the SC-OHIP14 was 6.11 ± 5.07. The mean OHRQoL was higher in females than in males, and this difference was statistically significant. OHRQoL was significantly lower in patients wearing a removable prosthesis than in those without one. The relationship between age and xerostomia was significant in this study, and patients with xerostomia had a lower quality of life than those without xerostomia. Also, the mean DMFT index in subjects with xerostomia was 23.69 ± 7.76, which was statistically significant compared to those without xerostomia.

Conclusion

Cardiovascular patients experienced a decreased OHRQoL. Prevention or treatment of these problems seems to justify improving the quality of life in these patients.

177Lutetium PSMA-617 and idronoxil (NOX66) in men with end-stage metastatic castrate-resistant prostate cancer (LuPIN): Patient outcomes and predictors of treatment response of a Phase I/II trial

¹⁷⁷Lu-PSMA-617 is an effective therapy for metastatic castration-resistant prostate cancer (mCRPC). However, treatment resistance occurs frequently, and combination therapies may improve outcomes. We report the final safety and efficacy results of a phase I/II study combining ¹⁷⁷Lu-PSMA-617 with idronoxil (NOX66), a radiosensitizer, and examine potential clinical, blood-based, and imaging biomarkers. Methods: Fifty-six men with progressive mCRPC previously treated with taxane chemotherapy and novel androgen signaling inhibitor (ASI) were enrolled. Patients received up to 6 doses of ¹⁷⁷Lu-PSMA-617 (7.5 GBq) on day 1 in combination with a NOX66 suppository on days 1–10 of each 6-wk cycle. Cohort 1 (n = 8) received 400 mg of NOX66, cohort 2 (n = 24) received 800 mg, and cohort 3 (n = 24) received 1,200 mg. ⁶⁸Ga-PSMA and ¹⁸F-FDG PET/CT were performed at study entry, and semiquantitative imaging analysis was undertaken. Blood samples were collected for analysis of blood-based biomarkers, including androgen receptor splice variant 7 expression. The primary outcomes were safety and tolerability; secondary outcomes included efficacy, pain scores, and xerostomia. Regression analyses were performed to explore the prognostic value of baseline clinical, blood-based, and imaging parameters. Results: Fifty-six of the 100 men screened were enrolled (56%), with a screening failure rate of 26% (26/100) for PET imaging criteria. All men had received prior treatment with ASI and docetaxel, and 95% (53/56) had received cabazitaxel. Ninety-six percent (54/56) of patients received at least 2 cycles of combination NOX66 and ¹⁷⁷Lu-PSMA-617, and 46% (26/56) completed 6 cycles. Common adverse events were anemia, fatigue, and xerostomia. Anal irritation attributable to NOX66 occurred in 38%. Forty-eight of 56 had a reduction in prostate-specific antigen (PSA) level (86%; 95% CI, 74%–94%); 34 of 56 (61%; 95% CI, 47%–74%) had a PSA reduction of at least 50%. Median PSA progression-free survival was 7.5 mo (95% CI, 5.9–9 mo), and median overall survival was 19.7 mo (95% CI, 9.5–30 mo). A higher PSMA SUV_mean correlated with treatment response, whereas a higher PSMA tumor volume and prior treatment with ASI for less than 12 mo were associated with worse overall survival. Conclusion: NOX66 with ¹⁷⁷Lu-PSMA-617 is a safe and feasible strategy in men being treated with third-line therapy and beyond for mCRPC. PSMA SUV_mean, PSMA-avid tumor volume, and duration of treatment with ASI were independently associated with outcome.

National Sjögren's Foundation Survey: Burden of Oral and Systemic Involvement on Quality of Life

OBJECTIVE

To define the association between oral and systemic manifestations of Sjögren syndrome (SS) and quality of life (QOL).

METHODS

We analyzed a cross-sectional survey conducted by the Sjögren's Foundation in 2016, with 2961 eligible responses. We defined oral symptom and sign exposures as parotid gland swelling, dry mouth, mouth ulcers/sores, oral candidiasis, trouble speaking, choking or dysphagia, sialolithiasis or gland infection, and dental caries. Systemic exposures included interstitial lung disease, purpura/petechiae/cryoglobulinemia, vasculitis, neuropathy, leukopenia, interstitial nephritis, renal tubular acidosis, autoimmune hepatitis, primary biliary cholangitis, or lymphoma. Outcomes included SS-specific QOL questions generated by SS experts and patients.

RESULTS

Using multivariable regression models adjusted for age, sex, race, and employment, we observed that mouth ulcers or sores, trouble speaking, and dysphagia were associated with poor quality of life. The following oral aspects had the greatest effect on the following QOL areas: (1) mouth ulcers/sores on the challenge and burden of living with SS (OR 4.26, 95% CI 2.89-6.28); (2) trouble speaking on memory and concentration (OR 4.24, 95% CI 3.28-5.48); and (3) dysphagia on functional interference (OR 4.25, 95% CI 3.13-5.79). In contrast, systemic manifestations were associated with QOL to a lesser extent or not at all.

CONCLUSION

Oral manifestations of SS, particularly mouth ulcers or sores, trouble speaking, and dysphagia, were strongly associated with worse QOL. Further study and targeted treatment of these oral manifestations provides the opportunity to improve quality of life in patients with SS.

Proton Beam Therapy for Head and Neck Carcinoma of Unknown Primary: Toxicity and Quality of Life

Purpose

Proton radiation therapy (PRT) may offer dosimetric and clinical benefit in the treatment of head and neck carcinoma of unknown primary (HNCUP). We sought to describe toxicity and quality of life (QOL) in patients with HNCUP treated with PRT.

Patients and Methods

Toxicity and QOL were prospectively tracked in patients with HNCUP from 2011 to 2019 after institutional review board approval. Patients received PRT to the mucosa of the nasopharynx, oropharynx, and bilateral cervical lymph nodes with sparing of the larynx and hypopharynx. Patient-reported outcomes were tracked with the MD Anderson Symptom Inventory–Head and Neck Module, the Functional Assessment of Cancer Therapy–Head and Neck, the MD Anderson Dysphagia Inventory, and the Xerostomia-Related QOL Scale. Primary study endpoints were the incidence of grade ≥ 3 (G3) toxicity and QOL patterns.

Results

Fourteen patients (median follow-up, 2 years) were evaluated. Most patients presented with human papillomavirus–positive disease (n = 12, 86%). Rates of G3 oral mucositis, xerostomia, and dermatitis were 7% (n = 1), 21% (n = 3), and 36% (n = 5), respectively. None required a gastrostomy. During PRT, QOL was reduced relative to baseline and recovered shortly after PRT. At 2 years after PRT, the local regional control, disease-free survival, and overall survival were 100% (among 7 patients at risk), 79% (among 6 patients at risk), and 90% (among 7 patients at risk), respectively.

Conclusion

Therefore, PRT for HNCUP was associated with highly favorable dosimetric and clinical outcomes, including minimal oral mucositis, xerostomia, and dysphagia. Toxicity and QOL may be superior with PRT compared with conventional radiation therapy and PRT maintains equivalent oncologic control. Further prospective studies are needed to evaluate late effects and cost-effectiveness.

Change in Spontaneous Swallowing Frequency in HNC Patients Undergoing C/RT

OBJECTIVE

This study sought to evaluate the role and trajectory of spontaneous swallowing frequency (SFA) in patients with head and neck cancer (HNC) undergoing chemoradiotherapy (C/RT).Study Design. Prospective cohort.

SETTING

University comprehensive cancer center.

METHODS

A prospective cohort of 80 patients with HNC was followed from baseline to 3 months post-C/RT. Subjects were evaluated for performance on swallowing function, functional diet consumed, weight, swallowing frequency rate, perceived xerostomia, perceived pain, and mucositis. Relationships were evaluated using univariate correlations, t tests, and repeated-measures analysis of variance. The diagnostic accuracy of SFA to express dysphagia was calculated by area under the curve (AUROC) and displayed using receiver operator characteristic curves.

RESULTS

In general, patients with HNC demonstrated a parabolic decline in most measures over the C/RT trajectory. SFA and perceived xerostomia did not show improved recovery by 3 months. SFA was related to swallow function, xerostomia, and functional diet consumed posttreatment and pain at 3 months. The ability of SFA to correctly identify clinical dysphagia (Mann Assessment of Swallowing-Cancer version [MASA-C]) and reduced oral intake (Functional Oral Intake Scale [FOIS]) at posttreatment was strong (AUROC MASA-C: 0.824 [95% CI, 0.63-1.00], P < .0018; AUROC FOIS: 0.96 [95% CI, 0.87-0.96], P < .0001).

CONCLUSION

This exploratory study suggests SFA may provide a useful method to identify dysphagia after HNC treatment. Furthermore, SFA may offer a simple, objective measure of swallowing function change in HNC over the C/RT trajectory.

Patient-reported quality of life and symptom burden measures in human papillomavirus associated oropharyngeal cancer - A review of the literature and PRO methodology

The emergence of human papillomavirus-associated oropharyngeal cancer (HPVOPC) has resulted in an explosion of clinical research offering reduced toxicity and improved health-related quality of life (HRQL) through treatment de-escalation. At the heart of this objective are patient-reported outcomes (PROs) which aim to quantify the patient experience, usually through the measurement of HRQL or symptom burden. A number of PRO measures (PROMs) are available to HNC researchers and selection of the optimal instrument relies on a detailed understanding of their content and psychometric properties matched to the clinical endpoint of interest. As PROMs become increasingly favoured as the primary or co-primary endpoints of interest in HNC clinical trials, particularly those focussed on HPVOPC, future treatment paradigms will be determined by these measures and it is imperative that they are applied with sophistication and rigor. This review draws attention to the limitations and challenges our specialty faces in PRO application, analysis and reporting. These shortfalls typically include a reliance on statistical rather than clinically relevant differences, multiple hypothesis testing, a lack of evidence-based minimal clinically important differences for the commonly used tools, as well as variations in PROM selection. The aim of this review is to provide: (1) an overview of PRO/PROM terminology and methodology in the HNC setting; (2) to provide a summary of HRQL and symptom burden reports in the HPVOPC literature; and (3) to draw attention to the unmet research need of refining PROM development, application and interpretation to guide our treatment decisions based on what matters to patients.

Nonmalignant Oral Disease--Specific Dental Patient-Reported Outcome Measures for Adult Patients: A Systematic Review

OBJECTIVES

Dental patient-reported outcome measures (dPROMs) can be differentiated into outcome measures for all oral diseases, so-called disease-generic dPROMs, and measures for specific oral diseases, so-called disease-specific dPROMs. The aim of this systematic review was to identify the psychometrically validated nonmalignant disease-specific dPROMs for adult patients and the dental patient-reported outcomes (dPROs) they measure.

METHODS

This systematic review searched Ovid MEDLINE, Embase, PsycINFO, and the Cochrane databases along with hand searching, through July 28, 2020, to identify original articles of English language, multi-item dPROMs for adult dental patients with a specific oral disease, condition, or oral manifestations of systemic diseases. We analyzed the questionnaires for content commonalities, the reference or recall period, and the dimensionality.

RESULTS

We retrieved 4228 unique references and identified 34 questionnaires; of which, 31 questionnaires captured impacts from oral diseases or conditions and three from oral manifestations of systemic diseases. All questionnaires together contained 102 dPROMs, measuring 75 dPROs. Oral health-related quality of life was a broader dPRO, which was measured by 24 dPROMs. The 74 narrower dPROs were measured by 78 dPROMs. The dPRO names suggested that essentially four dPROs were measured: Oral Function (N = 19), Orofacial Pain (N = 7), Orofacial Appearance (N = 11), and Psychosocial Impact (N = 37).

CONCLUSIONS

Many psychometrically validated tools (N = 102) are available to measure the impact of specific nonmalignant oral disease on patients. While these tools intend to measure the particular patient-perceived impact profile of the oral disease, all tools measure in essence only four, more general concepts - the dimensions of oral health-related quality of life.

Dosimetric comparison of intensity-modulated radiation therapy (IMRT) and field-in-field (FIF) technique for head-and-neck cancer

Purpose:

This study compared the plan dosimetry between the intensity-modulated radiation therapy (IMRT) and field-in-field (FIF) technique for head-and-neck cancer using the Elekta Monaco treatment planning system (TPS).

Materials and methods:

A total of 20 head-and-neck cancer patients were selected in this study. IMRT and FIF plans for the patients were created on the Monaco TPS (ver. 5.11.02) using the 6-MV photon beam generated by the Elekta Synergy linear accelerator. The dose–volume histograms, maximum doses, minimum doses, mean doses of the target volumes and organs-at-risk (OARs), conformity index (CI), homogeneity index (HI) and monitor units (MUs) were determined for each IMRT and FIF plan. All IMRT plans passed the patient-specific quality assurance tests from the 2D diode array measurements (MatriXX Evolution System, IBA Dosimetry, Germany).

Results:

The results showed that the dose distribution to the target volumes of IMRT plans was better than FIF plans, while the dose (mean or max dose) to the OAR was significantly lower than FIF plan, respectively. IMRT and FIF resulted in planning target volume coverage with mean dose of 71·32 ± 0·76 and 73·12 ± 0·62 Gy, respectively, and HI values of 0·08 ± 0·01 (IMRT) and 0·19 ± 0·06 (FIF). The CI for IMRT was 0·98 ± 0·01 and FIF was 0·97 ± 0·01. For the spinal cord tolerance (maximum dose < 45 Gy), IMRT resulted in 39·85 ± 2·04 Gy compared to 41·37 ± 2·42 Gy for FIF. In addition, the mean doses to the parotid grand were 27·27 ± 7·48 and 48·68 ± 1·62 Gy for the IMRT and FIF plans, respectively. Significantly more MUs were required in IMRT plans than FIF plans (on average, 846 ± 100 MU in IMRT and 467 ± 41 MU in FIF).

Conclusions:

It is concluded that the IMRT technique could provide a better plan dosimetry than the FIF technique for head-and-neck patients.

Short-term and long-term unstimulated saliva flow following unilateral vs bilateral radiotherapy for oropharyngeal carcinoma

BACKGROUND

We aimed to compare unstimulated saliva flow using 3-minute modified Schirmer test (MST) following bilateral vs unilateral radiotherapy (RT) in oropharyngeal carcinoma (OPC).

METHODS

We reviewed OPC patients treated with definitive intensity-modulated radiation therapy (IMRT) between 2011 and 2017. MST was measured at baseline, 1-/6-/12-/24-month post-RT. MST values were compared between bilateral-RT vs unilateral-RT groups. Multivariable logistic regression analysis (MVA) identified predictors of hyposalivation (MST < 25 mm).

RESULTS

Total 498 bilateral-RT and 36 unilateral-RT patients were eligible. The MST values at 1-/6-/12-/24-month post-RT were all significantly reduced from baseline for the entire cohort. Baseline unilateral-RT and bilateral-RT MST values (in mm) were similar (P = .2), but much higher for unilateral-RT 1-month (mean: 19.1 vs 13.0, P = .03), 6-month (20.5 vs 9.3, P < .001), 12-month (20.1 vs 11.9, P < .01), and 24-month post-RT (22.2 vs 13.9, P = .04). MVA confirmed that unilateral RT reduced the likelihood of hyposalivation vs bilateral RT (OR 2.36, P = .006).

CONCLUSION

Unilateral RT reduces unstimulated salivary flow in OPC patients.

Coconut Oil as a Novel Approach to Managing Radiation-Induced Xerostomia: A Primary Feasibility Study

Background

Xerostomia is a common complication following radiation therapy for head and neck cancer (HNC), for which there is no single, universally accepted therapy. Coconut oil has been anecdotally suggested to provide relief for this complication. This study sought to examine the feasibility and effectiveness of coconut oil as a therapy for radiation-induced xerostomia.

Methods

A feasibility study was performed among 30 patients with xerostomia subsequent to radiation for HNC. Coconut oil samples were provided along with a protocol for use over a 2-week period and the option to continue if they found it beneficial. Patients were also instructed to keep diaries to document their patterns of use. The Xerostomia-related Quality of Life Scale (XeQOLS) was administered at baseline and 3-month follow-up. Descriptive methods were used to summarize patterns of coconut oil use and paired t-tests were used to assess changes in XeQOLS scores over time.

Results

The mean total duration of coconut oil use during the study period was 16 days (1-71). The average number of uses per day was 3 (1-5), with an average amount per use of 5 mL (1.2-8.5). Twelve patients (41.4%) continued coconut oil use beyond the advised period. There was no statistically significant difference in XeQOLS scores pre- and post-treatment. There were no adverse events during the study period.

Conclusions

The use of coconut oil as a treatment strategy for xerostomia post-HNC radiation is feasible, inexpensive, and safe. This study demonstrates that there may be a group of HNC patients that benefit from its use.

Phase I/II Trial of the Combination of 177Lutetium Prostate specific Membrane Antigen 617 and Idronoxil (NOX66) in Men with End-stage Metastatic Castration-resistant Prostate Cancer (LuPIN)

BACKGROUND

Trials of lutetium prostate specific membrane antigen (PSMA) in men with metastatic castration-resistant prostate cancer (mCRPC) have demonstrated good safety and efficacy, but combination strategies may improve outcomes. Idronoxil is a synthetic flavonoid derivative with radiosensitising properties.

OBJECTIVE

To evaluate the safety and activity of ¹⁷⁷Lu PSMA 617 (LuPSMA-617) in combination with idronoxil suppositories (NOX66) in patients with end-stage mCRPC.

DESIGN, SETTING, AND PARTICIPANTS

Thirty-two men with progressive mCRPC previously treated with taxane-based chemotherapy (91% treated with both docetaxel and cabazitaxel) and abiraterone and/or enzalutamide were enrolled in this phase I dose escalation study with phase II dose expansion.

INTERVENTION

Screening with ⁶⁸Ga PSMA and ¹⁸F-fludeoxyglucose positron emission tomography (PET)/computed tomography (CT) was performed. Men received up to six cycles of LuPSMA-617 (7.5 GBq) on day 1, with escalating doses of NOX66 on days 1-10 of a 6-wk cycle. Cohort 1 (n = 8) received 400 mg and cohort 2 (n = 24) 800 mg of NOX66.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Adverse events (AEs), pain inventory scores, prostate-specific antigen (PSA) response, progression-free survival, and overall survival were evaluated.

RESULTS AND LIMITATIONS

Fifty-six men were screened and 32 (57%) were enrolled with a screen failure rate of 21% for PET imaging criteria. Dosing was as follows: 97% (31/32) received two or more doses and 47% (15/32) completed six doses. Common AEs included xerostomia, fatigue, and anaemia. Anal irritation attributable to NOX66 occurred in 28%. PSA responses were as follows: 91% (29/32) had any PSA response (median -74%; 95% confidence interval [CI] 76-97) and 62.5% (20/32) had a PSA fall of >50% (95% CI 45-77). The median PSA progression-free survival was 6.1 mo (95% CI 2.8-9.2) and median overall survival was 17.1 mo (95% CI 6.5-27.1).

CONCLUSIONS

NOX66 with LuPSMA-617 is a safe and feasible therapeutic strategy in men treated with third-line therapy and beyond for mCRPC.

PATIENT SUMMARY

Addition of NOX66 to ¹⁷⁷Lu prostate-specific membrane antigen 617 is safe, and further studies are needed to assess its potential to augment the anticancer effects of LuPSMA-617.

Evaluating the measurement properties of patient-reported outcome measures in radiotherapy-induced xerostomia

OBJECTIVE

Radiotherapy-induced xerostomia (RIX) is one of the most common adverse effects of radiotherapy to the head and neck, and a major determinant of survivors' quality of life. A number of patient-reported outcome measures (PROMs) have been used in clinical trials of therapeutic interventions for RIX; however, little is known regarding their measurement properties and methodological quality.

METHODS

We conducted a systematic literature search in Embase, MEDLINE and PsycINFO for articles published up to May 2019 and evaluating at least one measurement property of PROMs relevant to RIX. The COSMIN guidelines were used to assess relevant measurement properties and methodological quality.

RESULTS

Nine validations studies were identified reporting on four PROMs relevant to RIX. The Xerostomia Questionnaire (XQ) showed overall high-quality evidence for structural validity and internal consistency, but low-quality evidence supporting reliability. The methodological quality of the Groningen Radiotherapy-Induced Xerostomia scale (GRIX), Xerostomia Inventory (XI) and the Xerostomia Quality of Life Scale (XeQoLS) was relatively low for all measurement properties.

CONCLUSIONS

The XQ was found to have the highest potential to capture changes in RIX according to COSMIN guidelines. Additional validation studies are required to further understand the methodological quality of the XI, GRIX and XeQoLS.

Effectiveness of low-level laser therapy for oral mucositis prevention in patients undergoing chemoradiotherapy for the treatment of head and neck cancer: A systematic review and meta-analysis

Oral Mucositis is a frequent and debilitating inflammatory complication in patients with head and neck malignancies and may lead to unplanned treatment interruptions due to intense pain and dysphagia. This systematic review with meta-analysis was performed to determine the effectiveness of low-level laser therapy in preventing oral mucositis in this context. The following databases were searched through September 2018, with last search performed on May 2019, for clinical trials: MEDLINE via PubMed, Cochrane Central, Scopus, Lilacs, ISI Web of Science and SIGLE via Open Grey. From 14,525 records, 4 studies were included in the review and 3 studies were included in meta-analysis. Data from 500 patients (mean age of 53.595 and 54.14 for intervention and control groups, respectively) were analysed. Meta-analysis showed that laser therapy prevents oral mucositis incidence in 28% and 23% of cases during the third and fourth follow-up week, respectively, in comparison to a placebo-treated control group. There was no statistically significant difference the prevention of pain; dysphagia and quality of life were not analysed due to missing. Laser therapy was effective in preventing oral mucositis from the 15th to the 45th days of chemoradiotherapy. However, new primary studies with low risk of bias are needed so a higher scientific evidence can be obtained.

Two- Versus Four-Times Weekly Acupuncture-Like Transcutaneous Electrical Nerve Stimulation for Treatment of Radiation-Induced Xerostomia: A Pilot Study

Background: Xerostomia occurs in the majority of patients undergoing chemoradiation therapy for head and neck cancer (HNC). Acupuncture-like transcutaneous electrical nerve stimulation (ALTENS) treatment has been studied as an encouraging modality to improve salivary function and related symptoms. The purpose of this study was to compare ALTENS treatment by using a four-times weekly schedule for 6 weeks versus a twice-weekly schedule for 12 weeks with a validated xerostomia scale at 15 months from the start of ALTENS treatment. Materials and Methods: This single-center randomized study was conducted in 30 patients treated with radiotherapy with or without chemotherapy for HNC between 2014 and 2017, who had at least grade 1 or 2 symptomatic dry mouth (xerostomia) according to CTEP NCI Common Terminology Criteria for Adverse Events (CTCAE version 4.0). These patients were randomly assigned to receive ALTENS four-times weekly for 6 weeks or two-times weekly for 12 weeks. The University of Michigan 15-item Xerostomia-related Quality of Life Scale (XeQoLS) was administered at 6, 9, 15, and 21 months from the start of ALTENS treatment. A random-effects generalized linear model was used to model the overall XeQoLS score at the 15-month endpoint; adjusted for a random time effect, a fixed treatment arm, and interaction of time and treatment. Comparison between arms was based on a 0.05 nominal significance level. Results: XeQoLS decreased for all patients (although not statistically for each arm) from a mean of 22 and 21 at baseline (in the four times per week and twice weekly arms) to 12 in both arms at 15 months, with no difference between arms (p = 0.68). There were no attributable grade 1-3 adverse events. Arms were balanced for age, gender, race, and baseline xerostomia. Conclusions: This study demonstrates that both ALTENS regimens are safe, well tolerated, and appear to be equally effective. We now routinely make ALTENS units available for home use.

Predictors for improvement of xerostomia in nasopharyngeal carcinoma patients receiving intensity-modulated radiotherapy

To identify predictors for improvement of xerostomia in patients with nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiotherapy (IMRT).Patients diagnosed with stage I-IVb NPC (according to the 7th edition of the American Joint Committee on Cancer) between September 2015 and March 2016 were retrospectively analyzed. All the patients received IMRT. Predictors for improvement of xerostomia were analyzed using logistic regression analysis. Receiver operating characteristic curve analysis was used to identify the most appropriate cut-off values for predicting factors.This study included 195 patients: xerostomia improved in 109 patients and xerostomia remained unchanged in 86 patients. Volume of the parotid gland ≤52.2 cm was a risk factor for xerostomia improvement (odds ratio [OR] = 3.506, 95% confidence interval [CI]: 1.932-6.362, P = .001). The mean dose of <39 Gy to the ipsilateral parotid gland was a protective factor (OR = 0.417, 95% CI: 0.271-0.641, P = .001). V30 of the contralateral parotid gland ≤52% was a protective factor (OR = 0.593, 95% CI: 0.462-0.760, P = .001).Volume of the parotid gland, the mean dose of the ipsilateral parotid gland, and V30 of the contralateral parotid gland were independent predictors for improvement of xerostomia.

Xerostomia-related quality of life for patients with oropharyngeal carcinoma treated with proton therapy

PURPOSE

We report longitudinal patient-reported quality-of-life (QoL) outcomes related to xerostomia in patients with oropharyngeal cancer treated with intensity-modulated proton therapy (IMPT).

MATERIALS AND METHODS

Patients treated from May 2012 through December 2016 at a single institution for AJCC7 stage III-IV, M0 oropharyngeal cancer were given the 15-item Xerostomia-Related QoL Scale (XeQoLS) before, during, and for up to 2 years after treatment. We evaluated the evolution of xerostomia-related QoL over that time, and examined potential associations between those measures with clinical characteristics.

RESULTS

Sixty-nine patients had XeQoLS scores at baseline and at least once either during or after treatment. The mean (±SD) XeQoLS score (0-4) was 0.24 ± 0.57 at baseline. Subsequent scores were 2.00 ± 1.01 at 6 weeks on treatment, and 1.03 ± 0.76, 0.97 ± 0.78, 0.82 ± 0.69, and 0.70 ± 0.75 at 10 weeks, 6 months, 1 year, and 2 years after treatment, respectively. All were statistically different from baseline (p < 0.001). Univariate analyses demonstrated associations between XeQoLS score and time (p < 0.0001 for each interval), baseline XeQoLS score (p < 0.0001), stage (p = 0.008), N status (p = 0.006), and mean oral cavity dose (p = 0.038), but not for age, sex, T status, receipt of chemotherapy, smoking history, disease site, laterality of neck irradiation, mean parotid dose, or mean submandibular dose. Multivariate analysis suggested that baseline XeQoLS scores, phase of treatment, and N status were associated with XeQoLS scores measured during treatment and recovery.

CONCLUSIONS

Patients receiving IMPT reported the greatest xerostomia-related QoL impairment at 6 weeks on treatment, with a 49% improvement by 10 weeks after treatment; however, XeQoLS scores remained above baseline after 2 years. As we aim to establish the value of IMPT in oropharyngeal tumors to de-intensify treatment over conventional therapy, these data help inform discussions about xerostomia-related quality of life for patients with oropharyngeal cancer treated with IMPT.

[Normal tissue: radiosensitivity, toxicity, consequences for planning]

Along with chemotherapy, surgery and immunotherapy, radiotherapy is a mainstay of cancer treatment. Considering the improving survival rates for various malignancies during the past decades, the importance of radiation-induced late normal tissue response is increasing. Quality of life is becoming an important issue in modern cancer treatment and is correlated with acute and late normal tissue response after radiotherapy. A profound understanding of radiation-induced normal tissue response is necessary to sufficiently diagnose and treat radiation-induced side effects and thereby increase the patients' quality of life. Here, the various normal tissue responses in consideration of the radiation biology are specified and prospective options to attenuate radiation-induced side effects are discussed.

Disease activity and patient reported outcome measures in Sjögren's - what are the best tools to evaluate?

In primary SS (pSS), clinical features in SS can be divided into two facets: the patient perceived manifestations such as dryness, pain and fatigue, and the systemic manifestations. In the past decades, with efforts made by an international collaboration, consensual clinical indexes were developed for assessing both facets: one patient reported outcome, the EULAR SS Patients Reported Index (ESSPRI), and one activity index for systemic manifestations, the EULAR SS Disease Activity Index (ESSDAI). In addition, objective measures were developed to quantify the importance and consequence of ocular and oral dryness, few being specific of pSS. Work is ongoing to develop indexes combining all these approaches. Recent changes in the assessment of pSS patients, and the emergence of new targeted therapies, have put a greater emphasis on the design of clinical trials in pSS, and led for the first time to a positive randomized clinical trial.

What Are We Really Measuring? A Content Comparison of Swallowing Outcome Measures for Head and Neck Cancer Based on the International Classification of Functioning, Disability and Health (ICF)

A combination of outcome measures are required to provide important information on the physiological profile and associated impact of dysphagia in head and neck cancer (HNC). Choosing the most appropriate tool can be a difficult and time-consuming process. The aim of this study was to identify and then compare the content of tools commonly used to assess swallowing post HNC care using the International Classification of Functioning Disability and Health (ICF) as a reference. A literature audit of 11 databases was conducted for relevant articles published between January 2004 and June 2017 and total of 502 papers met the inclusionary criteria. These papers were audited and 27 tools were identified which met the study criteria. The meaningful concepts contained in each tool were mapped to the ICF. Within the 27 tools, 898 meaningful concepts were identified and matched to 60 ICF categories. The most frequently matched ICF categories related to body functions, while comparatively few concepts matched to activity and participation and environmental factors. This study has identified that a large number of tools are currently being used in HNC research to measure swallowing outcomes. The sheer number of tools available to explore dysphagia post HNC highlights the lack of a uniform approach to outcome measurement which limits the potential to compare and combine research studies in order to strengthen treatment evidence. There is a need to develop an international consensus for a core outcome set of swallowing related measures, that capture the holistic impact of dysphagia, for HNC.

Outcome and toxicity of intensity-modulated radiotherapy with simultaneous integrated boost in patients with pharyngo-laryngeal cancer

PURPOSE

The present work aims at evaluating intensity-modulated radiation therapy with simultaneous integrated boost (IMRT-SIB) in squamous cell carcinomas (SCC) of the larynx and hypopharynx.

METHODS/PATIENTS

We performed a single institutional retrospective analysis on 116 pharyngo (29%)-laryngeal (71%) SCC patients (93% male) treated with IMRT-SIB to 66-69.96 Gy in 33 fractions between 2008 and 2016. Those who underwent surgery (54%) received adjuvant radiation of 66 Gy at 2 Gy/fraction to the surgical bed. 16 patients (14%) were treated for a local recurrence after prior surgery. High-risk lymph node regions received 59.4 Gy at 1.8 Gy/fraction and low risk regions 54.12 Gy at 1.64 Gy/fraction. The median age was 60 years and 95% of patients had an ECOG performance status 0-2. Most had advanced stage disease (III 22%, IV 74%). Chemotherapy was delivered in 74% of cases.

RESULTS

Median follow-up was 32 months. Two and three-year overall survival for all patients was 87% and 82%, respectively. There were 28 (24%) locoregional recurrences and 19 (16%) distant failures. Grade 3 mucositis, dermatitis, and xerostomy were observed in 12%, 10%, and 3%, respectively. A longer IMRT-SIB overall treatment time was associated with a higher risk of mortality (HR 1.09, CI 1.01-1.17, P = 0.02). Postoperative IMRT-SIB associated with a significantly lower risk of any recurrence (HR 0.34, CI 0.18-0.64, P = 0.001) and higher local control (HR 0.06, CI 0.01-0.24, P < 0.01). Additionally, it associated with a lower risk of mucositis (P = 0.029) compared with definitive radio (chemo) therapy.

CONCLUSIONS

IMRT-SIB is a safe and feasible radiation treatment technique for pharyngo-laryngeal SCC patients with a tolerable acute toxicity profile.

Explorative study on quality of life in relation to salivary secretion rate in head and neck cancer patients treated with radiotherapy up to 2 years post treatment

OBJECTIVE

The aim of this study was to analyse quality of life (QoL) pretreatment and up to 24 months post radiation therapy (RT) in patients with head and neck (H&N) cancer.

METHODS

Twenty-nine patients (19 men and 10 women) with a mean age of 59 ± 8 years were included. The stimulated salivary secretion was measured and the patients completed the European Organisation for Research and Treatment of Cancer Quality of Life questionnaires (EORTC QLQ-C30 and H&N35) and the Hospital Anxiety and Depression scale (HADS) pretreatment and at 6, 12 and 24 months post RT.

RESULTS

At all time-points after RT (6, 12, and 24 months), patients with hyposalivation (stimulated secretion rate ≤0.7 mL/min) reported clinically significant differences (> 10 points) regarding insomnia, swallowing, social eating, dry mouth, and sticky saliva. Statistically significant differences were found for emotional functioning and insomnia at 12 months (P < 0.05 for both) and for sticky saliva at both 12 and 24 months (P < 0.05 and P < 0.01). The number of clinically significant differences increased from 10 at both 6 and 12 months post-RT to 14 functioning/symptom scales and single items at the 24 months follow-up. At 24 months post RT, 21% of patients with hyposalivation had HADS scores suggesting anxiety problems compared to 7% for those with stimulated salivary secretion rates >0.7 mL/min.

CONCLUSION

Patients with hyposalivation showed deterioration in health related quality of life (QoL) at 24 months compared with 12 months post RT. Most pronounced were problems with insomnia, swallowing, social eating, dry mouth, and sticky saliva.

Oral health-related quality of life in primary Sjögren's syndrome

OBJECTIVE

To assess health-related quality of life (HRQoL) and oral health-related quality of life, and correlate them with unstimulated whole salivary flow (UWSF) and oral sicca symptoms in patients with primary Sjögren's syndrome (PSS).

METHODS

We included 60 patients with PSS and 60 healthy controls matched according to gender and age (±3 years). We measured the UWSF and scored the European League Against Rheumatism (EULAR) Sjögren's Syndrome Patient Reported Index (ESSPRI). We assessed the short version of the SF-36 as a generic measurement of HRQoL and the Xerostomia Quality of Life Scale (XeQoLS) questionnaire to evaluate oral quality of life. We evaluated oral symptoms using an 8-item Visual Analogue Scale (VAS) questionnaire.

RESULTS

We observed a poorer HRQoL (lower scores in SF-36) and oral quality of life (higher scores in XeQoLS), as well as a greater severity of symptoms in the VAS questionnaire upon comparing patients vs. controls. The XeQoL correlated with the UWSF (τ = -0.24, P = .008), the ESSPRI (τ =0.45, P = .0001), VAS 1-2 and VAS 5-8 and the SF-36 score (τ = -0.28, P = .002).

CONCLUSIONS

Patients with PSS had a poorer HRQoL and oral quality of life than controls. UWSF contributes to the oral quality of life which, in turn, has an impact on HRQoL. Symptomatic treatment of xerostomia as well as the prevention of infections, decay and tooth loss would help to improve the oral quality of life in these patients.

Dysphagia and Oral Morbidities in Chemoradiation-Treated Head and Neck Cancer Patients

This study prospectively evaluated relationships between oral morbidities and swallowing ability in head/neck cancer patients following chemoradiation therapy (CRT) and at 3 months following CRT. Thirty patients with confirmed head/neck cancer undergoing chemoradiation were assessed with a battery of swallowing measures and measures of oral morbidities related to chemoradiation (xerostomia, mucositis, pain, taste/smell, oral moisture). All measures were completed at baseline (within the first week of CRT), at 6 weeks (end of treatment), and at 3 months following chemoradiation. Descriptive and univariate statistics were used to depict change over time in swallowing and each oral morbidity. Correlation analyses evaluated relationships between swallowing function and oral morbidities at each time point. Most measures demonstrated significant negative change at 6 weeks with incomplete recovery at 3 months. At 6 weeks, mucositis ratings, xerostomia, and retronasal smell intensity demonstrated significant inverse relationships with swallowing function. In addition, oral moisture levels demonstrated significant positive relationships with swallowing function. At 3 months, mucositis ratings maintained a significant, inverse relationship with swallow function. Taste and both orthonasal and retronasal smell intensity ratings demonstrated inverse relationships with measures of swallow function. Swallow functions and oral morbidities deteriorate significantly following CRT with incomplete recovery at 3 months post treatment. Furthermore, different patterns of relationships between swallow function measures and oral morbidities were obtained at the 6-week versus the 3-month assessment point suggesting that different mechanisms may contribute to the development versus the maintenance of dysphagia over the trajectory of treatment in these patients.

A Guide of the Questionnaires Used in the Measurement of Health-Related Quality of Life in Head and Neck Oncology

Aims and background

There is a plethora of instruments which measure health-related quality of life (HRQOL), although only a fraction of these have been used in surgical studies and palliative care. Clinicians involved in the management of head and neck pathology face the difficult task of selecting the instrument most suited to the aspect of the patients’ perspective that they want to measure. The aim of this article is to guide head and neck trainees in deciding on the use of the appropriate instrument for evaluation of the patient's perspective.

Methods and study design

The two authors independently searched and scrutinized the literature. The ISI search engine with cross-reference using PubMed and Ovid was searched with the terms “quality of life”, “questionnaire” and specific specialty terms. Studies written in the English language were selected and the abstracts searched for evidence of patient self-completed questionnaires and HRQOL outcome.

Results

There are five broad category headings into which quality of life studies in head and neck oncology can be divided. These include: patient performance questionnaires, generic quality of life questionnaires, generic cancer questionnaires, head and neck cancer questionnaires, and head and neck functional questionnaires.

Conclusions

Patient perspective can be assessed using a number of instruments, including open interview, semi-structured interview, and the simple questionnaire. The choice of instrument depends somewhat on personal preference, the outcomes being measured, and available resources.

Head and Neck Cancer Patients – Information for the General Dental Practitioner

Salivary gland damage is the most common adverse effect associated with radiation therapy to the head and neck. A combination of hyposalivation and dietary changes, with a reduced emphasis on oral hygiene practices can contribute to a massive increase in a person’s caries risk status. This can be further complicated by limited mouth opening. To enable optimal dental care for head and neck cancer patients before, during and after radiation therapy, patients must be informed and educated about the potential risks of dental caries and the preventive strategies available. All patients should receive a pre-radiotherapy dental assessment by a Restorative Dentistry Consultant. This information will be delivered to the patient, often at an emotionally charged time, and can be lost amongst all the information related to other aspects of his/her cancer management. General Dental Practitioners (GDPs) are therefore in a pivotal position to reiterate this information post radiation therapy and ensure compliance with preventive strategies, with the overall aim to improve quality of life and avoid the need for future extractions and the resulting risk of osteoradionecrosis. Clinical relevance: This article highlights the GDP’s role in the shared management of head and neck cancer patients who have received radiotherapy as part of their cancer treatment. The critical issue of dental caries, one of the late effects of radiation-induced hyposalivation, will be focused upon. Other side-effects, such as trismus and osteoradionecrosis, will also be discussed. This article aims to supply GDPs with accurate information to provide to their patients with post radiation therapy, whilst highlighting what treatment is within their remit and when it may be appropriate to refer.

Patient reported dry mouth: Instrument comparison and model performance for correlation with quality of life in head and neck cancer survivors

PURPOSE

To identify a clinically meaningful cut-point for the single item dry mouth question of the MD Anderson Symptom Inventory-Head and Neck module (MDASI-HN).

METHODS

Head and neck cancer survivors who had received radiation therapy (RT) completed the MDASI-HN, the University of Michigan Hospital Xerostomia Questionnaire (XQ), and the health visual analog scale (VAS) of the EuroQol Five Dimension Questionnaire (EQ-5D). The Bayesian information criteria (BIC) were used to test the prediction power of each tool for EQ-5D VAS. The modified Breiman recursive partitioning analysis (RPA) was used to identify a cut point of the MDASI-HN dry mouth score (MDASI-HN-DM) with EQ-5D VAS, using a ROC-based approach; regression analysis was used to confirm the threshold effect size.

RESULTS

Two-hundred seven respondents formed the cohort. Median follow-up from the end of RT to questionnaire completion was 88 months. The single item MDASI-HN-DM score showed a linear relationship with the XQ composite score (ρ = 0.80, p < 0.001). The MDASI-HN-DM displayed improved model performance for association with EQ-5D VAS as compared to XQ (BIC of 1803.7 vs. 2016.9, respectively). RPA showed that an MDASI-HN-DM score of ≥6 correlated with EQ-5D VAS decline (LogWorth 5.5).

CONCLUSION

The single item MDASI-HN-DM correlated with the multi-item XQ and performed favorably in the prediction of QOL. A MDASI-HN-DM cut point of ≥6 correlated with decline in QOL.

Patient Reported Outcome Assessment of Periodontal Therapy: A Systematic Review

INTRODUCTION

Patient Reported Outcomes (PROs) are now regarded as a fundamental measure of therapeutic success. Patient's opinion regarding the impact of disease and its treatment is assessed using scales such as Oral Health Related Quality Of Life (OHRQoL) tools. Patient centred outcome assessment is now being considered as a primary outcome measure in clinical trials.

AIM

To evaluate whether treatment of periodontal disease could influence OHRQoL based on available literature.

MATERIALS AND METHODS

An electronic search was done in Google, Google Scholar and Pubmed for articles in English language using the terms Quality of Life or ORHQoL or PROs or patient centered outcome and periodontal therapy. The search commenced on 1st September 2016 and ended on 15th December 2016. Studies that employed one or more than one multi-item OHRQoL instrument to assess PROs related to either non-surgical or surgical periodontal therapy were reviewed.

RESULTS

Initially 423 relevant articles were obtained, from which based on screening titles and abstracts 396 were excluded. Full text of remaining 27 articles were retrieved. Nineteen clinical studies with 1345 participants and 2 systematic reviews were included after the full text review.

CONCLUSION

Both surgical and Non-surgical Periodontal Therapy (NSPT) significantly influenced the OHRQoL scores. However the change in scores after surgical therapy when compared to nonsurgical therapy was not statistically significant. There is a need for a specific PROs scale that could potentially tap the entire dimension of the change in patients' perception brought about by periodontal therapy.

Accupuncture-like transcutaneous electrical nerve stimulation therapy success using a commercially available unit 8 years post-radiation for xerostomia: a case report

BACKGROUND

Accupuncture-like transcutaneous electrical nerve stimulation (ALTENS) therapy has been shown in prospective studies to be effective in the treatment of radiation-induced xerostomia. Those studies treated patients within 27 months from end of radiation with ALTENS delivered in the clinic using a Codetron unit. However, that unit is no longer produced and there is limited data on success of ALTENS when delivered at home.

METHODS

A 50-year old man with xerostomia, 8 years post-radiation for T4N1 squamous cell carcinoma of the tonsillar fossa, was given ALTENS with a currently commercially available unit from Girish Surgical. He used the unit at home, 20 minutes daily for 8 weeks.

RESULTS

After 8 weeks of ALTENS therapy the patient saw a reduction in the Self-Reported University of Michigan Xerostomia-Related Quality of Life Scale from 20 to 1.

CONCLUSION

This case report demonstrates (1) the Girish Surgical unit is effective, (2) self-administration of ALTENS in patients who cannot come to clinic regularly may be practical and (3) ALTENS can still offer durable benefit to patients even 8 years after chemoradiation therapy.