Similar decreases in local tumor control are calculated for treatment protraction and for interruptions in the radiotherapy of carcinoma of the larynx in four centers

Latin American Consensus on the Treatment of Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) is well known as a serious health problem worldwide, especially in low-income countries or those with limited resources, such as most countries in Latin America. International guidelines cannot always be applied to a population from a large region with specific conditions. This study established a Latin American guideline for care of patients with head and neck cancer and presented evidence of HNSCC management considering availability and oncologic benefit. A panel composed of 41 head and neck cancer experts systematically worked according to a modified Delphi process on (1) document compilation of evidence-based answers to different questions contextualized by resource availability and oncologic benefit regarding Latin America (region of limited resources and/or without access to all necessary health care system infrastructure), (2) revision of the answers and the classification of levels of evidence and degrees of recommendations of all recommendations, (3) validation of the consensus through two rounds of online surveys, and (4) manuscript composition. The consensus consists of 12 sections: Head and neck cancer staging, Histopathologic evaluation of head and neck cancer, Head and neck surgery-oral cavity, Clinical oncology-oral cavity, Head and neck surgery-oropharynx, Clinical oncology-oropharynx, Head and neck surgery-larynx, Head and neck surgery-larynx/hypopharynx, Clinical oncology-larynx/hypopharynx, Clinical oncology-recurrent and metastatic head and neck cancer, Head and neck surgery-reconstruction and rehabilitation, and Radiation therapy. The present consensus established 48 recommendations on HNSCC patient care considering the availability of resources and focusing on oncologic benefit. These recommendations could also be used to formulate strategies in other regions like Latin America countries.

Fosaprepitant Weekly vs Every 3 Weeks for the Prevention of Concurrent Chemoradiotherapy-Induced Nausea and Vomiting: A Pilot Randomized Clinical Trial

Importance

Unlike substantial evidence in the prevention of chemotherapy-induced nausea and vomiting (CINV), research in the prevention of nausea and vomiting caused by concurrent chemoradiotherapy (CCRT) is currently lacking.

Objective

To compare the efficacy and safety of fosaprepitant weekly vs every 3 weeks for the prevention of nausea and emesis caused by CCRT among patients with nasopharyngeal carcinoma.

Design, Setting, and Participants

This pilot randomized clinical trial was conducted at a single cancer center from November 24, 2020, to July 26, 2021, among patients with nasopharyngeal carcinoma who had achieved CINV control after 2 to 3 cycles of induction chemotherapy. Efficacy analyses were performed in the intention-to-treat population. Data were analyzed on November 4, 2022.

Interventions

Eligible patients were randomly assigned (1:1) to receive fosaprepitant either weekly or every 3 weeks.

Main Outcomes and Measures

The primary end point was the proportion of patients with sustained complete response (defined as no emesis and no rescue therapy) during CCRT. Secondary end points were sustained no emesis, no nausea, no significant nausea, mean time to first emetic episode, quality of life, and 1-year progression-free survival (PFS).

Results

A total of 100 patients (mean [SD] age, 46.6 [10.9] years; 83 [83.0%] male) who had achieved CINV control after induction chemotherapy were randomly assigned to receive fosaprepitant weekly (50 patients) or every 3 weeks (50 patients). There was no significantly significant difference in cumulative risk of emesis or rescue therapy in the group that received weekly fosaprepitant compared with those who received fosaprepitant every 3 weeks (subhazard ratio, 0.66 [95% CI, 0.43-1.02]; P = .06). The proportion of patients with sustained no emesis (38% vs 14%; P = .003) or no significant nausea (92% vs 72%; P = .002) was significantly higher in the group that received fosaprepitant weekly vs those who received fosaprepitant every 3 weeks. Treatments were well tolerated. Patients in the weekly group had improved scores for multiple quality-of-life measures. There was no significant difference in survival outcomes between groups (91.8% vs 93.7%; P = .99). In the mean brainstem dose subgroups, a possible treatment interaction effect was observed in sustained complete response (mean brainstem dose ≥36 Gy: hazard ratio [HR], 0.32 [95% CI, 0.15-0.69]; mean brainstem dose <36 Gy: HR, 0.95 [95% CI, 0.55-1.63]) and sustained no emesis (mean brainstem dose ≥36 Gy: HR, 0.21 [95% CI, 0.08-0.53]; mean brainstem dose <36 Gy: HR, 0.73 [95% CI, 0.41-1.28]).

Conclusions and Relevance

In this pilot randomized clinical trial, there was no statistically significant difference in the complete response primary end point, but patients receiving weekly fosaprepitant were less likely to experience emesis compared with those who received fosaprepitant every 3 weeks, especially in the subgroup with a mean brainstem dose of 36 Gy or more. Weekly fosaprepitant was well tolerated and improved quality of life of patients without compromising survival.

Trial Registration

ClinicalTrials.gov Identifier: NCT04636632.

Treatment Considerations for Patients with Locoregionally Advanced Head and Neck Cancer with a Contraindication to Cisplatin

OPINION STATEMENT

Significant advancements have been made in the treatment of locally advanced head and neck cancer, predominantly driven by the integration of concurrent chemotherapy with radiation therapy as a standard of care for many patients. The most heavily investigated chemotherapeutic is cisplatin, yet many patients are ineligible for cisplatin due to the presence of pre-existing medical comorbidities. Moreover, given the toxicity profile of cisplatin, identifying which patients stand to benefit from cisplatin is challenging, which is particularly evident in older patients. Efforts to better risk-stratify patients based on age, performance status, and the degree of pre-existing comorbidities are ongoing and have been increasingly utilized in national clinical trials. In parallel, exploration into alternative systemic agents, including novel targeted therapies and immunotherapies, in cisplatin-ineligible patients are rapidly expanding. Cumulatively, identifying appropriate treatment paradigms in patients who harbor contraindications to cisplatin can not only improve clinical outcomes but also critically mitigate detrimental adverse effects.

IMPT of head and neck cancer: unsupervised machine learning treatment planning strategy for reducing radiation dermatitis

Radiation dermatitis is a major concern in intensity modulated proton therapy (IMPT) for head and neck cancer (HNC) despite its demonstrated superiority over contemporary photon radiotherapy. In this study, dose surface histogram data extracted from forty-four patients of HNC treated with IMPT was used to predict the normal tissue complication probability (NTCP) of skin. Grades of NTCP-skin were clustered using the K-means clustering unsupervised machine learning (ML) algorithm. A new skin-sparing IMPT (IMPT-SS) planning strategy was developed with three major changes and prospectively implemented in twenty HNC patients. Across skin surfaces exposed from 10 (S10) to 70 (S70) GyRBE, the skin's NTCP demonstrated the strongest associations with S50 and S40 GyRBE (0.95 and 0.94). The increase in the NTCP of skin per unit GyRBE is 0.568 for skin exposed to 50 GyRBE as compared to 0.418 for 40 GyRBE. Three distinct clusters were formed, with 41% of patients in G1, 32% in G2, and 27% in G3. The average (± SD) generalised equivalent uniform dose for G1, G2, and G3 clusters was 26.54 ± 6.75, 38.73 ± 1.80, and 45.67 ± 2.20 GyRBE. The corresponding NTCP (%) were 4.97 ± 5.12, 48.12 ± 12.72 and 87.28 ± 7.73 respectively. In comparison to IMPT, new IMPT-SS plans significantly (P < 0.01) reduced SX GyRBE, gEUD, and associated NTCP-skin while maintaining identical dose volume indices for target and other organs at risk. The mean NTCP-skin value for IMPT-SS was 34% lower than that of IMPT. The dose to skin in patients treated prospectively for HNC was reduced by including gEUD for an acceptable radiation dermatitis determined from the local patient population using an unsupervised MLA in the spot map optimization of a new IMPT planning technique. However, the clinical finding of acute skin toxicity must also be related to the observed reduction in skin dose.

The effect of short radiation treatment breaks on chemo-radiotherapy for oropharyngeal cancers

BACKGROUND

Numerous studies and guidelines suggest an outcome detriment from radiation treatment breaks (rTBs) and the need for compensatory dosing in patients with head and neck cancer.

METHODS

In a consecutive cohort of 521 patients with oropharyngeal squamous cell carcinoma (OPSCC), we investigated the impact of rTBs and prolongation of overall treatment time (OTT) on OS, DFS, LRC, and cancer recurrence using competing risk and multivariate analyses.

RESULTS

Neither OTT prolongation by ≤2 days nor rTBs of ≤3 days were associated with detriments to clinical outcomes. Consecutive breaks of ≥3 days were also not significantly associated with detriment to clinical outcomes. There was significantly increased competing mortality in those with longer breaks.

CONCLUSIONS

In OPSCC patients treated with definitive concurrent chemoradiotherapy, there is no significant association between disease failure and total rTBs of ≤3 consecutive or scattered days. Further investigation is needed for longer breaks.

The 3 Bs of cancer care amid the COVID-19 pandemic crisis: "Be safe, be smart, be kind"-A multidisciplinary approach increasing the use of radiation and embracing telemedicine for head and neck cancer

Because of the national emergency triggered by the coronavirus disease 2019 (COVID-19) pandemic, government-mandated public health directives have drastically changed not only social norms but also the practice of oncologic medicine. Timely head and neck cancer (HNC) treatment must be prioritized, even during emergencies. Because severe acute respiratory syndrome coronavirus 2 predominantly resides in the sinonasal/oral/oropharyngeal tracts, nonessential mucosal procedures are restricted, and HNCs are being triaged toward nonsurgical treatments when cures are comparable. Consequently, radiation utilization will likely increase during this pandemic. Even in radiation oncology, standard in-person and endoscopic evaluations are being restrained to limit exposure risks and preserve personal protective equipment for other frontline workers. The authors have implemented telemedicine and multidisciplinary conferences to continue to offer standard-of-care HNC treatments during this uniquely challenging time. Because of the lack of feasibility data on telemedicine for HNC, they report their early experience at a high-volume cancer center at the domestic epicenter of the COVID-19 crisis.

Protective effects of doxepin cream on radiation dermatitis in breast cancer: A single arm double-blind randomized clinical trial

AIMS

Breast cancer is the most frequently occurring cancer in women. Lumpectomy followed by radiotherapy is suggested to be as effective as a total mastectomy. Radiation-induced dermatitis often occurs as a result of breast radiotherapy. Recent studies suggest that doxepin has promising anti-inflammatory properties. This study was undertaken to evaluate the effects of doxepin therapy on radiation dermatitis.

METHODS

A double-blind randomized clinical trial was launched from 2016 to 2017, with a total of 48 patients who had undergone breast-conserving surgery and received postoperative radiation therapy. Radiotherapy was applied 5 days per week for 5 weeks. Adverse dermatological effects were evaluated by a physician at the beginning of the fifth week of radiotherapy and the patients were then randomly assigned (1:1 ratio) to receive either doxepin (5%) or placebo cream for 7 days.

RESULTS

There were no significant differences in the dermatitis grade between doxepin and placebo groups at baseline (P > .5). The occurrence of acute dermatitis (grade 2 or higher) was significantly lower with the use of doxepin than with placebo (P ≤ .0001, Z_α = 1.96 at 95% confidence interval).

CONCLUSION

Doxepin cream prevents dermatitis grade 2 or higher during post-operative breast irradiation. Doxepin cream is easy to use, affordable and prevents pain and irritation.

Lower pretreatment hemoglobin status and treatment breaks in locally advanced head and neck squamous cell carcinoma during concurrent chemoradiation

Background

Treatment breaks during radiation for locally advanced Head and Neck Squamous Cell Carcinoma (HNSCC) is one of the important factors affecting the loco-regional control rate. We prospectively analysed the role lower pre-treatment hemoglobin (pre-T Hb) status and its influence on treatment breaks amongst patients undergoing concurrent chemoradiation (CRT).

Methods

One hundred and twenty HNSCC (T3-T4a, N1-N2c) patients treated by CRT were prospectively analysed for influence of pre-T Hb on treatment breaks. Sub-sites included oral cavity, oropharynx, hypopharynx & larynx. All patients received radiation to a total dose of 66Gy to PTV along with weekly Inj. Cisplatin 40 mg/m². All patients were evaluated weekly and at the end of 6 weeks by hemogram, physician and radiological examination.

Results

Our study population had a mean age (±standard deviation) of 55 (± 10.7) years (range: 27 - 69 years), 85 men and 35 women with a performance status of the Eastern Cooperative Oncology Group (ECOG) 1-2. The mean pre-T Hb calculated (using receiver operating characteristic curve [ROC]) was 10.3 g/dL. Among 120 patients, in the pre-T Hb of ≤10.3 g/dL group, 44 (75.9%) patients had treatment breaks of ≥5 days and 11 (17.7%) patients had treatment breaks < 5 days; in the pre-T Hb of >10.3 g/dL group, 14 (24.1%) patients had treatment breaks of ≥5 days and 51 (82.3%) patients had treatment breaks < 5 days (P = 0.001).

Conclusion

Lower pre-T Hb level of ≤ 10.3 g/dL is statistically significantly associated with higher treatment breaks of ≥ 5 days.

Influence of time between surgery and postoperative radiation therapy and total treatment time in locoregional control of patients with head and neck cancer: a single center experience

OBJECTIVE

This study aimed to evaluate the effect of the delay to initiate postoperative radiation therapy (RT) on locoregional control to head and neck squamous cell carcinoma patients.

METHODS

Retrospective cohort study that included patients submitted to surgery followed by adjuvant RT (with/without chemotherapy). The time interval between surgery and RT was dichotomized by the receiver operating characteristics curve method at 92 days. Other possible sources of heterogeneity with potential impact on locoregional control were explored by regressive analysis.

RESULTS

A total of 168 patients were evaluated. The median time for locoregional recurrence (LRR) was 29.7 months. The relapse-free survival rates were 66.4% and 75.4% for patients who initiated RT more than and within 92 postoperative days (p=0.377), respectively. Doses lower than 60Gy were associated with worse rates of locoregional control (HR=6.523; 95%CI:2.266-18.777, p=0.001). Patients whose total treatment time (TTT) was longer than 150 days had LRR rate of 41.8%; no patient with TTT inferior to 150 days had relapses (p=0.001).

CONCLUSIONS

The interval between surgery and RT did not show influence on locoregional control rates. However, doses <60Gy and the total treatment time >150 days were associated with lower locoregional control rates.

Association of Survival With Shorter Time to Radiation Therapy After Surgery for US Patients With Head and Neck Cancer

Importance

Shortening the time from surgery to the start of radiation (TS-RT) is a consideration for physicians and patients. Although the National Comprehensive Cancer Network recommends radiation to start within 6 weeks, a survival benefit with this metric remains controversial.

Objective

To determine the association of delayed TS-RT with overall survival (OS) using a large cancer registry.

Design, Setting, and Participants

In this observational cohort study, 25 216 patients with nonmetastatic stages III to IV head and neck cancer were identified from the National Cancer Database (NCDB).

Exposures

Patients received definitive surgery followed by adjuvant radiation therapy, with an interval duration defined as TS-RT.

Main Outcomes and Measures

Overall survival as a function of TS-RT and the effect of clinicopathologic risk factors and accelerated fractionation.

Results

We identified 25 216 patients with nonmetastatic squamous cell carcinoma of the head and neck. There were 18 968 (75%) men and 6248 (25%) women and the mean (SD) age of the cohort was 59 (10.9) years. Of the 25 216 patients, 9765 (39%) had a 42-days or less TS-RT and 4735 (19%) had a 43- to 49-day TS-RT. Median OS was 10.5 years (95% CI, 10.0-11.1 years) for patients with a 42-days or less TS-RT, 8.2 years (95% CI, 7.4-8.6 years; absolute difference, -2.4 years, 95% CI, -1.5 to -3.2 years) for patients with a 43- to 49-day TS-RT, and 6.5 years (95% CI, 6.1-6.8 years; absolute difference, -4.1 years, 95% CI, -3.4 to -4.7 years) for those with a 50-days or more TS-RT. Multivariable analysis found that compared with a 42-days or less TS-RT, there was not a significant increase in mortality with a 43- to 49-day TS-RT (HR, 0.98; 95% CI, 0.93-1.04), although there was for a TS-RT of 50 days or more (HR, 1.07; 95% CI, 1.02-1.12). A significant interaction was identified between TS-RT and disease site. Subgroup effect modeling found that a delayed TS-RT of 7 days resulted in significantly worse OS for patients with tonsil tumors (HR, 1.22; 95% CI, 1.05-1.43) though not other tumor subtypes. Accelerated fractionation of 5.2 fractions or more per week was associated with improved survival (HR, 0.93; 95% CI, 0.87-0.99) compared with standard fractionation.

Conclusions and Relevance

Delayed TS-RT of 50 days or more was associated with worse overall survival. The multidisciplinary care team should focus on shortening TS-RT to improve survival. Unavoidable delays may be an indication for accelerated fractionation or other dose intensification strategies.

A scoring system predicting acute radiation dermatitis in patients with head and neck cancer treated with intensity-modulated radiotherapy

Background and purpose

We created a scoring system incorporating dosimetric and clinical factors to assess the risk of severe, acute skin reactions in patients undergoing intensity-modulated radiation therapy (IMRT) to treat head and neck cancer (HNC).

Materials and methods

A total of 101 consecutive patients who received definitive IMRT or volumetric modulated arc therapy (VMAT) with a prescription dose of 70 Gy to treat HNC between 2013 and 2017 in our hospital were enrolled. Skin V_5Gy, V_10Gy, V_20Gy, V_30Gy, V_40Gy, V_50Gy, and V_60Gy values delivered 5 mm within the body contour were compared between patients with Grades 1–2 and Grade 3 dermatitis. A scoring system was created based on logistic regression analysis (LRA) that identified the most significant dosimetric and clinical factors.

Results

The V_60Gy was significantly associated with radiation dermatitis grade in both LRA and recursive partitioning analysis (RPA). A scoring system incorporating the V_60Gy, concurrent chemotherapy status, age, and body mass index was used to divide all patients into three subgroups (0–1, 2–3, and 4–6 points) in the RPA. The incidence of Grade 3 dermatitis significantly differed among the subgroups (0, 20.5, and 58.6%, respectively, P < 0.01).

Conclusions

A risk analysis model incorporating dose-volume parameters successfully predicted acute skin reactions and will aid in the appropriate management of radiation dermatitis.

The impact of treatment package time on survival in surgically managed head and neck cancer in the United States

OBJECTIVES

Delays in the initiation of postoperative radiation have been associated with worse outcomes; however, the effect of the overall treatment package time (interval from surgery through the completion of radiation) remains undefined. The purpose of this study was to determine the impact of package time on survival and to evaluate this effect among different subgroups of head and neck cancer patients.

PATIENTS AND METHODS

In this observational cohort study, the National Cancer Database was used to identify 35,167 patients with resected nonmetastatic head and neck cancer who underwent adjuvant radiation from 2004 to 2014. Kaplan-Meier survival estimates and multivariate Cox regression analyses were performed to determine the effect of treatment package time on overall survival.

RESULTS

Median package time was 96 days (interquartile range, 85-112 days). After adjusting for covariates, package times of 11 weeks or less were associated with improved survival (adjusted hazard ratio (aHR), 0.90; 95% confidence interval, 0.83-0.97) compared to an interval of 12-13 weeks, whereas package times of more than 14 weeks were associated with worse survival (aHR, 1.14, 1.14, and 1.22 for 14-15, 15-17, and >17 weeks, respectively). A significant interaction was identified between package time and disease site, nodal status, and stage. Specifically, patients with oropharyngeal tumors, advanced stage (III or IV) disease, or nodal involvement experienced more pronounced increases in mortality risk with delays in treatment time.

CONCLUSIONS

Treatment package time independently impacts survival. This effect may be strongest for patients with oropharyngeal tumors or advanced stage disease.

Prophylactic versus reactive gastrostomy tube placement in advanced head and neck cancer treated with definitive chemoradiotherapy: A systematic review

Although chemoradiotherapy (CRT) has improved disease outcomes in advanced head and neck cancer (aHNC), toxicity remains a major concern. Treatment interruptions and decreased quality of life (QOL) can occur due to malnutrition, secondary to mucositis, dysphagia and odynophagia. Gastrostomy tubes are used in many patients to improve nutrition during CRT. The optimal timing of PEG placement in patients with aHNC undergoing CRT remains controversial. Using the PubMed database, we performed a systematic review of published CRT series in aHNC to guide decision-making regarding optimal timing of percutaneous endoscopic gastrostomy (PEG) placement. We aimed to compare outcomes when patients are treated with prophylactic PEG (pPEG) versus reactive PEG (rPEG). Twenty-two studies examining the role of PEG placement in CRT for aHNC were reviewed. pPEG reduces the number of malnourished patients (defined as >10% of body weight), but average weight loss at various time points following treatment appears similar to patients with rPEG. pPEG is also associated with improved QOL at 6 months, and greater long term PEG dependence. Clinical and dosimetric parameters that correlate with malnutrition in patients without pPEG include advanced age, percent weight loss preceding treatment, and radiation dose to the pharyngeal constrictor muscles. Based on this evidence, our institutional strategy is to encourage pPEG in those patients deemed at greatest risk of becoming malnourished during the course of treatment, and to approach the remainder of patients with rPEG.

The alfa and beta of tumours: a review of parameters of the linear-quadratic model, derived from clinical radiotherapy studies

BACKGROUND

Prediction of radiobiological response is a major challenge in radiotherapy. Of several radiobiological models, the linear-quadratic (LQ) model has been best validated by experimental and clinical data. Clinically, the LQ model is mainly used to estimate equivalent radiotherapy schedules (e.g. calculate the equivalent dose in 2 Gy fractions, EQD₂), but increasingly also to predict tumour control probability (TCP) and normal tissue complication probability (NTCP) using logistic models. The selection of accurate LQ parameters α, β and α/β is pivotal for a reliable estimate of radiation response. The aim of this review is to provide an overview of published values for the LQ parameters of human tumours as a guideline for radiation oncologists and radiation researchers to select appropriate radiobiological parameter values for LQ modelling in clinical radiotherapy.

METHODS AND MATERIALS

We performed a systematic literature search and found sixty-four clinical studies reporting α, β and α/β for tumours. Tumour site, histology, stage, number of patients, type of LQ model, radiation type, TCP model, clinical endpoint and radiobiological parameter estimates were extracted. Next, we stratified by tumour site and by tumour histology. Study heterogeneity was expressed by the I² statistic, i.e. the percentage of variance in reported values not explained by chance.

RESULTS

A large heterogeneity in LQ parameters was found within and between studies (I² > 75%). For the same tumour site, differences in histology partially explain differences in the LQ parameters: epithelial tumours have higher α/β values than adenocarcinomas. For tumour sites with different histologies, such as in oesophageal cancer, the α/β estimates correlate well with histology. However, many other factors contribute to the study heterogeneity of LQ parameters, e.g. tumour stage, type of LQ model, TCP model and clinical endpoint (i.e. survival, tumour control and biochemical control).

CONCLUSIONS

The value of LQ parameters for tumours as published in clinical radiotherapy studies depends on many clinical and methodological factors. Therefore, for clinical use of the LQ model, LQ parameters for tumour should be selected carefully, based on tumour site, histology and the applied LQ model. To account for uncertainties in LQ parameter estimates, exploring a range of values is recommended.

The alfa and beta of tumours: a review of parameters of the linear-quadratic model, derived from clinical radiotherapy studies

Background

Prediction of radiobiological response is a major challenge in radiotherapy. Of several radiobiological models, the linear-quadratic (LQ) model has been best validated by experimental and clinical data. Clinically, the LQ model is mainly used to estimate equivalent radiotherapy schedules (e.g. calculate the equivalent dose in 2 Gy fractions, EQD₂), but increasingly also to predict tumour control probability (TCP) and normal tissue complication probability (NTCP) using logistic models. The selection of accurate LQ parameters α, β and α/β is pivotal for a reliable estimate of radiation response. The aim of this review is to provide an overview of published values for the LQ parameters of human tumours as a guideline for radiation oncologists and radiation researchers to select appropriate radiobiological parameter values for LQ modelling in clinical radiotherapy.

Methods and materials

We performed a systematic literature search and found sixty-four clinical studies reporting α, β and α/β for tumours. Tumour site, histology, stage, number of patients, type of LQ model, radiation type, TCP model, clinical endpoint and radiobiological parameter estimates were extracted. Next, we stratified by tumour site and by tumour histology. Study heterogeneity was expressed by the I² statistic, i.e. the percentage of variance in reported values not explained by chance.

Results

A large heterogeneity in LQ parameters was found within and between studies (I² > 75%). For the same tumour site, differences in histology partially explain differences in the LQ parameters: epithelial tumours have higher α/β values than adenocarcinomas. For tumour sites with different histologies, such as in oesophageal cancer, the α/β estimates correlate well with histology. However, many other factors contribute to the study heterogeneity of LQ parameters, e.g. tumour stage, type of LQ model, TCP model and clinical endpoint (i.e. survival, tumour control and biochemical control).

Conclusions

The value of LQ parameters for tumours as published in clinical radiotherapy studies depends on many clinical and methodological factors. Therefore, for clinical use of the LQ model, LQ parameters for tumour should be selected carefully, based on tumour site, histology and the applied LQ model. To account for uncertainties in LQ parameter estimates, exploring a range of values is recommended.

Electronic supplementary material

The online version of this article (10.1186/s13014-018-1040-z) contains supplementary material, which is available to authorized users.

Oral curcumin for radiation dermatitis: a URCC NCORP study of 686 breast cancer patients

PURPOSE

Despite advances in medical technology, radiation dermatitis occurs in 95% of patients receiving radiation therapy (RT) for cancer. Currently, there is no standard and effective treatment for the prevention or control of radiation dermatitis. The goal of the study was to determine the efficacy of oral curcumin, one of the biologically active components in turmeric, at reducing radiation dermatitis severity (RDS) at the end of RT, using the RDS scale, compared to placebo.

METHODS

This was a multisite, randomized, double-blinded, placebo-controlled trial of 686 breast cancer patients. Patients took four 500-mg capsules of placebo or curcumin three times daily throughout their prescribed course of RT until 1 week post-RT.

RESULTS

A total of 686 patients were included in the final analyses (87.5% white females, mean age = 58). Linear mixed-model analyses demonstrated that curcumin did not reduce radiation dermatitis severity at the end of RT compared to placebo (B (95% CI) = 0.044 (- 0.101, 0.188), p = 0.552). Fewer curcumin patients with RDS > 3.0 suggested a trend toward reduced severity (7.4 vs. 12.9%, p = 0.082). Patient-reported changes in pain, symptoms, and quality of life were not statistically significant between arms.

CONCLUSIONS

Oral curcumin did not significantly reduce radiation dermatitis severity compared to placebo. The skin rating variation and broad eligibility criteria could not account for the undetectable therapeutic effect. An objective measure for radiation dermatitis severity and further exploration for an effective treatment for radiation dermatitis is warranted.

Hyperfractionated Radiotherapy for T2N0 Glottic Carcinoma: A Retrospective Analysis at 10 Years Follow-up in a Series of 60 Consecutive Patients

Aims and background

To report results of hyperfractionated radiotherapy for T2N0 glottic carcinoma at a single institution after extended follow-up.

Methods

Between 1980 and 1988 at Varese University Hospital, 60 consecutive patients with T2N0 glottic carcinoma received exclusive radiotherapy consisting of 1.5 Gy/fraction twice a day. Treatment gaps during the radiotherapy course were allowed according to individual tolerance. This policy resulted in a wide range of elapsed treatment time: median, 5.7 weeks; range, 3.7-8.9. Median follow-up is 9.8 years.

Results

As a result of dose/time distribution, 16, 20 and 24 patients received an average weekly dose rate of <10 Gy/week, equal to 10 Gy/week or >10 Gy/week, respectively. Mean total dose for each group was 62.8 Gy, 63.7 Gy and 63.8 Gy, respectively. Five-year local-regional control was 69 ± 6% (95% Cl); ultimate local-regional control, including salvage surgery, was 78 ± 5%. All failures were at the primary site, and no patient developed neck recurrence as first site of failure. The actuarial incidence of grade 2-3 late reactions at 5 years was 42 ± 6%. Most late toxicity events were grade 2: only 2 patients developed grade 3 reactions and none grade 4. None of the several clinical and treatment-related variables showed any statistically significant impact on local-regional control or late toxicity at univariate and multivariate analysis. In particular, 3-year local-regional control rates were 73 ± 11%, 84 ± 8% and 69 ± 10% for an average weekly dose rate of <10 Gy/week, equal to 10 Gy/week and >10 Gy/week, respectively (not significantly different).

Conclusions

At a very long follow-up, the hyperfractionated regimen tested in the study was shown to be effective and devoid of major complications, provided individual patient acute tolerance is carefully taken into account. Also, time factor did not affect outcome in this series.

Lack of a Time-Factor in Alternating Chemoradiotherapy for Advanced Head and Neck Squamous Cell Carcinoma

Purpose

To assess whether a radiotherapy time factor exists also for patients affected by head and neck squamous cell carcinoma and receiving combined chemoradiotherapy.

Methods and materials

From 1989 to 1997, of 121 patients affected by stage III or IV head and neck squamous cell carcinoma who underwent alternating chemotherapy and radiotherapy according to the Merlano regimen at our institution, 59 were selected for time factor analysis. Until 1995, if chemotherapy had to be delayed because of bone marrow toxicity, radiotherapy was also delayed accordingly. Since January 1996 in order to avoid treatment-free gaps, radiotherapy was delivered continuously until it was possible to resume chemotherapy. Potential predictive factors of local-regional control were included in univariate and multivariate models. The median follow-up is 26 months (5-121 months).

Results

As a result of change in treatment policy, mean radiotherapy duration was shorter for 25 patients treated after 1995 (group A, 8.4 weeks) than for those treated during 1995 or before (group B, 9.4 weeks) (t test, P = 0.0012). In contrast, as expected, mean chemotherapy duration remained relatively unchanged through the years (10.9 vs 10.7 weeks for groups B and A, respectively, t test, P = 0.77). At 2 years, the actuarial local-regional control rate was 53 ± 7% for the whole population. The estimated rates of local-regional control at 2 years were 49 ± 10% and 56 ± 9% for patients belonging to groups A and B, respectively. At univariate and multivariate analyses, treatment group was not predictive of local-regional control.

Conclusions

Our attempt to prospectively limit radiotherapy overall treatment time failed to improve outcome. The data, although obtained on a relatively limited number of patients, suggest that tumor cell repopulation during radiotherapy may not be clinically relevant when chemotherapy is part of the treatment for advanced head and neck squamous cell carcinoma.

Barriers affecting adherence to radiation treatment and strategies to overcome those barriers

BACKGROUND

The WHO defines adherence as the extent to which a patient's behavior coincides with recommendations from a health-care provider. Nonadherence to cancer treatment has a major impact on the therapeutic outcome.

AIM OF THE STUDY

To assess the prevalence of nonadherence to radiation regimen and to analyze the factors that affect adherence to cancer treatment.

MATERIALS AND METHODS

Patients receiving radiation treatment in our hospital were screened for adherence to appointment keeping and to the prescribed radiation regimen and patients who had unplanned treatment breaks during treatment were interviewed. Between January and July 2013, we identified 61 patients who had unplanned breaks during treatment. We analyzed the social, emotional, educational, economic, and therapeutic barriers that led to nonadherence.

RESULTS

Of the 61 patients who had unplanned breaks during treatment, 54% were males and 46% were females. Fifty-seven percent of patients had head and neck cancers and 25% had gynecological cancers. Seventy-one percent of patients were planned for concurrent chemoradiation. The number of days of unplanned treatment breaks ranged from 3 to 27 days. Social and therapeutic barriers were found to be the most common factor that led to nonadherence in these patients.

CONCLUSION

Identification of barriers that lead to nonadherence, designing strategies to overcome such barriers and effective communication becomes imperative to ensure uninterrupted treatment. Based on the above analysis, we have designed several strategies to improve adherence to treatment among our patients.

Effect of psychosocial distress on outcome for head and neck cancer patients undergoing radiation

OBJECTIVES/HYPOTHESIS

To determine the impact of pretreatment psychosocial distress on compliance to radiation therapy (RT) and clinical outcomes for patients with head and neck cancer STUDY DESIGN: Self-reported responses to the mood and anxiety domains of the University of Washington Quality of Life instrument were reviewed among 133 patients with newly diagnosed head and neck cancer prior to initiating RT.

METHODS

Varying definitions were used (total number of unexpectedly missed RT days, >5 days continuous interruption of RT outside of weekends, >10 days continuous interruption of RT, and failure to complete prescribed course of RT) to analyze the effect of psychosocial disruption on compliance. Survival was determined using the Kaplan-Meier method.

RESULTS

The prevalence of pretreatment depression and anxiety was 23% and 47%, respectively. Continuous RT breaks >5 days occurred in 46%, 33%, 10%, 9%, and 0% of patients whose mood was rated as "extremely depressed," "somewhat depressed," "neither in a good mood or depressed," "generally good," and "excellent," respectively (P = .0016). The corresponding proportion of patients who did not complete their planned RT was 23%, 11%, 5%, and 3%, and 0%, respectively (P = .043). The 2-year overall survival of patients who were "extremely depressed" or "somewhat depressed" at baseline was 71% versus 86% for all others (P = .026). Depression was independently associated with decreased overall survival on logistical regression analysis.

CONCLUSIONS

Pretreatment depression predicted for decreased RT compliance and inferior survival for head and neck cancer. Additional research to overcome potential barriers to treatment in this setting may be warranted.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:641-645, 2018.

Interruptions of Head and Neck Radiotherapy Across Insured and Indigent Patient Populations

Purpose:

Radiotherapy for head and neck cancer is a cornerstone of care, requiring 30 to 35 days of treatment over 6 to 7 weeks. Diligent patient compliance is crucial, and unplanned treatment interruptions reduce cure rates. We studied interruption rates in private carrier–insured and Medicare-insured populations versus indigent populations served by a single academic health system.

Materials and Methods:

A retrospective cohort study of electronic medical and billing records was performed analyzing treatment interruptions between January 2011 and December 2014. The study included 564 patients with head and neck cancer prescribed radiotherapy and referred from clinics run by University of Texas Southwestern Medical Center (UTSW) and the Parkland Health and Hospital System (PHHS), which provides indigent care to Dallas County, Texas.

Results:

Three-hundred sixteen patients (56%) had a treatment break; 114 patients missed a single session, and 202 patients missed multiple treatments. Seventy percent of PHHS patients had treatment delays compared with 47% of UTSW patients ( P < .001). The number of interrupted days in the PHHS population was nearly twice that observed in UTSW patients. PHHS patients most commonly missed treatment for nonmedical or logistical reasons. Delay was predictive for local recurrence ( P < .001) and overall survival ( P < .001). In compliant patients, there was no significant difference in local recurrence ( P = .43) or overall survival ( P = .27) across referral sites. However, among noncompliant patients, there was a higher likelihood for local recurrence in the PHHS cohort ( P = .016). Multivariable modeling suggested treatment interruption to be a key driver of outcome differences across referral sites.

Conclusion:

Survival outcomes in our at-risk population were inferior to those in patients insured by commercial carriers or Medicare. Treatment interruption predicted for poor outcome across all patients but was disproportionately experienced by at-risk patients. These results highlight cancer control needs specific to disadvantaged communities at risk for poor treatment compliance.

Treatment delays in oral cavity squamous cell carcinoma and association with survival

BACKGROUND

Treatment durations and factors associated with delays for oral cavity squamous cell carcinoma (SCC) have previously been described but are not fully understood. Impact of delays on overall survival (OS) remains unclear.

METHODS

The National Cancer Data Base (NCDB) was used to analyze 4868 patients with oral cavity SCC from 1998 to 2011. Diagnosis-to-surgery, surgery-to-radiotherapy (RT)_start , RT duration, total treatment package (surgery-to-RT_end ), and diagnosis-to-RT_end were evaluated. Associations between delays and various factors were analyzed using binary logistic regression. Associations with OS were analyzed using the Cox proportional hazards model.

RESULTS

Medians for diagnosis-to-surgery, surgery-to-RT_start , RT duration, total treatment package, and diagnosis-to-RT_end were 30, 50, 49, 101, and 136 days, respectively. Age ≥60 years, uninsured or Medicaid insurance, comorbidity, late pT, and treatment at an academic/research institution were associated with diagnosis-to-surgery delays. Only delays in RT duration were significantly associated with decreased OS (hazard ratio [HR] = 1.21; p = .02).

CONCLUSION

Numerous factors are associated with treatment delays. RT duration is significantly associated with OS. © 2017 Wiley Periodicals, Inc. Head Neck 39: 639-646, 2017.

Management of interruptions to fractionated radiotherapy treatments: Four and a half years of experience

BACKGROUND AND PURPOSE

The study objective was to report our four-and-a half years experience (March 1 2011-August 15 2015) of a program to manage interruptions in fractionated radiotherapy treatments.

METHODS

A program was developed, based on a specific database, to manage treatment interruptions. Benefits of the program were analyzed in reference to previously published data. Analysis was also performed of two measures to reduce OTT prolongation and improve treatment outcomes: working on public holidays and conducting treatment unit maintenance on Saturdays.

RESULTS

The study included 2352 patients. Patients with head and neck cancer obtained the greatest benefit from the program, with a mean increase in TCP of 3.5% and a benefit of at least 4% in 45.6% of them. In prostate cancer patients, the likelihood of biochemical failure was reduced by a mean of 2.0% and was reduced by at least 4% in 19.7% of them. Application of the two proposed measures would have improved the TCP by a mean of 5.4% in head and neck cancer patients. The impact of the compensations program and proposed measures is lesser in the remaining cancer types studied.

CONCLUSIONS

Implementation of a compensation program has a significant impact on patients with head and neck or prostate cancer but OTT prolongation remains excessive in many treatments. The introduction of fractions on public holidays would assist in the meeting of recommendations for these patients.

The "rocky treatment course": identifying a high-risk subgroup of head and neck cancer patients for supportive interventions

PURPOSE

We aim to identify the risk factors for a "rocky" treatment course (RTC) in head and neck cancer.

METHODS

A retrospective case-control study was conducted utilizing data from a prospective study. We defined the RTC as a composite of adverse outcomes including G-tube dependence and increased nursing interventions. Statistically associative variables were included in a multivariable logistic regression. We also evaluated whether the RTC, or its components, associated with worse cancer outcomes.

RESULTS

Being single, unemployed, having N2/3 disease and receiving chemoradiotherapy were associated with a RTC. In turn, G-tube dependence was associated with worse 3-year OS (73 vs 91 %; p = 0.02) and increased nursing interventions with worse 3-year locoregional recurrence-free survival (LRFS) (85 vs 92 %; p = 0.03) and locoregional recurrence (LRR) (14 vs 7 %; p = 0.03).

CONCLUSIONS

We identified baseline factors associated with a RTC for head and neck cancer patients. Future supportive care interventions could be evaluated using the RTC as a marker of benefit.

Effect of polaprezinc on oral mucositis, irradiation period, and time to discharge in patients with head and neck cancer

BACKGROUND

The purpose of the present study was to determine whether polaprezinc suspension in sodium alginate (P-AG) reduces the irradiation period and time to discharge after completion of radiotherapy in patients with head and neck cancer.

METHODS

The incidence and severity of oral mucositis, the irradiation period, and the time to discharge in patients who received radiotherapy with head and neck cancer were investigated retrospectively from the medical records.

RESULTS

The incidence of grade 3 oral mucositis was significantly lower in the P-AG group than in the control group (16.5% vs 52.0%; p = .0003). P-AG also significantly reduced median duration of radiotherapy (hazard ratio [HR] = 0.557; 95% confidence interval [CI] = 0.357-0.871; p = .0149) and median time to discharge after completion of radiotherapy (HR = 0.604; 95% CI = 0.386-0.946; p = .028).

CONCLUSION

P-AG reduced the irradiation period and the time to discharge after completion of radiotherapy by preventing oral mucositis in patients with head and neck cancer. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1387-1392, 2016.

Cetuximab and Radiotherapy Versus Cisplatin and Radiotherapy for Locally Advanced Head and Neck Cancer: A Randomized Phase II Trial

PURPOSE

No randomized trials have been conducted to directly compare radiotherapy (RT) with concomitant cisplatin (CDDP) versus concomitant cetuximab (CTX) as first-line treatment of locally advanced squamous cell carcinoma of the head and neck. In this randomized trial, we compared these two treatment regimens in terms of compliance, toxicity, and efficacy.

PATIENTS AND METHODS

Eligible patients were randomly assigned in a 1:1 ratio to receive either CDDP 40 mg/m(2) once per week or CTX 400 mg/m(2) as loading dose followed by CTX 250 mg/m(2) once per week concomitant to radical RT. For primary end points, compliance to treatment was defined as number of days of treatment discontinuation and drug dosage reduction. The acute toxicity rate was defined according to the National Cancer Institute Common Toxicity Criteria. Efficacy end points were local recurrence-free survival, metastasis-free survival, cancer-specific survival, and overall survival.

RESULTS

The study was discontinued early because of slow accrual after the enrollment of 70 patients. RT discontinuation for more than 10 days occurred in 13% of patients given CTX and 0% given CDDP (P = .05). Drug dosage reduction occurred in 34% given CTX and 53% given CDDP (difference not significant). Toxicity profiles differed between the two arms, with hematologic, renal, and GI toxicities more frequent in the CDDP arm, and cutaneous toxicity and the need for nutritional support more frequent in the CTX arm. Serious adverse events related to treatment, including four versus one toxic deaths, were higher in the CTX arm (19% v 3%, P = .044). Locoregional control, patterns of failure, and survivals were similar between the treatment arms.

CONCLUSION

CTX concomitant to RT lowered compliance and increased acute toxicity rates. Efficacy outcomes were similar in both arms. These results raise the issue of appropriately selecting patients with head and neck cancer who can benefit from CTX in combination with RT.

Six-year analysis of compliance to weekly concurrent chemoradiotherapy in head and neck carcinomas

OBJECTIVES

To evaluate treatment compliance to weekly concurrent chemoradiotherapy (CRT) in head and neck squamous cell carcinoma (HNSCC).

STUDY DESIGN

Retrospective analysis.

SETTING

Tertiary care hospital.

MAIN OUTCOME MEASURES

Overall treatment time (OTT), acute radiation morbidity and treatment completion rate without prolongation of overall treatment time of more than 2 days.

RESULTS

Three hundred and seventy-eight head and neck carcinoma patients treated with radical CRT with 70 Gy/35 fractions of radiotherapy with weekly cisplatin 40 mg/m(2) were included in the study. Median age was 52 years (range 22-77 years), oropharynx was most commonly (54%) involved site, and 55% were in stage IV disease. Majority (86%) of patients were able to complete cancer-directed therapy, median OTT was 52 days (46-140 days). Nineteen per cent of patients completed treatment without prolongation of OTT beyond 2 days and 68% of patients there completed treatment prolongation of OTT beyond 7 days. Nearly, sixty-six of the patients experienced grade II or higher acute radiation morbidities.

CONCLUSIONS

Delivery of weekly low-dose concurrent CRT is safe and feasible. Two-thirds of the patients experienced treatment prolongation of more than 2 days and 14% could not complete treatment. Results within in the study suggest to a greater need to lay emphasis on continuity of a course of radical CRT for HNSCC.

Oral Lapacho-Based Medication: An Easy, Safe, and Feasible Support to Prevent and/or Reduce Oral Mucositis During Radiotherapy for Head and Neck Cancer

The aim of our Phase II study is to demonstrate the benefits, safety, and tolerance of Orasol Plus, an easy and feasible Lapacho-based medication. Orasol Plus is a nutritional, swallowable solution, useful to support the defenses of the oropharyngeal mucosa. Between January and June 2014, 40 consecutive adult patients affected by head and neck cancer were enrolled. Orasol Plus was administered 3 times a day from the first day till the end of radiotherapy. Primary endpoint was to evaluate tolerance and safety of Orasol Plus; secondary endpoint was to evaluate the effect of Orasol Plus on the incidence of treatment discontinuation. Nearly all patients used Orasol Plus easily till the end of radiotherapy without interruptions. Only 11 (27.5%) patients developed oral mucositis (OM) Grade 2 and only 4 (10%) patients OM Grade 3, no patient developed OM Grade 4. No patient discontinued radiotherapy because of OM. Orasol Plus was well tolerated and the compliance of patients was optimal, mainly due to the fact that it can be swallowed. Data from our study are encouraging and they need to be confirmed by a Phase III study.

Adenosine A2A receptor plays an important role in radiation-induced dermal injury

Ionizing radiation is a common therapeutic modality and following irradiation dermal changes, including fibrosis and atrophy, may lead to permanent changes. We have previously demonstrated that occupancy of A2A receptor (A2AR) stimulates collagen production, so we determined whether blockade or deletion of A2AR could prevent radiation-induced fibrosis. After targeted irradiation (40 Gy) of the skin of wild-type (WT) or A2AR knockout (A2ARKO) mice, the A2AR antagonist ZM241385 was applied daily for 28 d. In irradiated WT mice treated with the A2AR antagonist, there was a marked reduction in collagen content and skin thickness, and ZM241385 treatment reduced the number of myofibroblasts and angiogenesis. After irradiation, there is an increase in loosely packed collagen fibrils, which is significantly diminished by ZM241385. Irradiation also induced an increase in epidermal thickness, prevented by ZM241385, by increasing the number of proliferating keratinocytes. Similarly, in A2ARKO mice, the changes in collagen alignment, skin thickness, myofibroblast content, angiogenesis, and epidermal hyperplasia were markedly reduced following irradiation. Radiation-induced changes in the dermis and epidermis were accompanied by an infiltrate of T cells, which was prevented in both ZM241385-treated and A2ARKO mice. Radiation therapy is administered to a significant number of patients with cancer, and radiation reactions may limit this therapeutic modality. Our findings suggest that topical application of an A2AR antagonist prevents radiation dermatitis and may be useful in the prevention or amelioration of radiation changes in the skin.

Complications after CO2 laser surgery for early glottic cancer: An institutional experience

BACKGROUND

Transoral laser microsurgery (TLM) of the glottis is increasingly utilized in the current management of early glottic cancer, its advantages being administrative ease, potential to be repeated, ability to keep radiotherapy and open laryngeal surgery available as salvage options, and low complication rates.

METHODS

A retrospective chart review of prospectively gathered data on all patients over a 10-year period who had undergone TLM for Tis or early (T1-2) glottic squamous cell carcinomas (SCCs) was analyzed to examine the complications experienced.

RESULTS

Of 132 patients undergoing TLM, complications were: edema requiring tracheostomy (n = 1), surgical emphysema (n = 1), pharyngeal bruising (n = 1), endotracheal tube cuff perforation (n = 1), anterior glottic web (n = 14), vocal cord granuloma (n = 14), laryngocele (n = 1), and none of airway fire or intraoperative or postoperative hemorrhage.

CONCLUSION

Our results suggest that for early glottic cancers, and in skilled hands, with appropriate anesthetic and theater staff support, TLM is a safe and repeatable procedure. © 2015 Wiley Periodicals, Inc. Head Neck 38: E987-E990, 2016.

Adjuvant chemoradiotherapy versus with radiotherapy alone for locally advanced salivary gland carcinoma among older patients

BACKGROUND

The majority of patients with locally advanced salivary gland carcinoma will die of the disease even after curative surgery. Few studies on adjuvant therapy have been conducted. In this study, we compared adjuvant chemoradiotherapy (CRT) with adjuvant radiotherapy among the older patient population.

METHODS

Surveillance, Epidemiology, and End Results (SEER)-Medicare database (1992-2009) was analyzed. Eligible cases were those receiving curative surgery followed by adjuvant therapy. Outcomes were overall survival and toxicity.

RESULTS

Analyses included 741 patients: 641 patients (86.5%) received adjuvant radiotherapy and 100 (13.5%) received adjuvant CRT. The median overall survival was 41.0 months with adjuvant radiotherapy and 24 months with CRT. Both multivariable and propensity score-adjusted analyses indicated that adjuvant CRT was associated with an increased mortality (hazard ratio [HR]: 1.39; 95% confidence interval [CI]: 1.07-1.79 and HR: 1.49; 95% CI: 1.14-1.94, respectively). Toxicity rates were significantly higher in the CRT group.

CONCLUSION

Treatment with adjuvant CRT was associated with an increased mortality and toxicity when compared to adjuvant radiotherapy alone. © 2015 Wiley Periodicals, Inc. Head Neck 38: 863-870, 2016.

Effect of radiotherapy delay in overall treatment time on local control and survival in head and neck cancer: Review of the literature

Treatment delays in completing radiotherapy (RT) for many neoplasms are a major problem affecting treatment outcome, as increasingly shown in the literature. Overall treatment time (OTT) could be a critical predictor of local tumor control and/or survival. In an attempt to establish a protocol for managing delays during RT, especially for heavily overloaded units, we have extensively reviewed the available literature on head and neck cancer. We confirmed a large deleterious effect of prolonged OTT on both local control and survival of these patients.

Pre-radiotherapy Haemoglobin Level is A Prognosticator in Locally Advanced Head and Neck Cancers Treated with Concurrent Chemoradiation

INTRODUCTION

Radiation plays a major role in treatment of locoregional control of Head and Neck Squamous cell carcinoma (HNSCC). Anaemia is considered a contributor to intra-tumour hypoxia and tumour resistance to ionizing radiation and most evidences are from developed world, we prospectively investigated the exact role of anaemia in treatment outcome of Stage III/IVA HNSCC in our patient population.

AIM OF THE STUDY

Primary end point: To analyse the Pre-Radiotherapy haemoglobin level and early response of treatment in stage III/IVA HNSCC and to determine the relationship of Pre-Radiotherapy haemoglobin level with other prognostic factors.

MATERIALS AND METHODS

This non-interventional single blinded randomized study enrolled patients attending the OPD consecutively, who met our eligibility criteria.

INCLUSION CRITERIA

HNSCC patients of Stage III/IVA aged ≥18 years and ≤ 70 years with ECOG status of 1or 2 and willing for concurrent chemoradiation and at least 6 weeks of follow up.

EXCLUSION CRITERIA

1) Previous history of treatment for malignancy or radiation in head and neck site. 2) Patients with other fatal and non-fatal pre-morbid or co-morbid conditions that can affect the outcome or the overall survival. Patients with Pre-radiotherapy haemoglobin status < 10 g/dl were given haematinic support and/or blood transfusion. All patients received concurrent chemotherapy (weekly cisplatin) and radiation in conventionally fractionated dose of 66Gy. Early treatment responses were evaluated with Revised RECIST version 1.1 and Data analysis using SPSS version 17.0.

RESULTS

Ninety one patients enrolled had mean age of 55.63 (range: 32-69), a median of 56 and mode of 60. Seventy one were males (78%) and 20 females (22%) with a performance status of ECOG 1 in 43 (47%) patients and ECOG 2 in 48 (53%); Pre-RT Hb level of <10.7 g/dl in 38 (42%) patients and ≥10.7 in 53 (58%) patients; Pre-RT Hb level was <12 g/dl in 67 (74%) patients and ≥12 in 24 (26%) patients. Tumour sites were - Nasopharynx 7 (8 %), Oral Cavity 18 (20 %), Oropharynx 32 (35 %), Hypopharynx 23 (25 %) and Larynx 11 (12 %). Twenty five (27%) had Grade 2 mucositis and 66 (73%) had Grade 3 mucositis. Fifty eight (64%) patients completed treatment with NO breaks and 33 (36%) with treatment breaks for ≥5 days. Pre-radiotherapy haemoglobin ≥ 10.7 g/dl (p < 0.001), ECOG performance status (p = 0.0002), Treatment interruptions for > 5 days (p = <0.0001), Mucositis reaction (p = <0.0001) showed statistical significance with outcome of response.

CONCLUSION

The study found that performance status, pre-RT haemoglobin level, radiotherapy interruptions > 5 days and non-development of grade III mucositis was found to be significantly associated with good loco-regional control. Haemoglobin level ≥10.7 g/dl was associated with better treatment outcome, higher performance status, fewer treatment interruptions and lesser degree of mucositis. Transfusion did not affect the outcome. Definitive conclusions and recommendations need further expansion of our study for better statistical power.

Interval From Imaging to Treatment Delivery in the Radiation Surgery Age: How Long Is Too Long?

PURPOSE

The purpose of this study was to evaluate workflow and patient outcomes related to frameless stereotactic radiation surgery (SRS) for brain metastases.

METHODS AND MATERIALS

We reviewed all treatment demographics, clinical outcomes, and workflow timing, including time from magnetic resonance imaging (MRI), computed tomography (CT) simulation, insurance authorization, and consultation to the start of SRS for brain metastases.

RESULTS

A total of 82 patients with 151 brain metastases treated with SRS were evaluated. The median times from consultation, insurance authorization, CT simulation, and MRI for treatment planning were 15, 7, 6, and 11 days to SRS. Local freedom from progression (LFFP) was lower in metastases with MRI ≥ 14 days before treatment (P = .0003, log rank). The 6- and 12-month LFFP rate were 95% and 75% for metastasis with interval of <14 days from MRI to treatment compared to 56% and 34% for metastases with MRI ≥ 14 days before treatment. On multivariate analysis, LFFP remained significantly lower for lesions with MRI ≥ 14 days at SRS (P = .002, Cox proportional hazards; hazard ratio: 3.4, 95% confidence interval: 1.6-7.3).

CONCLUSIONS

Delay from MRI to SRS treatment delivery for brain metastases appears to reduce local control. Future studies should monitor the timing from imaging acquisition to treatment delivery. Our experience suggests that the time from MRI to treatment should be <14 days.

Sepsis in head and neck cancer patients treated with chemotherapy and radiation: Literature review and consensus

The reporting of infection/sepsis in chemo/radiation-treated head and neck cancer patients is sparse and the problem is underestimated. A multidisciplinary group of head and neck cancer specialists from Italy met with the aim of reaching a consensus on a clinical definition and management of infections and sepsis. The Delphi appropriateness method was used for this consensus. External expert reviewers then evaluated the conclusions carefully according to their area of expertise. The paper contains seven clusters of statements about the clinical definition and management of infections and sepsis in head and neck cancer patients, which had a consensus. Furthermore, it offers a review of recent literature in these topics.

Symptom management during the radiation oncology treatment course: a practical guide for the oncology clinician

Symptom management during radiation therapy is critical to providing high-quality care for patients receiving treatment. Symptoms are varied and dependent on the site irradiated. Common symptoms associated with radiation therapy include dermatitis, xerostomia, mucositis, and pneumonitis. Treatment strategies include prevention, anticipation, and development of clinical practice enabling rapid identification and management of emerging symptoms. Understanding the spectrum of symptomatology affecting irradiated patients is integral to improved quality of life and treatment efficacy.

Compliance to therapy-elderly head and neck carcinoma patients

Background

Treatment compliance of elderly patients to intensive multi-modality cancer therapy can be challenging and has not been adequately addressed in developing countries. The present study evaluated compliance of elderly head and neck carcinomas patients to cancer-directed therapy.

Methods

Forty-seven elderly HNSCC patients were evaluated in the present study. Patients were assessed as per stage and site of disease, general condition, performance status, and any pre-existing co-morbidities. Compliance was defined as patients who were able to complete cancer therapy as intended at primary clinic. Non-compliance to therapy was stratified as early, mid- and late-course non-compliance. Statistical analysis was done using STATA 9.1 software, chi-square/Fischer’s exact test to see strength of association between two categorical variables that could possibly affect compliance in elderly patients.

Results

Sixty-eight per cent of elderly patients were subjected to radical treatment, majority (42/47) presented in loco-regionally advanced stage (III–IV), most common site of malignancy was oropharynx (21/47). Sixty-two per cent of elderly HNSCC patients were compliance to cancer therapy. Median overall treatment time for patients subjected to radical radiation therapy was 52 (range 47–99) days, and for radical surgery and adjuvant radiotherapy was 109 (95–190) days. Compliance to therapy for elderly HNSCC patients was not significantly associated with advanced stage, poor general condition, intent of treatment or presence of co-morbidity. As regards to non-compliance, majority (14/18) of elderly patients showed mid-course treatment non-compliance.

Conclusions

Nearly two-thirds of elderly head and neck carcinoma patients were compliant to cancer-directed therapy.

A traditional Japanese medicine--Hangeshashinto (TJ-14)--alleviates chemoradiation-induced mucositis and improves rates of treatment completion

PURPOSE

Oral mucositis induced by radiation or chemoradiation can cause devastating quality of life issues for patients undergoing treatment for head and neck cancer. In this study, we investigated the efficacy of a traditional Japanese medicine-Hangeshashinto (TJ-14)-for (chemo)radiation-induced oral mucositis.

METHODS

Eighty patients who underwent whole neck radiation of >60 Gy with or without chemotherapy (high-dose cisplatin or low-dose docetaxel) were enrolled in this retrospective study; 40 had received TJ-14 during treatment, and 40 had not (controls). Factors related to alleviation of oral mucositis were identified by multivariate logistic regression analysis. Rates of completion of (chemo)radiation treatments were compared between the patients who received TJ-14 and the control group according to the treatment regimen. The comparison of the nutrition status between groups was also performed.

RESULTS

Multivariate analysis indicated that the use of TJ-14 (p = 0.019), gender (p = 0.024), and primary tumor location (p = 0.028) were significant factors associated with the severity of oral mucositis. TJ-14 was associated with a significantly improved rate of completion of chemoradiation with cisplatin (p = 0.002). In the investigation of nutritional status, only serum albumin was significantly maintained better in the TJ-14 group than the control group in terms of mean change before and after (chemo)radiation (p = 0.024).

CONCLUSIONS

The present study indicates that TJ-14 is effective for ameliorating oral mucositis induced by (chemo)radiation in patients with head and neck cancers. TJ-14 was associated with improved completion rates of chemoradiation treatments with cisplatin. A randomized controlled trial is necessary to confirm the efficacy of TJ-14 for chemoradiation-induced mucositis in head and neck cancer patients.

Predictors of long-term opioid treatment among patients who receive chemoradiation for head and neck cancer

INTRODUCTION

The factors associated with successful opioid discontinuation after cancer treatment are not well-known. We determined the proportion of patients with advanced head and neck cancer who continued using opioids 3 months after the completion of radiation therapy with or without chemotherapy.

METHODS

We included 70 patients with head and neck cancer referred to our institution's supportive care center between January 1, 2008, and December 31, 2010. Patients who no longer used opioids 3 months after the completion of radiation therapy were classified as stoppers; patients who continued using opioids were considered nonstoppers. We compared demographics, cancer-related characteristics, alcoholism, substance abuse history, use of psychoactive drugs, and opioid-related factors between stoppers and nonstoppers.

RESULTS

In all, 44 of 70 patients (63%) and 23 of 70 patients (33%) continued opioids 3 months and 6 months after the completion of radiation therapy, respectively. A total of 18 of 44 nonstoppers (41%) and 3 of 26 stoppers (12%) were positive for alcoholism based on the CAGE questionnaire (i.e., Cut down, Annoying, Guilty, Eye opener; odds ratio: 5.3). Demographic and clinical characteristics did not differ between stoppers and nonstoppers. The median duration of any type of opioid use of CAGE-positive patients was significantly longer than that of CAGE-negative patients (median: 261 days vs. 93 days; hazard ratio: 2.5).

CONCLUSION

CAGE positivity is a risk factor for opioid use beyond 3 months after the completion of radiation therapy and for duration of opioid treatment. Routine CAGE screening and meticulous follow-up are needed for these patients.

Comparison of acute toxicities in two primary chemoradiation regimens in the treatment of advanced head and neck squamous cell carcinoma

PURPOSE

The optimal dosage and frequency of platinum-based chemoradiotherapy (CRT) regimen for treating advanced head and neck squamous cell carcinoma remains unresolved. This study aims to compare the toxicity and efficacy of weekly versus more dose-intensive cisplatin-based CRTs.

METHODS

We reviewed 155 stage III/IV head and neck squamous cell carcinoma patients with no evidence of distant metastasis treated with one of two CRT regimens from 2000 to 2010 at Greater Baltimore Medical Center. Twice-daily radiation was provided as a split course over a 45-day period. Regimen A consisted of concomitant cisplatin (30 mg/m2/1 h) weekly for 6 cycles; regimen B consisted of concomitant cisplatin (12 mg/m2/1 h) and 5-fluorouracil (600 mg/m2/20 h) on days 1 through 5 and days 29 through 33. Main outcome measures included acute toxicities (myelosuppression, neurotoxicity, nephrotoxicity, gastrointestinal dysfunction), unplanned hospitalizations, and disease control at 12 months.

RESULTS

Patients on regimen A were much less likely to experience ototoxicity due to their treatment (0% vs. 9.8%, P = 0.04). They were more likely to experience thrombocytopenia acutely (46% vs. 26%, P = 0.02), but the toxicity was not limiting (grade 1–2). No significant differences exist in the incidence of other toxicities or unplanned hospitalizations. At 1 year, 97% of patients on A vs. 86% of patients on regimen B were free of disease (P = 0.11).

CONCLUSIONS

With concurrent radiotherapy, low-dose, single-agent, weekly cisplatin is less likely than higher-dose daily cisplatin plus 5-fluorouracil provided at the beginning and end of treatment to be associated with ototoxicity. The preliminary data suggest at least equivalent efficacy, but longer follow-up is required.