Complications of radiation therapy for head and neck cancers. The patient's perspective

The influence of radiation-induced bystander effect in osteoblasts mediated by plasma-derived extracellular vesicles (EVs)

OBJECTIVES

Head and neck tumor patients may develop post-radiotherapy diseases after radiotherapy treatment. And radiotherapy can elicit radiation-induced bystander effect, wherein extracellular vesicles (EVs) play a crucial role. For normal parts of the body that have not been directly irradiated, the effect of EVs on them needs to be further explored. This study aims to investigate the functions of plasma-derived EVs in regulating normal osteoblasts during radiation-induced bystander effects.

METHODS AND MATERIALS

Rat plasma-derived EVs were isolated and identified firstly, followed by an evaluation of their intracellular biological effects on normal osteoblasts in vitro. Transcriptome sequencing analysis and confirmations were performed to identify potential mechanisms.

RESULTS

Irradiated plasma-derived EVs were found to enhance osteoblast proliferation, migration, and cell cycle progression, concurrently suppressing the expression of osteogenesis-related genes and proteins. Furthermore, these EVs attenuated the expression of osteogenesis and oxidative stress resistance related genes, while upregulating the PI3K-AKT pathway and intracellular reactive oxygen species in osteoblasts.

CONCLUSIONS

Irradiated plasma-derived EVs could alter the biological effects in osteoblasts, which is closely associated with the levels of GPX1 and the PI3K-AKT signaling pathway. This suggests that plasma-derived EVs serve as a crucial factor contributing to radiation-induced bystander effect in osteoblasts.

Oral glutamine: Is there a role in the amelioration of radiation-induced mucositis? A prospective case-control study at a tertiary care centre in North India

BACKGROUND

The most frequently occurring painful and dose-limiting side effect of radiation therapy (RT) to the head and neck region is oral mucositis (OM). Several studies demonstrated that glutamine may reduce the severity and the duration of OM significantly during RT and chemo-radiotherapy in patients with head and neck cancer (HNC).

MATERIALS AND METHODS

Between January 2021 and August 2022, a prospective single institutional case-control study compared the efficacy and safety of oral glutamine on radiation-induced mucositis in patients with HNC. Of 60 biopsy-proven patients with HNC, 30 patients in the study arm received oral glutamine suspension (10 g in 500 mL of water) orally once daily, 2 hours before RT, receiving definitive or adjuvant RT and chemo-radiotherapy, while as 30 patients in the control arm received placebo with the same dose and schedule (n = 30 in the study arm and n = 30 in the control arm).

RESULTS AND ANALYSIS

A total of 27 (90%) in the glutamine arm and 28 (93.33%) patients in the control arm developed mucositis. Grade 3 mucositis (13.33%) and Grade 4 mucositis (6.66%), respectively, were significantly less (P = .040 and P = .004) in the glutamine arm. The mean duration of grade 3 and grade 4 mucositis was significantly less in the glutamine arm (8.94 days in the study arm vs. 14.54 in the control arm; P = .0001). The mean time of onset of OM was significantly delayed in the glutamine arm in comparison to the control arm with P < .001.

CONCLUSION

Glutamine delays the onset of OM and decreases the severity of OM in patients of HNC receiving RT with or without chemotherapy.

Efficacy of matrix rhythm therapy (MaRhyThe©) over conventional therapy on radiation induced trismus-A pilot randomised control trial

BACKGROUND AND OBJECTIVES

Prevalence of radiation induced trismus in head and neck cancer (HNC) is 38% to 42% globally. Radiation induced trismus depends on the dosage of the radiation therapy and the surgical procedure. Myofascial release (MFR) and Matrix rhythm therapy (MaRhyThe©) are techniques used to treat the myofascial pain and muscular restriction. The present study aimed to compare the effect of MFR and MaRhyThe© on pain, mouth opening, TMJ disability index (TDI), Gothenburg Trismuus Questionnaire (GTQ), Functional Intraoral Glasgow Scale (FIGS) and quality of life in participants with Radiation induced trismus.

MATERIALS AND METHODOLOGY

About 30 participants in age group of 18 to 65 years diagnosed with radiation induced trismus were included in the study. All the participants were randomly allocated in 2 groups MFR group and MaRhyThe© group. Both the group received structured exercise program. Primary outcomes were Visual Analogue Scale (VAS), Vernier Caliper reading for maximum mouth opening. Secondary outcome measure viz. GTQ, TDI, FIGS and Functional Assessment of Cancer Therapy-Head and Neck (FACT-HN) all obtained values were analyzed at the end of 4th week.

RESULTS

The present study demonstrated significant improvement in terms of reduction in pain, improvement in maximum mouth opening and in GTQ, TMD, FIGS, and FACT-HN scores in all the participants in both group (p ≤ 0.05). However, the groups showed equal effectiveness in the treatment of radiation induced trismus.

A pharmacist-led opioid de-escalation program after completion of chemoradiotherapy in locally advanced head and neck cancer

Background

Persistent opioid use frequently leads to substantial negative impacts on quality of life, and as the outlook for numerous cancer types continues to improve, these complications become increasingly crucial. It is essential to acknowledge that extended or excessive opioid use may result in adverse effects in patients who completed radiation therapy (RT).

Methods

In this time-series analysis, we compared the outcomes of patients who participated in the pharmacist-led opioid de-escalation (PLODE) program after completing concurrent radiotherapy (CRT) between June 2018 and February 2019 against patients who completed CRT between June 2017 and March 2018 and did not participate in the program.

Results

Among 61 patients, 16 (26%) used opioids after completing CRT and participated in the PLODE program. Before starting the program, 93 patients completed CRT between June 2017 and March 2018 and 32 (34%) used opioids at CRT completion. These patients were deemed the control group. In the PLODE group, outpatient pharmacist intervention was performed, with 29 total interventions related to opioid use, of which 16 (55%) recommended tapering or discontinuing opioids according to the definition of this program. Patients who participated in the PLODE program discontinued opioids significantly earlier than those in the control group (median time to opioid discontinuation 11 days vs. 24.5 days, p < 0.001). None of the patients in the PLODE group resumed opioid use following discontinuation or escalated opioid dosing due to worsening pain.

Conclusion

This study showed the utility of pharmacist-initiated interventions for opioid use in patients with head and neck cancer who had completed CRT.

Supportive care among head and neck cancer patients: An initial validation of the Dutch version of the Performance Status Scale for Head and Neck Cancer (D-PSS-HN)

BACKGROUND

Acute and late toxicities in patients treated with (chemo)radiotherapy for head and neck cancer (HNC) is common and can negatively impact quality of life and performance. Performance status instruments measure the functional ability to perform daily life activities and are important tools in the oncologic population.

AIMS

Since Dutch performance status scales for the HNC population are lacking, we conducted this study to translate the Performance Status Scale for Head and Neck Cancer Patients (PSS-HN) into Dutch (D-PSS-HN) and to validate this version.

METHODS & PROCEDURES

The D-PSS-HN was translated into Dutch according to the internationally described cross-cultural adaptation process. It was administered to HNC patients and together with the Functional Oral Intake Scale completed by a speech and language pathologist at five different time points during the first 5 weeks of (chemo)radiotherapy. Patients were asked each time to complete the Functional Assessment of Cancer Therapy and the Swallowing Quality of Life Questionnaire. Pearson correlation coefficients were used to calculate convergent and discriminant validity and the evolution of D-PSS-HN scores was assessed by means of linear mixed models.

OUTCOMES & RESULTS

A total of 35 patients were recruited and > 98% of the clinician-rated scales were completed. Convergent and discriminant validity were demonstrated, with all correlations rs between 0.467 and 0.819, and between 0.132 and 0.256, respectively. The subscales of the D-PSS-HN are sensitive to detect changes through time.

CONCLUSION & IMPLICATIONS

The D-PSS-HN is a valid and reliable instrument to assess performance status in patients with HNC treated with (chemo)radiotherapy. It is a useful tool to measure HNC patients' current diet level and functional abilities to perform daily life activities.

WHAT THIS PAPER ADDS

What is already known on the subject Acute and late toxicities in patients treated with (chemo)radiotherapy for HNC are common and can negatively impact quality of life and performance. Performance status instruments measure the functional ability to perform daily life activities and are important tools in the oncologic population. However, Dutch performance status scales for the HNC population are lacking. Therefore, we translated the Performance Status Scale for Head and Neck Cancer Patients (PSS-HN) into Dutch (D-PSS-HN) and validated this version. What this paper adds to existing knowledge We translated the PSS-HN and demonstrated its convergent and discriminant validity. The subscales of the D-PSS-HN are sensitive to detect changes through time. What are the potential or actual clinical implications of this work? The D-PSS-HN is a useful tool to measure HNC patients' functional abilities to perform daily life activities. The tool can easily be used in clinical settings: since data collection duration is very short, this facilitates clinical (and research-related) implementation of the scale. Patients' individual needs could be identified by using the D-PSS-HN, resulting in more appropriate approaches and (early) referrals if needed. Interdisciplinary communication could be facilitated.

Clinical use of photobiomodulation for the prevention and treatment of oral mucositis: the real-life experience of MASCC/ISOO members

AIM

To assess clinical use and patient outcome of photobiomodulation (PBM) for oral mucositis (OM) prevention and treatment among specialized practitioners.

METHODS

A poll was emailed to the members of the Mucositis Study Group of MASCC/ISOO. The PBM parameters used by the respondents were analyzed using exploratory statistical methods to identify combinations of PBM parameters (patterns) that characterize the variance in the protocols (principal component analysis).

RESULTS

Responses were received from 101 MSG members, with 78 providing analyzable data. Most of the responders were dental practitioners or oral medicine specialists. PBM was used by 59% of the responders for OM or targeted therapy stomatitis. Technical parameters varied widely. Most responders used wavelengths ∼650 nm intra-orally. The spot-size and distance from the tissue were the main factors driving the variation. All PBM users noted that PBM relieved pain, either immediately or a delayed effect. High likelihood of pain relief (measured as responder's report of pain relief in 67-100% of patients) was reported by 22% and 19% of PBM users for immediate pain relief and delayed pain relief, respectively. The most common reported barriers to using PBM were financial considerations, time constraints, lack of training or experience and concern about the potential for malignant transformation or increased risk of cancer recurrence.

CONCLUSIONS

The use of PBM for OM prevention or treatment is in early phases of adoption in practices, facing some obstacles to implement it. A wide variation in technical parameters was found. Nonetheless, responses indicate that PBM provided pain relief.

Oral-Functioning Questionnaires in Patients with Head and Neck Cancer: A Scoping Review

Background: Oral-functioning impairment can negatively affect the quality of life (QoL) of head and neck cancer (HNC) patients after receiving radiotherapy (RT). Assessment of patient-reported oral functioning throughout treatment can improve patient care. This scoping review aims to propose a definition for oral functioning for HNC patients and to map out the available questionnaires measuring patient-reported oral functioning in RT-treated HNC patients. Methods: A literature search in relevant databases was performed. Each questionnaire was scored on the domains validity, reliability, and responsiveness. Furthermore, the items from the questionnaires were analyzed to define the common denominators for oral functioning in HNC patients. Results: Of the 6434 articles assessed, 16 met the inclusion criteria and employed 16 distinct instruments to evaluate QoL. No questionnaire covered all oral-health-related QoL items nor assessed all aspects of validity, reliability, and responsiveness. Chewing, speaking, and swallowing were the common denominators for oral functioning. Conclusions: Based on the included studies, we suggest using the VHNSS 2.0 questionnaire to assess oral functioning in HNC patients. Furthermore, we suggest to more clearly define oral functioning in HNC patients by focusing on masticatory function (chewing and grinding), mouth opening, swallowing, speaking, and salivation.

Clinical investigation of use of Episil® oral solution in oral mucositis during radiotherapy for head and neck cancer

Objective

Episil® is a bio adhesive barrier-forming oral liquid gel that has been used in recent years to relieve pain of oral mucositis (OM) with radiotherapy (RT) or chemoradiotherapy (CRT) in head and neck cancer (HNC) patients. We conducted a retrospective analysis of the clinical effects of Episil® on OM in these patients.

Study design

Between June 2018 and May 2020, 65 patients with HNC were treated with RT or CRT at our hospital.

Results

The median total RT dose was 50 Gy (range, 30-70 Gy) and the completion rate was 63/65 (97%). The median time to OM resolution was 47 (6-90) days and was significantly longer (53 [27-90] days) when the total RT dose was ≥51 Gy (P < 0.001). Episil® was used in 26 patients. Among them, 10 discontinued its use due to ineffective pain relief, usage difficulties, and taste intolerance. The median duration of use was 30 days and was significantly longer (34.5 days) (P < 0.001) when patients experienced pain relief at treatment initiation.

Conclusion

Although Episil® has been shown to be effective in improving the pain of OM caused by RT for HNC patients, and medical professionals are required to give careful attention to each patient.

Radiation-induced mucositis: A retrospective study of dexamethasone-lidocaine-vitamin B12 mouth rinse versus compound chlorhexidine mouthwash in nasopharyngeal carcinoma

Oral mucositis causes substantial morbidity during head and neck radiotherapy, especially nasopharyngeal carcinoma. During radiotherapy, patients develop severe oral mucositis, which leads to oral pain and difficulty in eating and interruption of radiotherapy, affects the treatment effect and increase the probability of recurrence. Although we have explored various methods to reduce the mucosal damage caused by radiotherapy, these methods still cannot reduce pain caused by mucositis clinically. Therefore, the use of Dexamethasone-Lidocaine-Vitamin B12 Mouth rinse (DLVBM) proved its role in reducing oral mucosal pain, reducing the weight loss of patients, and completing radiotherapy according to the course of treatment. 133 patients with nasopharyngeal carcinoma who received radiotherapy (a total dose of 70 Gy) in our hospital from January to December 2020-2021 were selected. 67 patients received DLVBM treatment for mucositis reaction, and 66 patients received Compound chlorhexidine mouthwash (CCM) to deal with mucositis. Symptoms related to oral mucosal pain score and body weight, mucosal healing time were analyzed retrospectively. We found that patients with the DLVBM group significantly reduced oral pain and reduced weight loss. However, there was no significant difference about the mucosal healing time between the DLVBM group and CCM group. DLVBM may be moderately more effective in preventing radiation-induced mucositis and mucositis-related pain, and their use may lead to less frequent RT course interruptions from mucositis.

Lycium barbarum polysaccharide-glycoprotein ameliorates ionizing radiation-induced epithelial injury by regulating oxidative stress and ferroptosis via the Nrf2 pathway

Radiation-induced oral mucositis (RIOM) is considered to be the most common acute side effect of radiation therapy and occurs during intentional or accidental radiation exposure. Antioxidant synthesis agents have been reported to protect against or alleviate the development of mucositis, but the resulting side effects of chemical synthesis agents limit their use in clinical practice. Lycium barbarum polysaccharide-glycoprotein (LBP), a polysaccharide extract of the Lycium barbarum fruit, has superior antioxidant capacity and biosafety and is a potential option for radiation prevention and treatment. Here, we aimed to investigate whether LBP conferred radioprotection against ionizing radiation-induced oral mucosal damage. We found that LBP exerted radioprotective effects in irradiated HaCaT cells, improving cell viability, stabilizing mitochondrial membrane potential, and decreasing cell death. LBP pretreatment reduced oxidative stress and ferroptosis in radioactivity-damaged cells by activating the transcription factor Nrf2 and promoting its downstream targets, such as HO-1, NQO1, SLC7A11, and FTH1. Knockdown of Nrf2 eliminated the protective effects of LBP, implying the essential role of Nrf2 in LBP activity. Additionally, the topical application of LBP thermosensitive hydrogel on rat mucosa resulted in a significant decrease in ulcer size in the irradiated group, suggesting that LBP oral mucoadhesive gel may be a potential tool for the treatment of irradiation. In conclusion, we demonstrated that LBP attenuates ionizing radiation-induced oral mucosa injury by reducing oxidative stress and inhibiting ferroptosis via the Nrf2 signaling pathway. LBP may be a promising medical countermeasure against RIOM.

Prevention of radiotherapy-related oral mucositis with zinc and polyherbal mouthwash: a double-blind, randomized clinical trial

BACKGROUND

A significant percentage of head and neck cancer (HNCs) patients receiving RT experience oral mucositis (OM). This study aimed to evaluate the effect of the polyherbal (containing chamomile, peppermint oil, Aloe vera, and honey) and zinc mouthwashes in comparison to the control (chlorhexidine) and placebo groups for prevention of radiation-induced OM.

METHODS

This study was a double-blinded randomized clinical trial, conducted on 67 patients with HNCs undergoing radiotherapy. The eligible participants were randomized to receive either one of the following; zinc sulfate, polyherbal, chlorhexidine (Vi-one 0.2% CHX), or placebo mouthwash for 6 weeks. Follow-up evaluation of oral hygiene and the checklists of OM and the intensity of pain were filled out according to WHO assessment tool, Oral Mucositis Assessment Scale (OMAS), and Visual Analog Scale (VAS) in all the participants weekly for seven consecutive weeks.

RESULTS

The results of present clinical trial demonstrated that the use of either zinc sulfate or polyherbal mouthwash significantly reduced the scores of OM and the severity of pain during weeks 2 to 7 after consumption compared with the CHX or placebo mouthwashes (P < 0.05). According to the post hoc analysis and compared with the placebo, a significantly better result was reported for zinc sulfate and polyherbal mouthwashes at weeks 2 to 7, but not for the CHX mouthwash.

CONCLUSION

This study showed that the use of zinc sulfate or polyherbal mouthwashes is effective in prevention of both OM severity scores and pain related to OM intensity at weeks 2 to 7 following consumption in HNCs patients. Trial registration IRCT20190123042475N1 and IRCT20190123042475N2. Registration date: 2019-06-09, 2019-07-26.

Photodynamic therapy in oral cancer: a review of clinical studies

A significant mortality rate is associated with oral cancer, particularly in cases of late-stage diagnosis. Since the last decades, oral cancer survival rates have only gradually improved despite advances in treatment. This poor success rate is mainly due to the development of secondary tumors, local recurrence, and regional failure. Invasive treatments frequently have a negative impact on the aesthetic and functional outcomes of survivors. Novel approaches are thus needed to manage this deadly disease in light of these statistics. In photodynamic therapy (PDT), a light-sensitive medication called a photosensitizer is given first, followed by exposure to light of the proper wavelength that matches the absorbance band of the photosensitizer. The tissue oxygen-induced cytotoxic free radicals kill tumor cells directly, harm the microvascular structure, and cause inflammatory reactions at the targeted sites. In the case of early lesions, PDT can be used as a stand-alone therapy, and in the case of advanced lesions, it can be used as adjuvant therapy. The current review article discussed the uses of PDT in oral cancer therapy based on recent advances in this field.

Efficacy of Prophylactic High-Dose Gabapentin and Venlafaxine on Reducing Oral Mucositis Pain Among Patients Treated With Chemoradiation for Head and Neck Cancer: A Single-Institution, Phase 2, Randomized Clinical Trial

PURPOSE

Given the paucity of level 1 evidence, the optimal regimen to control oral mucositis pain remains unclear. Although national guidelines allow consideration of prophylactic gabapentin, prior trials showed improved pain control with venlafaxine among patients with diabetic neuropathy. We sought to investigate the role of prophylactic high-dose gabapentin with venlafaxine to reduce oral mucositis pain among patients with head and neck cancer.

METHODS AND MATERIALS

We performed a single-institution, phase 2 randomized trial on nonmetastatic squamous cell carcinoma of the head and neck treated with chemoradiation. Patients were randomized to either prophylactic gabapentin (3600 mg daily) with or without venlafaxine (150 mg daily). Primary endpoint was differences in pain levels at the end of chemoradiation. Secondary endpoint was toxicity profiles, quality of life changes, opioid use, and feeding tube placement. Differences between the 2 arms at multiple time points were evaluated using a generalized linear mixed regression model with Sidak correction.

RESULTS

Between May 2018 and March 2021, a total of 62 patients were enrolled and evaluable for analysis (n = 32 for the gabapentin alone arm, n = 30 for the gabapentin + venlafaxine arm). Over 90% of patients tolerated gabapentin well. Head and neck pain level showed a mean value of 45 (standard deviation, 23) and 43 (standard deviation, 21) for the gabapentin alone and the gabapentin + venlafaxine arms, respectively (P = .65). No statistically significant differences were observed in adverse events, opioid use, feeding tube placement, or quality of life.

CONCLUSIONS

The addition of venlafaxine to prophylactic gabapentin did not result in improvements in pain control and quality of life among patients with head and neck cancer.

Efficacy and safety of a colostrum- and Aloe vera-based oral care protocol to prevent and treat severe oral mucositis in patients undergoing hematopoietic stem cell transplantation: a single-arm phase II study

Oral mucositis is one of the worst effects of the conditioning regimens given to patients undergoing hematopoietic stem cell transplantation. It is characterized by dry mouth, erythema, mucosal soreness, ulcers, and pain, and it may impact patient outcomes. Bovine colostrum and Aloe vera contain a wide variety of biologically active compounds that promote mucosal healing. A non-randomized phase II study was designed to assess the safety and efficacy of a combined bovine colostrum and Aloe vera oral care protocol to prevent and to treat severe oral mucositis in transplant patients. Two commercially available products were given to patients in addition to the standard protocol: Remargin Colostrum OS® mouthwash and Remargin Colostrum Gastro-Gel® taken orally. Forty-six (78.0%) patients experienced oral mucositis, 40 (67.8%) developed mild-moderate forms, and 6 (10.2%) severe ones. Comparing the study group's outcomes with those of a homogeneous historical control group, severe oral mucositis decreased significantly (10.2% vs. 28.4%; P < 0.01), as did its duration (0.5 ± 1.9 vs. 1.5 ± 3.0 days; P < 0.01). Febrile neutropenia episodes (69.5% vs. 95.1%; P < 0.01) and duration (4.0 ± 4.7 vs. 6.2 ± 4.5 days; P < 0.01) also decreased. These findings show that the experimental protocol seems effective in preventing severe forms of oral mucositis. However, a randomized controlled trial is necessary to confirm this.

Radiotherapy of tongue cancer using an intraoral stent: a pilot study

Aim:

The aim was to evaluate the feasibility of an intraoral stent (10 and 20 mm thickness) in radiotherapy of tongue cancer, and to measure the reduction in acute mucositis in the palate.

Materials and method:

There were six patients in the intervention group, and seven patients in the control group. Target coverage was measured by the minimum dose covering 98% of the clinical target volume (CTV). Data were collected from the planning CT and daily cone-beam computer tomography (CBCT).

Results:

The 10 and 20 mm stent yielded a mean distance of 26 and 36 mm, respectively, between the tongue and the hard palate. We found comparable dose coverage of the CTV in the treatment plan, and on the CBCT. The stent reduced mean dose to the hard palate by 61.0% (p = 0.002). Dose to the soft palate was not reduced (p = 0.18). Average Common Terminology Criteria for Adverse Events (CTCAE) mucositis scores of the hard palate were 0 and 0.8 in the intervention and control group, respectively. The mucositis scores of the soft palate were 1.2 and 1.8.

Findings:

Use of an intraoral stent substantially reduced the dose to the hard palate. CTV coverage was maintained. We did not find any significant reduction in visually scored radiation-induced mucositis.

Effectiveness of topical fluorides in prevention of radiation caries in adults: A systematic review and meta- analysis

BACKGROUND

Topical fluoride is used for prevention of dental caries. However, its effectiveness and more specifically its formulation and frequency of application in patients undergoing head and neck radiotherapy are still debatable. The aim of this systematic review was to pool the evidence of effectiveness of various topical fluorides in preventing radiation caries or change in bacterial growth in adult patients of head and neck cancer.

METHODS

Three databases (PubMed and Google Scholar and Cochrane) were searched for randomized controlled or uncontrolled trials or quasi randomised trials published till February 2021. Two independent reviewers screened 346 abstracts finally 14 articles were included in the current systematic review. Primary outcome evaluated was the prevention of radiation caries or change in bacterial growth in saliva. Meta-analysis was performed for the sub groups formed on the basis of fluoride formulations and adjuncts used with it.

RESULTS

Studies included were highly heterogeneous. Majority of studies found different fluoride formulations to be effective in controlling radiation caries to a variable extent up to 70% depending upon the intervention, patient compliance, rate of attrition and follow up period. Sodium fluoride was the most commonly used caries preventive agent. Meta-analysis showed no significant difference between sodium fluoride formulations and other fluoride agents. Fluoride treatment when incorporated with re-mineralising agent had no significant effect on caries prevention CONCLUSION: Fluoride prevents radiation caries. However, to delineate its exact formulation, dosage or frequency, there is need for more well conducted randomised controlled trials.

The health risks of dysphagia for patients with head and neck cancer: a multicentre prospective observational study

It is well known that malnutrition is a frequent co-morbidity in cancer patients, especially in those with head and neck neoplasms. This may be due both to the presence of dysphagia symptoms and to the appearance of adverse effects on chemotherapy and / or radiotherapy. The aim of this retrospective observational multicentric study is to evaluate the nutritional status between dysphagia cancer patients and non-dysphagia cancer patients. Data from 60 patients were analysed, 31 of which without dysphagia and 29 with dysphagia. Results highlight that patients with dysphagia had higher involuntary body weight loss than non-dysphagia ones (p < 0.001). By analysing the entire population, it stands out a weight loss rate of 12 ± 9% compared to the usual weight was observed and a prevalence of moderate / severe malnutrition diagnosis of 53%. Furthermore, 76% of the population who manifested the symptom of dysphagia presented severe malnutrition already at the first visit, compared to 32% of non-dysphagia subjects.

Evaluation of Extended-Release Oxycodone Administered through Enteral Tubes for the Management of Pain in Patients with Head and Neck Cancer: A Case Series

An abuse-deterrent, microsphere-in-capsule extended-release formulation of oxycodone myristate (Xtampza® ER, Collegium Pharmaceutical Inc, Canton, Massachusetts), was approved by the FDA in 2016 for the management of pain. The advantage of this formulation of oxycodone is that the microspheres can be administered via enteral tubes without compromising the long-acting formulation. This case series characterizes the experiences of five head and neck cancer patients initiated on oxycodone myristate through enteral tube administration for control of cancer-related pain. The primary outcome of patient reported subjective improvement in pain within one week occurred in all five patients. The median time to pain control was 4 days. The safety profile of oxycodone myristate was consistent with the package insert with no new findings reported. Oxycodone myristate can be an appropriate long-acting opioid analgesic option for patients requiring enteral tube administration of medications to achieve adequate cancer-related pain control.

Customized 3D Bolus Applied to the Oral Cavity and Supraclavicular Area for Head and Neck Cancer

BACKGROUND/AIM

In this study, a new method to create a customized three-dimensional (3D) bolus by accurately considering the anatomy of an individual patient is demonstrated.

PATIENTS AND METHODS

A 3D bolus structure was created from an extended planning target volume (PTV) to reduce an inevitable skin reaction. In addition, during computed tomography simulation in patients with oral cavity cancers, a balloon was inserted into the mouth of a patient to secure space, and then the area surrounding the balloon was designed into a 3D bolus structure.

RESULTS

For patients with head and neck cancers, a customized 3D bolus can reduce the unnecessary skin dose by 14.4% compared to a commercial bolus. For patients with oral cavity cancer, the PTV and tongue doses were 93.8% and 8% of the prescribed dose, respectively.

CONCLUSION

The customized 3D bolus enables effective skin sparing and full coverage of the target area.

Geometric and dosimetric impact of 3D generative adversarial network-based metal artifact reduction algorithm on VMAT and IMPT for the head and neck region

Background

We investigated the geometric and dosimetric impact of three-dimensional (3D) generative adversarial network (GAN)-based metal artifact reduction (MAR) algorithms on volumetric-modulated arc therapy (VMAT) and intensity-modulated proton therapy (IMPT) for the head and neck region, based on artifact-free computed tomography (CT) volumes with dental fillings.

Methods

Thirteen metal-free CT volumes of the head and neck regions were obtained from The Cancer Imaging Archive. To simulate metal artifacts on CT volumes, we defined 3D regions of the teeth for pseudo-dental fillings from the metal-free CT volumes. HU values of 4000 HU were assigned to the selected teeth region of interest. Two different CT volumes, one with four (m4) and the other with eight (m8) pseudo-dental fillings, were generated for each case. These CT volumes were used as the Reference. CT volumes with metal artifacts were then generated from the Reference CT volumes (Artifacts). On the Artifacts CT volumes, metal artifacts were manually corrected for using the water density override method with a value of 1.0 g/cm³ (Water). By contrast, the CT volumes with reduced metal artifacts using 3D GAN model extension of CycleGAN were also generated (GAN-MAR). The structural similarity (SSIM) index within the planning target volume was calculated as quantitative error metric between the Reference CT volumes and the other volumes. After creating VMAT and IMPT plans on the Reference CT volumes, the reference plans were recalculated for the remaining CT volumes.

Results

The time required to generate a single GAN-MAR CT volume was approximately 30 s. The median SSIMs were lower in the m8 group than those in the m4 group, and ANOVA showed a significant difference in the SSIM for the m8 group (p < 0.05). Although the median differences in D_98%, D_50% and D_2% were larger in the m8 group than the m4 group, those from the reference plans were within 3% for VMAT and 1% for IMPT.

Conclusions

The GAN-MAR CT volumes generated in a short time were closer to the Reference CT volumes than the Water and Artifacts CT volumes. The observed dosimetric differences compared to the reference plan were clinically acceptable.

Clinical Outcome in Children with Chemotherapy-Induced Mucositis

OBJECTIVES

This study was conducted to assess the impact of oral mucositis on nutrition and performance status in pediatric cancer patients treated by chemotherapy.

DATA SOURCES

A total of 46 children were followed for mucositis episode, and their mean Oral Assessment Guide score was 20.2. Main concomitant disorders were hematological changes (86.9%), loss of appetite (60.7%), vomiting (28.3%), and diarrhea (10.9%).

CONCLUSION

Anthropometric changes were highlighted by a decrease in body mass index (P = .03) and a decrease of Waterlow score (P = .007). Most patients had a low Lansky Play Performance Scale (LPPS) ≤40 (86.9%). High mucositis grades (P = .007) and long hospital stay (P = .005) were associated with a significant reduction in Lansky Play Performance Scale. Patient's follow-up showed need for hospitalization (84.8%), delay in chemotherapy treatment (71.7%), use of opioides (34.8%), and use of parenteral nutrition (26.1%). Death occurred in 10.9% of the cases.

IMPLICATIONS FOR NURSING PRACTICE

These findings illustrate the impact of mucositis on nutrition and performance status in children undergoing chemotherapy, which considerable affected their outcome.

Intravenous fluids for pain management in head and neck cancer patients undergoing chemoradiation

Background

Pain due to oral mucositis affects the majority of patients receiving chemoradiation (CRT) for head and neck cancer (HNC), and often results in dehydration. Anecdotally, intravenous (IV) fluids administered during treatment for the resultant dehydration was found to alleviate this pain. The purpose of this retrospective study was to evaluate the effectiveness of IV fluids as a method pain management in this patient population.

Methods

Patients with oral mucositis pain, secondary to CRT for HNC, were given IV fluids according to standard clinic protocol. Patients were evaluated using orthostatic vital signs and prospectively surveyed pre- and post-IV fluid administration, which included the Visual Analog Scale (VAS) for pain. Difference in pain pre- and post-IV fluid administration was evaluated using a two-tailed paired Student’s t-test.

Results

Twenty-four patients with a total of 31 fluid administrations was available for analysis. Twenty-three patients were receiving or had recently completed CRT. One patient was receiving radiation alone. Six instances of fluid administration were excluded due to: refusal to complete the survey, concurrent pulmonary embolism, concurrent pain medication, and drug seeking behavior. Average pain score decreased from 6.5 [standard deviation (SD) 2.1] prior to IV fluids to 4.0 (SD 2.4) following fluid administration (P<0.001).

Conclusions

To our knowledge, this is the first report directly correlating IV fluid administration with pain relief, even in the absence of orthostasis. Our findings indicate that in patients undergoing CRT for HNC, the use of IV fluids alone was effective in acutely and significantly reducing pain secondary to oral mucositis.

Narrative review of the management of oral mucositis during chemoradiation for head and neck cancer

Oral mucositis (OM) can be a significant problem for patients undergoing radiation or chemoradiation for head and neck cancer. In modern clinical trials, grade 3–4 OM can be seen in over 40% of patients and can cause a significant impact on their quality of life (QOL). Despite this fact, strategies for the prevention and treatment of OM vary widely, with options including both lifestyle modifications and pharmaceuticals. Here we evaluate and summarize the current clinical interventions for the management of radiation-induced OM. The majority of the current evidence focuses on reducing OM related pain. These agents are detailed over multiple clinical trials including treatment modalities such as: GC4419, doxepin mouthwash, diphenhydramine-lidocaine-antacid (DLA) mouthwash, gabapentin, and methadone. While several strategies have been employed to prevent radiation-induced OM, there is currently no strong evidence for the routine use of these agents in the clinic. After summarization of these treatments, we offer practical guidance for the treatment of OM in the clinic. We recommend a multiagent approach of pharmacological and non-pharmacological treatments including oral rinses, home humidification, escalating doses of gabapentin, doxepin or DLA mouthwash, over the counter analgesics, and lastly methadone. These interventions are tailored to address the expected increase of severity of symptoms during the course of head and neck radiotherapy.

Concordance of the WHO, RTOG, and CTCAE v4.0 grading scales for the evaluation of oral mucositis associated with chemoradiation therapy for the treatment of oral and oropharyngeal cancers

BACKGROUND

The ability to consistently and accurately assess oral mucositis (OM) is critical to descriptions of its incidence and severity and in evaluating the effectiveness of potential interventions. The lack of a single grading scale compounds outcome interpretation. Consequently, we assessed the concordance of three of the most commonly used OM grading criteria (World Health Organization (WHO), Radiation Therapy Oncology Group (RTOG), and the common terminology criteria for adverse events (CTCAE).

METHODS

Data was evaluated from two hundred patients with oropharyngeal or oral cavity cancers who underwent chemoradiation therapy and were enrolled in a double-blind, randomized, placebo-controlled trial in which trained assessors evaluated patients twice weekly. WHO, RTOG, and CTCAE scores were assigned centrally by independent evaluators blinded to the study group. Concordance among the three scales for all OM scores and severe OM scores (score ≥ 3) was defined as the percentage agreement and measured using Cohen's weighted Kappa.

RESULTS

Of 3,578 OM assessments, 57% had identical scores for all three scales. When any score was considered, the concordance between WHO and RTOG scales was 71% (kappa 0.58; 95%CI: 0.56-0.60), 62% for the WHO and CTCAE scales (kappa 0.46; 95%CI: 0.44-0.48) and 78% for the CTCAE and RTOG scales (kappa 0.69; 95%CI: 0.68-0.71). When patients had severe OM (WHO score ≥ 3), 99.6% (521/523) of the CTCAE OM assessments had scores of 3 or 4 (kappa 0.98; 95%CI: 0.98-0.999) and 97.7% of the RTOG ones (511/523) had scores of 3 or 4 (kappa 0.69; 95%CI: 0.62-0.75). Among patients who had a WHO score of 4, 31.7% (63/199) and 96.0% (196/199) of patients had RTOG or CTCAE scores of 2 or 3, respectively.

CONCLUSIONS

Discordance was seen with patients who exhibited mild to moderate OM or most severe OM (grade 4) as described by WHO criteria. Whereas scale selection seems less critical in studies in which general "severe mucositis" is the primary outcome, it is particularly important in accurately describing OM's clinical trajectory and the frequency and impact in its most severe forms.

A Bioadhesive Barrier-Forming Oral Liquid Gel Improved Oral Mucositis and Nutritional Status in Patients With Head and Neck Cancers Undergoing Radiotherapy: A Retrospective Single Center Study

Background

Episil^® is a bioadhesive barrier-forming oral liquid gel that can relieve oral mucositis (OM) caused by radiotherapy (RT) and hence relieves pain effectively. In this study, we observed the effects of Episil^® on the OM and nutritional status of patients with head and neck cancers (HNCs) undergoing RT.

Methods

A total of 50 HNC patients were divided into the Episil^® (25 patients) and control (25 patients) groups. Patients in the Episil^® group were sprayed with Episil^®. In the control group, the kangfuxin solution or Kangsu™ oral gargle was used. Medical staff assessed the OM extent and timing as well as the nutritional status during treatment and recorded adverse reactions other than OM. The nutritional status assessment included the following indicators: Patient Generated-Subjective Global Assessment (PG-SGA) score, body mass index (BMI), body weight, albumin levels, and other hematological indicators.

Results

The incidence of high-level OM (III–IV) after RT was lower in the Episil^® group than in the control group (P < 0.05). Nutritional status assessments showed that the Episil^® group had a lower percentage of weight loss than the control group at weeks 4 and 7 after RT. Similar results were also obtained for BMI and albumin levels (P < 0.05). Moreover, according to PG-SGA scores, fewer patients in the Episil^® group were malnourished and more patients were well-nourished (P < 0.05) compared with the control group.

Conclusion

Episil^® effectively improved OM and malnutrition in HNC patients who received RT and has a good clinical application value.

Low-risk human papilloma virus positive oropharyngeal cancer with one positive lymph node: Equivalent outcomes in patients treated with surgery and radiation therapy versus surgery alone

BACKGROUND

For human papilloma virus positive (HPV+) oropharyngeal squamous cell carcinoma (OPSCC), management recommendations for patients with a single metastatic lymph node <6 cm in diameter remain nebulous, leading to treatment heterogeneity in this common subgroup of patients.

METHODS

We utilized the National Cancer Database to perform survival and multivariable analyses of patients with HPV+ OPSCC with one positive lymph node <6 cm and negative surgical margins.

RESULTS

We found that 5-year survival is comparable between patients who receive surgery and adjuvant radiation versus surgery alone. In multivariable analyses, we found no significant difference in the hazard ratio of overall survival after adjusting for various potential confounders.

CONCLUSIONS

These data suggest that patients with margin-negative HPV+ OPSCC with a single positive lymph node <6 cm have comparable survival with or without adjuvant radiation. Future studies exploring outcomes for this specific group in randomized-controlled trials will be critical for further evaluating these initial observations.

Feasibility of Continual Deep Learning-Based Segmentation for Personalized Adaptive Radiation Therapy in Head and Neck Area

Simple Summary

We analyzed the contouring data of 23 organs-at-risk from 100 patients with head and neck cancer who underwent definitive radiation therapy (RT). Deep learning-based segmentation (DLS) with continual training was compared to DLS with conventional training and deformable image registration (DIR) in both quantitative and qualitative (Turing’s test) methods. Results indicate the effectiveness of DLS over DIR and that of DLS with continual training over DLS with conventional training in contouring for head and neck region, especially for glandular structures. DLS with continual training might be beneficial for optimizing personalized adaptive RT in head and neck region.

Abstract

This study investigated the feasibility of deep learning-based segmentation (DLS) and continual training for adaptive radiotherapy (RT) of head and neck (H&N) cancer. One-hundred patients treated with definitive RT were included. Based on 23 organs-at-risk (OARs) manually segmented in initial planning computed tomography (CT), modified FC-DenseNet was trained for DLS: (i) using data obtained from 60 patients, with 20 matched patients in the test set (DLSm); (ii) using data obtained from 60 identical patients with 20 unmatched patients in the test set (DLSu). Manually contoured OARs in adaptive planning CT for independent 20 patients were provided as test sets. Deformable image registration (DIR) was also performed. All 23 OARs were compared using quantitative measurements, and nine OARs were also evaluated via subjective assessment from 26 observers using the Turing test. DLSm achieved better performance than both DLSu and DIR (mean Dice similarity coefficient; 0.83 vs. 0.80 vs. 0.70), mainly for glandular structures, whose volume significantly reduced during RT. Based on subjective measurements, DLS is often perceived as a human (49.2%). Furthermore, DLSm is preferred over DLSu (67.2%) and DIR (96.7%), with a similar rate of required revision to that of manual segmentation (28.0% vs. 29.7%). In conclusion, DLS was effective and preferred over DIR. Additionally, continual DLS training is required for an effective optimization and robustness in personalized adaptive RT.

The Effects of Early Nutritional Intervention on Oral Mucositis and Nutritional Status of Patients With Head and Neck Cancer Treated With Radiotherapy

Radiation-induced oral mucositis (RIOM) is a common side effect after radiotherapy (RT) in head and neck cancer (HNC) patients. RIOM patients with severe pain have difficulty in eating, which increases the incidence of malnutrition and affects patients' quality of life and the process of RT. The mechanism of RIOM is not fully understood, and inflammatory response and oxidative stress appear to be important for RIOM occurrence and development. The nutritional status of patients is very important for their RT tolerance and recovery. Malnutrition, which can lead to anemia, low protein, decreased immunity and other problems, is an important clinical factor affecting tumor progression and treatment. Recent studies have shown that early nutritional intervention can ameliorate oral mucositis and nutritional status of patients with HNC. However, in clinical practice, early nutritional intervention for patients with HNC is not a conventional intervention strategy. Therefore, this review summarized the possible pathogenesis of RIOM, commonly used assessment tools for malnutrition in patients, and recent studies on the effects of early nutritional interventions on RIOM and nutritional status of patients with HNC. We hope to provide the basis and reference for the clinical application of early nutritional intervention models.

Therapeutic effects of andiroba (Carapa guianensis Aubl) oil, compared to low power laser, on oral mucositis in children underwent chemotherapy: A clinical study

ETHNO-PHARMACOLOGICAL RELEVANCE

The Carapa guianensis Aubl, popularly known as andiroba, is a large tree of the Meliaceae family, commonly found in the Amazon region. The oil extracted from its seeds is recognized in traditional medicine and has high anti-inflammatory and analgesic potential, which are the basic prerequisites for a therapeutic agent that can be used in the treatment of oral mucositis (OM). Moreover, the aforementioned oil has antimicrobial, antiallergic, and parasiticidal actions and is effective in the management of cutaneous and muscular dysfunctions.

AIM OF THE STUDY

To evaluate the therapeutic effects of andiroba gel (Carapa guianensis Aubl) on the symptomatology and evolution of OM in children with leukemia who underwent chemotherapy and to compare it to the effects of low power laser.

MATERIALS AND METHODS

This randomized, double-blind clinical trial involved 60 patients of both genders with leukemia, with age ranging from six to twelve years. The patients were divided into two study groups: the andiroba group (n = 30) and the laser group (n = 30). The level of pain experienced by the patients was assessed using the Wong-Baker visual analog scale and the degree of severity of OM was assessed using a table, recommended by the World Health Organization, that depicts the degrees of severity of OM. The data obtained were analyzed using the Mann-Whitney test, with statistical significance indicated by a P value less than or equal to 0.05.

RESULTS

A statistically significant reduction in the degree of OM was observed on the fourth, fifth, and sixth days and in the pain scores on the second, third, and fourth days in the andiroba group after the manifestation of OM, compared to the laser group.

CONCLUSIONS

The use of andiroba oil effectively reduced the severity of OM and relieved pain, which resulted in a decrease in the severity of signs and symptoms in the patients in the andiroba group, compared to the laser group.

Can cryoprevention of oral mucositis be obtained at a higher temperature?

OBJECTIVES

Ice chips (IC) have successfully been used to prevent the development of chemotherapy-induced oral mucositis (OM). Although effective, IC entails several shortcomings and may open avenues for systemic infections as the water used may be contaminated by microorganisms, which may jeopardise the medical rehabilitation of an already immunosuppressed patient. This study aimed to investigate the efficacy and tolerability profile of a novel intraoral cooling device (ICD).

SUBJECTS AND METHODS

In total, 20 healthy volunteers were enrolled in this randomised crossover study. Intraoral temperatures were registered using an IR camera, at baseline and following 30 and 60 min of cooling with the ICD, set to 8 °C or 15 °C. Following each cooling session, tolerability was assessed using a questionnaire.

RESULTS

A statistically significant difference in the intraoral temperature was observed using 8 °C compared with 15 °C, following both 30 (1.87 °C, p < 0.001) and 60 min (2.48 °C, p < 0.001) of cooling. Thus, the difference of the intraoral temperatures was less than the 7 °C difference between 8 °C and 15 °C. Furthermore, 60 min of cooling with 15 °C compared with 8 °C was better tolerated and preferred by 15 out of 20 participants (p < 0.001).

CONCLUSION

Cooling was better tolerated when the ICD was set to 15 °C compared with 8 °C, although the difference in reduction of the intraoral mucosal temperature was marginal and may not affect cryoprevention of oral mucositis.

CLINICAL RELEVANCE

The ICD has the potential to improve the care for patients with cancer at high risk of developing OM.

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.

Post cricoid tumours; a limiting factor for percutaneous endoscopic gastrostomy insertion in cancer patients: Results from a tertiary care hospital

BACKGROUND AND STUDY AIMS

The aim of this study was to review all episodes of PEG insertion in patients with head and neck cancer (HNC) at a cancer specialist centre.

PATIENTS AND METHODS

Using a structured data extraction form, we abstracted patients' demographic data and clinical information including the primary site of tumour, TNM staging, whether PEG tube was inserted successfully, any complications resulting from PEG tube insertion and duration the tube was in place.

RESULTS

We identified a total of 339 HNC patients who had received at least one attempted PEG tube insertion. The mean age of patients was 49.5 ± 14.5 years and 66% (n: 233/339) were males. 151/ 339 (44.5%) patients had a tumour in the pharynx and nasopharynx, 103/ 339 (30.4%) in oral cavity, 81/ 339 (23.9%) in post-cricoid region and 4 (1.1%) of the patients had a laryngeal carcinoma. Histopathologically, most tumours (75.8%) were squamous cell carcinoma presenting at a T4 (52.6%), N0 (38.3%) and M0 (91.7%) stage. PEG tube was successfully inserted in 303/339 (89.4%) patients. There were 36 PEG failures; 24 (66.6%) in postcricoid and laryngeal tumours, 8 (22.3%) in pharynx/nasopharynx and 4 (11.1%) in oral cavity tumours. Of the 81 patients with post-cricoid tumour, PEG tube was successfully inserted in 57/ 81 (70.3%) of the patients. Age, gender or T stage of the tumour was not found to be statistically significant predictors of PEG failure. The only significant factor was presence of post-cricoid or laryngeal tumours that increased the risk of PEG failure 12 times (95% confidence interval: 3.4 to 42.3).

CONCLUSION

PEG tube should be used as a first line feeding option in patients with all type of head and neck cancers, however, the attending clinicians should have this foresight of higher failure rates in patients with post-cricoid tumour.

A Dosimetric Comparison of Oral Cavity Sparing in the Unilateral Treatment of Early Stage Tonsil Cancer: IMRT, IMPT, and Tongue-Deviating Oral Stents

Introduction

Tongue-deviating oral stents (TDOS) are commonly used during unilateral neck radiation therapy to reduce unnecessary dose to nontarget oral structures. Their benefit in the setting of highly conformal treatment techniques, however, is not defined. The goal of this study was to investigate the potential benefit of TDOS use on dosimetric parameters in unilateral intensity modulated radiation therapy (IMRT) and intensity modulated proton therapy (IMPT).

Methods

A total of 16 patients with T1-2 tonsil cancer treated at a single institution were selected, of which 8 were simulated/treated with a TDOS and 8 without a TDOS. All received definitive unilateral IMRT to a dose of 66 Gy in 30 fx. IMPT plans were generated for each patient for study purposes and optimized according to standard institutional practice.

Results

For IMRT plans, the presence of a TDOS (vs without) was associated with a significantly lower oral mucosa mean dose (31.4 vs 35.3 Gy; P = .020) and V30 (42.7% vs 57.1%; P = .025). For IMPT plans, the presence of TDOS (vs without) was not associated with any improvement in oral mucosa mean dose (18.3 vs 19.9 Gy; P = .274) or V30 (25.0% vs 26.2%; P = .655). IMPT plans without TDOS compared with IMRT plans with TDOS demonstrated reduced oral mucosa mean dose (P < .001) and V30 (P < .001).

Conclusion

The use of a TDOS for the unilateral treatment of well-lateralized tonsil cancers was associated with oral mucosa sparing for IMRT, but not for IMPT. Moreover, mucosa sparing was improved for IMPT plans without a TDOS compared to IMRT plans with a TDOS.

Oral Glutamine May Have No Clinical Benefits to Prevent Radiation-Induced Oral Mucositis in Adult Patients With Head and Neck Cancer: A Meta-Analysis of Randomized Controlled Trials

Objectives: The role of oral glutamine for the management of oral mucositis (OM) has not yet been confirmed. The objective of the present study is to further investigate whether oral glutamine is effective in preventing and treating OM among patients with head and neck cancer (HNC) receiving radiotherapy alone or concurrent with chemotherapy.

Methods: A systematic search was performed in PubMed, EMBASE, EBSCO, and Cochrane Central Register of Controlled Trials (CENTRAL) to capture all potential citations from the inception to June 2019. Then data extraction and assessment of risk of bias were carried out after selecting the eligible citations. RevMan 5.3 software was used to perform all statistical analyses.

Results: Six randomized controlled trials (RCTs) including 441 patients were included in the final analysis. The meta-analysis showed that oral glutamine couldn't significantly decrease the incidence of OM (risk ratio [RR] = 0.98, 95% confidence interval [CI] = 0.94−1.02) and alleviate the development of moderate or severe grade of OM (Moderate-to-severe OM: RR = 0.81, 95% CI = 0.59−1.12; Severe OM: RR = 0.45, 95% CI = 0.13−1.52). But oral glutamine may have the potential to reduce the opioid use (RR = 0.84, 95% CI = 0.71−0.99). The role of oral glutamine in delaying the onset of OM remains uncertain due to conflicting results between quantitative (mean difference [MD] = 4.11 days, 95% CI = 3.49−4.73) and qualitative results.

Conclusions: Oral glutamine may have no clinical benefits to prevent or reduce the incidence and severity of radiation-induced OM in patients with HNC receiving radiotherapy alone or concurrent with chemotherapy. It is also uncertain whether oral glutamine can delay the onset of OM. But it may have the potential to relieve the degree of oral pain. Nevertheless, we must cautiously interpret the results because the observed effect size for delay in mucositis start or reduction in opioid use is marginal. Moreover, further RCTs with more rigorous methodology and large-scale are required to enhance the quality of evidence.

Transcutaneous Electrical Nerve Stimulation Reduces Resting Pain in Head and Neck Cancer Patients: A Randomized and Placebo-Controlled Double-Blind Pilot Study

BACKGROUND

Individuals receiving radiation for head and neck cancer (HNC) often develop painful oral mucositis that impairs function, possibly leading to feeding tubes, hospitalization, and treatment delays. Although pharmacologic medications provide some relief, many report inadequate analgesia and adverse effects. Transcutaneous electrical nerve stimulation (TENS) is a safe, nonpharmacologic intervention; it decreases pain and analgesics and improves function, yet no studies examined TENS for HNC.

OBJECTIVE

The aim of this study was to examine the efficacy of TENS for pain and function in HNC patients.

METHODS

This study used a randomized, double-blinded crossover design; participants received 3 TENS treatments during weeks 4 to 6 of radiation: active, placebo, and no TENS over the temporomandibular joint and upper cervical region. Pain (McGill Pain Questionnaire, visual analog scale [VAS] resting and function), function (mouth opening, tongue movement, speaking), fatigue (VAS), and treatment effectiveness (VAS) were assessed before and after TENS at 3 visits.

RESULTS

Resting pain (McGill Pain Questionnaire and VAS) decreased significantly more after active TENS than placebo or no TENS; changes in function and pain with function did not differ between conditions. Active TENS decreased fatigue significantly more than no TENS and was rated as more effective than placebo TENS.

CONCLUSION

Transcutaneous electrical nerve stimulation improves pain in HNC patients receiving radiation but not function or pain with function relative to placebo or no TENS.

IMPLICATIONS FOR PRACTICE

Transcutaneous electrical nerve stimulation may be a viable tool for radiation-induced HNC pain to complement pharmacologic approaches. This nonpharmacologic intervention could decrease the debilitating effects of radiation and analgesics, and improve quality of life. Clinical trials should examine the effects and safety of repeated, daily TENS in HNC patients receiving radiation.

Decreased Tongue Volume Post Radiation

OBJECTIVES

To evaluate volume changes within the tongue post chemoradiation therapy (CRT).

STUDY DESIGN

Retrospective review.

SETTING

Academic Medical Center.

SUBJECTS AND METHODS

Subjects included 19 patients that received CRT as the primary treatment for tonsillar or hypopharynx squamous cell carcinoma. Tongue volumes were calculated by three raters from thin slice computed tomography images collected before treatment and up to 29 months post-CRT. Body mass index (BMI) was also collected at each time point.

RESULTS

Inter-rater reliability was high with an ICC of 0.849 (95% CI = 0.773, 0.905). Linear mixed effects modeling showed a mean decrease of 0.45 cm³ (standard error of the mean [SEM] = 0.11) in tongue volume per month post-CRT (P < .001). However, the addition of BMI to the model was significant (χ² (4) = 25.0, P < .001), indicating that BMI was a strong predictor of tongue volume, with a mean decrease of 1.75 cm³ (SEM = 0.49) in tongue volume per unit decrease in BMI (P < .001) and reducing the post-CRT effect on tongue volume decrease per month to 0.23 cm³ (P = .02). BMI significantly (P < .001) decreased by 0.11 units (SEM = 0.02) per month post radiation.

CONCLUSION

Tongue dysfunction and decreased tongue strength are significant contributors to the dysphagia that patients experience after receiving CRT. In this study, both tongue volume and BMI decreased post-CRT; therefore, BMI could potentially be used as a predictor of tongue volume post-CRT.

Daily Time of Radiation Treatment Is Associated with Subsequent Oral Mucositis Severity during Radiotherapy in Head and Neck Cancer Patients

BACKGROUND

Limited treatment options are available for oral mucositis, a common, debilitating complication of cancer therapy. We examined the association between daily delivery time of radiotherapy and the severity of oral mucositis in patients with head and neck cancer.

METHODS

We used electronic medical records of 190 patients with head and neck squamous cell carcinoma who completed radiotherapy, with or without concurrent chemotherapy, at Roswell Park Comprehensive Cancer Center (Buffalo, NY) between 2015 and 2017. Throughout a 7-week treatment course, patient mouth and throat soreness (MTS) was self-reported weekly using a validated oral mucositis questionnaire, with responses 0 (no) to 4 (extreme). Average treatment times from day 1 until the day before each mucositis survey were categorized into seven groups. Multivariable-adjusted marginal average scores (LSmeans) were estimated for the repeated- and maximum-MTS, using a linear-mixed model and generalized-linear model, respectively.

RESULTS

Radiation treatment time was significantly associated with oral mucositis severity using both repeated-MTS (n = 1,156; P = 0.02) and maximum-MTS (n = 190; P = 0.04), with consistent patterns. The severity was lowest for patients treated during 8:30 to <9:30 am (LSmeans for maximum-MTS = 2.24; SE = 0.15), increased at later treatment times and peaked at early afternoon (11:30 am to <3:00 pm, LSmeans = 2.66-2.71; SEs = 0.16/0.17), and then decreased substantially after 3 pm.

CONCLUSIONS

We report a significant association between radiation treatment time and oral mucositis severity in patients with head and neck cancer.

IMPACT

Although additional studies are needed, these data suggest a potential simple treatment time solution to limit severity of oral mucositis during radiotherapy without increasing cost.

Severe Oral Mucositis in Pediatric Cancer Patients: Survival Analysis and Predictive Factors

This paper investigates the occurrence of severe oral mucositis and associated factors in blood and solid cancer pediatric patients subjected to cancer treatment, using a survival analysis. A longitudinal, descriptive, observational and inductive study of 142 pediatric patients aged from 0 to 19 years was conducted from 2013 to 2017. Data were collected using a form to record the sociodemographic characteristics and health-related aspects of patients and the modified Oral Assessment Guide (OAG). Survival analysis was performed using the Kaplan-Meier method and Cox semiparametric model. The median times to occurrence of severe oral mucositis were 35.3 and 77.1 days for patients with hematologic malignancies and solid tumors, respectively. The Cox model showed that white cell changes and platelet counts as well as the use of natural chemotherapeutic agents are risk factors for the occurrence of oral mucositis among patients with hematologic malignancies. Nonetheless, among patients with solid tumors, the occurrence of oral mucositis was associated with female sex, mixed ethnicity, the presence of metastasis, abnormal creatinine levels, a combination of chemotherapy, radiotherapy, and surgery, and the administration of chemotherapeutic agents included in the miscellaneous group. The time to occurrence of severe oral mucositis and its associated factors varied according to cancer type.

Effects of early nutritional intervention on oral mucositis in patients with radiotherapy for head and neck cancer

BACKGROUND

To observe the effect of early nutritional intervention on radiation-induced oral mucositis and nutritional status in patients with head and neck cancer (HNC).

METHODS

A total of 54 HNC patients were divided into early (28 cases) and late (26 cases) nutritional intervention groups. The early group received enteral nutrition at the beginning of radiotherapy (RT), while the late group received enteral nutrition after restricted feeding. Operators reported and assessed the timing and extent of oral mucositis and nutritional status during treatment. The nutritional status assessment indicators included body weight; body mass index (BMI); Patient-Generated-Subjective Global Assessment (PG-SGA) score; levels of albumin, hemoglobin and pre-albumin and total lymphocyte count.

RESULTS

The incidence of high-grade oral mucositis was significantly lower in the early group than that in the late group (P < 0.05). Nutritional status assessments showed more significant weight and BMI losses in the late group than in the early group at weeks 4 and 7 after RT (P < 0.01). The albumin decreased in the late group at week 7 after RT was more significant than that in the early group (P < 0.05). Albumin, hemoglobin and pre-albumin levels and total lymphocyte count decreased significantly in both groups (P > 0.05). During therapy, more patients in the early group were well-nourished and fewer were malnourished according to PG-SGA scores (P < 0.05).

CONCLUSION

Early nutritional intervention can reduce the incidence of high-grade oral mucositis during RT in patients with HNC and improve the nutritional status during treatment, which has important clinical significance.

A single-institution, randomized, pilot study evaluating the efficacy of gabapentin and methadone for patients undergoing chemoradiation for head and neck squamous cell cancer

BACKGROUND

The objective of the current study was to compare the safety and efficacy between 2 analgesic regimens for patients with head and neck cancer (HNC) undergoing definitive chemoradiation (CRT).

METHODS

The current study was a prospective, single-institution, 2-arm, randomized pilot study. Patients with American Joint Committee on Cancer seventh edition stage II to stage IV squamous cell carcinoma of the head and neck who were undergoing CRT were randomized to either arm 1, which entailed high-dose gabapentin (2700 mg daily) with the institutional standard of care (hydrocodone and/or acetaminophen progressing to fentanyl as needed), or arm 2, which comprised low-dose gabapentin (900 mg daily) with methadone. The primary endpoints were safety and toxicity. Secondary endpoints were pain, opioid requirement, and quality of life (QOL). Differences between the treatment arms at multiple time points were compared using a generalized linear mixed regression model with Sidak correction.

RESULTS

A total of 60 patients (31 in arm 1 and 29 in arm 2) were enrolled from April 2015 to August 2017. There was no difference between the treatment arms with regard to adverse events or serious adverse events. Pain was not found to be different between the treatment arms. More patients in arm 1 did not require an opioid during treatment (42% vs 7%; P = .002). Patients in arm 2 experienced significantly better QOL outcomes across multiple domains, including overall health (P = .05), physical functioning (P = .04), role functioning (P = .01), and social functioning (P = .01).

CONCLUSIONS

High-dose prophylactic gabapentin increased the percentage of patients who required no opioid during treatment. Methadone may improve QOL compared with a regimen of short-acting opioids and fentanyl. However, pain was found to significantly worsen throughout treatment regardless of treatment arm, necessitating further studies to identify a more optimal regimen.

Mucoadhesive Electrospun Patch Delivery of Lidocaine to the Oral Mucosa and Investigation of Spatial Distribution in a Tissue Using MALDI-Mass Spectrometry Imaging

Many oral mucosal conditions cause considerable and prolonged pain that to date has been difficult to alleviate via topical delivery, and the use of injection causes many patients dental anxiety and needle-prick pain. Therefore, developing a noninjectable drug delivery system as an alternative administration procedure may vastly improve the health and wellbeing of these patients. Recent advances in the development of mucoadhesive electrospun patches for the direct delivery of therapeutics to the oral mucosa offer a potential solution, but as yet, the release of local anesthetics from this system and their uptake by oral tissue have not been demonstrated. Here, we demonstrate the fabrication of lidocaine-loaded electrospun fiber patches, drug release, and subsequent uptake and permeation through the porcine buccal mucosa. Lidocaine HCl and lidocaine base were incorporated into the electrospun patches to evaluate the difference in drug permeation for the two drug compositions. Lidocaine released from the lidocaine HCl-containing electrospun patches was significantly quicker than from the lidocaine base patches, with double the amount of drug released from the lidocaine HCl patches in the first 15 min (0.16 ± 0.04 mg) compared to that from the lidocaine base patches (0.07 ± 0.01 mg). The permeation of lidocaine from the lidocaine HCl electrospun patches through ex vivo porcine buccal mucosa was also detected in 15 min, whereas permeation of lidocaine from the lidocaine base patch was not detected. Matrix-assisted laser desorption ionization-mass spectrometry imaging was used to investigate localization of lidocaine within the oral tissue. Lidocaine in the solution as well as from the mucoadhesive patch penetrated into the buccal mucosal tissue in a time-dependent manner and was detectable in the lamina propria after only 15 min. Moreover, the lidocaine released from lidocaine HCl electrospun patches retained biological activity, inhibiting veratridine-mediated opening of voltage-gated sodium channels in SH-SY5Y neuroblastoma cells. These data suggest that a mucoadhesive electrospun patch may be used as a vehicle for rapid uptake and sustained anesthetic drug delivery to treat or prevent oral pain.

Oral Candida colonization in xerostomic postradiotherapy head and neck cancer patients

OBJECTIVES

To evaluate (a) oral colonization of Candida species, especially for non-albicans Candida species (NACS), in xerostomic postradiotherapy head and neck cancer patients and (b) risk factors affecting their colonization.

MATERIALS AND METHODS

Subjective and objective dry mouth scores, stimulated salivary flow rates, pH and buffering capacity were measured in 72 xerostomic postradiotherapy head and neck cancer patients. Candida counts and species identification were performed using oral rinse samples cultured in Candida Chromagar, followed by polymerase chain reaction and API 20C AUX system.

RESULTS

Candida colonization was observed in 87.5% of subjects, with 80.6% and 48.6% of study population colonized by C. albicans and NACS, respectively. NACS was associated with high objective dry mouth scores, denture use, and females (p = .006, .009, and .036, respectively). In addition, Candida glabrata was detected more in females (p = .018) and denture wearers (p = .026), while Candida tropicalis was associated with high objective dry mouth scores (p = .022) and females (p = .027). Quantity of Candida colonization correlated positively with objective dry mouth scores (r = 0.599, p < .001) and negatively with salivary flow rates (r = -0.258, p = .041) and pH (r = -0.290, p = .022).

CONCLUSION

NACS colonization was common in xerostomic head and neck cancer patients. Increased signs of dry mouth, female and dental prostheses may promote NACS colonization.

Utilization of rehabilitation services in patients with head and neck cancer in the United States: A SEER-Medicare analysis

BACKGROUND

Head and neck cancer (HNC) and its treatment lead to functional impairments. Rehabilitation by speech-language pathology (SLP) and occupational/physical therapy (OT/PT) can decrease morbidity.

METHODS

The Surveillance, Epidemiology and End Results-Medicare data for patients with HNC diagnosed between 2002 and 2011 was utilized to evaluate posttreatment rehabilitation.

RESULTS

In 16 194 patients, the overall utilization rate was 20.7% for SLP and 26.2% for OT/PT services. Treatment modality was significantly associated rehabilitation utilization. Compared to patients treated with primary surgery, those treated with primary radiotherapy had significantly lower odds of OT/PT utilization. Patients treated with surgery plus adjuvant treatment and primary concurrent chemoradiation had higher odds of SLP utilization compared to patients treated with surgery alone.

CONCLUSIONS

Rehabilitation services appeared to be underutilized by patients with HNC in the United States and vary with treatment modality. There is a need to improve integration of rehabilitation services into the HNC care continuum.

SUMMARY

Rehabilitation services are underutilized by patients with HNC during posttreatment surveillance in the United States. Treatment modality significantly impacts rehabilitation utilization patterns.

Effect of Doxepin Mouthwash or Diphenhydramine-Lidocaine-Antacid Mouthwash vs Placebo on Radiotherapy-Related Oral Mucositis Pain: The Alliance A221304 Randomized Clinical Trial

IMPORTANCE

Oral mucositis causes substantial morbidity during head and neck radiotherapy. In a randomized study, doxepin mouthwash was shown to reduce oral mucositis-related pain. A common mouthwash comprising diphenhydramine-lidocaine-antacid is also widely used.

OBJECTIVE

To evaluate the effect of doxepin mouthwash or diphenhydramine-lidocaine-antacid mouthwash for the treatment of oral mucositis-related pain.

DESIGN, SETTING, AND PARTICIPANTS

A phase 3 randomized trial was conducted from November 1, 2014, to May 16, 2016, at 30 US institutions and included 275 patients who underwent definitive head and neck radiotherapy, had an oral mucositis pain score of 4 points or greater (scale, 0-10), and were followed up for a maximum of 28 days.

INTERVENTIONS

Ninety-two patients were randomized to doxepin mouthwash (25 mg/5 mL water); 91 patients to diphenhydramine-lidocaine-antacid; and 92 patients to placebo.

MAIN OUTCOME AND MEASURES

The primary end point was total oral mucositis pain reduction (defined by the area under the curve and adjusted for baseline pain score) during the 4 hours after a single dose of doxepin mouthwash or diphenhydramine-lidocaine-antacid mouthwash compared with a single dose of placebo. The minimal clinically important difference was a 3.5-point change. The secondary end points included drowsiness, unpleasant taste, and stinging or burning. All scales ranged from 0 (best) to 10 (worst).

RESULTS

Among the 275 patients randomized (median age, 61 years; 58 [21%] women), 227 (83%) completed treatment per protocol. Mucositis pain during the first 4 hours decreased by 11.6 points in the doxepin mouthwash group, by 11.7 points in the diphenhydramine-lidocaine-antacid mouthwash group, and by 8.7 points in the placebo group. The between-group difference was 2.9 points (95% CI, 0.2-6.0; P = .02) for doxepin mouthwash vs placebo and 3.0 points (95% CI, 0.1-5.9; P = .004) for diphenhydramine-lidocaine-antacid mouthwash vs placebo. More drowsiness was reported with doxepin mouthwash vs placebo (by 1.5 points [95% CI, 0-4.0]; P = .03), unpleasant taste (by 1.5 points [95% CI, 0-3.0]; P = .002), and stinging or burning (by 4.0 points [95% CI, 2.5-5.0]; P < .001). Maximum grade 3 adverse events for the doxepin mouthwash occurred in 3 patients (4%); diphenhydramine-lidocaine-antacid mouthwash, 3 (4%); and placebo, 2 (2%). Fatigue was reported by 5 patients (6%) in the doxepin mouthwash group and no patients in the diphenhydramine-lidocaine-antacid mouthwash group.

CONCLUSIONS AND RELEVANCE

Among patients undergoing head and neck radiotherapy, the use of doxepin mouthwash or diphenhydramine-lidocaine-antacid mouthwash vs placebo significantly reduced oral mucositis pain during the first 4 hours after administration; however, the effect size was less than the minimal clinically important difference. Further research is needed to assess longer-term efficacy and safety for both mouthwashes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02229539.

Prophylaxis With Oral Zinc Sulfate Against Radiation Induced Oral Mucositis in Patients With Head and Neck Cancers: A Systematic Review and Meta-Analysis of Four Randomized Controlled Trials

Background: Oral mucositis is an inevitable and distressing adverse event patients, who were treated with irradiation for head and neck cancer, face. Although several studies have investigated the potential of oral zinc sulfate in preventing radiation-induced oral mucositis in patients with head and neck cancers, conclusive results have not yet been found.

Objective: The aim of the present study is to determine whether oral zinc sulfate is effective in preventing radiation-induced oral mucositis, in patients with head and neck cancers.

Methods: We electronically searched all potential citations in PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and EBSCO from their inception to December 2018. After the search and checked literatures, extracted data and appraised risk of bias, RevMan software version 5.3 was used to perform meta-analysis.

Results: Four randomized controlled trials (RCTs) involving 162 patients were included. A meta-analysis showed that zinc sulfate did not decrease the incidence (RR [relative risk], 0.97; 95% CI [confidence interval], 0.74–1.28), and did not relieve the moderate and severe grade of radiation induced oral mucositis (moderate and severe oral mucositis: RR, 0.84; 95% CI, 0.14–4.87; severe oral mucositis: RR, 0.43; 95% CI, 0.00–38.98). A qualitative analysis suggested that zinc sulfate was associated with the onset of oral mucositis.

Conclusions: Based on limited evidence, zinc sulfate may not have the benefit of prophylaxis against radiation-induced oral mucositis, in patients with head and neck cancers. However, further RCTs with larger sample sizes and more rigorous methodologies are needed to enhance the evidence of these results.

Non-coplanar whole brain radiotherapy is an effective modality for parotid sparing

Background

The purpose of this study was to evaluate the efficacy and feasibility of non–coplanar whole brain radiotherapy (NC–WBRT) for parotid sparing.

Methods

Fifteen cases, previously treated with WBRT were selected. NC–WBRT plans were generated. The beam arrangement for the non–coplanar plans consisted of superior anterior, right, and left beams. After generation of the non–coplanar plans a field–in–field technique was applied to the bilateral parallel opposed beams in order to reduce maximum dose and increase dose homogeneity. The NC–WBRT plans were subsequently compared with the previously generated bilateral WBRT (B–WBRT) plans. A field–in–field technique was also used with the B–WBRT plans according to our departmental protocol. As per our institutional practice a total dose of 30 Gy in 10 fractions of WBRT was administered 5 days a week.

Results

The mean dose to the parotid gland for the two different plans were 16.2 Gy with B–WBRT and 13.7 Gy with NC–WBRT (p<0.05). In the NC–WBRT plan, the V_5Gy, V_10Gy, V_15Gy, V_20Gy, and V_25Gy of the parotid were significantly lower (p<0.05) than those of the B–WBRT plan. The D_max of the lens was also lower by 10% with NC–WBRT.

Conclusion

The use of NC–WBRT plans could be a simple and effective method to reduce irradiated volumes and improve the dose–volume parameters of the parotid gland.

Prophylaxis with oral zinc sulfate against radiation-induced oropharyngeal mucositis in patients with head and neck cancer: Protocol for a meta-analysis of randomized controlled trials

BACKGROUND

Oropharyngeal mucositis is considered to be an inevitable and the most troubling side effect of head and neck irradiation, which is caused by the direct toxic action of radiation on oral mucosa. Several randomized controlled trials (RCTs) have investigated the efficacy of zinc sulfate in prevention of radiation-induced oropharyngeal mucositis in patients with head and neck cancer. However, the definite conclusions have not been confirmed. The systematic review and meta-analysis will be performed to comprehensively evaluate whether zinc sulfate is effective in prevention of radiation-induced oropharyngeal mucositis in patients with head and neck cancer.

METHODS

Relevant information will be identified by a comprehensive search of the following electronic databases: PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and EBSCO from their inception to October 2018. Only RCTs which evaluated whether zinc sulfate is effective in prevention of radiation-induced oropharyngeal mucositis in patients with head and neck cancer will be eligible. Two independent investigators will be assigned to search literature, screen information, extract data, and appraise the risk of bias. The primary investigator will use Revman 5.3 software to perform all statistical analyses. We designed this systematic review and meta-analysis on June 5. 2018, and expect to complete the full-text on December 20, 2018.

RESULTS

This protocol has been registered with a unique identifier of CRD42018108533. We will submit this systematic review and meta-analysis to a peer-reviewed journal. Meanwhile, we also will dissemination the whole findings in topic-related conferences.

CONCLUSION

As the first systematic review and metaanalysis, the present study will elucidate current evidence of the role of oral zinc for the prevention and treatment of radiation-induced oropharyngeal mucositis in the head and neck cancer.

Explorative study on quality of life in relation to salivary secretion rate in head and neck cancer patients treated with radiotherapy up to 2 years post treatment

OBJECTIVE

The aim of this study was to analyse quality of life (QoL) pretreatment and up to 24 months post radiation therapy (RT) in patients with head and neck (H&N) cancer.

METHODS

Twenty-nine patients (19 men and 10 women) with a mean age of 59 ± 8 years were included. The stimulated salivary secretion was measured and the patients completed the European Organisation for Research and Treatment of Cancer Quality of Life questionnaires (EORTC QLQ-C30 and H&N35) and the Hospital Anxiety and Depression scale (HADS) pretreatment and at 6, 12 and 24 months post RT.

RESULTS

At all time-points after RT (6, 12, and 24 months), patients with hyposalivation (stimulated secretion rate ≤0.7 mL/min) reported clinically significant differences (> 10 points) regarding insomnia, swallowing, social eating, dry mouth, and sticky saliva. Statistically significant differences were found for emotional functioning and insomnia at 12 months (P < 0.05 for both) and for sticky saliva at both 12 and 24 months (P < 0.05 and P < 0.01). The number of clinically significant differences increased from 10 at both 6 and 12 months post-RT to 14 functioning/symptom scales and single items at the 24 months follow-up. At 24 months post RT, 21% of patients with hyposalivation had HADS scores suggesting anxiety problems compared to 7% for those with stimulated salivary secretion rates >0.7 mL/min.

CONCLUSION

Patients with hyposalivation showed deterioration in health related quality of life (QoL) at 24 months compared with 12 months post RT. Most pronounced were problems with insomnia, swallowing, social eating, dry mouth, and sticky saliva.