Hypofractionated Palliative Radiotherapy in Locally Advanced Inoperable Head and Neck Cancer: CMC Vellore Experience

Are oral cancers effectively palliated with radiotherapy? Outcomes of treatment with a modified QUAD SHOT regimen

BACKGROUND

This study assessed a palliative radiotherapy regimen using daily radiation over 4 days for three courses in inoperable head and neck cancers, emphasizing oral primary cancers.

METHODS

Retrospective data of 116 patients treated with a daily dose of 3.6-3.7 Gy in four fractions over 4 days to a total of three courses, with a 2-week gap after every course, were analyzed for survival outcomes. A subgroup analysis was done for oral cancer.

RESULTS

Ninety-nine (85%) completed three courses. Overall subjective response rate was 77%. Median overall survival and progression-free survival were 12 months (95% confidence interval [CI]: 8-20) and 8 months (95% CI: 6-10), with numerically higher overall survival in oral cancer. The treatment was well tolerated, with no on-treatment hospitalization or grade 3-4 toxicities.

CONCLUSION

The modified QUAD SHOT regimen is practical for palliation in head and neck cancers.

Outcome of Hypofractionated Palliative Radiotherapy Regimens for Patients With Advanced Head and Neck Cancer in Tikur Anbessa Hospital, Ethiopia: A Prospective Cohort Study

PURPOSE

Head and neck cancers (HNCs) are the third most commonly treated cancer with radiation in Ethiopia. Most patients present with advanced stage and are not candidates for curative treatment. The objective of our study is to assess the outcome of hypofractionated palliative radiotherapy (RT) for advanced HNCs in a resource-limited setting.

MATERIALS AND METHODS

Patients with histology-proven advanced HNC candidates for hypofractionated palliative RT were enrolled. Three regimens were allowed: 44.4 Gy in 12 fractions, 30 Gy in 10 fractions, and 20 Gy in five fractions. Response to treatment was assessed at baseline and at 4 weeks after treatment completion. The Kaplan-Meier curve was used to measure the survival.

RESULTS

Between January 2022 and January 2023, 52 patients were enrolled and 25 patients were eligible for outcome assessment. Index symptoms include pain, bleeding, dysphagia, respiratory distress, and others in 25, 13, 10, 6, and 17 patients, respectively. Complete relief of the top three symptoms include pain in 52% of patients, hemostasis in 84% of patients, and dysphagia in 30% of patients. Objectively, 64% of patients attained partial response. For 48% of patients, their quality of life (QoL) improved in one parameter of the physical scores. Moreover, 64% of patients showed improvement in three parameters. The global functional score improved in 80% of patients. One patient had grade 3 xerostomia. At the end of the study period, 44% of patients died. The median survival after radiation was 9 months (95% CI, 7.2 to 10.8).

CONCLUSION

All palliative hypofractionated regimens used were effective in terms of symptom control, tumor response rate, and QoL, and were well tolerated. This makes it appropriate for our setup because the majority of patients require palliation.

Identification of an endoplasmic reticulum stress-related prognostic risk model with excellent prognostic and clinical value in oral squamous cell carcinoma

BACKGROUND

Recently, endoplasmic reticulum stress related gene (ERS) markers have performed very well in predicting the prognosis of tumor patients.

METHODS

The differentially expressed genes in Oral squamous cell carcinoma (OSCC) were obtained from TCGA and GTEx database. Three prognosis-related and differentially expressed ERSs were screened out by Least Absolute Selection and Shrinkage Operator (Lasso) regression to construct a prognostic risk model. Receiver Operating Characteristic Curve (ROC), riskplots and survival curves were used to verify the model's accuracy in predicting prognosis. Multi-omics analysis of immune infiltration, gene mutation, and stem cell characteristics were performed to explore the possible mechanism of OSCC. Finally, we discussed the model's clinical application value from the perspective of drug sensitivity.

RESULTS

Three genes used in the model (IBSP, RDM1, RBP4) were identified as prognostic risk factors. Bioinformatics analysis, tissue and cell experiments have fully verified the abnormal expression of these three genes in OSCC. Multiple validation methods and internal and external datasets confirmed the model's excellent performance in predicting and discriminating prognosis. Cox regression analysis identified risk score as an independent predictor of prognosis. Multi-omics analysis found strong correlations between risk scores and immune cells, cell stemness index, and tumor mutational burden (TMB). It was also observed that the risk score was closely related to the half maximal inhibitory concentration of docetaxel, gefitinib and erlotinib. The excellent performance of the nomogram has been verified by various means.

CONCLUSION

A prognostic model with high clinical application value was constructed. Immune cells, cellular stemness, and TMB may be involved in the progression of OSCC.

Assessing the efficacy of palliative radiation treatment schemes for locally advanced squamous cell carcinoma of the head and neck: a meta-analysis

Background

The objective to assess the outcomes from different palliative radiotherapy (RT) schedules in incurable head and neck cancer (HNC), to evaluate if there is a relationship between RT dose, technique, and fractionation with tumor response in contrast to the occurrence of adverse effects.

Materials and methods

Eligible studies were identified on Medline, Embase, the Cochrane Library, and annual meetings proceedings through June 2020. Following PRISMA and MOOSE guidelines, a cumulative meta-analysis of studies for overall response rate (ORR), overall survival (OS), progression-free survival (PFS), pain/dysphagia relief, and toxicity was performed. A meta-regression analysis was done to assess if there is a connection between RT dose, schedule, and technique with ORR.

Results

Twenty-eight studies with 1,986 patients treated with palliative RT due to incurable HNC were included. The median OS was 6.5 months [95% confidence interval (CI): 5.6-7.4], and PFS was 3.6 months (95% CI: 2.7-4.3). The ORR, pain and dysphagia relief rates were 72% (95% CI: 0.6-0.8), 83% (95% CI: 52-100%), and 75% (95% CI: 52-100%), respectively. Conventional radiotherapy (2D-RT) or conformational radiotherapy (3D-RT) use were significantly associated with a higher acute toxicity rate (grade ≥ 3) than intensity-modulated radiation therapy (IMRT) or stereotactic body radiation therapy (SBRT). On meta-regression analyses, the total biological effective doses (BED) of RT (p = 0.001), BED > 60 Gy10 (p = 0.001), short course (p = 0.01) and SBRT (p = 0.02) were associated with a superior ORR.

Conclusions

Palliative RT achieves tumor response and symptom relief in incurable HNC patients. Short course RT of BED > 60 Gy using IMRT could improve its therapeutic ratio. SBRT should be considered when available.

A prospective randomized comparative study to evaluate the effect of palliative hypo-fractionated radiotherapy with concurrent chemotherapy versus hypo-fractionated radiotherapy alone in advanced and unresectable head and neck cancer with no metastasis

Introduction

A short duration, palliative radiotherapy schedule for locally advanced and unresectable head and neck cancer (LAUHNC) was evaluated in terms of palliation of cancer-related symptoms and acute toxicities.

Aims and objectives

The aim of the study was to compare the role and feasibility of hypo-fractionated radiotherapy with concurrent chemotherapy and hypo-fractionated radiotherapy in LAUHNC.

Materials and methods

All the patients included in this study of LAUHNC were not fit for curative treatment. These patients are assessed on the basis of quality of life (QOL), tumour response, toxicities, and relief in symptoms. QOL was assessed on the basis of University of Washington QOL questionnaire version 4 before and after treatment. Patients are divided into two arms, Arm A patients received 40 Gy in ten fractions concurrent cisplatin 50 mg/m2 with weekly and Arm B patients received 40 Gy in ten fractions. To assess the tumour response response evaluation criteria in solid tumours criteria were used.

Results

A total of 40 patients were enrolled in this study, with 20 patents in both arms. Three patients defaulted during treatment and one patient died during treatment. A total of 36 patients completed treatment. Before treatment common complaints was distressing pain in primary site, and difficulty in chewing and swallowing. After treatment there was reduction of pain and improvement in swallowing in both arms. Overall QOL improvement in Arm A (28.89 ± 18.44 to 46.67 ± 15.34) and in Arm B (31.11 ± 15.68 to 43.33 ± 15.72). Neither of the arms experienced grade IV mucositis and skin reaction.

Conclusion

Toxicity in the form of mucositis and dermatitis was higher in the concurrent hypo-fractioned arm compared to the only hypo-fractionated radiotherapy arm during the treatment and in follow up period. The QOL in both individual arms showed statistically significant results, however when the QOL of both the arms was compared, the results were not statistically significant.

Palliative radiotherapy: a one-week course in advanced head and neck cancer - quality of life outcomes

OBJECTIVES

Palliative radiotherapy regimens for advanced head and neck cancers vary in doses and treatment times. Their quality of life (QoL) implications are not clearly established.

METHODS

We randomised patients with advanced, non-metastatic, head and neck squamous cell carcinomas (stage IVA-B) with WHO performance score of 2 or higher to receive 30 Gy in 10 fractions over two weeks (arm A) or 20 Gy in 5 fractions over one week (arm B). QoL was assessed using European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaires (QLQ)-C30 and QLQ-H&N35 questionnaires at baseline and postradiotherapy. The primary endpoint was the EORTC-defined global health status. Secondary endpoints were functional and symptom scores of QoL, response to radiotherapy and acute toxicities. The primary aim was to evaluate the one-week regimen in terms of QoL to the longer regimen.

RESULTS

110 patients were randomised, the number of patients in the final analysis was 95: 49 in arm A and 46 in arm B. Baseline characteristics were similar. Clinical outcomes post-treatment were comparable. Postradiotherapy, there were improved scores for functional and symptom scales, the differences were non-significant. The duration of treatment was significantly reduced in arm B (p<0.01) with a lower score for financial difficulty (p<0.001). The difference in global health status (primary endpoint) was non-significant (p=0.82). The median overall survival was 7 months, the median progression-free survival was 5 months and these did not vary between the two groups.

CONCLUSION

One-week palliative radiotherapy for head and neck cancers achieves similar QoL and clinical outcomes as more protracted radiotherapy schedules with significantly reduced treatment time and financial toxicity.

Patient-Reported Outcomes Assessing the Impact of Palliative Radiotherapy on Quality of Life and Symptom Burden in Head and Neck Cancer Patients: A Systematic Review

Incurable head and neck cancer has a poor prognosis and impairs a patient's health-related quality of life. Palliative radiotherapy may improve or stabilize health-related quality of life and symptoms, best measured by patient-reported outcomes. There is no systematic analysis if palliative radiotherapy for head and neck cancer improves or stabilizes health-related quality of life or symptoms as validly measured by patient-reported outcomes. Therefore, the primary objective of this systematic review (PROSPERO-ID: CRD42020166434) was to assess the effect of palliative radiotherapy for head and neck cancer on patient-reported outcomes. The secondary objective was to assess the rate and quality of use of patient-reported outcomes in relevant studies claiming a "palliative effect" of radiotherapy. The databases MEDLINE/PubMed, EMBASE, Cochrane CENTRAL, "ClinicalTrials.gov" were searched. Concerning the primary objective, four studies were eligible to assess the effectiveness of palliative radiotherapy as measured by patient-reported outcomes. A narrative synthesis suggests a favorable impact of palliative radiotherapy on health-related quality of life and symptom burden. The risk of bias, however, is considerable and the overall quality of evidence low. Concerning the secondary objective, over 90% of studies claiming a "palliative effect" of palliative radiotherapy did either not use patient-reported outcomes or did so by limited quality. In conclusion, implementation of patient-reported outcomes in studies assessing palliative radiotherapy for head and neck cancer should be fostered. Palliative radiotherapy remains an option for head and neck cancer patients, although more studies focusing on patient-reported outcomes are needed.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier CRD42020166434.

Quality of life of cancer patients at palliative care units in developing countries: systematic review of the published literature

Purpose

This systematic review aims to summarize factors that influence the quality of life (QOL) of advanced cancer patients in palliative care (PC) in developing countries. Understanding this context in developing countries milieu is necessary; however, this outcome is rarely reported.

Methods

Following the PRISMA guidelines, the electronic databases MEDLINE, Embase, CINAHL, and Web of Science were systematically searched using the search terms: QOL, cancer, PC, and names of all developing countries. Studies with less than ten subjects, qualitative or pilot studies, reviews, conference abstracts, and that reported validation of QOL questionnaires were excluded.

Results

Fifty-five studies from 15 developing countries in the African (n = 5), Latin America and the Caribbean (n = 10), and Asian (n = 40) region were included in the narrative synthesis. 65.4% were cross-sectional, 27.3% were cohort studies, 7.3% were RCTs or quasi-experimental studies. Around 30 QOL factors were studied with 20 different types of QOL instruments. Advanced cancer patients who were older, married/ever married, participated in additional care within PC, used complementary and alternative medicine (CAM), and practiced spirituality/religiosity showed higher QOL score. Low educational level and high depression were associated with a lower QOL.

Conclusion

Various factors affect QOL among cancer patients in PC. Patients valued the use of CAMs; however, the quality and safety aspects should be properly addressed. Important factors that influenced the QOL score were social and spiritual support. While there is a general need to develop PC strategies further, recognizing patients’ needs should be prioritized in national cancer programs.

Electronic supplementary material

The online version of this article (10.1007/s11136-020-02633-z) contains supplementary material, which is available to authorized users.

Effect of Hypofractionated, Palliative Radiotherapy on Quality of Life in Late-Stage Oral Cavity Cancer: A Prospective Clinical Trial

Context:

The study was designed to evaluate the effect of a hypofractionated, palliative conformal radiotherapy regimen of 5250 cGy in 15 fractions in inoperable/incurable oral cavity carcinoma.

Aims:

The primary objective was to assess the change in the quality of life (QOL) with respect to pain and mouth opening pre- and post-radiotherapy using standardized questionnaires. The secondary objective was to assess overall QOL using the same questionnaires and also to assess response rates, survival, compliance, early and late toxicity.

Settings and Design:

This was a single-arm, prospective trial. Patients with incurable oral cavity cancer referred for palliative intent radiotherapy to the Department of Radiotherapy, RCC, JIPMER were recruited into the study.

Subjects and Methods:

Forty-eight patients were recruited and twenty-five patients were given conformal radiotherapy to a dose of 52.5 Gy in 15 fractions. QOL was assessed using the European Organization of Research and Treatment of Cancer (EORTC) questionnaires before and 2 months after the completion of radiotherapy. The response assessment was made using the Response Evaluation Criteria in Solid Tumors (RECIST) criteria 2 months after radiotherapy. The early and late toxicities were assessed at 2 months and 6 months after radiotherapy completion, respectively.

Statistical Analysis Used:

Sample size was calculated to be 53. The Wilcoxon signed-rank test was used to compare QOL scores pre- and post-radiotherapy. Median survival was assessed using the Kaplan–Meier method.

Results:

There was a significant improvement in the pain, mouth opening, speech, social contact, social eating, felt ill items of the EORTC QLQ-H and N35 questionnaire and role functioning, emotional functioning, social functioning, fatigue, pain, insomnia, appetite loss, financial difficulties, and Global QOL subscales of the QLQ-C30 questionnaire. 72% of the patients had grade 3 acute radiation oral mucositis and 36% had grade 3 acute radiation dermatitis. There were no significant treatment breaks due to toxicity. There were no grade 3 late toxicities observed. Overall median survival was 5.1 months. The overall response rate was 47%. The median time to treatment completion was 24 days.

Conclusions:

The improvement in QOL parameters suggests that the regimen of 52.5 Gy in 15 fractions is suitable for palliative intent radiotherapy in late-stage oral cavity cancer for effective palliation for short periods.

Symptom palliation of hypofractionated radiotherapy for patients with incurable inflammatory breast cancer

Background

Incurable inflammatory breast cancer (IBC) patients occasionally suffer from general symptoms such as breast pain, bleeding, ulceration, and discharge, and thus require palliative radiotherapy (RT). Hypofractionated RT has many advantages in palliative settings, but very few studies on IBC have been conducted. This study was conducted to evaluate the effects of hypofractionated RT on symptomatic IBC patients.

Methods

Twenty-two patients with IBC who underwent hypofractionated palliative RT between 2010 and 2016 were retrospectively analyzed. RT was performed at a total dose of 42.5–55 Gy with 2.5–3 Gy per fraction. The treatment effects were evaluated with respect to symptom improvement, tumor response, and treatment-related toxicity.

Results

The main symptoms that the patients complained of before RT were pain, bleeding, and discharge. According to the percentage of symptom relief compared with pre-RT symptoms, the number of patients with < 30, 30–70%, and ≥ 70% were 2 (9.1%), 7 (31.8%), and 13 (59.1%), respectively. Eighteen (81.8%) patients showed tumor response. No patient experienced grade 3 or higher acute or chronic toxicity during a median follow-up period of 13 months. In univariate analysis, symptom type was a significant factor for predicting the degree of symptom relief. Meanwhile, RT field and C-reactive protein increase were significant factors for predicting the incidence of radiation-induced skin toxicity.

Conclusions

Hypofractionated RT could safely and effectively relieve symptoms among incurable symptomatic IBC patients.

Palliative Radiation Therapy for Head and Neck Cancers

Patients with advanced head and neck cancers who are not eligible for curative treatment represent a challenging cohort of patients to manage given the complexity and severity of their presenting symptoms. Palliative radiation therapy, along with other systemic and surgical measures, has the potential to significantly improve the quality of life of such patients. There is little high-level evidence and a lack of consensus to direct the selection of an optimal palliative radiation regimen. An ideal palliative radiation regimen should alleviate symptoms secondary to the cancer with minimal treatment toxicity and side effects while improving a patient's quality of life. This review presents the treatment approaches, outcomes, and toxicities associated with different radiation regimens and proposes a multidisciplinary framework for the selection of an individualized treatment regimen for patients that centers around patient prognosis, goals of care, logistics of treatment, and the availability of other surgical and systemic therapies.

Downregulation of GBAS regulates oral squamous cell carcinoma proliferation and apoptosis via the p53 signaling pathway

Purpose: Oral squamous cell carcinoma (OSCC) is the most common and severe type of head and neck malignancy. The mechanisms by which OSCC arises depend on changes in a number of different factors and genes and the clinicopathological stage of the tumors. Better understanding the possible mechanisms of OSCC would help to identify a new target for molecular targeted therapy. The current study was focused on elucidating the significance of the glioblastoma-amplified sequence (GBAS) on malignant behaviors in OSCC, including proliferation and apoptosis.

Patients and methods: In this study, we measured the levels of mRNA in OSCC and normal oral tissue samples using Affymetrix microarrays. We examined GBAS expression in OSCC tissues and the effect of GBAS knockdown on cell proliferation and apoptosis in vitro and in vivo. The mechanisms underlying GBAS were investigated.

Results: In the present study, GBAS expression was substantially elevated in the majority of tested OSCC tissues. Further, knockdown of GBAS using lentiviral-delivered shRNA in cells had significant effects on cell proliferation, apoptosis and the cell cycle. A xenograft model was also used to assess the tumorigenicity of the GBAS knockdown on OSCC cells in vivo. Mechanistically, GBAS activated p53 signaling by regulating the mRNA and protein expression of CHEK1, AKT1, AKT2 and Bax. Finally, we also investigated the expression of GBAS in patients with OSCC, and the data revealed that GBAS expression was correlated with the rates of relapse and tumor grade.

Conclusion: Our studies provide evidence that GBAS regulates OSCC cell proliferation and apoptosis via p53 signaling, which may be a candidate biomarker for the prognosis and treatment of OSCC.

Reirradiation for Recurrent Nasopharyngeal Carcinomas: Experience From an Academic Tertiary Center in a Low- to Middle-Income Country

PURPOSE

The objectives of this study were to report the oncologic outcomes and the treatment-related toxicities after reirradiation (re-RT) for recurrent nasopharyngeal carcinoma (rNPC) at our institution and to apply a recently published prognostic model for survival in rNPC in our cohort.

PATIENTS AND METHODS

Thirty-two patients with rNPC treated at the authors' institution with re-RT were retrospectively reviewed. Treatment modalities for re-RT were intensity-modulated radiotherapy (n = 14), three-dimensional conformal radiotherapy (n = 9), single-fraction stereotactic radiosurgery (n = 6), fractionated stereotactic radiotherapy (n = 2), and high dose rate intracavitary brachytherapy (n = 1). Twenty-seven patients received re-RT with curative intent, whereas five patients were treated palliatively.

RESULTS

Median follow-up time was 15.5 months (range, 1 to 123 months) for the entire cohort and 20 months (range, 3 to 123 months) for patients treated with curative intent. For the entire cohort, median locoregional recurrence-free survival (LRRFS) was 14 months, with actuarial 1- and 2-year LRRFS estimates of 67.5% and 44.0%, respectively. Median overall survival (OS) time was 38 months, with actuarial 1- and 2-year estimates of 74.2% and 57.2%, respectively. For patients treated with curative intent, median LRRFS was not reached. Actuarial 1- and 2-year LRRFS estimates were 68.2% and 54.5%, respectively. Median OS time after curative intent re-RT was 42 months, with actuarial 1- and 2-year estimates of 75.4% and 63.8%, respectively. One- and 2-year OS estimates based on risk stratification were 68.6% for high risk compared with 80.8% for low risk and 34.3% for high risk compared with 70.7% for low risk, respectively (P = .223). Three patients (9.4%) developed symptomatic temporal lobe necrosis. There was no reported grade 5 treatment-related toxicity.

CONCLUSION

Results of the study suggest that re-RT is an effective and safe salvage treatment strategy for rNPC. Re-RT to a maximum equivalent dose in 2-Gy fractions of 60 Gy may yield good LRRFS and translate to prolonged OS.

Conventional Fractionation versus Quad Shot in Advanced Head-and-Neck Cancers: A Randomized Controlled Trial

Context:

A significant number of patients with head-and-neck cancers have an incurable disease with limited life expectancy. The objective of the present study was to compare two different short courses of hypofractionated palliative radiotherapy regimens to evaluate symptoms, disease response, and acute toxicity.

Materials and Methods:

Previously untreated 50 patients of Stage IV B and IV C head and neck cancers were randomized to receive conventional hypofractionated palliative radiotherapy 30 Gy/10 fractions/2 weeks (control group) or Quad Shot regimen (study group) 14 Gy in 4 fractions given twice a day at least 6 h apart for 2 consecutive days. This regimen was repeated at 4 weekly intervals for a further two courses if there was no tumor progression.

Results:

Symptom relief was similar among the two schedules for pain (60.86 vs. 57.17), dysphagia (60.86 vs. 52.17%), and hoarseness (43.85 vs. 38.09%). Overall response (that is partial response and stable disease) was seen in majority (>70%) of the patients in both the groups. Treatment was very well tolerated with no patient experiencing more than Grade 3 toxicity in the control group and Grade 2 toxicity in the study group.

Conclusions:

Quad Shot regimen is an effective hypofractionated palliative radiotherapy schedule with minimal toxicity, good symptom relief, and response rate as compared to conventionally used regimen (30 Gy/10 fractions/2 weeks).

Proton Radiotherapy for Recurrent or Metastatic Head and Neck Cancers with Palliative Quad Shot

Purpose

Some patients with previously treated, unresectable, recurrent or metastatic head and neck malignancies are not amenable to curative-intent treatment. Here, we investigated the quad-shot (RTOG 8502) regimen of hypofractionated proton radiotherapy (RT) in that patient population.

Materials and Methods

From 2013 to 2015, 26 patients with recurrent or metastatic cancers were treated with palliative proton RT to the head and neck with quad shot (3.7 Gy twice daily for 2 days). Patient characteristics and survival data were reviewed.

Results

Seventeen (65%) patients received ≥ 3 quad-shot cycles and 23 (88%) had prior head and neck RT. Overall palliative response was 73% (n = 19). The most common presenting symptom was pain (50%; n = 13), which improved in 85% (n = 22) of all patients. The overall grade-1 acute-toxicity rate was 58% (n = 15), and no acute grade 3 to 5 toxicities were observed.

Conclusions

The proton quad-shot regimen demonstrates favorable palliative response and toxicity profile, even in patients that received prior RT.

An Extended Hypofractionated Palliative Radiotherapy Regimen for Head and Neck Carcinomas

Background

Palliative radiotherapy to patients with head and neck cancer is often necessary, but there is a substantial variation in the treatment regimens reported in the literature, and consensus on the most appropriate schedules does not exist. In order to minimize acute toxicity while at the same time trying to achieve prolonged tumor control, a long hypofractionated regimen has been used routinely in Denmark. In the current retrospective study, we investigated the outcome in patients intended for palliative radiotherapy with this regimen.

Materials and methods

Patients with newly diagnosed head and neck cancer treated with palliative radiotherapy of 52-56 Gy in 13-14 fractions twice weekly from 2009 to 2014 were included. Patients were excluded if they had previously received radiotherapy. Data on disease location, stage, patient performance status (PS), treatment response, acute skin and mucosal toxicity, and late fibrosis were collected prospectively and supplemented with information from medical records.

Results

77 patients were included in the study. Fifty-eight patients (75%) completed the intended treatment. Loco-regional tumor response (complete or partial) was evaluated 2 months posttreatment and observed in 45% of the entire population corresponding to 71% of patients alive. PS had a significant influence on survival (p = 0.007) and on not completing the intended treatment. Grade III or IV acute mucositis were observed in 25%, and grade III or IV acute dermatitis observed in 15%.

Conclusion

Palliative hypofractionated radiotherapy with 52-56 Gy in 13-14 fractions shows good tumor response and tolerability in a vulnerable patient population. However, it may not be suited for patients in poor PS.

Palliative radiotherapy for locally advanced non-metastatic head and neck cancer: A systematic review

OBJECTIVES

The objective of this systematic review was to identify and appraise the existing evidence of role of palliative radiotherapy for locally advanced non-metastatic head and neck cancer.

METHODS

A systematic search of the literature was conducted using Medline, Embase and Cochrane databases and relevant references were included.

RESULTS

Literature search revealed a wide variation in dose fractionation regimens. Reported outcomes showed high efficacy and low rate of significant side effects, except in studies utilising higher doses of radiotherapy where higher grade toxicities were seen. Reported median overall survival was in the range of 3.3-17 months, but most studies reported median survival of around 6 months.

CONCLUSIONS

The choice of palliative radiotherapy varies significantly. This is in contrast to regimens of curative radiotherapy for locally advanced head and neck cancer, which are well standardised. Given the reported relatively short overall survival of this patient group, an ideal treatment should be of the shortest possible duration whilst ensuring effective palliation and minimal side effects. Future well designed trials are needed to evaluate quality of life and duration of side effects in addition to survival and severity of toxicities in this group of patients.

Ten-Year Outcome of Different Treatment Modalities for Squamous Cell Carcinoma of Oral Cavity

Objective:

This study reports outcomes of squamous cell carcinoma of oral cavity (SCCOC) patients with different treatment modalities.

Materials and Methods:

We evaluated the treatment outcomes of 775 newly diagnosed SCCOC patients treated in our hospital between 2001 and 2010. Outcome data were obtained from the medical records. Survival rates were estimated by the Kaplan-Meyer method. Cox-proportional-hazard regression models were used to compare the risk of death among all risk factors.

Results:

The patients were divided into group 1) surgery ± adjuvant radiotherapy (RT) (n = 323) or group 2) RT ± chemotherapy (CT) for curative intent (n = 315) or group 3) RT/CT for palliative intent (n = 137). The overall 10-year survival rate was 17%. Statistically significant difference was noted in 10-year overall survival when SCCOC was managed surgically as compared to curative RT and palliative RT/CT with 25.3 %, 12.9%, 4.7%, respectively. The hazard ratio of cancer death in group 1 was 2.0 (95% CI 1.7-2.4) as compared to group 2.

Conclusion:

This study suggested that surgery must be the mainstay of treatment in locally advanced stage SCCOC. Palliative RT/CT still offered long term survival in some SCCOC patients.

An audit of the results of a triplet metronomic chemotherapy regimen incorporating a tyrosine kinase inhibitor in recurrent/metastatic head and neck cancers patients

BACKGROUND

Addition of erlotinib to metronomic chemotherapy (MCT) may lead to further improvement in progression-free survival (PFS) and overall survival in head and neck cancers. The aim of this study was to study the PFS with MCT + erlotinib combination in our setting.

METHODS

A single-arm prospective observational study conducted at Malabar Cancer Center. Patients warranting palliative chemotherapy for head and neck cancers, having adequate organ function, not-affording cetuximab and not willing for intravenous chemotherapy were included in this study. Oral methotrexate (15 mg/m(2)/week), oral celecoxib (200 mg twice daily), and erlotinib (150 mg once daily) were administered till the progression of the disease or till intolerable side-effects. Patients underwent toxicity (CTCAE version 4.02) and response (RECIST version 1.1) assessment every 30 days. Statistical analysis was performed using SPSS version 16 (IBM, New York, USA). Descriptive statistics and Kaplan-Meier analysis have been performed.

RESULTS

A total of 15 patients received MCT. The median age of these patients was 65 years (range: 48-80). The Eastern Cooperative Oncology Group Performance Status was 0-1 in seven patients (46.7%), while it was 2 in eight patients (53.3%). The primary sites of tumor were predominantly oral cavity, 11 (73.4%). Prior to MCT, treatment with palliative radiation therapy was given in 11 patients and curative treatment in two patients. The best response post-MCT was complete remission in two patients, partial remission in seven patients, stable disease in four patients, and progressive disease in two patients. The median estimated PFS was 148 days (95% confidence interval 95.47-200.52 days). For a median follow-up of 181 days, there were only three deaths. Grade 3-4 toxicity was seen in six patients (40%). Dose reduction was required in four patients (26.7%).

CONCLUSION

The addition of erlotinib to an MCT schedule of methotrexate and celecoxib resulted in a promising PFS and should be tested in future studies.

Initial Experience of Head and Neck Cancer Patients Treated in an Oncologist Led Palliative Cancer Care Clinic at a Tertiary Cancer Care Center in Uttar Pradesh: Is the Initiative of a Full-fledged Palliative Care for Cancer Patients Justified

Introduction:

Poor socioeconomic status and illiteracy attribute to the advanced presentation of head and neck cancer (HNC) patients in India and are candidates for palliation in our setup. We set up a palliative cancer care clinic (PCCC), and an audit of initial 153 HNC patients is presented.

Aims and Objectives:

To assess the impact of palliative cancer care services.

Methodology:

Data of advanced HNC patients suited for palliation were collected to document demography, symptomatology, cancer treatment, and supportive care.

Results:

One hundred and fifty-three patients were seen during January 2013 to March 2015 in the PCCC. Seventy-two (47%) referral cases were due to disease progression and 81 (53%) due to de novo advanced cases. Median follow-up for this group was 5.3 months. Ninety (59%) cases needed some degree of assistance for their normal activities. Sixty-seven (44%) patients belonged to poor socioeconomic status and 65 (43%) were educated up to equivalent of high school. One hundred and thirty-five (88%) patients had an adequate family support. Pain was the most common presenting symptom in 134 (87%) cases with adequate relief in 112 (84%) patients with another 13 (09%) could not be assessed. Overall median duration of symptoms was 6 months. Cancer-directed therapy was used in 143 (93%) patients. Near the end of life in 47 (73%) out of 63 documented cases, caregivers were psychologically prepared for the inevitable.

Conclusion:

The role of palliative care team in alleviating physical, psychosocial, and emotional issues of patient and family members was significant. PCCC seems to be a feasible working model in our setup.

Stereotactic body radiotherapy as primary treatment for elderly patients with medically inoperable head and neck cancer

PURPOSE

With a growing elderly population, elderly patients with head and neck cancers represent an increasing challenge with limited prospective data to guide management. The complex interplay between advanced age, associated co-morbidities, and conventional local therapies, such as surgery and external beam radiotherapy ± chemotherapy, can significantly impact elderly patients' quality of life (QoL). Stereotactic body radiotherapy (SBRT) is a well-established curative strategy for medical-inoperable early-stage lung cancers even in elderly populations; however, there is limited data examining SBRT as primary therapy in head and neck cancer.

MATERIAL/METHODS

Twelve patients with medically inoperable head and neck cancer treated with SBRT ± cetuximab from 2002 to 2013 were retrospectively reviewed. SBRT consisted of primarily 44 Gy in five fractions delivered on alternating days over 1-2 weeks. Concurrent cetuximab was administered at a dose of 400 mg/m(2) on day -7 followed by 250 mg/m(2) on day 0 and +7 in n = 3 (25%). Patient-reported quality of life (PRQoL) was prospectively recorded using the previously validated University of Washington quality of life revised (UW-QoL-R).

RESULTS

Median clinical follow-up was 6 months (range: 0.5-29 months). The 1-year actuarial local progression-free survival, distant progression-free survival, progression-free survival, and overall survival for definitively treated patients were 69, 100, 69, and 64%, respectively. One patient (8%) experienced acute grade 3 dysphagia and one patient (8%) experienced late grade 3 mucositis; there were no grade 4-5 toxicities. Prospective collection of PRQoL as assessed by UW-QoL-R was preserved across domains.

CONCLUSION

Stereotactic body radiotherapy shows encouraging survival and relatively low toxicity in elderly patients with unresectable head and neck cancer, which may provide an aggressive potentially curative local therapy while maintaining QoL.