Prehabilitation of dysphagia in the therapy of head and neck cancer- a systematic review of the literature and evidence evaluation

Background

Prehabilitation is becoming increasingly important in oncology because of the significant survival benefits that the reduction of malnutrition provide. Specifically, tumor- and therapy-related dysphagia leads to malnutrition in more than half of head and neck tumor patients. Studies describe the positive effects of an early onset of swallow-specific prehabilitation on the protection of the swallowing function. This paper intents to evaluate the existing evidence on the efficacy of preventive forms of swallowing therapy.

Methods

A systematic literature search was performed in February 2022 in the Cochrane Library, MEDLINE via PubMed, and ClinicalTrials.gov databases for randomized controlled trials investigating preventive swallowing therapy in head and neck tumor patients. This Procedure complies with the PRISMA statement. The RCTs were evaluated by using the PEDro Scale and the Cochrane Risk of Bias tool RoB2.

Results

Five randomized-controlled trials with 423 participants were identified. Four Studies showed moderate to high quality in the PEDro analysis, one showed less. The risk of bias was high in all studies because there was no possibility for blinding and there were high dropout rates. Heterogeneity in interventions, measurement instruments, measurement time points, and outcomes limits a general statement about which swallowing exercises are suitable for the prevention of dysphagia in head and neck tumor patients. Evidence is provided for short-term effects (≤24 months) on functional aspects of swallowing and quality of life. Overall, a decreasing adherence over time was observed in the intervention groups.

Discussion

Initial studies describe swallowing-specific prehabilitation programs in head and neck tumor patients as effective, at least in the short term, whereas long-term effects need to be further investigated. At the current time the evidence base for clear recommendations does not appear to be sufficiently high and studies share a high risk of bias. Further well-designed research, especially considering the conditions in the national health care system, is needed.

Other

There was no funding and no registration.

Current situation in radiation oncology residency-Results of a national survey performed by the working group Young DEGRO of the German Society of Radiation Oncology

BACKGROUND

The aim of this study was to assess the current status of the radiation oncology (RO) residency programs in Germany. For this, RO residents and RO specialists were surveyed regarding the current situation of the RO residency training and the working conditions in Germany.

METHODS

The Continuing Education Section of the Young DEGRO (yDEGRO) Working Group of the German Society of Radiation Oncology (DEGRO) developed a survey to assess (1) the overall satisfaction, learning objectives, and teaching methods used during training; and (2) the perception of the importance of specific disease patterns in RO training. Open-ended questions were also asked to elicit opinions on areas for improvement. From 21 November to 27 December 2022, RO residents registered with DEGRO and/or in the working group yDEGRO were invited to participate anonymously in an online questionnaire.

RESULTS

Overall, 97 participants completed the survey, including 65 RO residents (67%) and 32 RO specialists (33%); 66 (68%) of the respondents reported being employed in the university setting, 23 (23.7%) in the non-university setting, and 8 (8.3%) in private practice. Within the training, heterogeneity was found in the teaching methods used. In terms of knowledge transfer, the greatest importance was accorded to annual continuing education discussions with the head of the residency training (92.8%), participation in tumor boards (85.6%), written training concepts (81.4%), and evaluations at the beginning (76.3%) and end of a rotation (80.4%). The arithmetic mean of satisfaction with specialist training was 6/10 points (SD: 1.99); 88.7% of respondents would like to see a nationally uniform and mandatory curriculum in RO residency training.

CONCLUSION

The study provides suggestions for improving RO medical training in Germany: further development of accompanying education and training programs in cooperation with professional associations, e.g., the DEGRO, structured feedback, and supervision.

MRI, FDG-PET/CT and Image-Guidance for Re-Irradiation of Locoregionally Recurrent or Second Primary Head-and-Neck Squamous Cell Carcinoma Patients - Results of a Multicenter Cohort Study

PURPOSE/OBJECTIVE(S)

To investigate patterns of care and prognostic benefits of MRI, FDG-PET/CT and image-guidance in re-irradiation of locoregionally recurrent or second primary head-and-neck squamous cell carcinomas (r/s HNSCCs) within a multicenter cohort study.

MATERIALS/METHODS

Patients receiving re-irradiation for r/s HNSCC between 2009 and 2020 at 16 tertiary cancer centers in Germany were retrospectively analyzed in terms of MRI and FDG-PET/CT usage for treatment planning and regarding image-guidance frequency during re-irradiation. Patterns of use of these modalities over time were analyzed by binary logistic regression analysis, and the association between the usage of these modalities and best locoregional treatment response was analyzed with chi-square tests. Cumulative incidence analyses of locoregional failures with death as competing event were performed.

RESULTS

In the total cohort of 297 patients, 226 (76%) were male, median age was 62 years (IQR, 56-70), and median ECOG was 1 (IQR, 1-2). There were 260 locoregionally recurrent HNSCCs, and 37 second primary HNSCCs; 44 patients (15%) had distant metastases at the time of re-irradiation. MRI and FDG-PET/CT was used for re-irradiation planning in 117 (39%) and 71 patients (24%), respectively. In median, image guidance (IGRT) was performed twice weekly (IQR, 1-5), usually with cone beam CTs or megavolt-CTs, and 85 patients (29%) received daily IGRT during re-irradiation. Usage of MRI (OR = 0.967; 95% CI, 0.892-1.048; p = .416), FDG-PET/CT (OR = 1.053; 95% CI, 0.960-1.156; p = .274), or daily IGRT (OR = 1.057; 95% CI, 0.968-1.115; p = .218) did not increase in frequency over time within the analyzed time span but was significantly dependent on the treatment center (χ2(15), P<.001 for all modalities). Daily IGRT was associated with a higher rate of at least stable disease after re-irradiation as assessed by RECIST criteria (χ2(1) = 4.011, p<.05). There was a trend towards better RECIST-assessed treatment response for MRI (χ2(1) = 3.223, p = .073) and FDG-PET/CT (χ2(1) = 2.792, p = .095) as part of the re-irradiation planning process. Incidence of locoregional failures was not dependent on MRI (SHR = 0.94; 95% CI, 0.67-1.33; p = 0.741, Fine-Gray), FDG-PET/CT (SHR = 0.88; 95% CI, 0.59-1.33; p = 0.552) or daily IGRT (SHR = 0.76; 95% CI, 0.51-1.14, p = 0.182), There was a trend towards lower acute grade 3/4-toxicities in patients receiving daily IGRT (χ2(1) = 3.354, p = 0.067).

CONCLUSION

Our data suggest that daily IGRT may increase disease control and should be regularly applied for re-irradiation of r/s HNSCCs. MRI and FDG-PET/CT usage were not associated with the incidence of locoregional failures after re-irradiation. However, prospective trials with multiparametric MRI and/or FDG-PET/CT for optimal re-irradiation planning are warranted.

Dose-escalated re-irradiation improves outcome in locally recurrent head and neck cancer - Results of a large multicenter analysis

To determine efficacy and prognostic parameters of definitive re-irradiation of locoregionally recurrent squamous cell carcinoma of the head and neck (HNSCC).

MATERIALS AND METHODS

Patients with locoregionally recurrent or second primary HNSCC undergoing re-irradiation with modern radiotherapy technique were eligible for this multicentric retrospective analysis. Main endpoints were overall survival (OS), progression-free survival (PFS) and locoregional control (LC). Univariate analyses were performed using the Kaplan Meier Method (log-rank). For multivariable analysis, Cox regression was used.

RESULTS

A total of 253 patients treated between 2009 and 2020 at 16 university hospitals in Germany were included. The median follow up was 27.4 months (range 0.5-130). The median OS and PFS were 13.2 (CI: 10.7 - 15.7) months and 7.9 (CI: 6.7 - 9.1) months, respectively, corresponding to two-year OS and PFS rates of 29 % and 19 %. Rates of locoregional progression and "in-field-failure" were 62 % and 51 % after two years. Multivariable Cox regression analysis identified good ECOG performance status and high radiation dose as independent prognostic parameters for OS. Doses above 50 Gy (EQD2) achieved longer median OS of 17.8 months (vs 11.7 months, p < 0.01) and longer PFS of 9.6 months (vs 6.8 months, p < 0.01). In addition, there was a trend for worse survival in patients with tracheostomy (multivariable, p = 0.061). Concomitant systemic therapy did not significantly impact PFS or OS.

CONCLUSION

Re-irradiation of locally recurrent or second primary HNSCC is efficient, especially if doses above 50 Gy (EQD2) are delivered. ECOG performance score was the strongest prognostic parameter for OS and PFS.