Supportive care in head and neck oncology

Personalised treatment for older adults with cancer: The role of frailty assessment

It is widely accepted in clinical practice that chronological age is a poor predictor of treatment tolerance and outcomes in older adults with cancer. Intrinsic vulnerability is more a function of underlying frailty, rather than chronological age. Frailty is a state of increased vulnerability to stressors, such as cancer and its treatment, which can lead to adverse health outcomes for patients. Capturing this heterogeneity in reserve capacity is the cornerstone of management in geriatricmedicine, but remains poorly understood or adopted in radiation oncology. A two-step approach, using a shorter screening tool, followed by full assessment for those who need it, is the mostresourceful way of implementing frailty assessment in radiotherapy departments. It is important for radiation oncology professionals to identify frailty and to use this information in multidisciplinary decision making in order to develop a personalised radiotherapy approach for the older person. There are many ways we can effectively use this information, such as considering treatment fractionation schedules that would limit the burden of travel for those with social frailty, or reviewing the range of modalities at our disposal, which might limit toxicity in the older person at high risk of deterioration during treatment. Frailty assessment is not carried out in many radiotherapy departments presently, but there are many international models to use as exemplars as to how it may be implemented in clinical practice. There are many opportunities for further research and role development in this field at the current time.

Palliative Radiation Therapy in Older Adults With Cancer: Age-Related Considerations

There are many additional considerations when treating older adults with cancer, especially in the context of palliative care. Currently, radiation therapy is underutilised in some countries and disease sites, but there is also evidence of unnecessary treatment in other contexts. Making rational treatment decisions for older adults necessitates an underlying appraisal of the person's physiological reserve capacity. This is termed 'frailty', and there is considerable heterogeneity in its clinical presentation, from patients who are relatively robust and suitable for standard treatment, to those who are frail and perhaps require a different approach. Frailty assessment also presents an important opportunity for intervention, when followed by Comprehensive Geriatric Assessment (CGA) in those who require it. Generally, a two-step approach, with a short initial screening, followed by CGA, is advocated in geriatric oncology guidelines. This has the potential to optimise care of the older person, and may also reverse or slow the development of frailty. It therefore has an important impact on the patient's quality of life, which is especially valued in the context of palliative care. Frailty assessment also allows a more informed discussion of treatment outcomes and a shared decision-making approach. With regards to the radiotherapy regimen itself, there are many adaptations that can better facilitate the older person, from positioning and immobilisation, to treatment prescriptions. Treatment courses should be as short as possible and take into account the older person's unique circumstances. The additional burden of travel to treatment for the patient, caregiver or family/support network should also be considered. Reducing treatments to single fractions may be appropriate, or alternatively, hypofractionated regimens. In order to enhance care and meet the demands of a rapidly ageing population, future radiation oncology professionals require education on the basic principles of geriatric medicine, as many aspects remain poorly understood.

Radiation oncology outpatient medication management needs and service gaps – A cross-sectional study of patients and clinicians

Background

Patients receiving radiotherapy for the treatment of cancer can have complex medication requirements related to the management of side-effects and impaired swallowing ability. This study surveyed patients and clinicians to identify service gaps and unmet medication management needs.

Methods

Patient and clinician surveys were developed by a multidisciplinary team based on previously validated questionnaires. The patient survey focused on medication use and adherence. The clinician survey was based around a clinical case study and focused on identifying service gaps and practice variations. This survey was disseminated to radiation oncologists, pharmacists and nurses involved with the care of head and neck or lung cancer patients in Victoria.

Results

A total of 93 surveys were completed including 53 patient surveys and 40 clinician surveys. Radiotherapy patients reported high medication usage with up to 53% taking five or more medications daily. When asked the same set of questions relating to medication education requirements, patients receiving polypharmacy reported greater needs (72%) than recognised by the surveyed multidisciplinary clinician group (58%). They also reported a non-adherence rate of 46%. In addition, further disparities were identified in clinician practices and their approach to clinical situations which may result in conflicting advice and confusion for patients.

Conclusion

While recognising deficiencies relating to the provision of medication information, oncologists, nurses and pharmacists underestimated patient needs for medication information, education and follow-up. Findings support the rationale for integration of pharmacy services within the radiotherapy clinics to support patient care and bridge service gaps relating to medication management.

Mechanism and therapeutic window of a genistein nanosuspension to protect against hematopoietic-acute radiation syndrome

There are no FDA-approved drugs that can be administered prior to ionizing radiation exposure to prevent hematopoietic-acute radiation syndrome (H-ARS). A suspension of synthetic genistein nanoparticles was previously shown to be an effective radioprotectant against H-ARS when administered prior to exposure to a lethal dose of total body radiation. Here we aimed to determine the time to protection and the duration of protection when the genistein nanosuspension was administered by intramuscular injection, and we also investigated the drug's mechanism of action. A single intramuscular injection of the genistein nanosuspension was an effective radioprotectant when given prophylactically 48 h to 12 h before irradiation, with maximum effectiveness occurring when administered 24 h before. No survival advantage was observed in animals administered only a single dose of drug after irradiation. The dose reduction factor of the genistein nanosuspension was determined by comparing the survival of treated and untreated animals following different doses of total body irradiation. As genistein is a selective estrogen receptor beta agonist, we also explored whether this was a central component of its radioprotective mechanism of action. Mice that received an intramuscular injection of an estrogen receptor antagonist (ICI 182,780) prior to administration of the genistein nanosuspension had significantly lower survival following total body irradiation compared with animals only receiving the nanosuspension (P < 0.01). These data define the time to and duration of radioprotection following a single intramuscular injection of the genistein nanosuspension and identify its likely mechanism of action.

A systematic review of the impact of outpatient clinical pharmacy services on medication-related outcomes in patients receiving anticancer therapies

BACKGROUND

Patients receiving anticancer therapies are frequently prescribed complex and high-risk medication regimens, which at times can result in medication misadventures. The objective of this review was to assess the effect of outpatient clinical pharmacy services on medication-related outcomes in patients receiving anticancer therapies, including patients undergoing radiotherapy.

METHODS

A systematic review of original publications indexed in EMBASE, MEDLINE and Cochrane Library from June 2007 to June 2017. Eligible studies evaluated outpatient pharmacy clinic services for cancer patients and reported at least one medication-related quantitative outcome measure. Two authors independently reviewed full-text articles for inclusion, then extracted data and performed quality and risk of bias assessments.

RESULTS

Of 908 identified publications, 13 met predefined eligibility criteria; 1 randomised control trial, 2 controlled cohort studies and 10 uncontrolled before-after studies. Many excluded studies described outpatient pharmacy services but lacked medication-related outcomes. All included studies had informative practice model designs, with interventions for drug-related problems including drug dose optimisation ( n = 8), reduced drug interaction ( n = 6) and adverse drug reaction reporting ( n = 3). Most studies ( n = 11) reported on symptom improvement, commonly nausea ( n = 7) and pain ( n = 5). Of four studies in radiotherapy cohorts, pharmacist involvement was associated with improved symptoms, satisfaction and wellbeing scores.

CONCLUSION

Few studies have objectively assessed outpatient pharmacy cancer services, even fewer in the radiotherapy settings. Although the results support these services, significant heterogeneity and bias in the study designs prohibit robust conclusions and further controlled trials are required.

Assessment and management of radiotherapy induced toxicity in older patients

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

Oral mucositis prevention by low-level laser therapy in head-and-neck cancer patients undergoing concurrent chemoradiotherapy: a phase III randomized study

PURPOSE

Oral mucositis is a major complication of concurrent chemoradiotherapy (CRT) in head-and-neck cancer patients. Low-level laser (LLL) therapy is a promising preventive therapy. We aimed to evaluate the efficacy of LLL therapy to decrease severe oral mucositis and its effect on RT interruptions.

METHODS AND MATERIALS

In the present randomized, double-blind, Phase III study, patients received either gallium-aluminum-arsenide LLL therapy 2.5 J/cm(2) or placebo laser, before each radiation fraction. Eligible patients had to have been diagnosed with squamous cell carcinoma or undifferentiated carcinoma of the oral cavity, pharynx, larynx, or metastases to the neck with an unknown primary site. They were treated with adjuvant or definitive CRT, consisting of conventional RT 60-70 Gy (range, 1.8-2.0 Gy/d, 5 times/wk) and concurrent cisplatin. The primary endpoints were the oral mucositis severity in Weeks 2, 4, and 6 and the number of RT interruptions because of mucositis. The secondary endpoints included patient-reported pain scores. To detect a decrease in the incidence of Grade 3 or 4 oral mucositis from 80% to 50%, we planned to enroll 74 patients.

RESULTS

A total of 75 patients were included, and 37 patients received preventive LLL therapy. The mean delivered radiation dose was greater in the patients treated with LLL (69.4 vs. 67.9 Gy, p = .03). During CRT, the number of patients diagnosed with Grade 3 or 4 oral mucositis treated with LLL vs. placebo was 4 vs. 5 (Week 2, p = 1.0), 4 vs. 12 (Week 4, p = .08), and 8 vs. 9 (Week 6, p = 1.0), respectively. More of the patients treated with placebo had RT interruptions because of mucositis (6 vs. 0, p = .02). No difference was detected between the treatment arms in the incidence of severe pain.

CONCLUSIONS

LLL therapy was not effective in reducing severe oral mucositis, although a marginal benefit could not be excluded. It reduced RT interruptions in these head-and-neck cancer patients, which might translate into improved CRT efficacy.