Quality of life and salivary output in patients with head-and-neck cancer five years after radiotherapy

Reducing Target Volumes of Intensity Modulated Radiation Therapy After Induction Chemotherapy in Locoregionally Advanced Nasopharyngeal Carcinoma: Long-Term Results of a Prospective, Multicenter, Randomized Trial

PURPOSE

The objective of this study was to estimate the long-term survival, late toxicity profile, and quality of life of patients with locoregionally advanced nasopharyngeal carcinoma (NPC) treated with combined induction chemotherapy (IC) and concurrent chemoradiotherapy from a clinical trial focused on reducing the target volume of intensity modulated radiation therapy (IMRT).

METHODS AND MATERIALS

This prospective, randomized clinical trial was conducted across 6 Chinese hospitals and included 212 patients with stage III-IVB NPC who were randomly allocated to a pre-IC or post-IC group. Eligible patients were treated with 2 cycles of IC + CCRT. All patients underwent radical IMRT. Gross tumor volumes of the nasopharynx were delineated according to pre-IC and post-IC tumor extent in the pre-IC and post-IC groups, respectively.

RESULTS

After a median follow-up of 98.4 months, 32 of 97 (32.9%) and 33 of 115 (28.7%) patients experienced treatment failure or died in the pre-IC and post-IC groups, respectively. None of the patients developed grade 4 late toxicity. Late radiation-induced toxicity predominantly manifested as grade 1 to 2 subcutaneous fibrosis, hearing loss, tinnitus, and xerostomia, whereas grade 3 late toxicity included xerostomia and hearing loss. The 5-year estimated overall, progression-free, locoregional recurrence-free, and distant metastasis-free survival rates in the pre-IC and post-IC groups were 78.2% versus 83.3%, 72.0% versus 78.1%, 90.2% versus 93.5%, and 78.1% versus 82.1%, respectively. The pre-IC group had a significantly higher incidence of xerostomia and hearing damage than the post-IC group. In terms of quality of life, compared with the pre-IC group, the post-IC group showed significant improvement in cognitive function (P = .045) and symptoms including dry mouth (P = .004), sticky saliva (P = .047), and feeling ill (P = .041).

CONCLUSIONS

After long-term follow-up, we confirmed that reducing the target volumes of IMRT after IC in locoregionally advanced NPC showed no inferiority in terms of the risk of locoregional relapse and potentially improved quality of life and alleviated late toxicity.

Serial Changes in Parotid Gland Volume and Symptoms After Radiation Therapy in Oropharyngeal Cancer

Objective: To evaluate the serial changes in the volume of the parotid gland and clinical symptoms after a course of radiation therapy (RT) in patients with oropharyngeal cancer. Methods: A total of 33 patients who were diagnosed with oropharyngeal cancer and had been treated with RT or concurrent chemoradiation therapy were evaluated. Parotid gland volumes were measured serially by head and neck computed tomography with contrast-enhanced images before RT, and 6 months, 1 year, and 2 years after RT. Patients also filled out EORTC (European Organization for the Research and Treatment of Cancer) QLQ-C30 questionnaires on the quality of life (QOL) at the same time. This questionnaire included questions about salivary gland function: dry mouth, sticky saliva, and taste disorder. Higher scores on EORTC questionnaire translates to worse QOL. Results: All patients received more than 60 Gy irradiation in total. The mean volume of parotid gland decreased from 23.30 mL before RT to 15.80 mL, 15.93 mL, and 16.67 mL after 6 months, 1 year, and 2 years, respectively (P < 0.001 between pre-RT and all other 3 periods). The scores on the QOL questionnaire were higher (worsened QOL) at all 3 times after radiation than in the pre-RT period. The mean score of QOL increased from pre-RT to 2 years post-RT: "dry mouth" from 1.65 to 2.70, "sticky saliva" from 1.19 to 2.00, and "taste disorder" from 1.12 to 1.94. All 3 of these parameters were correlated with the volume of the parotid gland (P < 0.005 each). Conclusions: The volume of the parotid gland decreases significantly after RT for oropharyngeal cancer and does not recover significantly for at least 2 years. There was a significant correlation between decreased parotid volume and a lower QOL involving salivation.

What Risk Factors Are Associated With Poorer Quality of Life in Patients With Head and Neck Cancer?

PURPOSE

Head and neck cancer (HNCA), as well as the sequelae of its treatment, has a significant negative impact on the quality of life (QOL) for patients. We aim to identify patient and surgical factors negatively influencing QOL of patients with HNCA.

MATERIALS AND METHODS

A cross-sectional study was used to identify specific risk factors associated with a poorer QOL. The University of Michigan Head and Neck Quality of Life (HNQOL) instrument was used to assess QOL. Predictor variables included risk factors (smoking, alcohol, past medical history), demographic (sex, age, marital status), anatomical features (tumor location, tumor stage), perioperative adjuncts (utilization of a feeding tube, tracheostomy, neck dissection), and postoperative adjuncts (chemotherapy or radiation therapy utilization). The primary outcome variable was the HNQOL score. Descriptive statistics were completed for all the variables. Association between the predictor variables and HNQOL scores were examined using bivariate statistics, and statistical significance was set at P < .05.

RESULTS

The study sample composed of 78 patients with HNCA who underwent surgery at Head and Neck Maxillofacial and Reconstructive Surgery Clinic at Ascension Macomb-Oakland from January 2017 to August 2018. Of the 78 patients meeting inclusion, 31 patients completed the HNQOL survey. The median HNCA QOL score was 18 with a maximum score of 80, representing a worse QOL. Radiation therapy (21 vs 5.5, P = .033), and perioperative feeding tube (31 vs 9, P = .012) had statistically significant negative impacts on QOL scores. Variables associated with poorer QOL scores in descending order: radiation therapy perioperative feeding tube utilization of chemotherapy (12.5 vs 9.0, P = .60), male gender (17 vs 9.5, P = .39), perioperative tracheostomy (26 vs 14.5 P = .26), tobacco use (19.5 vs 11.5, P = .81), single marital status (27 vs 16, P = .48), neck dissection (17.5 vs 15.5, P = .91), and alcohol use (18.5 vs 16.0, P = .65).

CONCLUSIONS

Feeding tube and radiotherapy utilization had a statistically significant decrease of QOL scores among patients with HNCA. Additional risk factors associated with poorer QOL include chemotherapy, male sex, tracheostomy utilization, tobacco use, single or divorced marital status, neck dissection, and alcohol abuse.

A Prospective Cohort Study Analyzing Radiation-Induced Xerostomia and Quality of Life of Head and Neck Cancer Patients Treated With Intensity-Modulated Radiotherapy and 3D Conformal Radiotherapy Techniques at a Tertiary Cancer Center in Eastern India

Introduction Cancer of the head and neck is one of the most common cancers in India. Radiotherapy (RT) plays a vital role in the management of head and neck cancer both as a curative and adjuvant modality. Xerostomia is the most common acute and late toxicity. Therefore, this study aimed to analyze radiation-induced xerostomia and the quality of life of patients treated with intensity-modulated radiotherapy (IMRT) and three-dimensional (3D) conformal radiotherapy (3DCRT). Objectives We aim to evaluate radiation-induced acute xerostomia both subjectively and objectively at three-month and one-year post-radiotherapy follow-up period in patients who received radiotherapy in conformal technique (IMRT) to the head and neck region and compare it with those who received the 3DCRT technique. We also aim to assess the recovery of salivary flow in the third month post-radiotherapy by measuring the parotid scintigraphy excretion fraction. Materials and methods Forty patients with head and neck squamous cell carcinoma (SCC) were randomly assigned to the IMRT and 3DCRT arms. Xerostomia during radiation and at three-month and one-year post-radiotherapy follow-up was assessed subjectively using the xerostomia-related quality of life (XeQOL) questionnaire and objectively by measuring the salivary flow rate and parotid scintigraphy. Results The result is analyzed using an independent t-test, Mann-Whitney U test, and Fisher's exact test. The analysis showed that patients treated with radiation by IMRT showed better XeQOL scores (43.40±2.326 in IMRT and 52.10±2.573 in 3DCRT, p<0.001) and Eating Assessment Tool-10 (EAT-10) score (27.65±2.796 in IMRT and 33.80±1.936 in 3DCRT, p<0.001) compared to those treated with 3DCRT. Analysis of the excretion fraction (EF%) of parotid scintigraphy depicted improvement in EF% for both right and left parotids in the IMRT arm with statistical significance (for right parotid, 25.22±12.98 in IMRT and 19.60±10.17 in 3DCRT, p=0.136, and for left parotid, 28.03±12.51 in IMRT and 15.35±11.49 in 3DCRT, p=0.0019). The mean rate of flow (ROF) of saliva showed a declining trend during the end of radiotherapy treatment compared to baseline, but the mean ROF of saliva was better in IMRT compared to 3DCRT, and the difference was statistically significant. The ROF of saliva starts improving during the one-year post-radiotherapy follow-up period. Pearson's chi-square test was used to analyze the correlation between mean parotid dose with EF% of parotid scintigraphy, and it showed a negative correlation, which is statistically significant for both 3DCRT and IMRT arms. Conclusion Xerostomia can be reduced by precision radiotherapies such as the parotid-sparing IMRT technique in head and neck cancer patients, hence improving the quality of life.

ASSESSMENT OF DISTRESS DYNAMICS AND QUALITY OF LIFE OF CANCER PATIENTS AT THE STAGE OF RADIATION THERAPY AND POSSIBILITIES OF THEIR CORRECTION

Radiation therapy (RT) is the main type of antitumor treatment in inoperable patients. Low awareness and fear of the development of radiation reactions contributes to the destabilization of psycho-emotional state of patients, which can result in withdrawal from treatment and deterioration of their quality of life (QOL). Despite a steady increase in cancer rates in Ukraine, there are currently no studies to develop measures to improve psychological condition of patients undergoing treatment in radiation therapy departments.

OBJECTIVE

to assess the dynamics of psycho-emotional status and QOL of cancer patients at the stage of radiation therapy.

MATERIALS AND METHODS

The study involved psychodiagnostic examination of 66 cancer patients who underwent radiation treatment in the clinic of the State Organization «Grigoriev Institute for Medical Radiology and Oncology of the NAMS of Ukraine», of whom Group 1 included 44 patients with head and neck cancer, Group 2 comprised 22 patients with colorectal cancer. Comparison group comprised 30 conditionally «healthy» respondents without cancer. All patients had stage III-IV cancer. The study implied the employment of «Distress Thermometer», Hospital Anxiety and Depression Scale (HADS), and the SF-36 Questionnaire (Short Form). The examination was performed before and following the course of radiation therapy. Group 1 patients underwent only psychodiagnostic examination, Group 2 patients apart from psychodiagnostic were accompanied by a psychologist before undergoing radiation procedures. In the comparison group, the survey was conducted once.

RESULTS AND DISCUSSION

Assessment of the data showed that before the start of RT most subjects (72.73 % in Group 1 and 77.3 % in Group 2) had a high level of distress, they were worried and nervous before the first radiation procedure, had fears about the consequences and side effects. The level of anxiety in Group 1 at the pathological and subclinical level was recorded in 54.55 % of patients, the rate of depression at the subclinical level was diagnosed in 18.20 %, and in 9.10 % of patients at the clinical one. In Group 2, the level of anxiety that exceeded the norm was recorded significantly less often (27.25 % vs. 54.55 %, pt < 0.05), and the rate of depression at the subclinical level was diagnosed significantly more often than in Group 1 (54.50 % vs. 18.20 %, pt < 0.05), and in 18.2 % of patients at the clinical level. After radiation, 81.81 % of Group 1 patients showed an increase in distress and anxiety, and depressive symptoms tended to worsen. The level of distress in Group 2 after consulting a psychologist in preparation for RT and undergoing radiation procedures decreased almost twice, the level of anxiety decreased to normal, the indicators of depressive symptoms remained unchanged. According to QOL assessments on the scales of physical and role functioning (PF and RP), general health (GH) and mental health (MH), patients in both groups had significantly lower scores before the RT than in the comparison groups. After the procedures, there was a significant deterioration in the RP scale in Group 1 (18.75 vs. 40.00, pt < 0.05), and an improvement of almost 2 times in Group 2 (35.73 vs. 68.33, pt < 0.06). The indicator of general health (GH) at the end of RT in Group 1 did not change, and in Group 2 it tended to improve (20.93 vs. 47.26, pt < 0.06). Life expectancy (LE) in Group 1 tended to decrease further after treatment, having increased 1.7 times in Group 2.

CONCLUSIONS

The study showed that cancer patients before the onset of RT experienced a rather strong distress and level of anxiety. Psychological correction of the emotional state at the beginning of treatment allowed for a significant improvement in the QOL of patients on the scales of role physical functioning (RF) and vitality (VT). An important area of work of a clinical psychologist at this stage of treatment involved correction of cognitive sphere, support of role functioning and formation of behavior aimed at further treatment.

Salivary Gland Function, Development and Regeneration

Salivary glands produce and secrete saliva, which is essential for maintaining oral health and overall health. Understanding both the unique structure and physiological function of salivary glands, as well as how they are affected by disease and injury will direct the development of therapy to repair and regenerate them. Significant recent advances, particularly in the OMICS field, increase our understanding of how salivary glands develop at the cellular, molecular and genetic levels; the signaling pathways involved, the dynamics of progenitor cell lineages in development, homeostasis and regeneration and the role of the extracellular matrix microenvironment. These provide a template for cell and gene therapies as well as bioengineering approaches to repair or regenerate salivary function.

Mathematical evaluation of post-radiotherapy salivary gland function using salivary gland scintigraphy

OBJECTIVE

Xerostomia is the most common treatment-related toxicity after radiotherapy (RT) for head and neck carcinoma, reducing the quality of life of patients due to a decrease in salivary gland function.

METHODS

Salivary gland scintigraphy was performed to quantitatively evaluate the salivary gland functions in patients undergoing RT. It was done chronologically for 62 salivary glands of 31 patients before RT and retested 12 months later.

RESULTS

The salivary gland functions of most patients deteriorated post-RT and recovered when the radiation dose to the salivary gland was not high. The mean dose to the salivary gland was found to be the most reliable factor in deteriorating salivary gland function, and the tolerance dose was determined to be 46 Gy. The recovery rate of salivary gland function after 1 year of RT was 72% in the RT alone group (n = 10), 56% in the conformal radiotherapy group (n = 15), and 44% in the bioradiotherapy group (n = 6).

CONCLUSION

Scintigraphy revealed that the salivary glands recovered from post-RT hypofunction when decreased doses were administered. The determined tolerance dose of 46 Gy may guide the approach to minimizing associated xerostomia in RT.

ADVANCES IN KNOWLEDGE

In this study, the average tolerated dose to the salivary glands was 46 Gy.

Intensity-modulated proton therapy for oropharyngeal cancer reduces rates of late xerostomia

BACKGROUND AND PURPOSE

To determine rates of xerostomia after intensity-modulated radiotherapy (IMRT) or intensity-modulated proton therapy (IMPT) for oropharyngeal cancer (OPC) and identify dosimetric factors associated with xerostomia risk.

MATERIALS AND METHODS

Patients with OPC who received IMRT (n = 429) or IMPT (n = 103) from January 2011 through June 2015 at a single institution were studied retrospectively. Every 3 months after treatment, each patient completed an eight-item self-reported xerostomia-specific questionnaire (XQ; summary XQ score, 0-100). An XQ score of 50 was selected as the demarcation value for moderate-severe (XQs ≥ 50) and no-mild (XQs < 50) xerostomia. The mean doses and percent volumes of organs at risk receiving various doses (V5-V70) were extracted from the initial treatment plans. The dosimetric variables and xerostomia risk were compared using an independent-sample t-test or chi-square test.

RESULTS

The median follow-up time was 36.2 months. The proportions of patients with moderate-severe xerostomia were similar in the two treatment groups up to 18 months after treatment. However, moderate-severe xerostomia was less common in the IMPT group than in the IMRT group at 18-24 months (6% vs. 20%; p = 0.025) and 24-36 months (6% vs. 20%; p = 0.01). During the late xerostomia period (24-36 months), high dose/volume exposures (V25-V70) in the oral cavity were associated with high proportions of patients with moderate-severe xerostomia (all p < 0.05), but dosimetric variables regarding the salivary glands were not associated with late xerostomia.

CONCLUSION

IMPT was associated with less late xerostomia than was IMRT in OPC patients. Oral cavity dosimetric variables were related to the occurrence of late xerostomia.

A longitudinal study on parotid and submandibular gland changes assessed by magnetic resonance imaging and ultrasonography in post-radiotherapy nasopharyngeal cancer patients

Objectives

With regard to the intensity modulated radiotherapy (IMRT) of nasopharyngeal carcinoma (NPC) patients, this longitudinal study evaluated the radiation-induced changes in the parotid and submandibular glands in terms of gland size, echogenicity and haemodynamic parameters.

Methods

21 NPC patients treated by IMRT underwent MRI and ultrasound scans before radiotherapy, and at 6, 12, 18 and 24 months after treatment. Parotid and submandibular gland volumes were measured from the MRI images, whereas the parotid echogenicity and haemodynamic parameters including the resistive index, pulsatility index, peak systolic velocity and end diastolic velocity were evaluated by ultrasonography. Trend lines were plotted to show the pattern of changes. The correlations of gland doses and the post-RT changes were also studied.

Results

The volume of the parotid and submandibular glands demonstrated a significant drop from pre-RT to 6 months post-RT. The parotid gland changed from hyperechoic before RT to either isoechoic or hypoechoic after treatment. The resistive index and pulsatility index decreased from pre-RT to 6 month post-RT, then started to increase at 12 month time interval. Both peak systolic velocity and end diastolic velocity increased after 6 months post-RT then followed a decreasing trend up to 24 months post-RT. There was mild correlation between post-RT gland dose and gland volume, but not with haemodynamic changes.

Conclusions

Radiation from IMRT caused shrinkage of parotid and submandibular glands in NPC patients. It also changed the echogenicity and vascular condition of the parotid gland. The most significant changes were observed at 6 months after radiotherapy.

Advances in knowledge

It is the first paper that reports on the longitudinal changes of salivary gland volume, echogenicity and haemodynamic parameters altogether in NPC patients after radiotherapy. The results are useful for the prediction of glandular changes that is associated with xerostomia, which help to provide timely management of the complication when the patients attend follow-up visits.

[Late toxicity following primary conservative treatment : Dysphagia and xerostomia]

Dysphagia and xerostomia are still among the most important acute and late side effects of radiotherapy. Technical developments over the past two decades have led to improved diagnostics and recognition as well as understanding of the causes of these side effects. Based on these findings and advances in both treatment planning and irradiation techniques, the incidence and severity of treatment-associated radiogenic late sequelae could be clearly reduced by the use of intensity-modulated radiotherapy (IMRT), which could contribute to marked long-term improvements in the quality of life in patients with head and neck cancer. Highly conformal techniques, such as proton therapy have the potential to further reduce treatment-associated side effects in head and neck oncology and are currently being prospectively tested within clinical trial protocols at several centers.

Self-derived organ attention for unpaired CT-MRI deep domain adaptation based MRI segmentation

To develop and evaluate a deep learning method to segment parotid glands from MRI using unannotated MRI and unpaired expert-segmented CT datasets. We introduced a new self-derived organ attention deep learning network for combined CT to MRI image-to-image translation (I2I) and MRI segmentation, all trained as an end-to-end network. The expert segmentations available on CT scans were combined with the I2I translated pseudo MR images to train the MRI segmentation network. Once trained, the MRI segmentation network alone is required. We introduced an organ attention discriminator that constrains the CT to MR generator to synthesize pseudo MR images that preserve organ geometry and appearance statistics as in real MRI. The I2I translation network training was regularized using the organ attention discriminator, global image-matching discriminator, and cycle consistency losses. MRI segmentation training was regularized by using cross-entropy loss. Segmentation performance was compared against multiple domain adaptation-based segmentation methods using the Dice similarity coefficient (DSC) and Hausdorff distance at the 95th percentile (HD95). All networks were trained using 85 unlabeled T2-weighted fat suppressed (T2wFS) MRIs and 96 expert-segmented CT scans. Performance upper-limit was based on fully supervised MRI training done using the 85 T2wFS MRI with expert segmentations. Independent evaluation was performed on 77 MRIs never used in training. The proposed approach achieved the highest accuracy (left parotid: DSC 0.82 ± 0.03, HD95 2.98 ± 1.01 mm; right parotid: 0.81 ± 0.05, HD95 3.14 ± 1.17 mm) compared to other methods. This accuracy was close to the reference fully supervised MRI segmentation (DSC of 0.84 ± 0.04, a HD95 of 2.24 ± 0.77 mm for the left parotid, and a DSC of 0.84 ± 0.06 and HD95 of 2.32 ± 1.37 mm for the right parotid glands).

Efficacy of gel-based artificial saliva on Candida colonization and saliva properties in xerostomic post-radiotherapy head and neck cancer patients: a randomized controlled trial

Objective

To evaluate the efficacy of an edible artificial saliva gel, oral moisturizing jelly (OMJ), and a topical commercial gel (GC dry mouth gel) on Candida colonization and saliva properties.

Materials and methods

This study was a secondary analysis of a single-blinded randomized controlled trial conducted in xerostomic post-radiotherapy head and neck cancer patients. Candida colonization, stimulated salivary flow rate (SSFR), saliva pH, and buffering capacity (BC) were measured at 0, 1, and 2 months after each intervention. Candida colonization was quantified by colony counts and species identified by Candida Chromagar, polymerase chain reaction, and API 20C AUX system. Statistical significance level was 0.05.

Results

A total of 56 participants in OMJ (N = 30) and GC (N = 26) groups completed the study. OMJ significantly increased saliva pH (p = 0.042) and BC (p = 0.013) after 1-month use, while GC only improved saliva pH (p = 0.027). Both interventions tended to increase SSFR but only GC had a significant increase at 2 months (p = 0.015). GC and OMJ significantly decreased the number of Candida species at 1 and 2 months, respectively. Both groups tended to reduce Candida counts but not significant.

Conclusions

Both OMJ and GC saliva gels could improve saliva pH and decrease the number of Candida species. OMJ is superior to GC in its buffering capacity, while GC may better improve salivary flow rate. Long-term and large-scale study is warranted to test the efficacy of artificial saliva in oral health improvement.

Clinical relevance

OMJ and GC gel could decrease the number of Candida species and improve saliva properties in post-radiation xerostomic patients.

Trial registration number

Clinicaltrials.gov NCT03035825. Date of registration: 25th January 2017.

Mouse parotid salivary gland organoids for the in vitro study of stem cell radiation response

OBJECTIVE

Hyposalivation-related xerostomia is an irreversible, untreatable, and frequent condition after radiotherapy for head and neck cancer. Stem cell therapy is an attractive option of treatment, but demands knowledge of stem cell functioning. Therefore, we aimed to develop a murine parotid gland organoid model to explore radiation response of stem cells in vitro.

MATERIALS AND METHODS

Single cells derived from murine parotid gland organoids were passaged in Matrigel with defined medium to assess self-renewal and differentiation potential. Single cells were irradiated and plated in a 3D clonogenic stem cell survival assay to assess submandibular and parotid gland radiation response.

RESULTS

Single cells derived from parotid gland organoids were able to extensively self-renew and differentiate into all major tissue cell types, indicating the presence of potential stem cells. FACS selection for known salivary gland stem cell markers CD24/CD29 did not further enrich for stem cells. The parotid gland organoid-derived stem cells displayed radiation dose-response curves similar to the submandibular gland.

CONCLUSIONS

Murine parotid gland organoids harbor stem cells with long-term expansion and differentiation potential. This model is useful for mechanistic studies of stem cell radiation response and suggests similar radiosensitivity for the parotid and submandibular gland organoids.

A Review on the Assessment of Radiation Induced Salivary Gland Damage After Radiotherapy

Head and neck cancers are common in Southern China including Hong Kong. Intensity modulated radiotherapy has been the treatment of choice for these patients. Although radiotherapy provides good local control, radiotherapy treatment side-effects are still inevitable due to close proximity of the organs at risk from the target volume. Xerostomia, which is caused due to the damage of salivary glands, is one of the main radiation induced toxicities in post-radiotherapy head and neck patients. This review article discusses the methods for the assessing of radiation induced salivary gland changes including the gland morphology and saliva flow rate. The discussion also includes the recovery of the salivary gland after radiotherapy and how it is affected by the dose. It is expected that the future direction in monitoring the recovery of salivary glands will focus in cellular or molecular levels, and the development of imaging biomarker.

Xerostomia-related quality of life for patients with oropharyngeal carcinoma treated with proton therapy

PURPOSE

We report longitudinal patient-reported quality-of-life (QoL) outcomes related to xerostomia in patients with oropharyngeal cancer treated with intensity-modulated proton therapy (IMPT).

MATERIALS AND METHODS

Patients treated from May 2012 through December 2016 at a single institution for AJCC7 stage III-IV, M0 oropharyngeal cancer were given the 15-item Xerostomia-Related QoL Scale (XeQoLS) before, during, and for up to 2 years after treatment. We evaluated the evolution of xerostomia-related QoL over that time, and examined potential associations between those measures with clinical characteristics.

RESULTS

Sixty-nine patients had XeQoLS scores at baseline and at least once either during or after treatment. The mean (±SD) XeQoLS score (0-4) was 0.24 ± 0.57 at baseline. Subsequent scores were 2.00 ± 1.01 at 6 weeks on treatment, and 1.03 ± 0.76, 0.97 ± 0.78, 0.82 ± 0.69, and 0.70 ± 0.75 at 10 weeks, 6 months, 1 year, and 2 years after treatment, respectively. All were statistically different from baseline (p < 0.001). Univariate analyses demonstrated associations between XeQoLS score and time (p < 0.0001 for each interval), baseline XeQoLS score (p < 0.0001), stage (p = 0.008), N status (p = 0.006), and mean oral cavity dose (p = 0.038), but not for age, sex, T status, receipt of chemotherapy, smoking history, disease site, laterality of neck irradiation, mean parotid dose, or mean submandibular dose. Multivariate analysis suggested that baseline XeQoLS scores, phase of treatment, and N status were associated with XeQoLS scores measured during treatment and recovery.

CONCLUSIONS

Patients receiving IMPT reported the greatest xerostomia-related QoL impairment at 6 weeks on treatment, with a 49% improvement by 10 weeks after treatment; however, XeQoLS scores remained above baseline after 2 years. As we aim to establish the value of IMPT in oropharyngeal tumors to de-intensify treatment over conventional therapy, these data help inform discussions about xerostomia-related quality of life for patients with oropharyngeal cancer treated with IMPT.

Gustatory disturbances occur in patients with head and neck cancer who undergo radiotherapy not directed to the oral cavity

INTRODUCTION

Even the most modern radiation techniques still result in some degree of toxicity to adjacent normal tissues. Consequently, the radiotherapy treatment in head and neck neoplasms potentially leads to gustatory dysfunction even in cases when the treatment area is outside or adjacent to the oral cavity. In this study we quantitatively and qualitatively assessed gustatory function in patients with head and neck cancers who underwent radiotherapy inside and outside of the oral cavity.

METHODS

Fifty-six patients with head and neck cancer responded to a specific questionnaire and had their gustatory function tested before, immediately after, and at 3 and 6 months following radiotherapy treatment. The irradiation field did not include the oral cavity in 29 patients and included it in 27 patients.

RESULTS

All patients suffered a severe loss of taste immediately after radiotherapy. The identification of sweet and bitter tastes decreased in both groups, but the sour decrement was exclusive to those who had the oral cavity irradiated. Fourteen percent of patients complained of qualitative changes of taste, namely taste distortions. No impact of xerostomia on the taste measures was apparent.

CONCLUSION

We found that patients with head and neck neoplasms submitted to radiotherapy have disturbed taste even when irradiation does not include the oral cavity. This deficit is worse immediately after the end of radiotherapy. Our findings do not support the hypothesis that decreased salivary flow is the major cause for radiation-induced changes in taste function.

Pharmacokinetics of Sublingually Delivered Fentanyl in Head and Neck Cancer Patients Treated with Curatively Aimed Chemo or Bioradiotherapy

Over 90% of patients treated for head and neck cancer with curatively aimed chemo or bioradiotherapy will develop painful mucositis and xerostomia. Sublingually delivered fentanyl (SDL) is a rapid acting opioid to treat breakthrough pain. It is unclear how SDL is absorbed by the mucosa of these patients. Therefore, the aim of this study was to investigate the effects of mucositis and xerostomia on the absorption of SDL. Thirteen patients who received chemo or bioradiotherapy (RT), were given a single dose of fentanyl: Before start of RT, 3 and 6 weeks after start of RT, and 6 weeks after finishing RT. Pharmacokinetic samples were taken. The primary endpoint was the relative difference (RD) between systemic exposure to fentanyl (area under the curve; AUC) at baseline (AUC_baseline) and fentanyl AUC in the presence of mucositis grade ≥2. The secondary endpoint was the RD between AUC_baseline and fentanyl AUC in the presence of xerostomia, which were analyzed by means of a paired t-test on log-transformed data. Mucositis resulted in a 12.7% higher AUC (n = 13; 95% CI: −10.7% to +42.2%, p = 0.29) compared to baseline levels and xerostomia resulted in a 22.4% lower AUC (n = 8; 95% CI: −51.9% to +25.3%, p = 0.25) compared to baseline levels. Mucositis grade ≥2 or xerostomia caused by chemo or bioradiotherapy does not significantly alter the systemic exposure to SDL. Patients with pain during and after chemo or bioradiotherapy may be safely treated with SDL.

Comparison of treatment techniques for reduction in the submandibular gland dose: A retrospective study

Introduction

Recent studies have suggested reducing the dose submandibular glands receive when patients undergo head and neck radiotherapy can play a crucial role in preventing xerostomia. However, they are traditionally not spared due to concern that target coverage may be compromised. We investigated the possibility of sparing the contralateral submandibular gland (cSM) by utilising modern planning techniques.

Methods

10 head and neck patients previously treated with conformal therapy at our centre were retrospectively planned using intensity modulated radiation therapy (IMRT), and volumetric modulated arc therapy (VMAT). Each patient was prescribed 70 Gy in 35 fractions to the primary volume, with 56 Gy delivered to the elective nodal areas. The primary objective was to spare the cSM gland using appropriate dose constraints.

Results

Mean dose to the cSM gland was reduced to an acceptable dose level (39 Gy) for all patients replanned using an IMRT or VMAT technique, without compromising planned target volume (PTV) coverage or other critical structures. VMAT was able to reduce the mean dose to 31.5 ± 5.5 Gy compared to 34.5 ± 4.8 Gy of IMRT and offered improved plan conformity.

Conclusion

Sparing the cSM gland is possible using IMRT and VMAT planning, whilst preserving coverage on the elective PTV. This has produced a change in protocol in our department, more focus placed on sparing the SM glands. VMAT is a viable alternative method of delivering treatment and will be utilised when required.

Effect of Xerostomia on the Functional Capacity of Subjects with Rheumatoid Arthritis

OBJECTIVE

To evaluate the intensity of xerostomia and hyposalivation in subjects with rheumatoid arthritis (RA) as well as the effects of these conditions on functional incapacity and disease activity.

METHODS

The study sample comprised 236 individuals of both sexes who had RA. All the individuals were submitted to clinical evaluation and unstimulated sialometry. Functional capacity was determined by using the Health Assessment Questionnaire (HAQ), xerostomia was assessed using the Xerostomia Inventory, and disease activity was evaluated with the 28-joint Disease Activity Score (DAS28). The effect of Sjögren syndrome (SS) was analyzed, and the sample was divided into 2 groups: RA (191 subjects) and RA/SS (45 subjects).

RESULTS

The Xerostomia Inventory showed positive and significant correlation with fatigue (r = 0.243; p < 0.0001), number of painful joints (r = 0.218; p = 0.001), HAQ (r = 0.279; p < 0.0001), and DAS28 (r = 0.156; p < 0.0001). On regression analysis, both xerostomia (OR 3.89, 95% CI 1.84-8.23, p < 0.001) and DAS28 (for severe disease activity: OR 13.26, 95% CI 3.15-55.79, p < 0.001) showed influence on functional incapacity. Forty-five individuals (19.1%) presented with secondary SS, and having this diagnosis was not associated with disease activity or functional capacity.

CONCLUSION

Xerostomia demonstrated an adverse effect on quality of life of subjects with RA, being associated with a reduction in functional capacity. In this clinical setting, xerostomia can be monitored as a marker of worse clinical evolution.

Survival and quality of life in oropharyngeal cancer patients treated with primary chemoradiation after salivary gland transfer

Objectives:

Salivary gland transfer surgery can reduce xerostomia in oropharyngeal squamous cell carcinoma patients undergoing primary chemoradiation. A potential drawback of salivary gland transfer is the treatment delay associated with the surgery, and its complications. This study aimed to determine whether the treatment delay affects patient survival and to evaluate patient quality of life after salivary gland transfer.

Methods:

A retrospective analysis of 138 patients (salivary gland transfer group, n = 58; non-salivary gland transfer group, n = 80) was performed. Patient survival was compared between these groups using multivariate analysis. Salivary gland transfer patients were further evaluated for surgical complications and for quality of life using the head and neck module of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire.

Results:

Salivary gland transfer and non-salivary gland transfer patients had comparable baseline clinical characteristics. Salivary gland transfer patients experienced a median treatment delay of 16.5 days before chemoradiation (p = 0.035). Multivariate analysis showed that this did not, however, correspond to a survival disadvantage (p = 0.24 and p = 0.97 for disease-free and disease-specific survival, respectively). A very low complication rate was reported for the salivary gland transfer group (1.7 per cent). Questionnaire scores for the item ‘xerostomia’ were very low in salivary gland transfer patients.

Conclusion:

The treatment delay associated with salivary gland transfer surgery does not negatively affect patient survival. Oropharyngeal squamous cell patients have an excellent quality of life after salivary gland transfer.

Proteins and peptides in parotid saliva of irradiated patients compared to that of healthy controls using SELDI-TOF-MS

Background

Radiotherapy to the head and neck area damages the salivary glands. As a consequence hyposalivation may occur, but also the protein composition of saliva may be affected possibly compromising oral health. The aim of our study was to compare the relative abundance of proteins and peptides in parotid saliva of irradiated patients to that of healthy controls.

Methods

Using Lashley cups and citric acid, saliva from the parotid glands was collected from nine irradiated patients and ten healthy controls. The samples were analyzed with SELDI-TOF-MS using a NP20 and IMAC-30 chip in the molecular weight range of 1–30 kDa.

Results

On the NP20 chip 61 (out of 217) and on the IMAC-30 chip 32 (out of 218) peaks differed significantly in intensity between the saliva of the irradiated patients and healthy controls. 55 % of the significant peaks showed higher intensity and 45 % showed lower intensity in the saliva of irradiated patients. The peaks may represent, amongst others, the salivary proteins lysozyme, histatins, cystatin, protein S100 and PRP’s.

Conclusions

Large differences were found in the relative abundance of a wide range of proteins and peptides in the parotid saliva of irradiated patients compared to healthy controls.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1641-7) contains supplementary material, which is available to authorized users.

Long-term quality of life after intensified multi-modality treatment of oral cancer including intra-arterial induction chemotherapy and adjuvant chemoradiation

Background:

Quality of life (QoL) studies are well established when accompanying trials in head and neck cancer, but studies on long-term survivors are rare.

Aims:

The aim was to evaluate long-term follow-up patients treated with an intensified multi-modality therapy.

Setting and Design:

Cross-sectional study, tertiary care center.

Patients and Methods:

A total of 135 oral/oropharyngeal cancer survivors having been treated with an effective four modality treatment (intra-arterial induction chemotherapy, radical surgery, adjuvant radiation, concurrent systemic chemotherapy) filled European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and HN35 questionnaires. Mean distance to treatment was 6.1 (1.3–16.6) years. Results were compared with a reference patient population (EORTC reference manual). In-study group comparison was also carried out.

Statistical Analysis:

One-sample t-test, Mann–Whitney-test, Kruskal–Wallis analysis.

Results:

QoL scores of both populations were well comparable. Global health status, cognitive and social functioning, fatigue, social eating, status of teeth, mouth opening and dryness, and sticky saliva were significantly worse in the study population; pain and need for pain killers, cough, need for nutritional support, problems with weight loss and gain were judged to be significantly less. Patients 1-year posttreatment had generally worse scores as compared to patients with two or more years distance to treatment. Complex reconstructive measures and adjuvant (chemo) radiation were main reasons for significant impairment of QoL.

Conclusion

Subjective disease status of patients following a maximized multi-modality treatment showed an expectable high degree of limitations, but was generally comparable to a reference group treated less intensively, suggesting that the administration of an intensified multi-modality treatment is feasible in terms of QoL/effectivity ratio.

Prospective longitudinal assessment of parotid gland function using dynamic quantitative pertechnate scintigraphy and estimation of dose-response relationship of parotid-sparing radiotherapy in head-neck cancers

Purpose

To estimate dose–response relationship using dynamic quantitative ^99mTc-pertechnate scintigraphy in head-neck cancer patients treated with parotid-sparing conformal radiotherapy.

Methods

Dynamic quantitative pertechnate salivary scintigraphy was performed pre-treatment and subsequently periodically after definitive radiotherapy. Reduction in salivary function following radiotherapy was quantified by salivary excretion fraction (SEF) ratios. Dose–response curves were modeled using standardized methodology to calculate tolerance dose 50 (TD50) for parotid glands.

Results

Salivary gland function was significantly affected by radiotherapy with maximal decrease in SEF ratios at 3-months, with moderate functional recovery over time. There was significant inverse correlation between SEF ratios and mean parotid doses at 3-months (r = −0.589, p < 0.001); 12-months (r = −0.554, p < 0.001); 24-months (r = −0.371, p = 0.002); and 36-months (r = −0.350, p = 0.005) respectively. Using a post-treatment SEF ratio <45% as the scintigraphic criteria to define severe salivary toxicity, the estimated TD50 value with its 95% confidence interval (95% CI) for the parotid gland was 35.1Gy (23.6-42.6Gy), 41.3Gy (34.6-48.8Gy), 55.9Gy (47.4-70.0Gy) and 64.3Gy (55.8-70.0Gy) at 3, 12, 24, and 36-months respectively.

Conclusions

There is consistent decline in parotid function even after conformal radiotherapy with moderate recovery over time. Dynamic quantitative pertechnate scintigraphy is a simple, reproducible, and minimally invasive test of major salivary gland function.

Electronic supplementary material

The online version of this article (doi:10.1186/s13014-015-0371-2) contains supplementary material, which is available to authorized users.

Residual deficits in quality of life one year after intensity-modulated radiotherapy for patients with locally advanced head and neck cancer: Results of a prospective study

PURPOSE

Patients with locally advanced head and neck cancer (LAHNC) undergo life-changing treatments that can seriously affect quality of life (QoL). This prospective study examined the key QoL domains during the first year after intensity-modulated radiotherapy (IMRT) and identified predictors of these changes in order to improve patient outcomes.

PATIENTS AND METHODS

A consecutive series of patients with LAHNC completed the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core module (QLQ-C30) and the HNC-specific QLQ-HN35 before (t0) and at the end (t1) of definitive or adjuvant IMRT, then at 6-8 weeks (t2), 6 months (t3), and 1 year (t4) after IMRT.

RESULTS

Patients (n = 111) completing questionnaires at all five time points were included (baseline response rate: 99%; dropout rate between t0 and t4: 5%). QoL deteriorated in all domains during IMRT and improved slowly during the first year thereafter. Many domains recovered to baseline values after 1 year but problems with smelling and tasting, dry mouth, and sticky saliva remained issues at this time. Increases in problems with sticky saliva were greater after 1 year in patients with definitive versus adjuvant IMRT (F = 3.5, P = 0.05).

CONCLUSION

QoL in patients with LAHNC receiving IMRT takes approximately 1 year to return to baseline; some domains remain compromised after 1 year. Although IMRT aims to maintain function and QoL, patients experience long-term dry mouth and sticky saliva, particularly following definitive IMRT. Patients should be counseled at the start of therapy to reduce disappointment with the pace of recovery.

Undesirable financial effects of head and neck cancer radiotherapy during the initial treatment period

BACKGROUND

Healthcare cost and reforms are at the forefront of international debates. One of the current discussion themes in oncology is whether and how patients' life changes due to costs of cancer care. In Norway, the main part of the treatment costs is supported by general taxpayer revenues.

OBJECTIVES

The objective of this study was to clarify whether head and neck cancer patients (n=67) in northern Norway experienced financial health-related quality of life (HRQOL) deterioration due to costs associated with treatment.

DESIGN

HRQOL was examined by the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 in the beginning and in the end of radiation treatment in patients treated at the University Hospital in Northern Norway. Changes in financial HRQOL were calculated and compared by paired sample T-tests. Multiple regression analyses were used to examine correlations among gender, marital status, age and treatment with or without additional chemotherapy and changes in the HRQOL domain of financial difficulties.

RESULTS

The majority of score results at both time points were in the lower range (mean 15-25), indicating limited financial difficulties. We observed no statistically significant differences by gender, marital status and age. Increasing financial difficulties during treatment were reported by male patients and those younger than 65, that is, patients who were younger than retirement age. The largest effect was seen in singles. However, differences were not statistically significant.

CONCLUSIONS

During the initial phase of the disease trajectory, no significant increase in financial difficulties was found. This is in line with the aims of the Norwegian public healthcare model. However, long-term longitudinal studies should be performed, especially with regard to the trends we observed in single, male and younger patients.

Automated segmentation of the parotid gland based on atlas registration and machine learning: a longitudinal MRI study in head-and-neck radiation therapy

PURPOSE

To develop an automated magnetic resonance imaging (MRI) parotid segmentation method to monitor radiation-induced parotid gland changes in patients after head and neck radiation therapy (RT).

METHODS AND MATERIALS

The proposed method combines the atlas registration method, which captures the global variation of anatomy, with a machine learning technology, which captures the local statistical features, to automatically segment the parotid glands from the MRIs. The segmentation method consists of 3 major steps. First, an atlas (pre-RT MRI and manually contoured parotid gland mask) is built for each patient. A hybrid deformable image registration is used to map the pre-RT MRI to the post-RT MRI, and the transformation is applied to the pre-RT parotid volume. Second, the kernel support vector machine (SVM) is trained with the subject-specific atlas pair consisting of multiple features (intensity, gradient, and others) from the aligned pre-RT MRI and the transformed parotid volume. Third, the well-trained kernel SVM is used to differentiate the parotid from surrounding tissues in the post-RT MRIs by statistically matching multiple texture features. A longitudinal study of 15 patients undergoing head and neck RT was conducted: baseline MRI was acquired prior to RT, and the post-RT MRIs were acquired at 3-, 6-, and 12-month follow-up examinations. The resulting segmentations were compared with the physicians' manual contours.

RESULTS

Successful parotid segmentation was achieved for all 15 patients (42 post-RT MRIs). The average percentage of volume differences between the automated segmentations and those of the physicians' manual contours were 7.98% for the left parotid and 8.12% for the right parotid. The average volume overlap was 91.1% ± 1.6% for the left parotid and 90.5% ± 2.4% for the right parotid. The parotid gland volume reduction at follow-up was 25% at 3 months, 27% at 6 months, and 16% at 12 months.

CONCLUSIONS

We have validated our automated parotid segmentation algorithm in a longitudinal study. This segmentation method may be useful in future studies to address radiation-induced xerostomia in head and neck radiation therapy.

Changes in health related quality of life in women and men undergoing radiation treatment for head and neck cancer and the impact of smoking status in the radiation treatment period

PURPOSE

The aim of this study was to evaluate health-related quality of life (HRQOL) in women and men undergoing radiation treatment for head and neck cancer through the intervention period and examine if age, body mass index (BMI) and smoking status at baseline may modify changes in HRQOL.

METHODS

HRQOL was examined by the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and the EORTC QLQ-H&N35, in the beginning and end of the treatment period in 65 patients at the University Hospital in Northern Norway. Changes in HRQOL were calculated and compared by paired sample T-tests. Linear multiple regression analyses were used to examine if baseline characteristics had any influence towards HRQOL changes.

RESULTS

Most aspects of HRQOL declined substantially and significantly (p < 0.001) with a magnitude of more than one standard deviation during the radiation treatment period irrespective of sex and age. Smoking status at baseline had some, albeit minor, influence on changes in HRQOL. Patients who continued smoking during therapy had significantly higher decline in several aspects of HRQOL, compared to patients who stopped smoking.

CONCLUSIONS

HRQOL declined with substantial magnitude in patients undergoing radiation treatment for head and neck cancer, but smoking cessation may modify the declining quality of life.

Toxicity and biodistribution of the serotype 2 recombinant adeno-associated viral vector, encoding Aquaporin-1, after retroductal delivery to a single mouse parotid gland

In preparation for testing the safety of using serotype 2 recombinant adeno-associated vector, encoding Aquaporin-1 to treat radiation-induced salivary gland damage in a phase 1 clinical trial, we conducted a 13 week GLP biodistribution and toxicology study using Balb/c mice. To best assess the safety of rAAV2hAQP1 as well as resemble clinical delivery, vector (10(8), 10(9), 10(10), or 4.4 × 10(10) vector particles/gland) or saline was delivered to the right parotid gland of mice via retroductal cannulation. Very mild surgically induced inflammation was caused by this procedure, seen in 3.6% of animals for the right parotid gland, and 5.3% for the left parotid gland. Long term distribution of vector appeared to be localized to the site of cannulation as well as the right and left draining submandibular lymph nodes at levels >50 copies/μg in some animals. As expected, there was a dose-related increase in neutralizing antibodies produced by day 29. Overall, animals appeared to thrive, with no differences in mean body weight, food or water consumption between groups. There were no significant adverse effects due to treatment noted by clinical chemistry and pathology evaluations. Hematology assessment of serum demonstrated very limited changes to the white blood cell, segmented neutrophils, and hematocrit levels and were concluded to not be vector-associated. Indicators for liver, kidney, cardiac functions and general tissue damage showed no changes due to treatment. All of these indicators suggest the treatment is clinically safe.

Quality of life of patients with head and neck cancer

Patients with head and neck cancer have to deal with the impact of treatment on its functional and aesthetic aspects, and its self-report enables improvements in clinical and social support.

Objective

To evaluate the quality of life of patients dealing with squamous cell carcinoma of the head and neck.

Method

A prospective analytical study. Twenty nine patients with mean age of 57 years answered at three stages: onset, middle and end of treatment, the questionnaires: Quality of Life Core Questionnaire - Cancer 30 and the Quality of Life Questionnaire - Head and Neck, the European Organization for Research and Treatment of Cancer. We used the Friedman test at: 0.05.

Results

There were high mean values concerning physical, cognitive, social functions; improvements in general health and social function decline during treatment; and a significant difference in taste and smell (p = 0.020), swallowing (p = 0.040), cough (p = 0.013) and weight loss (p = 0.011).

Conclusion

There was a significant reduction in the quality of life for some common symptoms resulting from cancer treatment, which was not seen in the evaluation of the aspects related to physical, cognitive and social functions, and general health.

Longitudinal quality of life in Turkish patients with head and neck cancer undergoing radiotherapy

PURPOSE

This study aims to assess the quality of life and to define its determinants in patients with head and neck cancer undergoing radiotherapy.

METHOD

This prospective study was performed in an outpatient clinic of radiation oncology with a sample of 54 consecutive patients. Interview forms-European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire and Head and Neck Module to measure quality of life, Radiation Therapy Oncology Group criteria to determine radiation toxicity, and Patient-Generated Subjective Global Assessment to assess nutritional status-were used to obtain personal and disease-related data before, at the end of radiotherapy, and 1 and 3 months post-therapy.

RESULTS

It was determined that various subscales of functional and symptom scales of quality of life were deteriorated at the end of radiotherapy and started to improve at 1 month after treatment. However, dry mouth and sticky saliva symptom scales did not follow the same pattern, and they took more time to improve. Quality of life (QoL) was found to be worse in younger age, higher education, higher income level, type of cancer, advanced stage, presence of tracheostomy, chemoradiation, higher dose of RT, bad nutritional status, and radiation toxicity.

CONCLUSIONS

Our results emphasize the vital need of support for head and neck cancer patients during radiotherapy, especially during the first month.

ARIX: a randomised trial of acupuncture v oral care sessions in patients with chronic xerostomia following treatment of head and neck cancer

BACKGROUND

Radiation treatment of head and neck cancer can cause chronic xerostomia which impairs patients' quality of life. The study reported here examined the efficacy of acupuncture in alleviating xerostomia symptoms especially dry mouth.

PATIENTS AND METHODS

A total of 145 patients with chronic radiation-induced xerostomia >18 months after treatments were recruited from seven UK cancer centres. The study employed a randomised crossover design with participants receiving two group sessions of oral care education and eight of acupuncture using standardised methods. Patient-reported outcome (PROs) measures were completed at baseline and weeks 5, 9, 13, 17, and 21. The primary outcome was improvement in dry mouth.

OBJECTIVE

saliva measurements were also carried out.

RESULTS

Acupuncture compared with oral care, produced significant reductions in patient reports of severe dry mouth (OR = 2.01, P = 0.031) sticky saliva (OR = 1.67, P = 0.048), needing to sip fluids to swallow food (OR = 2.08, P = 0.011) and in waking up at night to drink (OR = 1.71, P = 0.013). There were no significant changes in either stimulated or unstimulated saliva measurements over time.

CONCLUSION

Eight sessions of weekly group acupuncture compared with group oral care education provide significantly better relief of symptoms in patients suffering from chronic radiation-induced xerostomia.

Ultrasound histogram assessment of parotid gland injury following head-and-neck radiotherapy: a feasibility study

Xerostomia (dry mouth), resulting from radiation damage to the parotid glands, is one of the most common and distressing side effects of head-and-neck cancer radiotherapy. A noninvasive, objective imaging method to assess parotid injury is lacking, but much needed in the clinic. Therefore, we investigated echo histograms to quantitatively evaluate the morphologic and microstructural integrity of the parotid glands. Six sonographic features were derived from the echo-intensity histograms to assess the echogenicity, homogeneity and heterogeneity of the parotid gland: (1) peak intensity value (I(peak)), (2) -3-dB intensity width (W(3-dB)), (3) the low (<50% I(peak)) intensity width (W(low)), (4) the high (>50% I(peak)) intensity width (W(high)), (5) the area of low intensity (A(low)) and (6) the area of high intensity (A(high)). In this pilot study, 12 post-radiotherapy patients and seven healthy volunteers were enrolled. Significant differences (p < 0.05) were observed in four sonographic features between 24 irradiated and 14 normal parotid glands. In summary, we developed a family of sonographic features derived from echo histograms and demonstrated the feasibility of quantitative evaluation of radiation-induced parotid-gland injury.

Quality-of-life among head and neck cancer survivors at one year after treatment--a systematic review

BACKGROUND

The importance of quality-of-life (QoL) research has been recognised over the past two decades in patients with head and neck (H&N) cancer. The aims of this systematic review are to evaluate the QoL status of H&N cancer survivors one year after treatment and to identify the determinants affecting their QoL.

METHODS

Pubmed, Medline, Scopus, Sciencedirect and CINAHL (2000-2011) were searched for relevant studies, and two of the present authors assessed their methodological quality. The characteristics and main findings of the studies were extracted and reported.

RESULTS

Thirty-seven studies met the inclusion criteria, and the methodological quality of the majority was moderate to high. While patients of the group in question recover their global QoL by 12 months after treatment, a number of outstanding issues persist - deterioration in physical functioning, fatigue, xerostomia and sticky saliva. Age, cancer site, stage of disease, social support, smoking, feeding tube placement and alcohol consumption are the significant determinants of QoL at 12 months, while gender has little or no influence.

CONCLUSIONS

Regular assessments should be carried out to monitor physical functioning, degree of fatigue, xerostomia and sticky saliva. Further research is required to develop appropriate and effective interventions to deal with these issues, and thus to promote the patients' QoL.

Evidence-based review: quality of life following head and neck intensity-modulated radiotherapy

Inverse planned Intensity modulated radiotherapy (IMRT) can minimize the dose to normal structures and therefore can reduce long-term radiotherapy-related morbidity and may improve patients' long-term quality of life. Despite overwhelming evidence that IMRT can reduce late functional deficits in patients with head and neck cancer, treated with radiotherapy, a review of the published literature produced conflicting results with regard to quality of life outcomes. Following a critical appraisal of the literature, reasons for the discrepant outcomes are proposed.

A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: prevalence, severity and impact on quality of life

PURPOSE

This systematic review aimed to assess the literature for prevalence, severity, and impact on quality of life of salivary gland hypofunction and xerostomia induced by cancer therapies.

METHODS

The electronic databases of MEDLINE/PubMed and EMBASE were searched for articles published in English since the 1989 NIH Development Consensus Conference on the Oral Complications of Cancer Therapies until 2008 inclusive. Two independent reviewers extracted information regarding study design, study population, interventions, outcome measures, results and conclusions for each article.

RESULTS

The inclusion criteria were met by 184 articles covering salivary gland hypofunction and xerostomia induced by conventional, 3D conformal radiotherapy or intensity-modulated radiotherapy in head and neck cancer patients, cancer chemotherapy, total body irradiation/hematopoietic stem cell transplantation, radioactive iodine treatment, and immunotherapy.

CONCLUSIONS

Salivary gland hypofunction and xerostomia are induced by radiotherapy in the head and neck region depending on the cumulative radiation dose to the gland tissue. Treatment focus should be on optimized/new approaches to further reduce the dose to the parotids, and particularly submandibular and minor salivary glands, as these glands are major contributors to moistening of oral tissues. Other cancer treatments also induce salivary gland hypofunction, although to a lesser severity, and in the case of chemotherapy and immunotherapy, the adverse effect is temporary. Fields of sparse literature included pediatric cancer populations, cancer chemotherapy, radioactive iodine treatment, total body irradiation/hematopoietic stem cell transplantation, and immunotherapy.