Quality of life of nasopharyngeal cancer survivors in China

Effects of tislelizumab on health-related quality of life in patients with recurrent or metastatic nasopharyngeal cancer

BACKGROUND

This study evaluated health-related quality of life (HRQoL) in the RATIONALE-309 (NCT03924986) intent-to-treat (ITT) population and in a subgroup of patients with liver metastases.

METHODS

Patients were randomized 1:1 to tislelizumab + chemotherapy or placebo + chemotherapy. As the secondary endpoint, HRQoL was evaluated using seven selected scores from the EORTC QLQ-C30 and QLQ Head and Neck Cancer module (QLQ-H&N35).

RESULTS

Of 263 randomized patients in the ITT population (tislelizumab + chemotherapy n = 131, placebo + chemotherapy n = 132), 43% had liver metastases (tislelizumab + chemotherapy n = 56; placebo + chemotherapy n = 57). No differences in change in selected scores on the QLQ-C30 from baseline to cycle 4 or cycle 8 were observed for the ITT or liver metastases subgroup. No differences in selected QLQ-H&N35 scores were observed between the arms from baseline to cycle 4. In the ITT population and the liver metastases subgroup, a greater reduction from baseline to cycle 8 was observed in the tislelizumab + chemotherapy arm than the placebo + chemotherapy arm in QLQ-H&N35 pain score. At cycle 8 in the liver metastases subgroup, the tislelizumab + chemotherapy arm experienced greater improvement in the QLQ-H&N35 senses problems score than the placebo + chemotherapy arm. Differences in time to deterioration between arms were not observed.

CONCLUSIONS

The current findings, along with improved survival and favorable safety, suggests that tislelizumab + chemotherapy represents a potential first-line treatment for recurrent or metastatic nasopharyngeal cancer.

Examining patient-reported late toxicity and its association with quality of life and unmet need for symptom management among nasopharyngeal cancer survivors: a cross-sectional survey

Introduction

Alongside the improved survival of nasopharyngeal cancer (NPC), late radiation toxicities are alarmingly hampering survivors' quality of life. A patient-reported symptom burden survey is lacking to address the unmet need for symptom management among local NPC survivors.

Methods

A single-center cross-sectional survey was conducted on 211 NPC survivors who had completed radiation therapy for three to 120 months. We employed the Chinese version M. D. Anderson Symptom Inventory - Head & Neck Module (MDASI-HN-C), Functional Assessment of Cancer Therapy - Head & Neck (FACT-HN-C), and a question extracted from the Cancer Survivors' Unmet Needs Measure (CaSUN).

Results

Two hundred valid responses were collected. Participants suffered from at least four moderate to severe symptoms (mean = 4.84, SD = 4.99). The top five severe symptoms were dry mouth, mucus problems, difficulty swallowing or chewing, teeth or gum problems, and memory problems. MDASI-HN-C subscales were negatively correlated with the physical, emotional, functional, and HN-specific domains of the FACT-HN-C. The unmet need for symptom management was positively associated with symptom burden, either general symptoms (Adjusted odds ratio [ORadj] = 1.566, 95% CI = 1.282 - 1.914, p < 0.001) or top-5 symptoms (ORadj = 1.379, 95% CI = 1.185 - 1.604, p < 0.001), while negatively associated with post-RT time (ORadj = 0.981, 95% CI [0.972, 0.991], p < 0.001).

Conclusion

Virtually all NPC survivors suffer from late toxicities, which interplay with survivors' perceptions intricately to affect their unmet needs for symptom management. Personalized supportive care strategies with regular assessments and stratifications are warranted.

The quality of life in nasopharyngeal carcinoma radiotherapy: A longitudinal study

Objective

This article aims to longitudinally compare nasopharyngeal carcinoma (NPC) patients' quality of life (QoL) during radiotherapy (RT) and identify QoL correlates.

Methods

This study included 98 patients, with 85 completing full follow-up. Data were collected at baseline (T₁), midpoint of RT (T₂), and RT completion (T₃), between October 2021 and November 2022. QoL was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). RIOM severity was evaluated by the toxicity criteria of Radiation Therapy Oncology Group (RTOG). The nutritional status was evaluated using the Nutritional Risk Screening 2002 (NRS 2002), body mass index (BMI), and the Patient-Generated Subjective Global Assessment (PG-SGA). The generalized estimating equation described the QoL evolution and correlated it with RIOM, nutritional status, and other influential factors.

Results

Significant deterioration was observed in various subscales of EORTC QLQ-C30 during RT, including global health status (GHS), physical function, role function, emotional function, fatigue, nausea/vomiting, pain, insomnia, appetite loss, and constipation (all P ​< ​0.05). Substantial deterioration was also observed in RIOM, nutritional status, and part of hematological indexes (all P ​< ​0.05). The decline of QoL was associated with gender, age, education level, chemotherapy regimen, Karnofsky performance status (KPS) score, RIOM severity, NRS 2002 score, PG-SGA score, and lymphocyte level (all P ​< ​0.05).

Conclusions

QoL declined during RT and were associated with certain factors. Healthcare professionals should focus on alleviating treatment-related complications and identifying individuals at high risk of malnutrition early to improve outcomes for patients with NPC.

Effect of Percutaneous Endoscopic Gastrostomy on Quality of Life after Chemoradiation for Locally Advanced Nasopharyngeal Carcinoma: A Cross-Sectional Study

(1) Background: Prophylactic percutaneous endoscopic gastrostomy (PEG) maintained nutritional status and improved survival of patients with locally advanced nasopharyngeal carcinoma (LA-NPC). However, the role of PEG in patients’ quality of life (QoL) is still controversial. We aimed to investigate the effect of PEG on the QoL of patients with LA-NPC without progression. (2) Methods: Patients with LA-NPC between 1 June 2010 and 30 June 2014 in Fujian Cancer Hospital were divided into PEG and non-PEG groups. The QoL Questionnaire core 30 (QLQ-C30), incidence of adverse effects, weight, and xerostomia recovery were compared between the two groups of patients without progression as of 30 June 2020. (3) Results: No statistically significant difference in the scores of each QLQ-C30 scale between the two groups (p > 0.05). The incidence of xerostomia was higher in the PEG group than in the non-PEG group (p = 0.044), but the association was not seen after adjusting for gender, age, T, and N stage (OR: 0.902, 95%CI: 0.485−1.680). No significant difference in the incidence of other adverse effects as well as in weight and dry mouth recovery (p > 0.05). (4) Conclusion: PEG seems not to have a detrimental effect on long-term Qol, including the self-reported swallowing function of NPC patients without progressive disease.

Impairment mechanism of nasal mucosa after radiotherapy for nasopharyngeal carcinoma

The nasal mucosa, which performs the crucial functions of filtering, humidifying and temperature regulation, is one of the most vulnerable areas of nasopharyngeal carcinoma (NPC) patients after radiotherapy (RT). Following RT, NPC patients experience a series of pathological changes in the nasal mucosa, ultimately leading to physiological dysfunction of the nasal epithelium. This article systematically reviews the clinical and pathological manifestations of RT-related nasal damage in NPC patients and summarizes the potential mechanism of damage to the human nasal epithelium by RT. Finally, we outline the current mechanistic models of nasal epithelial alterations after RT in NPC patients and provide additional information to extend the in-depth study on the impairment mechanisms of the nasal mucosa resulting from RT. We also describe the relationship between structural and functional alterations in the nasal mucosa after RT to help mitigate and treat this damage and provide insights informing future clinical and fundamental investigations.

Interaction of chemotherapy and radiotherapy in altering the shape of subcortical structures in patients with nasopharyngeal carcinoma

Neuroimaging studies have found significant structural alterations of the cerebral cortex in patients with nasopharyngeal carcinoma (NPC) following radiotherapy (RT) or concomitant chemoradiotherapy (CCRT), while their effects on the shape of subcortical structures remain largely unknown. In this study, we investigated the subcortical shape alterations between three groups: 56 untreated NPC patients (pre-RT group), 37 RT-treated NPC patients (post-RT group), and 108 CCRT-treated NPC patients (post-CCRT group). Using FSL-FIRST, we found that, compared with the pre-RT group, the post-CCRT group exhibited significant inward atrophy in the bilateral thalamus, bilateral putamen, left pallidum, and left caudate and outward inflation in the left caudate, while the post-RT group only exhibited inward atrophy in the bilateral thalamus. In addition, greater maximum dosage of RT for temporal lobes was associated with more severe inward atrophy of the bilateral thalamus in treated NPC patients. These results indicated that there may be an interaction between RT and CT that can cause subcortical damage.

The Correlation Between Radiotherapy and Patients' Fear of Cancer Recurrence: A Systematic Review and Meta-analysis

The purpose of this review was to explore the correlation between patients' fear of cancer recurrence (FCR) and radiotherapy. National Knowledge Infrastructure, Wanfang Database, China Science and Technology Journal Database, SinoMed, PubMed, Web of Science, EBSCO-CINAHL, Cochrane Library, and Ovid Embase were searched to identify relevant studies. Thirty-five eligible studies were included in the systematic review, and 22 of them were included in further meta-analysis. The results of the meta-analysis showed that the level of patients' FCR was positively correlated with radiotherapy, but the correlation was weak (overall r = 0.075; 95% confidence interval [CI], 0.046-0.103; P = .000). In terms of subgroup analysis based on cancer site (breast cancer vs other types of cancer), the breast cancer group (r = 0.086; 95% CI, 0.027-0.143; P = .004), the mixed-type group (r = 0.073; 95% CI, 0.033-0.112; P = .000), and the other-type group (r = 0.071; 95% CI, 0.015-0.126; P = .013) have a positive correlation with radiotherapy. Patients' FCR positively correlated with the receipt of radiotherapy. However, because of the variability among the studies, the results have limitations. Therefore, longitudinal studies are needed to verify the trajectory of FCR over radiation therapy.

Management of Nasopharyngeal Carcinoma in Elderly Patients

Nasopharyngeal cancer (NPC) is one of the most difficult cancers in the head and neck region due to the complex geometry of the tumour and the surrounding critical organs. High-dose radical radiotherapy with or without concurrent platinum-based chemotherapy is the primary treatment modality. Around 10%–15% of NPC patients have their diagnosis at age after 70. The management of NPC in elderly patients is particularly challenging as they encompass a broad range of patient phenotypes and are often prone to treatment-related toxicities. Chronologic age alone is insufficient to decide on the management plan. Comprehensive geriatric assessment with evaluation on patients’ functional status, mental condition, estimated life expectancy, comorbidities, risks and benefits of the treatment, patients’ preference, and family support is essential. In addition, little data from randomized controlled trials are available to guide treatment decisions in elderly patients with NPC. In deciding which treatment strategy would be suitable for an individual elderly patient, we reviewed the literature and reviewed the analysis of primary studies, reviews, and guidelines on management of NPC. This review also summarises the current evidence for NPC management in elderly adults from early to late stage of disease.

Cerebral Structural Abnormalities and Their Associations With Peripheral Cytokine Levels in a Group of Untreated Patients With Nasopharyngeal Carcinoma

The current study is to characterize the alterations of peripheral cytokines and anatomical brain changes, and their relationships in untreated nasopharyngeal carcinoma (NPC) patients with depressive symptoms. Twenty-nine newly diagnosed NPC patients without any treatment and 46 matched healthy comparisons were recruited, scanned with high-resolution T1 images and assessed psychologically using Hamilton Rating Scale for Depression (HAMD). Serum levels of interleukin-1 beta (IL-1β), IL-2, IL-6, IL-8, IL-10, interferon-gamma (IFN-γ) and transforming growth factor-beta (TGF-β) were measured by quantitative chemiluminescence assay. Inter-group comparisons of anatomical brain measures were performed, and regions with significant inter-group differences were correlated to HAMD scores and cytokines in NPC patients. A subgroup analysis especially within NPC patients with depression was conducted to precisely characterize the associations among serum cytokines, brain changes and depressive symptoms. Relative to healthy subjects, NPC patients showed significantly decreased cortical thickness in the left parahippocampal gyrus, increased surface area in the right superior parietal lobule and precentral gyrus, and increased gray matter volume in the right postcentral gyrus, bilateral caudate nucleus and right thalamus, as well as significantly elevated IL-1β, IL-2 and IL-10. The elevated IL-2 and IL-10 were negatively correlated with surface area in right superior parietal lobule, whilst IL-1β level was positively correlated to HAMD scores. In patients with depression, specific brain changes and evaluated IL-1β were identified, and the IL-1β interacted with right precentral gyrus to significantly affect the depressive symptoms. Our findings provide novel evidence indicating potential effects of inflammation on brain structure and behavior in NPC patients.

Quality of Life as a Mediator between Cancer Stage and Long-Term Mortality in Nasopharyngeal Cancer Patients Treated with Intensity-Modulated Radiotherapy

Simple Summary

Even after the implementation of intensity-modulated radiotherapy (IMRT), nasopharyngeal cancer (NPC) survivors may continue to exhibit several physical symptoms that negatively affect long-term quality of life (QoL). An NPC patient cohort study (n = 682) was conducted to examine the potential mediating effect of QoL (evaluated at multiple treatment-related time points) on the cancer stage–mortality association. Patients with advanced NPC exhibited low global health QoL and high QoL-HN35 symptom pre-IMRT, 3 months post-IMRT, and 2 years post-IMRT. Global health QoL and QoL-HN35 symptom scores 2 years after IMRT explained 49.4% and 39.4% of the excessive effect of advanced NPC on mortality risk. Our findings indicate that global health QoL and QoL-HN35 symptom 2 years after IMRT are key mediators of the relationship between advanced NPC and high mortality. These findings emphasize the significance of QoL-HN35 symptom and global health QoL-associated medical support and care for patients with NPC who received IMRT.

Abstract

Background: Quality of life (QoL) attained before, during, or after treatments is recognized as a vital factor associated with therapeutic benefits in cancer patients. This nasopharyngeal cancer (NPC) patient longitudinal study assessed the relationship among QoL, cancer stage, and long-term mortality in patients with nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiotherapy (IMRT). Patients and Methods: The European Organization for Research and Treatment of Cancer (EORTC) core QoL questionnaire (QLQ-C30) and the head and neck cancer-specific QoL questionnaire module (QLQ-HN35) were employed to evaluate four-dimensional QoL outcomes at five time points: pre- (n = 682), during (around 40 Gy) (n = 675), 3 months (n = 640), 1 year (n = 578) and 2 years post-IMRT (n = 505), respectively, for 682 newly diagnosed NPC patients treated between 2003 and 2017 at a single institute. The median followed-up time was 7.5 years, ranging from 0.3 to 16.1 years. Generalized estimating equations, multivariable proportional hazards models, and Baron and Kenny’s method were used to assess the investigated effects. Results: Advanced AJCC stage (III–IV) patients revealed a 2.26-fold (95% CI—1.56 to 3.27) higher covariate-adjusted mortality risk than early-stage (I–II) patients. Compared with during IMRT, advanced-stage patients had a significantly low global health QoL and a significantly high QoL-HN35 symptom by a large magnitude at pre-, 3 months, and 2 years post-IMRT. QoL scales at pre-IMRT, 1 year, and 2 years post-IMRT were significantly associated with mortality. The effect changes of mortality risk explained by global health QoL, QoL-C30, and QoL-HN35 symptom were 5.8–9.8% at pre-IMRT but at 2 years post-IMRT were 39.4–49.4% by global health QoL and QoL-HN35 symptoms. Conclusions: We concluded advanced cancer stage correlates with a long-term high mortality in NPC patients treated with IMRT and the association is partially intermediated by QoL at pre-IMRT and 2 years post-IMRT. Therefore, QoL-HN35 symptom and global health QoL-dependent medical support and care should be focused and tailored at 2 years post-IMRT.

Anxiety and depression status prior to radiotherapy in patients with nasopharyngeal carcinoma and its effect on acute radiation toxicities

OBJECTIVE

The objective of this work is to explore anxiety and depression status prior to radiotherapy in patients with nasopharyngeal carcinoma (NPC) and its effect on acute radiation toxicities.

METHODS

A total of 267 NPC patients were enrolled between August 2013 and September 2016. The anxiety and depression status of the patients prior to radiotherapy was evaluated using the Hospital Anxiety and Depression Scale. Acute radiation toxicities were assessed weekly and recorded according to the Common Terminology Criteria for Adverse Events version 4.0. Logistic regression analysis was used to identify the predictive factors for acute radiation toxicities.

RESULTS

The rates of anxiety and depression status prior to radiotherapy were 35.2% and 25.5%, respectively. Anxiety was a significant predictor of vomiting (P = 0.001, OR = 2.874) and dysphagia (P = 0.029, OR = 2.080). Depression was a significant predictor of dysgeusia (P = 0.030, OR = 2.957). In addition, age was a significant predictor of dysphagia (P = 0.001, OR = 1.131).

CONCLUSIONS

Anxiety and depression status prior to radiotherapy aggravate acute radiation toxicities in patients with NPC. Assessment of the anxiety and depression status and appropriate interventions should be an integral part of treatment to relieve radiation injury during intensity-modulated radiotherapy.

Spatiotemporal dynamics of γH2AX in the mouse brain after acute irradiation at different postnatal days with special reference to the dentate gyrus of the hippocampus

Gamma H2A histone family member X (γH2AX) is a molecular marker of aging and disease. However, radiosensitivity of the different brain cells, including neurons, glial cells, cells in cerebrovascular system, epithelial cells in pia mater, ependymal cells lining the ventricles of the brain in immature animals at different postnatal days remains unknown. Whether radiation-induced γH2AX foci in immature brain persist in adult animals still needs to be investigated. Hence, using a mouse model, we showed an extensive postnatal age-dependent induction of γH2AX foci in different brain regions at 1 day after whole body gamma irradiation with 5Gy at postnatal day 3 (P3), P10 and P21. P3 mouse brain epithelial cells in pia mater, glial cells in white matter and cells in cerebrovascular system were more radiosensitive at one day after radiation exposure than those from P10 and P21 mice. Persistent DNA damage foci (PDDF) were consistently demonstrated in the brain at 120 days and 15 months after irradiation at P3, P10 and P21, and these mice had shortened lifespan compared to the age-matched control. Our results suggest that early life irradiation-induced PDDF at later stages of animal life may be related to the brain aging and shortened life expectancy of irradiated animals.

The psychological status in patients with nasopharyngeal carcinoma during radiotherapy

PURPOSE

The psychological status of nasopharyngeal carcinoma (NPC) patients cannot be ignored. Few studies have studied the dynamic changes and influencing factors of psychological status in NPC patients during radiotherapy. The purpose of this study was to investigate the changing trends and risk factors of anxiety and depression in NPC patients during radiotherapy.

METHODS

Demographic and clinical data of 232 newly treated NPC patients were collected. Before radiotherapy, the fourth week, and the end of radiotherapy were observational timepoints. Anxiety and depression states were evaluated by the hospital anxiety and depression scale.

RESULTS

Scores of anxiety before radiotherapy, in the fourth week and at the end of radiotherapy were 6.32 ± 3.19, 7.87 ± 3.49, and 9.08 ± 3.69, respectively (P < 0.001). Incidence rates of anxiety were 34.0%, 55.1%, and 64.0% (P < 0.001). Depression scores were 5.31 ± 3.19, 7.07 ± 3.63, and 8.32 ± 3.89 (P < 0.001). Incidence rates of depression were 25.0%, 43.9%, and 56.0% (P < 0.001). Gender, age, education level, smoking, and treatment-related toxicity scores (P < 0.05) were independent risk factors for anxiety in patients with NPC during radiotherapy, while age, education level, and treatment-related toxicity scores (P < 0.05) were independent risk factors for depression in these patients.

CONCLUSION

The incidence and degree of anxiety and depression in NPC patients increased during radiotherapy. Age, education level, and treatment-related side effects influenced anxiety and depression. More psychological nursing should be given to the NPC patients who are more likely to suffer from psychological distress.

BIX-01294, a G9a inhibitor, suppresses cell proliferation by inhibiting autophagic flux in nasopharyngeal carcinoma cells

G9a, a histone methyltransferase, has been found to be upregulated in a range of tumor tissues, and contributes to tumor growth and metastasis. However, the impact of G9a inhibition as a potential therapeutic target in nasopharyngeal carcinoma (NPC) is unclear. In the present study we aimed to investigate the anti-proliferative effect of G9a inhibition in the NPC cell lines CNE1 and CNE2, and to further elucidate the molecular mechanisms underlying these effects. The expression of G9a in NPC tumor tissues was significantly higher than that in normal nasopharyngeal tissues. The pharmacological inhibition of G9a by BIX-01294 (BIX) inhibited proliferation and induced caspase-independent apoptosis in NPC cells in vitro. Treatment with BIX induced autophagosome accumulation, which exacerbated the cytotoxic activity of BIX in NPC cells. Mechanistic studies have found that BIX impairs autophagosomes by initiating autophagy in a Beclin-1-independent way, and impairs autophagic degradation by inhibiting lysosomal cathepsin D activation, leading to lysosomal dysfunction. BIX was able to suppress tumor growth, possibly by inhibiting autophagic flux; it might therefore constitute a promising candidate for NPC therapy.

Effects of Cognitive Behavioral Therapy for Depression and Anxiety, Response Rates and Adverse Events in Patients with Locoregional Advanced Nasopharyngeal Carcinoma

Purpose:

This retrospective study investigated the effects of cognitive behavioral therapy (CBT) on depression, anxiety, response rates, and adverse events in patients with locoregional advanced nasopharyngeal carcinoma (NPC).

Methods:

A total of 269 patients with diagnosis of stage III-IVA NPC received either CBT plus chemoradiotherapy (CBT group, n = 136) or treatment as usual (TAU) plus chemoradiotherapy (TAU group, n = 133). Patients in the CBT group received a series of 6 CBT sessions for 6 weeks during concurrent chemoradiotherapy. Depression and anxiety were assessed using the Hospital Anxiety and Depression Scale (HADS) score at baseline, the completion of radiotherapy, and 6, 12, and 24 months after radiotherapy. Response rates and adverse events were also evaluated.

Results:

Patients in the CBT group showed significantly less depression and anxiety than patients in the TAU group after the completion of radiotherapy (P < .05). Complete response rates were 99.3% (135/136) and 92.5% (123/133) in the CBT group and TAU group with a small effect size (Phi coefficient = .171), respectively (P = .005). Compared with the TAU group, the CBT group showed a significantly lower incidence of acute adverse events and late toxic effects.

Conclusions:

The addition of CBT to chemoradiotherapy significantly reduced depressive and anxiety symptoms. CBT combined with chemoradiotherapy is associated with improved response rates, with reduced incidence of toxic effects in patients with locoregional advanced NPC. Based on this study, we registered a randomized controlled clinical trials to better define the role of CBT in patients with locoregional advanced NPC (Registration number: ChiCTR2000034701).

The effect of psychological condition before radiotherapy on prognosis in 390 patients initially treated for nasopharyngeal carcinoma

PURPOSE

To explore whether anxiety and depression are prognostic indexes for overall survival in patients with nasopharyngeal carcinoma (NPC) who underwent intensity-modulated radiotherapy (IMRT).

METHODS

Clinical data were collected for NPC patients who underwent IMRT. Anxiety and depression were investigated before radiotherapy by using the Hospital Anxiety and Depression Scale (HADS). The survival rate was calculated by the Kaplan-Meier method, and survival curves were compared among patients with different levels of anxiety and depression. The Cox risk regression model was used to screen the factors affecting survival.

RESULTS

A total of 390 initially treated NPC patients were included in the study. Among them, 166 patients suffered from anxiety, and 95 patients suffered from depression before radiotherapy. The 5-year overall survival rates for patients with and without anxiety before radiotherapy were 71.6% and 81.8% (χ² = 5.31, P = 0.021), respectively. The 5-year overall survival rates for patients with and without depression before radiotherapy were 74.3% and 78.1% (χ² = 0.05, P = 0.82), respectively. Cox regression analysis indicated clinical stages (HR = 3.982, 95% CI: 2.365~6.705), anxiety (HR = 1.832, 95% CI: 1.140~2.944), and gender (HR = 0.555, 95% CI: 0.313~0.984) as independent prognostic factors.

CONCLUSION

Anxiety before radiotherapy is associated with poor prognosis in NPC patients.

Applicability of the Nutrition Risk Screening 2002 Combined with a Patient-Generated Subjective Global Assessment in Patients with Nasopharyngeal Carcinoma

Purpose

This study aims to explore the applicability of the Nutrition Risk Screening 2002 (NRS2002) tool in screening nutritional risk and the Patient-Generated Subjective Global Assessment (PG-SGA) in determining nutrition status in nasopharyngeal carcinoma (NPC) patients.

Materials and Methods

NRS2002 and PG-SGA were simultaneously applied to evaluate the nutritional status of NPC patients before induction chemotherapy, as well as before and after radiotherapy. The PG-SGA results were considered golden standard in evaluating nutrition status, and the ROC curve value and Youden index were applied to analyze NRS2002 effectiveness in screening nutritional risk.

Results

A total of 102 NPC patients were included in this study. Patients with an NRS2002 score <3 and PG-SGA score ≥4 accounted for 5.3% (5/95), 19.6% (18/92) and 94.8% (36/38) at the time before induction chemotherapy, before radiotherapy and at the end of radiotherapy, respectively. The cut-off values of NRS2002 scores all <2 corresponded to the maximum Youden index at the three procedural times. And the area under curve (AUC) were 0.598 (P = 0.390), 0.665 (P = 0.015) and 0.940 (P = 0.034), respectively. At the end of radiotherapy, NRS2002 scores of <3 and <2 were used as cut-off values for nutritional risk screening, respectively. Additionally, the malnutrition-missed detection rates were 36.0% and 12.0% (χ² = 15.789; P <0.001).

Discussion

NRS2002 nutritional risk screening combined with the PG-SGA nutritional assessment has certain applicability in NPC. NRS2002 score ≥2 can be considered as a new cut-off point for nutritional assessment.

Development and validation of immune inflammation-based index for predicting the clinical outcome in patients with nasopharyngeal carcinoma

Inflammation indicators, such as systemic inflammation response index (SIRI), systemic immune‐inflammation index (SII), neutrophil‐to‐lymphocyte ratio (NLR) and platelet‐lymphocyte ratio (PLR), are associated with poor prognosis in various solid cancers. In this study, we investigated the predictive value of these inflammation indicators in nasopharyngeal carcinoma (NPC). This retrospective study involved 559 patients with NPC and 500 patients with chronic rhinitis, and 255 NPC patients were followed up successfully. Continuous variables and qualitative variables were measured by t test and chi‐square test, respectively. The optimal cut‐off values of various inflammation indicators were determined by receiver operating characteristic (ROC) curve. Moreover, the diagnostic value for NPC was decided by the area under the curves (AUCs). The Kaplan‐Meier methods and the log‐rank test were used to analyse overall survival (OS) and disease‐free survival (DFS). The independent prognostic risk factors for survival and influencing factors of side effects after treatment were analysed by Cox and logistic regression analysis, respectively. Most haematological indexes of NPC and rhinitis were significantly different between the two groups, and PLR was optimal predictive indicators of diagnosis. In the multivariable Cox regression analysis, PLR, WBC, RDW, M stage and age were independent prognostic risk factors. Many inflammation indicators that affected various side effects were evaluated by logistic regression analysis. In conclusion, the combined inflammation indicators were superior to single haematological indicator in the diagnosis and prognosis of NPC. These inflammation indicators can be used to supply the current evaluation system of the TNM staging system to help predict the prognosis in NPC patients.

Quality of Life, Toxicity and Unmet Needs in Nasopharyngeal Cancer Survivors

Concerted research efforts over the last three decades have resulted in improved survival and outcomes for patients diagnosed with nasopharyngeal carcinoma (NPC). The evolution of radiotherapy techniques has facilitated improved dose delivery to target volumes while reducing dose to the surrounding normal tissue, improving both disease control and quality of life (QoL). In parallel, clinical trials focusing on determining the optimal systemic therapy to use in conjunction with radiotherapy have been largely successful, resulting in improved locoregional, and distant control. As a consequence, neoadjuvant chemotherapy (NACT) prior to definitive chemoradiotherapy has recently emerged as the preferred standard for patients with locally advanced NPC. Two of the major challenges in interpreting toxicity and QoL data from the published literature have been the reliance on: (1) clinician rather than patient reported outcomes; and (2) reporting statistical rather than clinical meaningful differences in measures. Despite the lower rates of toxicity that have been achieved with highly conformal radiotherapy techniques, survivors remain at moderate risk of persistent and long-lasting treatment effects, and the development of late radiation toxicities such as hearing loss, cranial neuropathies and cognitive impairment many years after successful treatment can herald a significant decline in QoL. Future approaches to reduce long-term toxicity will rely on: (1) identifying individual patients most likely to benefit from NACT; (2) development of response-adapted radiation strategies following NACT; and (3) anticipated further dose reductions to organs at risk with proton and particle therapy. With increasing numbers of survivors, many in the prime of their adult life, research to identify, and strategies to address the unmet needs of NPC survivors are required. This contemporary review will summarize our current knowledge of long-term toxicity, QoL and unmet needs of this survivorship group.

Sleep in nasopharyngeal carcinoma patients before chemotherapy, after induction chemotherapy, and after concurrent chemoradiotherapy

Sleep disturbance is frequently observed in cancer patients before, during and after oncology treatment. We explored the sleep features of patients before treatment, after induction chemotherapy, and after concurrent chemoradiotherapy for nasopharyngeal carcinoma (NPC). Ninety eligible patients diagnosed with NPC (stages III to IVc) and treated with induction chemotherapy plus concurrent chemoradiotherapy were included. The Pittsburgh Sleep Quality Index (PSQI) was applied to assess sleep before treatment, after induction chemotherapy, and after concurrent chemoradiotherapy. The median global PSQI scores in patients with NPC before treatment, after induction chemotherapy, and after concurrent chemoradiotherapy were 5, 6, and 10, respectively. The median scores of daytime dysfunction, sleep disturbance and habitual sleep efficiency were statistically significant at the pretreatment, after induction chemotherapy and after concurrent chemoradiotherapy timepoints (P < 0.049, P < 0.001 and P < 0.001, respectively). However, minimal changes were observed in all subscores after induction chemotherapy. Patients with poor sleep quality after induction chemotherapy were more prone to suffer worse sleep after concurrent chemoradiotherapy (OR = 12.6, 95%; CI = 2.4-67.3). Induction chemotherapy had less effect on the quality of sleep in NPC patients. Patients experienced a significant increase in sleep disturbance after concurrent chemoradiotherapy, particularly those with bad sleep after induction chemotherapy.

Chibby suppresses aerobic glycolysis and proliferation of nasopharyngeal carcinoma via the Wnt/β-catenin-Lin28/let7-PDK1 cascade

BACKGROUND

Great progress has been achieved in the study of the aerobic glycolysis or the so-called Warburg effect in a variety of cancers; however, the regulation of the Warburg effect in Nasopharyngeal carcinoma (NPC) has not been completely defined.

METHODS

Gene expression pattern of NPC cells were used to test associations between Chibby and β-catenin expression. Chibby siRNAs and over-expression vector were transfected into NPC cells to down-regulate or up-regulate Chibby expression. Loss- and gain-of function assays were performed to investigate the role of Chibby in NPC cells. Western blot, cell proliferation, Glucose uptake, Lactate release, ATP level, and O2 consumption assays were used to determine the mechanism of Chibby regulation of underlying targets. Finally, immunohistochemistry assay of fresh NPC and nasopharyngeal normal tissue sample were used to detect the expression of Chibby, β-Catenin, and PDK1 by immunostaining.

RESULTS

We observed that Chibby, a β-catenin-associated antagonist, is down-regulated in nasopharyngeal carcinoma cell lines and inhibits Wnt/β-Catenin signaling induced Warburg effect. Mechanism study revealed that Chibby regulates aerobic glycolysis in NPC cells through pyruvate dehydrogenase kinase 1(PDK1), an important enzyme involved in glucose metabolism. Moreover, Chibby suppresses aerobic glycolysis of NPC via Wnt/β-Catenin-Lin28/let7-PDK1 cascade. Chibby and PDK1 are critical for Wnt/β-Catenin signaling induced NPC cell proliferation both in vitro and in vivo. Finally, immunostaining assay of tissue samples provides an important clinical relevance among Chibby, Wnt/β-Catenin signaling and PDK1.

CONCLUSIONS

Our study reveals an association between Chibby expression and cancer aerobic glycolysis, which highlights the importance of Wnt/β-catenin pathway in regulation of energy metabolism of NPC. These results indicate that Chibby and PDK1 are the potential target for NPC treatment.

Efficacy and Safety of Chemotherapy Combined with Stereotactic Radiotherapy in the Treatment of Nasopharyngeal Carcinoma

Background

The aim of this study was to investigate the efficacy and safety of chemotherapy (CT) combined with stereotactic radiotherapy (SRT) in the treatment of nasopharyngeal carcinoma (NPC).

Material/Methods

A total of 329 NPC patients without any previous treatment were included in this study between January 2009 and November 2013. These patients were divided into three groups: CT group (n=114), SRT group (n=109), and CT + SRT group (n=106). Contrast-enhanced nasopharyngeal computed tomography (CT)/magnetic resonance (MR) scan was performed on the third month after treatment. Short-term efficacy was evaluated according to the Response Evaluation Criteria in Solid Tumors (RECIST). Toxicity was graded according to the Acute Radiation Morbidity Scoring Criteria (RTOG) and the World Health Organization (WHO) toxicity grading scale. Overall survival (OS), progression free survival (PFS), and incidence rate of acute toxicity (grade ≥3) were calculated after a 24 month follow-up.

Results

Total response rate of all patients was 85.41%. Compared with the CT group and the SRT group, the CT + SRT group showed a substantially improved efficacy in NPC treatment. The incidence rate of the acute toxicity in the CT + SRT group was slightly higher than in the CT group and the SRT group, but the difference was not statistically significant. No treatment-related deaths were observed. The CT + SRT group had the highest two-year OS and PFS, followed by the CT group and the SRT group.

Conclusions

It was shown that NPC patients treated with CT + SRT had better short- and long-term efficacy than those treated with CT or SRT alone.

Endoscopic surgery for early-stage nasopharyngeal carcinoma: a justified initial option

OBJECTIVES

To assess the prognosis of initial endoscopic surgery in T1N0M0 and T2N0M0 staged NPC patients.

MATERIALS AND METHODS

Between 2002 and 2016, 10 previously untreated patients with T1N0M0 or T2N0M0 staged NPC volunteered to receive endoscopic surgery followed by four courses of TPF chemotherapy. EORTC QLQ-C30 and QLQ-H&N35 were used to evaluate the QOL after treatment.

RESULTS

With the median follow-up of 30 months (range, 9 months to 128 months), the 24-month survival rate was 100% (6/6), 90% (9/10) patients were still alive and well, 20% (2/10) patients reported tumor recurrence. One died of the disease at 128 months with nasopharyngeal recurrence. Another patient who refused preoperative PET-CT had a cervical recurrence at nine months, accepted nasopharynx and neck radiation two months later and was still alive and well at 50 months. In the post-treatment questionnaires, several NPC-specific (pain, swallowing, speech, social eating, opening mouth, dry mouth, sticky saliva) QOL domains were better preserved compared with radiotherapy alone or combined chemoradiotherapy in other surveys.

CONCLUSIONS

Initial endoscopic surgery combined with chemotherapy maybe justified in the hands of highly experienced surgeon in selected early-stage NPC cases and can improve their QOL. In addition, preoperative PET-CT should be included in case of possible minimal metastases.

RSF1 regulates the proliferation and paclitaxel resistance via modulating NF-κB signaling pathway in nasopharyngeal carcinoma

Purpose: Aberrant expression and dysfunction of RSF1 has been reported in diverse human malignancies. However, its exact role in nasopharyngeal carcinoma (NPC) remains unclear.

Methods: The expression of RSF1 mRNA and protein were assayed by qRT-PCR and western blotting, and their correlations with clinicopathological parameters of patients with NPC were further analysed. Lentivirus mediated RSF1 shRNA and RSF1 cDNA were used to knockdown and upregulate the expression of RSF1. CCK8 assays and flow cytometry were applied to monitor the changes of proliferation and paclitaxel sensitivity caused by RSF1 modulation, inhibition of NF-κB pathway by inhibitor Bay 11-7082 and Survivin knockdown. Western blotting was used to detect protein alterations in NF-κB signaling pathway.

Results: Our present study demonstrated that both mRNA and protein expressions of RSF1 were increased and correlated with advanced NPC clinical stage. Functional analyses revealed that RSF1 inhibition or overexpression induced changes in cell cycle, apoptosis, and then led to altered proliferation and paclitaxel sensitivity in diverse NPC cells in vitro. Further mechanism investigation hinted that RSF1 overexpression in NPC CNE-2 cells activated NF-κB pathway and promoted the expression NF-κB dependent genes involved in cell cycle and apoptosis including Survivin. Importantly, inhibition of NF-κB pathway by Bay 11-7082 and knockdown its downstream Survivin reversed the paclitaxel resistance caused by RSF1 overexpression.

Conclusions: Taken together, our data indicate that RSF1 regulates the proliferation and paclitaxel resistance via activating NF-κB signaling pathway and NF-κB-dependent Survivin upregulation, suggesting that RSF1 may be used as a potential therapeutic target in NPC.

Revalidation of a prognostic score model based on complete blood count for nasopharyngeal carcinoma through a prospective study

OBJECTIVE

In our previous work, we incorporated complete blood count (CBC) into TNM stage to develop a new prognostic score model, which was validated to improve prediction efficiency of TNM stage for nasopharyngeal carcinoma (NPC). The purpose of this study was to revalidate the accuracy of the model, and its superiority to TNM stage, through data from a prospective study.

METHODS

CBC of 249 eligible patients from the 863 Program No. 2006AA02Z4B4 was evaluated. Prognostic index (PI) of each patient was calculated according to the score model. Then they were divided by the PI into three categories: the low-, intermediate-and high-risk patients. The 5-year disease-specific survival (DSS) of the three categories was compared by a log-rank test. The model and TNM stage (7th edition) were compared on efficiency for predicting the 5-year DSS, through comparison of the area under curve (AUC) of their receiver-operating characteristic curves.

RESULTS

The 5-year DSS of the low-, intermediate-and high-risk patients were 96.0%, 79.1% and 62.2%, respectively. The low-and intermediate-risk patients had better DSS than the high-risk patients (P<0.001 and P<0.005, respectively). And there was a trend of better DSS in the low-risk patients, compared with the intermediate-risk patients (P=0.049). The AUC of the model was larger than that of TNM stage (0.726 vs. 0.661, P=0.023).

CONCLUSIONS

A CBC-based prognostic score model was revalidated to be accurate and superior to TNM stage on predicting 5-year DSS of NPC.

Effects of electrical stimulation on vocal functions in patients with nasopharyngeal carcinoma

OBJECTIVES/HYPOTHESIS

This study aimed to evaluate the effects of neuromuscular electrical stimulation (NMES) on vocal functions in patients with nasopharyngeal carcinoma following radiation therapy.

STUDY DESIGN

Prospective, randomized controlled trial.

METHODS

One hundred forty newly treated NPC patients were recruited and randomized into NMES or traditional swallowing exercise (TE) group. Participants received intensive NMES or traditional swallowing therapy and were followed up until 12 months postrandomization. Fifty-seven participants completed the treatment and all of the follow-up assessments. The Voice Handicap Index-30 (VHI-30) was used to measure the vocal functions of the participants.

RESULTS

The NMES group showed no significant changes to their vocal functions, whereas the TE group showed a short-term deterioration of voice functions at the 6-month follow-up. VHI-30 scores returned to the baseline level for both groups at the 12-month follow-up.

CONCLUSIONS

NMES is shown to provide a short-term benefit on vocal functions for NPC patients following radiation therapy.

LEVEL OF EVIDENCE

1b Laryngoscope, 127:1119-1124, 2017.

Factors influencing the health-related quality of life of Chinese advanced cancer patients and their spousal caregivers: a cross-sectional study

Background

Cancer and its treatment have a major impact on the lives of patients and their intimate partners, such as on their health-related quality of life (HRQOL). The aims of this study are to: (i) assess the HRQOL of advanced cancer patients and spousal caregivers, and explore the relationship between the HRQOL of cancer patients and that of their spousal caregivers; (ii) detect factors influencing the HRQOL of cancer patients and spousal caregivers; and (iii) explore the impact of anxiety and depression on the HRQOL of couples.

Methods

A total of 131 couples where one of the partners was hospitalized for advanced cancer were invited to complete a survey to assess their demographic and background information, HRQOL, and anxiety and depression. HRQOL was measured using the SF-12, while anxiety and depression were measured using the Hospital Anxiety and Depression Scale. Data were analyzed using a T-test, Pearson correlations, multiple linear regressions, and structural equation modeling.

Results

In general, the spousal caregivers had higher levels of HRQOL (seven out of eight SF-12 domains and two SF-12 dimensions) p = 0.038–0.000, anxiety (p = 0.002), and depression (p = 0.011) than patients. Correlations of HRQOL between patients and spouses were small to moderate (r = 0.193–0.398). Multiple independent factors influencing the physical component summary (PCS), mental component summary (MCS), vitality (VT), and role emotional (RE) sections of the SF-12 were identified, including: gender, time since diagnosis, levels of education, working status, the extent to which spousal caregivers were informed about the disease, improved marital relationship after the diagnosis of cancer, and anxiety and depression. For both patients and spousal caregivers, the strongest independent factor influencing HRQOL (SF-12 PCS, MCS, VT, and RE) was anxiety and depression. Anxiety and depression may have both actor and partner effects on the HRQOL of couples to various degrees.

Conclusions

The findings of this study call attention to the HRQOL of couples and its influencing factors. Individual characteristics of cancer patients and spouses, marital relationship, and anxiety and depression are highlighted as areas in which couples coping with cancer could benefit from interventions to improve their HRQOL.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-016-0142-3) contains supplementary material, which is available to authorized users.

β-Catenin is important for cancer stem cell generation and tumorigenic activity in nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) is one of the most common malignant tumors with poor prognosis and recurrence in South China. The hard eradication of NPC in clinic is predominantly due to cancer stem cells (CSCs). Increasing evidence revealed that the aberrant activation of Wnt/β-catenin was positively correlated with the produce of CSCs. To further investigate the effect of β-catenin on CSCs and tumorigenesis in NPC, a CNE2 cell line (pLKO.1-sh-β-catenin-CNE2) with stably suppressed expression of β-catenin was used in this study. The expressions of biomarkers in CSCs including c-myc, Nanog, Oct3/4, Sox2, EpCAM as well as adhesion-related proteins like E-cadherin and vimentin were analyzed by western blot analysis and immunofluorescent staining. The proliferation and migration abilities were investigated by MTT assay and Transwell assay, respectively. Cell cycle was analyzed by flow cytometry. Finally, xenograft was performed to determine the effect of β-catenin on oncogenesis in vivo. Results showed that the expressions of c-myc, Nanog, Oct3/4, Sox2, and EpCAM were all decreased in pLKO.1-sh-β-catenin-CNE2 cells. It was also found that vimentin was downregulated, while E-cadherin was upregulated. Results of MTT and Transwell assays suggested that the proliferation and migration abilities were impaired by silencing of β-catenin, and more cells were arrested in G1 phase when compared with the control. In vivo study indicated that the tumor growth was markedly suppressed in experimental group. Based on current findings, β-catenin may function as an essential protein for the maintenance of migration and proliferation abilities of NPC cells, and a complicated network consisting of c-myc, Nanog, Oct3/4, Sox2, EpCAM, E-cadherin, vimentin, and β-catenin may be involved in the inherent regulation mechanisms.