Taste dysfunction in head and neck malignancy

Inter-individual characteristics on basic taste recognition thresholds in a college-aged cohort: potential predictive factors

Studying nutritional status from the perspective of taste sensitivity, rather than only dietary patterns, may provide new insights into the role of taste receptor signaling in the development of metabolic-associated diseases. In this cross-sectional study, we investigated the possible influence of sociodemographic (sex and smoking habit) and clinical variables (dental cavities, missing teeth, sinusitis, rhinitis, body mass index and metabolic high prevalence family antecedent diseases) on tastant (sucrose, monosodium glutamate, sodium chloride, citric acid, quinine, sinigrin, phenylthiocarbamide) recognition thresholds (RTs) in a college-aged cohort (n = 397). Predictive models for the tastant RTs were generated and a higher sucrose RT was found in females than in males, while sinusitis and rhinitis explained sucrose and sodium chloride RTs. Smoking habit was not an important predictive factor of taste sensitivity, although its long-term influence on RTs remains unclear. Additionally, a positive correlation was found between all the tastant RTs studied. Although results did not show a clear pattern, the statistical approach employed should prove useful in future studies of predictors of taste sensitivity.

Brazilian organic propolis for prevention and treatment of radiation-related oral acute toxicities in head and neck cancer patients: A double-blind randomized clinical trial

Background: Oral mucositis (OM) is one of the most important acute toxicities from radiotherapy (RT) in head and neck cancer patients and can impair oncologic treatment. Dysphagia, dysgeusia, pain, and oral candidiasis are other common toxicities. Brazilian Organic Propolis (BOP) is a recently described propolis variant and BOP types 4 and 6 have shown important antioxidant, anti-inflammatory, and antifungal properties.

Purpose: To investigate the use of BOP as a preventive and/or complementary therapeutic option for radiotherapy-induced oral mucositis, dysphagia, dysgeusia, pain, and oral candidiasis. Additionally, proinflammatory cytokines were assessed to investigate their anti-inflammatory role.

Methods: Sixty patients were included in this randomized, double-blind, controlled clinical trial. Patients were randomized to receive either aqueous suspension of a BOP or placebo throughout RT. Also, all patients underwent low-level laser therapy as routine oral care. OM, dysphagia, and dysgeusia were assessed weekly according to WHO and NCI scales. Pain-related to OM was assessed according to a Visual Analog Scale and the presence or absence of oral candidiasis was checked by intraoral examination. Protein levels of TNF-α and IL-1β from oral mucosa were assessed by ELISA.

Results: Patients in the propolis group had a lower mean score of OM, dysphagia, dysgeusia, and most patients reported moderate pain. Fewer patients developed oral candidiasis in the propolis group, and the number of episodes was lower among patients that used BOP (p < 0.05). In addition, the BOP group presented significantly lower levels of IL-1β since the beginning of treatment when compared with placebo patients (p < 0.05) and a lower level of TNF-α at the end of treatment (p < 0.001).

Conclusion: Topic use of BOP reduced TNF-α and IL-1β levels, oral candidiasis episodes, and seems to be a useful complementary option for the prevention and treatment of the main acute oral toxicities of RT.

Clinical Trial Registration:http://www.ensaiosclinicos.gov.br/rg/RBR-9f8c78/, identifier RBR-9f8c78

Salivary Gland Hypofunction and/or Xerostomia Induced by Nonsurgical Cancer Therapies: ISOO/MASCC/ASCO Guideline

PURPOSE

To provide evidence-based recommendations for prevention and management of salivary gland hypofunction and xerostomia induced by nonsurgical cancer therapies.

METHODS

Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. PubMed, EMBASE, and Cochrane Library were searched for randomized controlled trials published between January 2009 and June 2020. The guideline also incorporated two previous systematic reviews conducted by MASCC/ISOO, which included studies published from 1990 through 2008.

RESULTS

A total of 58 publications were identified: 46 addressed preventive interventions and 12 addressed therapeutic interventions. A majority of the evidence focused on the setting of radiation therapy for head and neck cancer. For the prevention of salivary gland hypofunction and/or xerostomia in patients with head and neck cancer, there is high-quality evidence for tissue-sparing radiation modalities. Evidence is weaker or insufficient for other interventions. For the management of salivary gland hypofunction and/or xerostomia, intermediate-quality evidence supports the use of topical mucosal lubricants, saliva substitutes, and agents that stimulate the salivary reflex.

RECOMMENDATIONS

For patients who receive radiation therapy for head and neck cancer, tissue-sparing radiation modalities should be used when possible to reduce the risk of salivary gland hypofunction and xerostomia. Other risk-reducing interventions that may be offered during radiation therapy for head and neck cancer include bethanechol and acupuncture. For patients who develop salivary gland hypofunction and/or xerostomia, interventions include topical mucosal lubricants, saliva substitutes, and sugar-free lozenges or chewing gum. For patients with head and neck cancer, oral pilocarpine and oral cevimeline, acupuncture, or transcutaneous electrostimulation may be offered after radiation therapy.Additional information can be found at www.asco.org/supportive-care-guidelines.

Long-Term Taste Impairment after Intensity-Modulated Radiotherapy to Treat Head-and-Neck Cancer: Correlations with Glossectomy and the Mean Radiation Dose to the Oral Cavity

We explored the effects of various parameters on taste impairments (TIs) in head-and-neck (H&N) cancer patients receiving intensity-modulated radiotherapy (IMRT). From January 2014 to September 2017, 88 H&N cancer patients subjected to curative or postoperative IMRT were enrolled in this prospective study. All patients underwent at least 1 year of follow-up after IMRT. Quality-of-life assessments in terms of patient-reported gustatory function were measured using the taste-related questions of the European Organization for Research and Treatment of Cancer H&N35 questionnaires. At a median follow-up time of 27 months, 27 of 88 patients (30.7%) reported long-term TIs. In multivariate analyses, glossectomy most significantly predicted TIs (P = 0.04). The percentage of TIs (61.5%) was significantly (P = 0.03) higher in patients who underwent partial or total glossectomy than in patients who did not undergo surgery (28.0%) and those who underwent radical surgery without glossectomy (20.0%). When we excluded surgical patients from analyses, the mean radiation dose to the oral cavity was of borderline significance in terms of TI prediction (P = 0.05). Only 10.5% of patients suffered from TIs when the mean radiation dose was <5000 cGy compared with 38.7% when the mean dose was ≥5000 cGy. In conclusion, glossectomy is the major cause of long-term TIs in H&N cancer patients receiving IMRT. In patients who do not undergo glossectomy, reduction of the mean radiation dose to the oral cavity may reduce TIs after IMRT.

The effect of radiotherapy on taste sensation in head and neck cancer patients - a prospective study

BACKGROUND

One of the main side effects of head and neck (H&N) radiation therapy (RT) is alteration in taste sensation. It causes significant morbidity and has a major effect on quality of life (QoL). The aim of this study was to prospectively define the effect of RT on taste sensation (general, and four basic tastes) and correlate these findings with changes in saliva secretion and QoL questionnaires.

METHODS

Patients with H&N cancer treated with RT, in which the oral cavity was expected to receive a mean dose of 30 Gray (Gy). Patients were evaluated by Whole-Saliva Sialometry, validated Taste Strips and European Organization for Research and Treatment of Cancer H&N QoL questionnaires prior to RT (T0), mid-point of radiotherapy dose (T1), at the end of radiotherapy (T2) and 1 (T3), 3 (T4) and 12 months (T5) after completion of treatment course.

RESULTS

Twenty-eight patients were recruited, and 21 patients completed study procedures and were analyzed. Median age was 66 years (range 18-90). The most common tumor site was the oral cavity. The median prescribed radiation dose to the high dose volume was 66 (range 60-70). The median mean and max dose to the oral cavity were 25.1 (range 14-69) and 64.9 (range 30-70), respectively. There was a significant decrease in overall taste sensation between T0 and T1 and T2. With specific tastes, there were significant decreases in sensation of sweet and salty, a trend with bitter and no change with sour. All returned to baseline at T3 and onwards. There was no significant correlation between the max or mean dose to the oral cavity and overall taste sensation or between doses to different areas of the tongue and overall or specific tastes. At T0 there was a significant positive correlation between overall taste sensation and whole-saliva sialometry, and at T1 and T2 there were strong trends. There were significant declines in QoL scores during RT.

CONCLUSIONS

We found a significant immediate reduction in taste sensation due to RT in H&N cancer patients with taste recovery 1 month after treatment completion. There were strong trends to a correlation with saliva production that requires further exploration.

Assessing taste and smell alterations in cancer patients undergoing chemotherapy according to treatment

PURPOSE

Taste and smell changes are common side effects in cancer patients undergoing chemotherapy treatments (CT). This can lead to a reduced food enjoyment and an inadequate nutrient intake with a high impact on nutritional status and quality of life. The aim of this study was to evaluate the self-reported chemosensory alterations of patients undergoing chemotherapy according to CT type.

METHODS

An observational study was conducted with 151 patients undergoing CT at Oncology Outpatient Unit from Onkologikoa Foundation. An interviewer-assisted questionnaire was designed to investigate chemosensory changes in patients undergoing CT.

RESULTS

Seventy-six percent patients reported taste disorders and 45% smell changes. Xerostomia is the most frequent symptom reported by patients receiving chemotherapy in our study (63.6%), and it is strongly associated to bad taste in mouth (OR = 5.96; CI = 2.37-14.94; p value = 0.000) and taste loss (OR = 5.96; CI = 2.37-14.94; p value = 0.000). Anthracyclines, paclitaxel, carboplatin, and docetaxel were the CT agents producing the highest taste disturbance rates. Cisplatin and 5-Fluorouracil are the CT resulting in the lowest complaints. Logistic regression revealed statistically significant associations between taste loss and carboplatin and docetaxel (OR = 3.50; CI = 1.12-10.90; p value = 0.031) and cold hypersensitivity and oxaliplatin (OR = 12.14; CI = 4.18-35.25; p value = 0.000). Not only platin-based CT such as carboplatin produced dysgeusia, but also anthracyclines and paclitaxel treatments.

CONCLUSIONS

The better knowledge of taste and smell alterations according to CT type may provide valuable information for the design of new strategies to tackle CT side effects. It is important to take into account taste and smell dysfunctions and other alterations such as xerostomia together.

Altered eating: a definition and framework for assessment and intervention

Background

Eating can be a significant challenge for cancer survivors; however, to date there is no systematic way of assessing and addressing food related quality of life in this group. The purpose of our study was to develop a framework for doing so.

Methods

Over the course of 6 years in participant-led food workshops, we worked alongside 25 head and neck cancer (HNC) survivors and their partners, employing video-reflexive ethnographic (VRE) methods. The current study reports on data from the two summative workshops of this series where we worked with participants to cohere the emergent themes. Video and transcripts were reviewed and coded with participants and stakeholders according to domains of life that were affected by food. Three of the authors, one of whom is both survivor and researcher, arrived at the consensus framework.

Results

Seven areas of life were identified as affecting, or being affected by, altered eating. Three were physiological: anatomical, functional and sensory. Two captured the cognitive and behavioural labour of eating. Social life and identity were altered. The foregoing had an enduring emotional impact.

Conclusions

Altered eating has physical, emotional and social consequences. The altered eating framework provides a systematic way of exploring those consequences with individual survivors. This framework has the potential to improve both the assessment and treatment of altered eating, to benefit food-related quality of life.

Differences in the Density of Fungiform Papillae and Composition of Saliva in Patients With Taste Disorders Compared to Healthy Controls

This study investigated the relation of the fungiform taste papillae density and saliva composition with the taste perception of patients suffering from diagnosed taste disorders. For this purpose, 81 patients and 40 healthy subjects were included. Taste was measured by means of regional and whole mouth chemosensory tests, and electrogustometry. Olfaction was assessed using the Sniffin Sticks. Fungiform papillae were quantified using the "Denver Papillae Protocol for Objective Analysis of Fungiform Papillae". In addition, salivary parameters [flow rate, total proteins, catalase, total anti-oxidative capacity (TAC), carbonic anhydrase VI (caVI), and pH] were determined and the Beck Depression Inventory was administered. Patients showed less taste papillae compared to healthy subjects. The number of papillae correlated with total taste strip score and salivary flow rate. Regarding salivary parameters, the flow rate, protein concentration, and TAC of patients were higher compared to controls. In addition, salivary flow rate, protease, caVI, and catalase values correlated with the summed taste strip score. Regarding various taste disorders, salty-dysgeusia patients showed the lowest taste test scores compared to those with bitter or metal-dysgeusia. Olfactory function of patients was significantly worse compared to healthy controls. This difference was most pronounced for ageusia patients. Compared to controls, patients also exhibited higher depressive symptoms. The density of fungiform papillae seemed to be positively associated with taste perception. Furthermore, patients exhibited changes in saliva composition (higher salivary flow rate, increased protein concentration, proteolysis, and TAC) compared to controls indicating that assessment of saliva may be critical for the diagnostic procedure in taste disorders.

Interventions for managing taste disturbances

BACKGROUND

The sense of taste is very much essential to the overall health of an individual. It is a necessary component to enjoy one's food, which in turn provides nutrition to an individual. Any disturbance in taste perception can hamper quality of life in such patients by influencing their appetite, body weight and psychological well-being. Taste disorders have been treated using different modalities of treatment and there is no consensus for the best intervention. Hence this Cochrane Review was undertaken. This is an update of the Cochrane Review first published in November 2014.

OBJECTIVES

To assess the effects of interventions for the management of patients with taste disturbances.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 4 July 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017 Issue 6) in the Cochrane Library (searched 4 July 2017); MEDLINE Ovid (1946 to 4 July 2017); Embase Ovid (1980 to 4 July 2017); CINAHL EBSCO (1937 to 4 July 2017); and AMED Ovid (1985 to 4 July 2017). The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for trials. Abstracts from scientific meetings and conferences were searched on 25 September 2017. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing any pharmacological agent with a control intervention or any non-pharmacological agent with a control intervention. We also included cross-over trials in the review.

DATA COLLECTION AND ANALYSIS

Two pairs of review authors independently, and in duplicate, assessed the quality of trials and extracted data. Wherever possible, we contacted trial authors for additional information. We collected adverse events information from the trials.

MAIN RESULTS

We included 10 trials (581 participants), nine of which we were able to include in the quantitative analyses (566 participants). We assessed three trials (30%) as having a low risk of bias, four trials (40%) at high risk of bias and three trials (30%) as having an unclear risk of bias. We only included studies on taste disorders in this review that were either idiopathic, or resulting from zinc deficiency or chronic renal failure.Of these, nine trials with 544 people compared zinc supplements to placebo for patients with taste disorders. The participants in two trials were children and adolescents with respective mean ages of 10 and 11.2 years and the other seven trials had adult participants. Out of these nine, two trials assessed the patient-reported outcome for improvement in taste acuity using zinc supplements (risk ratio (RR) 1.40, 95% confidence interval (CI) 0.94 to 2.09; 119 participants, very low-quality evidence). We meta-analysed for taste acuity improvement using objective outcome (continuous data) in idiopathic and zinc-deficient taste disorder patients (standardised mean difference (SMD) 0.44, 95% CI 0.23 to 0.65; 366 participants, three trials, very low-quality evidence). We also analysed one cross-over trial separately using the first half of the results for taste detection (mean difference (MD) 2.50, 95% CI 0.93 to 4.07; 14 participants, very low-quality evidence), and taste recognition (MD 3.00, 95% CI 0.66 to 5.34; 14 participants, very low-quality evidence). We meta-analysed taste acuity improvement using objective outcome (dichotomous data) in idiopathic and zinc-deficient taste disorder patients (RR 1.42, 95% 1.09 to 1.84; 292 participants, two trials, very low-quality evidence). Out of the nine trials using zinc supplementation, four reported adverse events like eczema, nausea, abdominal pain, diarrhoea, constipation, decrease in blood iron, increase in blood alkaline phosphatase, and minor increase in blood triglycerides.One trial tested taste discrimination using acupuncture (MD 2.80, 95% CI -1.18 to 6.78; 37 participants, very low-quality evidence). No adverse events were reported in the acupuncture trial.None of the included trials could be included in the meta-analysis for health-related quality of life in taste disorder patients.

AUTHORS' CONCLUSIONS

We found very low-quality evidence that was insufficient to conclude on the role of zinc supplements to improve taste acuity reported by patients and very low-quality evidence that zinc supplements improve taste acuity in patients with zinc deficiency/idiopathic taste disorders. We did not find any evidence to conclude the role of zinc supplements for improving taste discrimination, or any evidence addressing health-related quality of life due to taste disorders.We found very low-quality evidence that is not sufficient to conclude on the role of acupuncture for improving taste discrimination in cases of idiopathic dysgeusia (distortion of taste) and hypogeusia (reduced ability to taste). We were unable to draw any conclusions regarding the superiority of zinc supplements or acupuncture as none of the trials compared these interventions.

A systematic review of smell alterations after radiotherapy for head and neck cancer

PURPOSE

To review the current knowledge on radiotherapy associated olfactory dysfunction among head and neck cancer (HNC) patients.

METHODS

A systematic review of RT-related olfactory dysfunction in HNC was performed. Searches were conducted in several databases (Medline, EMBASE, CINAHL, CAB Abstracts, SCOPUS, Proquest Dissertations and Theses, PROSPERO, ALLEBM Reviews - Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA, and NHSEED). Publications investigating olfactory dysfunction as an explicit side effect of Radiotherapy (RT, or RT-chemo or RT-monoclonal antibodies) were eligible, no limits were applied.

RESULTS

Two hundred and twenty-nine papers were screened and 23 met inclusion criteria.

CONCLUSIONS

Odor detection, identification and discrimination are olfactory functions impaired after RT for HNC. An RT dose-effect has been calculated for odor identification and odor discrimination. There were no studies of the effect of olfactory dysfunction on weight loss or energy intake among RT-treated HNC patients. To improve our understanding of RT associated olfactory dysfunction among HNC patients, future studies should include a multi-dimensional assessment of olfactory function in a longitudinal design, track other conditions affecting olfaction, assess retronasal olfactory perception, adopt validated self-report tools and explore the impact of olfactory dysfunction on the eating experience of HNC patients.

Interventions for the management of taste disturbances

BACKGROUND

The sense of taste is very much essential to the overall health of the individual. It is a necessary component to enjoying one's food, which in turn provides nutrition to an individual. Any disturbance in taste perception can hamper the quality of life in such patients by influencing their appetite, body weight and psychological well-being. Taste disorders have been treated using different modalities of treatment and there is no consensus for the best intervention. Hence this Cochrane systematic review was undertaken.

OBJECTIVES

To assess the effects of interventions for the management of patients with taste disturbances.

SEARCH METHODS

We searched the Cochrane Oral Health Group Trials Register (to 5 March 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2014), MEDLINE via OVID (1948 to 5 March 2014), EMBASE via OVID (1980 to 5 March 2014), CINAHL via EBSCO (1980 to 5 March 2014) and AMED via OVID (1985 to 5 March 2014). We also searched the relevant clinical trial registries and conference proceedings from the International Association of Dental Research/American Association of Dental Research (to 5 March 2014), Association for Research in Otolaryngology (to 5 March 2014), the US National Institutes of Health Trials Register (to 5 March 2014), metaRegister of Controlled Trials (mRCT) (to 5 March 2014), World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP) (to 5 March 2014) and International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) Clinical Trials Portal (to 5 March 2014).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing any pharmacological agent with a control intervention or any non-pharmacological agent with a control intervention. We also included cross-over trials in the review.

DATA COLLECTION AND ANALYSIS

Two authors independently, and in duplicate, assessed the quality of trials and extracted data. Wherever possible, we contacted study authors for additional information. We collected adverse events information from the trials.

MAIN RESULTS

We included nine trials (seven parallel and two cross-over RCTs) with 566 participants. We assessed three trials (33.3%) as having a low risk of bias, four trials (44.5%) at high risk of bias and two trials (22.2%) as having an unclear risk of bias. We only included studies on taste disorders in this review that were either idiopathic, or resulting from zinc deficiency or chronic renal failure.Of these, eight trials with 529 people compared zinc supplements to placebo for patients with taste disorders. The participants in two trials were children and adolescents with respective mean ages of 10 and 11.2 years and the other six trials had adult participants. Out of these eight, two trials assessed the patient reported outcome for improvement in taste acuity using zinc supplements (RR 1.45, 95% CI 1.0 to 2.1; very low quality evidence). We included three trials in the meta-analysis for overall taste improvement (effect size 0.44, 95% CI 0.23 to 0.65; moderate quality evidence). Two other trials described the results as taste acuity improvement and we conducted subgroup analyses due to clinical heterogeneity. One trial described the results as taste recognition improvement for each taste sensation and we analysed this separately. We also analysed one cross-over trial separately using the first half of the results. None of the zinc trials tested taste discrimination. Only one trial tested taste discrimination using acupuncture (effect size 2.80, 95% CI -1.18 to 6.78; low quality evidence).Out of the eight trials using zinc supplementation, four reported adverse events like eczema, nausea, abdominal pain, diarrhoea, constipation, decrease in blood iron, increase in blood alkaline phosphatase, and minor increase in blood triglycerides. No adverse events were reported in the acupuncture trial.None of the included trials could be included in the meta-analysis for health-related quality of life in taste disorder patients.

AUTHORS' CONCLUSIONS

We found very low quality evidence that was insufficient to conclude on the role of zinc supplements to improve taste perception by patients, however we found moderate quality evidence that zinc supplements improve overall taste improvement in patients with zinc deficiency/idiopathic taste disorders. We also found low quality evidence that zinc supplements improve taste acuity in zinc deficient/idiopathic taste disorders and very low quality evidence for taste recognition improvement in children with taste disorders secondary to chronic renal failure. We did not find any evidence to conclude the role of zinc supplements for improving taste discrimination, or any evidence addressing health-related quality of life due to taste disorders.We found low quality evidence that is not sufficient to conclude on the role of acupuncture for improving taste discrimination in cases of idiopathic dysgeusia (distortion of taste) and hypogeusia (reduced ability to taste). We were unable to draw any conclusions regarding the superiority of zinc supplements or acupuncture as none of the trials compared these interventions.

Changes in taste preference after colorectal surgery: A longitudinal study

BACKGROUND & AIMS

Nutrition is a key component of surgical enhanced recovery programmes. However, alterations in food preferences are often reported as reasons for patients not eating in the early postoperative period. We hypothesised that taste preferences are altered in the early postoperative period and this dysgeusia affects patients' food choices during this critical time.

METHODS

This is a longitudinal study looking at taste preferences of patients recovering from surgery. Patients undergoing colonic resections were recruited. Using visual analogue scales participants completed a questionnaire, taste tests and preference scoring of food images for the 6 groups of taste (bitter, salty, savoury, sour, spicy and sweet) preoperatively and on postoperative days 1-3. Patients were also offered snacks postoperatively, which represented foods from the six groups and consumption was measured. Differences from baseline were assessed using the Friedman's and Wilcoxon tests.

RESULTS

31 patients were studied. In the immediate postoperative period participants reported deterioration in their sense of taste (p ≤ 0.001), increased nausea (p < 0.001) and hunger (p = 0.03). Sweet, savoury and spicy tastes were the most popular during the perioperative period. However, only palatability for salty taste increased (p = 0.001) following surgery. The highest rated images were for savoury food with only the ratings for salty food increasing after surgery (p < 0.05). These findings concurred with the sweet, savoury and salty snacks being the most consumed foods in the postoperative period. Bitter, sour and spicy foods were the least frequently consumed.

DISCUSSION

This is the first study to investigate postsurgical patients' food preferences. A consistent change in all the individual tastes with the exception of salty in the postoperative period was observed. The most desirable tastes were for savoury and sweet, reflecting patients' preoperative preferences. An improved understanding of taste may improve the resumption of eating after colonic surgery.

Persistent dysphagia after head and neck radiotherapy: a common and under-reported complication with significant effect on non-cancer-related mortality

AIMS

Dysphagia is a well-recognised acute complication after radiotherapy. However, knowledge about the long-term prevalence and effect remains limited. The aims of this study were to determine the prevalence, severity, morbidity, time course and reporting patterns of dysphagia symptoms after head and neck radiotherapy.

MATERIALS AND METHODS

An observational cross-sectional study was conducted in a large consecutive series of head and neck cancer patients. All patients in the St George Hospital Cancer Care database who had received head and neck radiotherapy with curative intent 0.5-8 years previously and recorded as being alive were surveyed using the Sydney Swallow Questionnaire (SSQ). Case notes were reviewed to determine the level of awareness of swallowing dysfunction in all patients, as well as the causes of mortality in the 83 deceased patients.

RESULTS

The mean follow-up at the time of survey was 3 years after radiotherapy (range 0.5-8 years). Of the 116 patients surveyed by questionnaire, the response rate was 72% (83). Impaired swallowing (SSQ score > 234) was reported by 59% of patients. Dysphagia severity was not predicted by tumour site or stage, nor by the time since therapy, age, gender or adjuvant chemotherapy. Review of the hospital medical records and cancer database revealed that cancer accounted for 55% of deaths and aspiration pneumonia was responsible for 19% of non-cancer-related deaths. Of those with abnormal SSQ scores, only 47% reported dysphagia during follow-up clinic visits.

CONCLUSIONS

Persistent dysphagia is a prevalent, under-recognised and under-reported long-term complication of head and neck radiotherapy which currently cannot be predicted on the basis of patient, tumour or treatment characteristics. Aspiration pneumonia is an important contributor to non-cancer-related mortality in these patients. These data highlight the need for closer monitoring of swallow dysfunction and its sequelae in this population.

Stomatological management of head and neck cancer patients treated with chemotherapy and radiotherapy

Treatment of head and neck cancer with radiotherapy and/or chemotherapy can cause oral damage. Long-term treatment can damage the salivary glands, the oral mucosa, and the maxilla, leading to altered production of saliva and to multiple infections. These lesions can be prevented, limited or avoided by thorough evaluation prior to treatment and by therapeutic follow-up and preventive measures. The dentist must have strong medical knowledge of the possible short-, medium-, and long-term oral complications of the cancer treatment, and must have knowledge of the protocols for oral management of cancer patients. The availability of a multidisciplinary medical team together with a dentist to attend to the patient prior to the cancer treatment, as well as close communication between team members during and after treatment, is crucial. The aim of the present study was review the stomatological management of head and neck cancer patients treated with chemotherapy and radiotherapy and summarizing current treatments, therapeutic innovation and tissue regeneration perspectives.

Taste dysfunction in head and neck cancer survivors

PURPOSE/OBJECTIVES

To describe the prevalence of issues with taste function in survivors of head and neck cancer.

DESIGN

Exploratory, cross-sectional.

SETTING

Outpatients from Saint Louis University Cancer Center in Missouri.

SAMPLE

92 adult head and neck cancer survivors, heterogeneous in cancer site, treatment type, and time post-treatment, ranging from three months to more than 28 years after completion of therapy.

METHODS

Taste discrimination was assessed using high, medium, and low concentrations of sweet, salty, sour, and bitter tasting solutions.

MAIN RESEARCH VARIABLES

Taste, percentage of weight change, tumor site and stage, treatment type, and time since completion of therapy.

FINDINGS

Eighty-five of 92 participants had some measurable taste dysfunction. Confusion between bitter and sour and the inability to discriminate among the different concentrations of the sweet solutions were common. Statistically significant weight loss was associated with dysgeusia.

CONCLUSIONS

Taste dysfunction was a persistent problem across all categories of head and neck cancer treatments, sites, and stages. Participants who reported the loss of one or more specific taste modality performed poorly on the taste test. However, participants could not accurately predict which taste was most severely impaired.

IMPLICATIONS FOR NURSING

Taste dysfunction is a long-term treatment-related side effect for head and neck cancer survivors. Assessing for taste changes and dysgeusia are important nursing considerations, as taste loss is distressing and associated with decreased appetite. Future studies are needed to identify interventions to help patients better manage and adapt to this long-term complication of cancer therapy.

KNOWLEDGE TRANSLATION

Flavors are recognized by taste, texture, aroma, thermal quality, and visual cues. A disruption of one or more of those sensory experiences alters flavor recognition. Having intact taste sense but impaired flavor recognition is possible. Finally, taste is not accurately self-reported because it is commonly confused with flavor recognition.

Mechanisms of taste bud cell loss after head and neck irradiation

Taste loss in human patients following radiotherapy for head and neck cancer is a common and significant problem, but the cellular mechanisms underlying this loss are not understood. Taste stimuli are transduced by receptor cells within taste buds, and like epidermal cells, taste cells are regularly replaced throughout adult life. This renewal relies on progenitor cells adjacent to taste buds, which continually supply new cells to each bud. Here we treated adult mice with a single 8 Gy dose of x-ray irradiation to the head and neck, and analyzed taste epithelium at 1-21 d postirradiation (dpi). We found irradiation targets the taste progenitor cells, which undergo cell cycle arrest (1-3 dpi) and apoptosis (within 1 dpi). Taste progenitors resume proliferation at 5-7 dpi, with the proportion of cells in S and M phase exceeding control levels at 5-6 and 6 dpi, respectively, suggesting that proliferation is accelerated and/or synchronized following radiation damage. Using 5-bromo-2-deoxyuridine birthdating to identify newborn cells, we found that the decreased proliferation following irradiation reduces the influx of cells at 1-2 dpi, while the robust proliferation detected at 6 dpi accelerates entry of new cells into taste buds. In contrast, the number of differentiated taste cells was not significantly reduced until 7 dpi. These data suggest a model where continued natural taste cell death, paired with temporary interruption of cell replacement, underlies taste loss after irradiation.