Assessment of xerostomia and its impact on quality of life in head and neck cancer patients undergoing radiation therapy

Radiation-associated changes in saliva composition of head and neck cancer patients: A systematic review

Xerostomia is a common radiation-associated toxicity in patients with head and neck cancer. Although several studies examined the decrease in saliva production due to radiotherapy (RT) and investigated the factors associated with this side effect, little is known about the change in radiation-associated saliva composition. This systematic review is the first to summarize existing data and give an overview of the change in pH/buffer capacity, electrolytes, proteins, enzymes, and mucins due to radiation to the salivary glands. Literature search was performed in PubMed and Embase with 47 articles finally eligible for the review, analyzing the saliva composition at several time points before, during and/or after RT, or comparing findings in irradiated patients to a healthy control group. Overall, RT leads to a substantial decrease in salivary pH and buffer capacity. For sodium, chloride and calcium ion, as well as amylase, an increased concentration or activity during RT was reported in most of the studies, followed by a subsequent decrease either already during RT or after the end of treatment. Different trends have been described for the total protein concentration during and after RT. Lactoferrin, however, increased considerably, especially in the first phase of RT. Mucin 5B (MUC5B) concentrations showed a slight increase during RT and concentrations around baseline values again six months post-radiotherapy.

Salivary toxicity from PSMA-targeted radiopharmaceuticals: What we have learned and where we are going

Clinical trials of prostate-specific membrane antigen (PSMA) targeted radiopharmaceuticals have shown encouraging results. Some agents, like lutetium-177 [177Lu]Lu-PSMA-617 ([177Lu]Lu-PSMA-617), are already approved for late line treatment of metastatic castration-resistant prostate cancer (mCRPC). Projections are for continued growth of this treatment modality; [177Lu]Lu-PSMA-617 is being studied both in earlier stages of disease and in combination with other anti-cancer therapies. Further, the drug development pipeline is deep with variations of PSMA-targeting radionuclides, including higher energy alpha particles conjugated to PSMA-honing vectors. It is safe to assume that an increasing number of patients will be exposed to PSMA-targeted radiopharmaceuticals during the course of their cancer treatment. In this setting, it is important to better understand and mitigate the most commonly encountered toxicities. One particularly vexing side effect is xerostomia. In this review, we discuss the scope of the problem, inventories to better characterize and monitor this troublesome side effect, and approaches to preserve salivary function and effectively palliate symptoms. This article aims to serve as a useful reference for prescribers of PSMA-targeted radiopharmaceuticals, while also commenting on areas of missing data and opportunities for future research.

Mesenchymal Stromal/Stem Cell Therapy Improves Salivary Flow Rate in Radiation-Induced Salivary Gland Hypofunction in Preclinical in vivo Models: A Systematic Review and Meta-Analysis

BACKGROUND

Mesenchymal stromal/stem cells (MSCs) have been suggested for salivary gland (SG) restoration following radio-induced salivary gland damage. This study aimed to determine the safety and effectiveness of MSC therapy on radio-induced SG damage and hypofunction in preclinical in vivo studies.

METHODS

PubMed and EMBASE were systematically searched for preclinical in vivo interventional studies evaluating efficacy and safety of MSC treatment following radio-induced salivary gland damage published before 10th of January 2022. The primary endpoint was salivary flow rate (SFR) evaluated in a meta-analysis. The study protocol was published and registered on PROSPERO ( www.crd.ac.uk/prospero ), registration number CRD42021227336.

RESULTS

A total of 16 preclinical in vivo studies were included for qualitative analysis (858 experimental animals) and 13 in the meta-analysis (404 experimental animals). MSCs originated from bone marrow (four studies), adipose tissue (10 studies) and salivary gland tissue (two studies) and were administered intravenously (three studies), intra-glandularly (11 studies) or subcutaneously (one study). No serious adverse events were reported. The overall effect on SFR was significantly increased with a standardized mean difference (SMD) of 6.99 (95% CI: 2.55-11.42). Studies reported improvements in acinar tissue, vascular areas and paracrine factors.

CONCLUSION

In conclusion, this systematic review and meta-analysis showed a significant effect of MSC therapy for restoring SG functioning and regenerating SG tissue following radiotherapy in preclinical in vivo studies without serious adverse events. MSC therapy holds significant therapeutic potential in the treatment of radio-induced xerostomia, but comprehensive, randomized, clinical trials in humans are required to ascertain their efficacy in a clinical setting.

Sodium-hyaluronate mouthwash on radiotherapy-induced xerostomia: a randomised clinical trial

INTRODUCTION

Radiotherapy-induced xerostomia (RIX) is one of the most common adverse effects of radiotherapy (RT) in head and neck cancer patients (HNC) and a major determinant of survivors' quality of life. The primary objective was to evaluate the reduction of patients' xerostomia symptoms after the utilisation of a sodium-hyaluronate mouthwash compared to a placebo solution. The secondary objectives were to evaluate the improvement of quality of life and to evaluate the patients' satisfaction.

METHODS

The protocol was approved by the ethical committee (Ref. 50,053/19) and registered at ClinicalTrials.gov (ID: NCT05103124). The study was a double-blind randomised clinical trial (RCT) with a crossover design and was conducted at the Fondazione Policlinico Universitario A. Gemelli, Rome.

RESULTS

Thirty-two patients completed the study protocol. Lower values of the modified Xerostomia Questionnaire (XQ) were retrieved when comparing the baseline scores to the ones after the treatment, when compared with placebo (Mann-Whitney U test = 0.01); higher values of patients' satisfaction (Likert scale) and modified XQ were retrieved for the sodium-hyaluronate mouthwash (Mann-Whitney U test = 0.001).

CONCLUSIONS

This RCT highlights the advantages of treating RIX with the sodium-hyaluronate mouthwash since it seems to be clinically effective in reducing its symptoms, without any reported adverse events.

CLINICALTRIALS

gov: NCT05103124 in 17/10/2021.

The Prevalence of Xerostomia in Older Thai Individuals with Type II Diabetes Mellitus and Its Association with Type of Toothpaste and Oral Functions: A Cross-Sectional Study Using Questionnaires

AIM

To investigate the prevalence of xerostomia in older people with diabetes mellitus and its impacts on oral functions, as well as to determine potential risk factors for xerostomia.

METHODS

An analytical cross-sectional study was conducted on 623 older type 2 diabetes mellitus (T2DM) Thai people using valid structural questionnaires. Patients were interviewed, and data were recorded. Xerostomia was assessed using subjective symptom questionnaires. Risk factors for xerostomia were analyzed using bivariate and multiple logistic regression analyses.

RESULTS

Among the study participants, 38.4% of the older T2DM people had xerostomia, which is associated with sex, age, type of toothpaste, years of diabetes, hemoglobin A1c level, other systemic diseases, medication, smoking, alcohol consumption, and denture wearing. It was significant that xerostomia was associated with toothpaste containing spicy herbal extracts (OR: 9.32 [3.46 to 15.25]), while toothpaste containing artificial sweeteners tended to lower the risk of xerostomia. In addition, older T2DM adults with xerostomia had greater impaired oral functions, which include difficulties in speaking (OR: 3.31 [1.11 to 9.80]), tasting (OR: 5.12 [3.26 to 8.06]), swallowing (OR: 3.59 [2.32 to 5.53]), and chewing (OR: 3.34 [1.15 to 5.82]).

CONCLUSIONS

Xerostomia is prevalent in older Thai people with T2DM. The results suggest that toothpaste containing spicy herbal extracts might increase the risk of xerostomia, resulting in various oral function problems. Therefore, greater awareness of xerostomia in this group should be raised to monitor dental health, and professionals should work in parallel with other aspects of oral health promotion.

Mesenchymal stromal/stem cell therapy for radiation-induced salivary gland hypofunction in animal models: a protocol for a systematic review and meta-analysis

BACKGROUND

Salivary gland (SG) hypofunction (objectively reduced saliva flow rate) and xerostomia (subjective sensation of dry mouth) are common and burdensome side effects of radiotherapy to the head and neck region. Currently, only sparse symptomatic treatment is available to ease the discomfort of xerostomia. The objective of this study is to assess the effect of mesenchymal stem cell (MSC) therapy on SG function after radiation-induced injury.

METHODS

This systematic review will include animal intervention studies assessing efficacy and safety of MSCs in treating radiation-induced SG hypofunction. The primary outcome is the effect of MSC administration on salivary flow rates (SFR), by comparing treated groups to control groups when available. Secondary outcomes are morphological and immunohistochemical effects as well as safety of MSC treatment. Electronic searches in MEDLINE (PubMed) and Embase databases will be constructed and validated according to the peer review of electronic search strategies (PRESS) and assessed by two independent researchers. Data from eligible studies will be extracted, pooled, and analyzed using random-effects models. Risk of bias will be evaluated with the Systematic Review Centre for Laboratory animal Experimentation (SYRCLE) risk of bias tool.

DISCUSSION

Thus far, critical appraisal of MSC therapy as an effective treatment for SG hypofunction caused solely by radiation injury has not been conducted. A summary of the existing literature on preclinical studies concerning this issue can provide valuable information about effectiveness, mode of action, and safety, allowing further optimization of preclinical and clinical trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021227336.

Patient-Reported Outcomes-Guided Adaptive Radiation Therapy for Head and Neck Cancer

Purpose

To identify which patient-reported outcomes (PROs) may be most improved through adaptive radiation therapy (ART) with the goal of reducing toxicity incidence among head and neck cancer patients.

Methods

One hundred fifty-five head and neck cancer patients receiving radical VMAT (chemo)radiotherapy (66-70 Gy in 30-35 fractions) completed the MD Anderson Symptom Inventory, MD Anderson Dysphagia Inventory (MDADI), and Xerostomia Questionnaire while attending routine follow-up clinics between June-October 2019. Hierarchical clustering characterized symptom endorsement. Conventional statistical approaches indicated associations between dose and commonly reported symptoms. These associations, and the potential benefit of interfractional dose corrections, were further explored via logistic regression.

Results

Radiotherapy-related symptoms were commonly reported (dry mouth, difficulty swallowing/chewing). Clustering identified three patient subgroups reporting: none/mild symptoms for most items (60.6% of patients); moderate/severe symptoms affecting some aspects of general well-being (32.9%); and moderate/severe symptom reporting for most items (6.5%). Clusters of PRO items broadly consisted of acute toxicities, general well-being, and head and neck-specific symptoms (xerostomia, dysphagia). Dose-PRO relationships were strongest between delivered pharyngeal constrictor Dmean and patient-reported dysphagia, with MDADI composite scores (mean ± SD) of 25.7 ± 18.9 for patients with Dmean <50 Gy vs. 32.4 ± 17.1 with Dmean ≥50 Gy. Based on logistic regression models, during-treatment dose corrections back to planned values may confer ≥5% decrease in the absolute risk of self-reported physical dysphagia symptoms ≥1 year post-treatment in 1.2% of patients, with a ≥5% decrease in relative risk in 23.3% of patients.

Conclusions

Patient-reported dysphagia symptoms are strongly associated with delivered dose to the pharyngeal constrictor. Dysphagia-focused ART may provide the greatest toxicity benefit to head and neck cancer patients, and represent a potential new direction for ART, given that the existing ART literature has focused almost exclusively on xerostomia reduction.

A Randomized, Double-Blind, Placebo-Controlled, Cross-Over Study to Evaluate the Efficacy of AqualiefTM Mucoadhesive Tablets in Head and Neck Cancer Patients Who Developed Radiation-Induced Xerostomia

Xerostomia, the subjective complaint of dry mouth, is caused by therapeutic interventions or diseases. Nowadays, radiotherapy (RT) in patients with head and neck cancer (HNC) stands out as one of the most important causes of xerostomia. Currently available therapies for the treatment of xerostomia are still less than optimal and xerostomia still represents an unmet clinical need. In this article, we present the results of a prospective clinical study with a new product, Aqualief^TM, in patients treated with curative RT with or without chemotherapy for HNC. Aqualief^TM is based on two main ingredients, carnosine and karkadé, which have acid buffering and antioxidant properties. The study was performed on 30 patients, with 4 of the patients being lost during the study period. Each patient received randomly one of the two treatments, Aqualief^TM or placebo, for 8 days. After a 10-day wash-out period, each patient received the other treatment for a further 8 days. The results show that Aqualief^TM stimulated salivation in these patients and reduced the pH drop that was observed in an equivalent placebo-treated population of patients. Moreover, no serious, treatment-related adverse events were observed. Aqualief^TM has shown positive results, although with limitations due to unsuccessful trial accrual. Therefore, it may be further investigated as a tool for the treatment of RT-related xerostomia.

The evaluation of the reliability and validity properties of the Greek version of the xerostomia questionnaire (ΧQ)

PURPOSE

Xerostomia is one of the multidimensional effects of cancer therapy that can impact on patients' quality of life. This study aims to evaluate the reliability and validity properties of the xerostomia questionnaire.

METHODS

The data were retrieved from a randomized, interventional and longitudinal follow-up study of 72 head and neck cancer patients on active oral radiotherapy. Data were retrieved by the Xerostomia Questionnaire, the EORTC-QLQ C30 and EORT QLQ HN35. Data analyzes included intrinsic credibility of affinity Cronbach alpha factor, which is related to validity and cross-sectional validity.

RESULTS

The Cronbach's alpha index of the Greek version of the questionnaire was high. Explicitly, the total scale of the questionnaire had an α = 0.97, and the individual dimensions - Degree of dryness and the quality of life had an alpha of 0.97 and 0.98 respectively. The xerostomia dimension of the questionnaire has a high positive correlation with QLQ C30 overall (r = 0.61, p < 0.001), and with the HN35 xerostomia dimension (r = 0.63, p < 0.001) which demonstrate its' concurrent validity. The dimensions of the xerostomia questionnaire were highly correlated with the EORTC-QLQ C30 dimensions which supports its' predictive validity. The level of xerostomia and the quality of life varied according to the level of pain of the patients (p < 0.001) that support the cross-sectional validity of the questionnaire.

CONCLUSION

The Greek version of the xerostomia questionnaire is a reliable and valid tool for use in head and neck cancer patients on active oral radiotherapy.

Volume changes during head-and-neck radiotherapy and its impact on the parotid dose - A single-institution observational study

Aims

This study aims at assessing the volume changes that occur in the targets (gross tumor volume and planning target volume [PTV]) and the organs at risk in squamous cell carcinoma of the head and neck during radiotherapy and assessing the dose changes that occur as a result of them.

Settings and Design

This was a prospective observational study in a tertiary care center after obtaining the appropriate scientific and ethics committee clearance.

Subjects and Methods

Forty-five patients diagnosed with squamous cell carcinoma of the head and neck, who were treated with intensity-modulated radiotherapy in the time period from March 2018 to May 2019, were enrolled in the study. A planning computed tomography (CT) scan (CT_plan) was done for all patients, followed by scans after 15 fractions (CT₁₅) and after 25 fractions (CT₂₅). The volume changes and the subsequent dose changes were assessed and recorded.

Statistical Analysis Used

Data entry was done in MS Excel spreadsheet. The continuous variables were expressed as mean + standard deviation. The comparison of normally distributed continuous variables was done by paired t-test. Data analysis was done by SPSS (Statistical Package for the Social Sciences) version 16.0. P < 0.05 was considered statistically significant. A multivariate linear regression model was constructed to study the correlation between mean dose to the parotid glands and the other variables. All statistical modeling and analysis were done using SAS (Statistical Analysis Software) version 9.4.

Results

Of the 45 patients, 25 were male and 20 were female. The majority of the patients had malignancies in the oral cavity (16) and hypopharynx (14). Most of them had Stage III/IV (AJCC v 8) disease (41). There were a 36% decrease in the PTV-high risk (PTV-HR) volume and a 6.05% decrease in the PTV-intermediate risk (PTV-IR) volume CT₁₅. In CT₂₅, the volume decrease in the PTV-HR and the PTV-IR was 47% and 9.06%, respectively. The parotid glands also underwent a reduction in their volume which has been quantified as 21.7% and 20.9% in the ipsilateral and contralateral parotids in CT₁₅ and 36% and 33.6% in CT₂₅, respectively. The D2 (dose received by 2% of the volume) and D98 (dose received by 98% of the volume) of the PTV-IR showed changes of +3.5% and -0.2% in CT₁₅ and + 4.6% and -0.31% in CT₂₅, respectively. The homogeneity index and conformity number of the PTV-IR changes by 0.03 and 0.08 in CT₁₅ and by 0.04 and 0.12 in CT₂₅, respectively. The mean dose to the ipsilateral parotid gland increased by 14% in CT₁₅ and 19% in CT₂₅. The mean dose to the contralateral parotid gland increased by 17% in CT₁₅ and 25% in CT₂₅.

Conclusion

The dose to the parotid glands increases as a result of the changes that occur during the course of radiation. The changes are significant after 15 fractions of radiation. A replanning at this juncture might be considered to reduce the dose to the parotid glands.

A preliminary study on submariners with xerostomia after a 3-month deployment

To observe the clinical manifestations and salivary secretion of xerostomia patients in submariners who engaged in a three-month deployment. The general conditions and clinical examination of the 136 submariners were evaluated, by which the patients with xerostomia were screened out and their clinical manifestations were recorded. Besides, the flow rate of unstimulated saliva and stimulated saliva was measured and calculated. Subsequently, the related factors of xerostomia were quantitatively classified and statistically analyzed. In all the involved submariners, 42 were diagnosed to have xerostomia by physical examination after they returned from the task, among which 71.4% showed a decrease in unstimulated salivary flow rate and it was significantly correlated with the accompanying symptoms and their general conditions. Therefore, it was concluded that the occurrence of xerostomia could be related to the service life and job responsibilities of the submariners. The main manifestations were the reduction of unstimulated salivary secretion and the accompanying clinical symptoms such as cheilosis and angular cheilitis. Noticeably, the high psychological pressure and harsh living conditions need to be concerned, and further study should place more concentrations on these comprehensive influence factors and preventive actions of xerostomia.

Quality of Life, Anxiety, and Depression in the Head-and-Neck Cancer Patients, Undergoing Intensity-Modulated Radiotherapy Treatment

Aims:

The aim of this study is to investigate and compare distress and quality-of-life parameters among head-and-neck cancer patients who underwent intensity-modulated radiotherapy (IMRT).

Subjects and Methods:

The patients' sample consists of 55 individuals under IMRT treatment. Three questionnaires (Quality of Life Questionnaire [QLQ]-C30 and QLQ-H and N35) of the European Organization for the Research and Treatment of Cancer and the Greek Hospital Anxiety and Depression Scales were used.

Results:

Functioning and symptoms scales measured a week before the scheduled treatment worsen significantly until the end of the treatment and at the 3-month follow-up, tend to revert to their pretreatment values.

Conclusions:

Our results showed that all parameters (functioning scales, symptoms scales, and G-HAD subscales) worsen from the start to the end treatment and tend to revert to their pretreatment values after a 3-month period.

Diffusion-weighted imaging as a follow-up modality for evaluation of major salivary gland function in nasopharyngeal carcinoma patients: a preliminary study

PURPOSE

To investigate the value of diffusion-weighted imaging (DWI) in assessing dynamic changes of major salivary gland function during follow-up post radiotherapy (RT) in nasopharyngeal carcinoma (NPC) patients.

MATERIALS AND METHODS

31 consecutive patients with pathologically confirmed NPC scheduled for RT underwent six routine follow-up MRI examinations including DWI sequence prior to (pre-RT) and 1, 3, 6, 9, and 12 months post RT. Mean apparent diffusion coefficient (ADC) values of bilateral parotid glands (PGs) and submandibular glands (SMGs) were measured. Objective measurement of salivary flow rate (SFR) under unstimulated (uSFR) and stimulated conditions (sSFR) as well as subjective xerostomia assessment according to a patient-rated questionnaire were conducted before each MRI. Variance analysis was used to evaluate dynamic changes of ADC, SFR and xerostomia questionnaire summary scores (XQ-sum) at different timepoints and the correlation between ADC and XQ-sum. Pearson's correlation test was used to evaluate the correlations between pre- and post-RT changes of ADC (ΔADC) and SFR (ΔSFR) or mean RT dose.

RESULTS

At each timepoint, ADCs of PGs were significantly lower than of SMGs, uSFR was significantly lower than sSFR. For both PGs and SMGs, ADC_post-RT were all higher than ADC_pre-RT, with significant differences. ADC_1m-post-RT initially increased and changed little to ADC_3m-post-RT, ADC_6m-post-RT, ADC_9m-post-RT, and ADC_12m-post-RT, then gradually declined over time. The dynamic change trends of SFR were negatively paralleled to those of ADC, while that of XQ-sum was similar. Dose-response relationships were detected between salivary gland mean RT dose and ΔADC. In PGs, negative correlations between ΔsSFR_9m-post-RT and ΔADC_9m-post-RT, and ΔsSFR_12m-post-RT and ΔADC_12m-post-RT were detected. In SMGs, negative correlations between ΔsSFR_12m-post-RT and ΔADC_12m-post-RT, and ΔuSFR_12m-post-RT and ΔADC_12m-post-RT were also detected. The ADCs of patients with severe subjective xerostomia were significantly higher, while patients with moderate subjective xerostomia presented a tendency toward higher ADCs compared to those with mild xerostomia from 6 to 12 months post RT.

CONCLUSION

As part of routine follow-up MRI in NPC patients, DWI might be a promising modality for follow-up assessing the dynamic changes of major salivary gland function and might be more powerful in the late post-RT period.

Current alternatives in the prevention and treatment of xerostomia in cancer therapy

ABSTRACT In the last decades, there has been a substantial increase in the occurrence of cancer. The most commonly used treatment for this disease involves surgery, radiotherapy and chemotherapy. These treatment modalities are associated with different kinds of side effects, acute or late. Xerostomia is one of the main oral complications that affect patients undergoing antineoplastic treatments, mainly head and neck cancer patients. It is characterized by a “dry mouth” sensation resulting from decreased salivary flow. It is persistent and affects the integrity of oral tissues, thereby significantly affecting patients’ quality of life. Many strategies have been applied and others developed to prevent and reduce xerostomia. Accordingly, the objective of this study was to review the literature about current prevention and treatment measures aimed at improving the quality of life of xerostomic patients.

Long-term effects of radioiodine treatment on salivary gland function in adult survivors of pediatric differentiated thyroid carcinoma

Pediatric differentiated thyroid cancer (DTC) is a rare disease. Initial treatment of DTC consists of a (near) total thyroidectomy and radioactive iodine (131I) therapy. Previous studies in adults showed that 131I treatment may result in a reduced salivary gland function. Studies regarding salivary gland function in children treated for DTC are sparse. Our aim was to assess long-term effects of 131I treatment on salivary gland function in survivors of pediatric DTC. Methods: In a nationwide cross-sectional study, salivary gland function of patients treated for pediatric DTC between 1970 and 2013 (>5 years after diagnosis, ≥18 years old at time of evaluation) was studied. Salivary gland function was assessed by sialometry, sialochemistry and a xerostomia inventory. Salivary gland dysfunction was defined as unstimulated whole saliva flow ≤0.2mL/min and/or a stimulated whole saliva flow ≤0.7 mL/min. Results: Sixty-five patients (median age at evaluation 33 [IQR, 25-40] years, 86.2% female, median follow-up period 11 [IQR, 6-22] years) underwent 131I treatment. Median cumulative 131I activity was 5.88 [IQR, 2.92-12.95] GBq, 47.7% underwent multiple 131I administrations. Salivary gland dysfunction was present in 30 (47.6%) patients. Levels of amylase and total protein in saliva were reduced. Moderate to severe xerostomia was present in 22 (35.5%) patients. Stimulated salivary secretion was lower and severity of xerostomia complaints higher in patients treated with higher cumulative 131I activity. Conclusion: In survivors of pediatric DTC, clinically significant salivary gland dysfunction was found in 35.5% and was related to the cumulative 131I activity of the treatment.