Evaluations of quality of life and organ function

High-dose-rate interstitial brachytherapy in head and neck cancer: do we need a look back into a forgotten art - a single institute experience

Purpose

To evaluate the treatment outcomes with high-dose-rate (HDR) interstitial brachytherapy (HDR-BRT) in head and neck cancers (HNC).

Material and methods

Fifty-eight patients with HNC as per American Joint Committee on Cancer (AJCC) TNM staging criteria were analyzed retrospectively between 2008 and 2015. Forty-two patients received external beam radiotherapy (EBRT) with HDR-BRT and 16 patients received BRT alone. The survival was calculated with respect to median biological equivalent doses (BED) and median 2 Gy equivalent dose (EQD₂), keeping α/β = 10 for tumor. Loco-regional control and disease free survival was assessed.

Results

The median follow-up period was 25 months (2-84 months). The disease-free survival (DFS) probability at year 1 was 82.7%, and 68% at year 7. The overall survival probability was 91.3% at year 1 and 85.8% at year 7. The local control rate was 70%. The rate of recurrence was 30%. Distant metastasis rate was 17.2%. The median BED and EQD₂, respectively, were 86.78 Gy and 71.6 Gy. The DFS was 74.1% and 75.9% in patients receiving a dose more than median BED and EQD₂, respectively, and was 64.8% and 61.5% for less than the median dose.

Conclusions

The overall outcome was good with implementation of HDR-BRT used alone or as boost, and shows DFS as better when the dose received is more than the median BED and median EQD₂. The role of HDR-BRT in HNC is a proven, effective, and safe treatment method with excellent long term outcome as seen in this study, which reflects the need for reviving the forgotten art and science of interstitial brachytherapy in HNC.

When is the optimal time for placing a gastrostomy in patients undergoing treatment for head and neck cancer?

PURPOSE OF REVIEW

Determining the optimal timing for placing a gastrostomy in patients undergoing treatment for head and neck cancer involves complex decision making and multifactorial analysis. Lack of high-quality studies with appropriate end points for nutritional outcomes and heterogeneity of patient, clinical and organizational factors makes determining best practice nutritional care challenging. This review provides a background rationale for gastrostomy placement and evaluates the relevant literature extending beyond the past 12 months due to limited numbers of published studies. Emerging concepts and controversies are highlighted to demonstrate that the decision to place a gastrostomy or not has eclipsed the significance of patients' nutritional needs leading to much debate and inconsistencies in clinical practice.

RECENT FINDINGS

While the optimal method of tube feeding remains unclear due to challenges with study design, improved outcomes have been demonstrated with prophylactic tube feeding. Variation exists with selection criteria in the decision for gastrostomy placement based on clinical opinion rather than evidence-based practice. Gastrostomy use as a measure of swallowing outcomes and the presence of a feeding tube for quality of life (QOL) have led to the concept of gastrostomy dependency and a perceived association with poorer outcomes. The multidimensional contributors have been inadequately explored leaving this phenomenon poorly defined and misinterpreted. Best practice nutritional care incorporates malnutrition screening and nutritional assessment using validated tools, early referral to the dietitian and ongoing monitoring to optimize nutritional status throughout the patient's entire care pathway.

SUMMARY

The decision for timing of gastrostomy placement should be made at diagnosis given the benefits of prophylactic tube feeding. Accountability for insertion and removal of gastrostomies with alignment of services will facilitate risk assessment, appropriate placement, effective patient counselling and monitoring for major and minor complications. Nutritional outcomes need to be distinguished from swallowing and QOL measures and evaluated to include effects on nutritional status, gastrostomy complications, intensity and frequency of dietetic support and effect on survival.

Does PEG use cause dysphagia in head and neck cancer patients?

Percutaneous endoscopic gastrostomy (PEG) use is common in patients who undergo radiotherapy (RT) for head and neck cancer to maintain weight and nutrition during treatment. However, the true effect of PEG use on weight maintenance and its potential impact on long-term dysphagia outcomes have not been adequately studied. This retrospective study looked at swallowing-related outcomes among patients who received prophylactic PEG vs. those who did not, and among patients who maintained oral diets vs. partial oral diets vs. those who were nil per os (NPO). Outcomes were assessed at the end of RT and at 3, 6, and 12 months post RT. A comprehensive review of patients' medical charts for a 6-year period yielded 59 subjects with complete data. Results showed no difference in long-term percent weight change between the prophylactic PEG patients vs. all others, or between patients who, during RT, had oral diets vs. partial oral diets vs. NPO. However, those who did not receive prophylactic PEGs and those who maintained an oral or a partial oral diet during RT had significantly better diet outcomes at all times post RT. Dependence on a PEG may lead to adverse swallowing ability in post-irradiated head and neck cancer patients possibly due to decreased use of the swallowing musculature.

Graphical modeling can be used to illustrate associations between variables describing functioning in head and neck cancer patients

OBJECTIVE

To examine the associations between variables of functioning measured by the International Classification of Functioning, Disability and Health (ICF) in head and neck cancer (HNC) patients by means of graphical modeling.

STUDY DESIGN AND SETTING

Graphical modeling was used on a data set of a cross-sectional multicentric study of 145 patients with HNC. Functioning was qualified using the extended ICF checklist. Multiple imputation was used to handle missing data. The least absolute shrinkage and selection operator for generalized linear models was used to identify conditional associations between the ICF categories. Bootstrap aggregating was used to enhance the accuracy and validity of model selection.

RESULTS

The resulting graph shows largely meaningful associations between the ICF categories. One central point could be visualized consisting of a circular path of d330 Speaking, d350 Conversation, b510 Ingestion functions, s320 Structure of mouth, and b310 Voice functions. Another important structure in the graph were the bow-shaped associations beginning with d335 Producing nonverbal messages to b130 Energy and drive functions.

CONCLUSION

Graphical modeling can be used to describe associations between different areas of functioning in HNC patients. They found associations can be the basis for improved rehabilitation and gives a deeper understanding of functioning in HNC patients.

Use of gastrostomy in head and neck cancer: a systematic review to identify areas for future research

OBJECTIVES

To perform a systematic review of studies, which investigate the role of gastrostomy tube feeding in head and neck squamous cell cancer.

DESIGN

A systematic review of the English literature, identifying areas of clinical equipoise and recommendations for future studies.

MAIN OUTCOME MEASURES

Varying practices in G-tube use in HNSCC, the benefits and disadvantages of G-tubes, the effect of G-tube placement on multidimensional outcomes in patients with head and neck cancer, including quality of life and health economics and to draw themes that may lend themselves to future research.

RESULTS

The search identified 216 articles of which 59 were considered relevant. During treatment, a significant number of patients need enteral nutritional supplementation through nasogastric or G-tubes. Gastrostomy tubes have a good safety profile. Most clinicians agree that the use should be restricted to advanced tumours. Studies on prophylactic insertion of G-tubes do not show a consistent advantage to the nutritional status compared with NG tubes. At 1 year, G-tube retention rates vary between 10% and 30%. The presence of a feeding tube has a negative impact on quality of life. Placing G-tubes may have an adverse effect on swallowing after chemoradiation.

CONCLUSIONS

There is a lack of consensus among clinicians about indications for placing G-tubes. There is sufficient equipoise in this area for further investigation of the effect of varying feeding practices on functional outcomes, quality of life and health economics.

Evaluation of Early and Late Toxicities in Chemoradiation Trials

Combined chemoradiotherapy is increasingly becoming a standard of care for the nonoperative management of a variety of solid malignancies. A string of randomized controlled phase III trials have shown statistically significant and clinically relevant improvements in outcome, ostensibly without any apparent increase in late toxicity. However, the reliability and the sensitivity of toxicity reporting in most trials are questionable. Audits and phase IV studies suggest that the chemoradiotherapy success comes at a price in terms of late toxicity. This review presents some of the challenges in recording, analyzing, and reporting toxicity data. Methods for summarizing toxicity are reviewed, and a new investigational metric, the TAME reporting system, is discussed. The need for special vigilance in the era of molecular-targeted agents is emphasized because of the possibility that unexpected serious adverse events with a low incidence may occur. Finally, we discuss how progress in molecular pathology and radiation biology may provide novel opportunities for stratifying patients according to risk of adverse effects, interventional targets for reducing or treating adverse effects, and surrogate markers of normal-tissue injury.

Functional outcomes after organ preservation treatment in head and neck cancer: a critical review of the literature

The use of radiation therapy and/or chemotherapy in advanced head and neck cancer is increasing in popularity, driven by the notion that sparing the organs of speech and swallowing from surgical resection will also spare function. This critical review of the literature considered functional outcomes after organ preservation to assess the impact of such treatment on speech, swallowing and quality of life in patients with head and neck cancer. Literature searches were conducted on several library databases. A total of 50 relevant articles were identified and found to meet the inclusion criteria specified a priori. The majority of reports suggested that organ preservation techniques have the potential to result in swallowing disorders, often related to dysmotility of the oropharyngeal and laryngeal structures, and resulting in frequent episodes of aspiration. This may lead to the need for enteral feeding in the short term for some patients while, in others, this need is life long. Speech does not appear to be affected to the same degree as swallowing. These results suggest that organ preservation does not translate into function preservation for all patients with head and neck cancer.