A Multicenter Study of Clinician and Patient Reported Acute and Late Toxicity after Radical (Chemo)Radiotherapy for Non-Endemic Nasopharyngeal Cancer

PURPOSE/OBJECTIVE(S)

Curative (chemo)radiotherapy ((CT)RT) for Nasopharyngeal cancers (NPC) achieves excellent disease control but is associated with significant late toxicities despite modern treatment delivery. Contemporary late toxicity data, including patient reported outcomes (PROs), is limited in the non-endemic population; we present a large contemporary series of toxicity outcomes and late PROs following treatment of non-endemic NPC.

MATERIALS/METHODS

Adult patients completing radical (CT)RT for primary NPC between February 2016 and 2020 at 7 large UK cancer centers were identified on institutional databases. Patients were excluded if they had prior head and neck cancer or prior therapeutic head and neck surgery (except neck dissection). Patients with an active other cancer were excluded from PRO assessment. Demographic, treatment, acute toxicity and outcome data were collected retrospectively from patient records. Disease-free patients were invited to complete an M.D. Anderson Dysphagia Index (MDADI) and University of Washington (UoW) Quality of Life (QoL) PROs questionnaires.

RESULTS

A total of 180 eligible patients were identified: 68% male, median age 54 years, 11% ≥70 years. EBV status was positive in 61% (unknown 12%). Patients had stage I (5%), II (22%), III (37%), IV (36%) disease; 95% were performance status ≤1 at baseline. Median follow-up was 31.2 months (range 0-68). A total of 54% received 70Gy in 33-35# and 43% received 65-66 Gy in 30-33#. 66% received induction and 65% received concurrent chemotherapy. 9.5% had residual disease at the first follow-up scan. Subsequent locoregional or distant recurrence occurred in 5% and 12% respectively. At last assessment, 84% patients were alive, 16% had died (of which 70% had active disease). Acute treatment toxicity included: 63% of patients required enteral support (median duration 98 days) with 9% a feeding tube at 1 year post treatment. 18% G3 dermatitis, 53% G3 mucositis. 82% requiring opioids and 40% admitted for symptom management. 90 patients completed the PROs (76% response rate) at a median of 37.8 months post treatment (Table 1). These demonstrate significant QoL detriment: 28% report significant pain, 24% require regular analgesia, and 59% report significant impact on daily activity. This was found to persist at different timepoints (not shown).

CONCLUSION

Excellent cancer survival outcomes are seen in a non-selected, non-endemic NPC population. However significant acute and late toxicity following radical treatment is identified which can profoundly negatively impact QoL in a relatively young cohort. This highlights the importance of ongoing efforts to reduce toxicity and supports the prospective evaluation of potential toxicity sparing technologies, such as proton beam radiotherapy.

Pretreatment Lymphocyte Count Predicts Benefit From Concurrent Chemotherapy With Radiotherapy in Oropharyngeal Cancer

PURPOSE

There is a need to refine the selection of patients with oropharyngeal squamous cell carcinoma (OPSCC) for treatment de-escalation. We investigated whether pretreatment absolute lymphocyte count (ALC) predicted overall survival (OS) benefit from the addition of concurrent chemotherapy to radical radiotherapy.

PATIENTS AND METHODS

This was an observational study of consecutive OPSCCs treated by curative-intent radiotherapy, with or without concurrent chemotherapy (n = 791) with external, independent validation from a separate institution (n = 609). The primary end point was OS at 5 years. Locoregional control (LRC) was assessed using competing risk regression as a secondary end point. Previously determined prognostic factors were used in a multivariable Cox proportional hazards model to assess the prognostic importance of ALC and the interaction between ALC and cisplatin chemotherapy use.

RESULTS

Pretreatment ALC was prognostic for 5-year OS on multivariable analysis (hazard ratio [HR] 0.64; 95% CI, 0.42 to 0.98; P = .04). It also predicted benefit from the use of concurrent cisplatin chemotherapy, with a significant interaction between cisplatin chemotherapy and pretreatment ALC (likelihood ratio test, P = .04): higher ALC count reduced the 5-year OS benefit compared with radiotherapy alone (HR 2.53; 95% CI, 1.03 to 6.19; P = .043). This was likely driven by an effect on LRC up to 5 years (interaction subdistribution HR 2.29; 95% CI, 0.68 to 7.71; P = .094). An independent validation cohort replicated the OS (HR 2.53; 95% CI, 0.98 to 6.52; P = .055) and LRC findings (interaction subdistribution HR 3.43; 95% CI, 1.23 to 9.52; P = .018).

CONCLUSION

For OPSCC, the pretreatment ALC is prognostic for OS and also predicts benefit from the addition of cisplatin chemotherapy to radiotherapy. These findings require prospective evaluation, and could inform the selection of good prognosis patients for a de-escalation trial.

The immune system--is it relevant to cancer development, progression and treatment?

The ability of the immune system to effectively respond to human tumours is a matter of long-term controversy. There is an increasing body of recent evidence to support a role for the immune system in eliminating pre-clinical cancers, an old concept termed 'immunosurveillance'. 'Immunoediting' is an updated hypothesis, in which selection pressures applied by the immune response to tumours modulate tumour immunogenicity and growth. Tumour infiltration by immune cells has been shown to have powerful prognostic significance in a host of cancer types. Paradoxically, in some circumstances the immune system can promote tumour development. Cytotoxic therapies, including radiotherapy and chemotherapy, induce potentially immunogenic cell death, releasing tumour-associated antigens in the context of a 'danger' signal to the immune system. An understanding of the interaction between immune cells, tumour cells and treatment modalities will therefore guide the future combination of immunotherapy with conventional therapy to achieve optimal anti-tumour effects.

Fatal pneumonitis in children with metastatic rhabdomyosarcoma following whole lung radiotherapy and sequential epirubicin

Interstitial pneumonitis is a recognized complication following whole lung radiotherapy. We report two cases in which fatal pneumonitis appeared to be precipitated by the administration of epirubicin-containing combination chemotherapy within 7 weeks of completion of whole lung radiotherapy. These cases highlight a potentially fatal interaction between radiotherapy and modern chemotherapy regimens.

Survival in high-grade glioma: a study of survival in patients unfit for or declining radiotherapy

AIMS

To determine the survival of patients with high-grade glioma (HGG) and a poor prognosis in terms of age or performance status managed with best supportive care alone.

METHODS

An analysis of survival was carried out on 123 patients with HGG declining or judged unfit to receive radiotherapy, on the basis of age or performance status, between February 1998 and October 2003. Karnofsky performance status (KPS), biopsy or resection or no surgery, attendance at clinic and reason for not receiving radiotherapy were prospectively recorded.

RESULTS

Of the 123 patients, three were excluded from the analysis, as no outcome data were available. Median age was 66 years (range 29-91 years), and median KPS was 50 (range 30-100). All 120 patients included had died at the time of analysis. Overall median survival was 68 days (95% CI 56-85), range 2-294 days and interquartile range 35-123 days. Median survival of 22 patients declining radiotherapy was 75 days (95% CI 53-123), of 98 patients unfit for radiotherapy 67 days (95% CI 48-88); non-significant difference P = 0.36. Median survival of 26 patients undergoing biopsy was 95 days (95% CI 66-123), of 56 undergoing surgical resection 74 days (95% CI 47-93), and of 38 receiving no surgical intervention 59 days (95% CI 47-70); non-significant difference P = 0.16.

CONCLUSION

For patients with HGG and a poor prognosis, in terms of age or performance status managed with best supportive care, survival is short. Survival may be too short to benefit from radiotherapy and possibly surgery.

Neuro-oncology Practice in the UK

The aim of the study was to determine current U.K. neuro-oncology practice. A questionnaire was sent to all U.K. clinical oncologists who treat primary brain tumours. Results were distributed to these doctors with an invitation to attend a workshop in September 2000 to debate areas of differing practice and to review the existing related evidence. A further workshop was held in May 2002. The questionnaire responses and discussion of controversial areas, including the management of high-grade gliomas, low-grade gliomas, meningiomas, pituitary adenomas and multiple-brain metastases are included in this paper.

Investigating the Palliative Efficacy of Whole-brain Radiotherapy for Patients with Multiple-brain Metastases and Poor Prognostic Features

AIMS

Trials have shown that patients with multiple-brain metastases and poor prognostic features have a short median survival after whole-brain radiotherapy (WBRT). Quality of life (QoL) and other parameters to assess the palliative efficacy of WBRT have not previously been studied in this group of patients. We therefore attempted to do this.

MATERIALS AND METHODS

We performed three studies between 1997 and 2001. The two later studies were designed according to the results from the preceding study. Each of them revealed the difficulties in studying this group of unwell patients with a short survival.

RESULTS

Thirty-eight patients were studied. They had at least two of three poor prognostic features, such as Karnofsky performance status (KPS) < 70, over 60 years of age, and primary other than breast cancer. The overall median survival was 8 weeks (95% CI 6-10). Twenty-four patients had a KPS < 70 and a median survival of 6 weeks (95% CI 4-9). At 8 weeks after WBRT, 14 out of 15 surviving patients for whom data were obtained suffered deterioration in QoL scores, Barthel or KPS. Ten of the 38 patients (26%, 95% CI 13-43%) improved in at least one of these parameters during the assessment period. Only three out of 38 patients discontinued steroids after the radiotherapy. Side-effects of WBRT were common. All patients experienced alopecia and lethargy after radiotherapy.

CONCLUSIONS

Further trials involving larger numbers of patients are necessary. These studies offer further information on the limited response rates to WBRT, side-effects and effects on QoL, which need to be discussed with patients before they accept or decline the offer of cranial irradiation.