xerostomia

Advanced type of cancer radiation reduces side effects, but impact on controlling cancer is unclear

Source: www.sunherald.com
Author: press release

An advanced type of cancer radiation is more successful than traditional radiation in avoiding “dry mouth” when treating head and neck cancers, but it is unknown whether the treatment is better or worse at reducing the size of tumors, according to a new comparative effectiveness review funded by HHS’ Agency for Healthcare Research and Quality.

The report finds that intensity-modulated radiation therapy (IMRT) leads to fewer cases of xerostomia, commonly known as dry mouth, than other types of radiation. Xerostomia, a potential side effect to radiation when salivary glands are damaged, can affect basic functions like chewing, swallowing and breathing; senses such as taste, smell and hearing; and can significantly alter a patient’s appearance and voice.

However, the report did not find evidence that IMRT is more successful than any other kind of radiation therapy in reducing tumors. Many scientists consider IMRT to be theoretically better able to target cancerous cells while sparing healthy tissues, but more research is needed, the report said. The comparative effectiveness review, Comparative Effectiveness and Safety of Radiotherapy Treatments for Head and Neck Cancer, was authored by the Blue Cross and Blue Shield (BC/BS) Association, Technology Evaluation Center in Chicago.

“The development of new technologies to treat cancer has been one of the true success stories of American medical research,” said AHRQ Director Carolyn M. Clancy, M.D. “This report provides patients and their doctors with more information about these advances, which they can use to make more informed choices about their own treatment.”

The report examines treatment for cancers to the head and neck, including the mouth, larynx and sinuses. (Tumors in the brain are considered a separate type of cancer and are not discussed in this report.) Non-brain head and neck cancers account for up to 5 percent of cancers that are diagnosed in the United States, with an estimated 47,560 new cases and 11,260 deaths in 2008.

As with other cancers, head and neck cancer often is treated by radiation, which can damage both cancerous and non-cancerous cells. To limit damage to non-cancerous cells, scientists have sought ways to target high doses of radiation to cancerous cells while sparing healthy ones. This is particularly important with head and neck cancers, because tumors can reside close to vital organs.

Standard radiation therapy has evolved over the past 20 years and now provides doctors with two- or three-dimensional images that simulate a patient’s treatment area on a computer screen. IMRT, which has been implemented over the past 10 years, also employs three-dimensional imaging and further technological and treatment enhancements that tightly control and target the amount of radiation delivered to the target area.

Time-released muco-adhesive patch more effective than oral rinse for xerostomia

Source: www.news-medical.net/news
Author: press release

A newly developed time-released muco-adhesive patch for treating oral health conditions, including the widespread condition of dry mouth (xerostomia), has been shown to be more effective than a leading oral rinse, according to a newly-published study. As increasing segments of the population consume more medications (one of the leading causes of dry mouth), the results of this study could potentially help provide relief for millions of Americans. Chronic dry mouth impacts the quality of life and for some, can be debilitating. Published in the March 2010 issue of Quintessence International, the study found that chronic dry mouth sufferers can now get a statistically significant reduction of mouth dryness from a new time-released muco-adhesive patch (OraMoist Dry Mouth Patch), compared with the leading oral rinse which has been on the market for nearly two decades.

Overall, patients with xerostomia treated with the muco-adhesive patch reported a statistically significant reduction in mouth dryness sensation with elevated salivary flow rate (150%) after just 30 minutes, which was considered clinically outstanding by the study authors, since the product does not contain any cholinergic agonist, a drug often used to treat dry mouth.

OraMoist, a new time-released, non-drug formula, not only outperformed the mouthwash, one of the most often used delivery formats for treating dry mouth, but unlike dry mouth sprays, rinses or gels, which need to be applied frequently – sometimes every 20 minutes – OraMoist works to increase moisture and help restore a healthy oral environment for hours at a time, day or night, and can even be used by those with dental appliances, such as dentures. It moistens and lubricates the mouth with time-released lipids, citrus oil and sea salt, while simultaneously stimulating saliva production and inhibiting bacterial growth and promoting oral health with enzymes and xylitol.

“Oral disorders such as dry mouth and canker sores require long residence of the active remedy in the mouth or the disease site for effective treatment. Muco-adhesive patches made of safe ingredients that adhere to the oral mucosal tissue and slowly erode while releasing active remedies for two to six hours provide the desired residence time for effective therapy,” said Professor Abraham J. Domb, PhD, Institute of Drug Research, School of Pharmacy, Faculty of Medicine at the Hebrew University, co-author of the new published study, inventor of the muco-adhesive time-released patch and world-renowned for his work in biodegradable polymers. “This novel approach of time-released delivery has proven to be a successful and desirable approach to treating chronic conditions that affect millions of people, and can be disruptive to their lifestyle.”

The evolution of the muco-adhesive patch has found commercial viability in treating canker sores as well because the patch can also act as a bandage for the sores for eight to twelve hours while releasing active remedial ingredients.

Dry mouth affects upwards of 17% of the population, increasing in older adults (65 years and older) to about 30%. In fact, 34% of people taking three or more medications suffer from dry mouth, which is also a chronic symptom of numerous medical conditions, such as diabetes and Sjogren’s Syndrome.

Source: OraMoist

March, 2010|Oral Cancer News|

Advances in radiation therapy enable doctors to improve the quality of treatments for patients with head and neck cancer

Source: www.prnewswire.com
Author: press release

Noted clinical experts detail recent developments at the annual ASTRO meeting in Chicago

Clinical studies suggest that advanced treatments like intensity-modulated radiotherapy (IMRT) and image-guided radiotherapy (IGRT) are enabling radiation oncologists to enhance post-treatment health-related quality of life for patients with head and neck cancer.

In an educational session for radiotherapy professionals, delivered by two noted experts during the annual meeting of the American Society for Radiation Oncology (ASTRO) in Chicago last week, Avraham Eisbruch, M.D., professor at the University of Michigan, discussed how careful implementation of IMRT in the treatment of head and neck cancer can achieve high tumor control rates while minimizing xerostomia, a dry mouth condition that occurs when salivary glands are damaged.

Citing a new report summarizing results from RTOG 0022, a multi-institutional study comparing IMRT with earlier forms of treatment for head and neck cancer, Dr. Eisbruch said that IMRT for head and neck cancer achieved important goals in reducing treatment toxicity, notably xerostomia, and in yielding a high tumor control rate of 90%.(1)

For patients enrolled in the study and treated with IMRT, only 55% experienced Grade 2 or worse xerostomia at six months after treatment, as compared with 84% of patients treated with earlier forms of radiotherapy — a reduction of 35%. For the IMRT group, the percentage of patients with Grade 2 or worse xerostomia decreased steadily, to 25% at 12 months and 16% at 24 months. “This kind of improvement over time is not something we had been seeing with conventional forms of radiotherapy,(2)” said Dr. Eisbruch, who served as chair of RTOG 0022.

“Also, emerging data is suggesting that we can get improvements in broader aspects of post-treatment quality of life by using IMRT, beyond reducing xerostomia,” Eisbruch said. “Several studies comparing IMRT with conventional radiotherapy found that the IMRT patients did better not just in terms of dry mouth, but also other quality of life dimensions, including swallowing and nutrition.”(3)(4)(5)

According to Eisbruch, RTOG 0225, another multi-institutional study looked at IMRT with or without chemotherapy for head and neck cancer, and also reached positive conclusions. “That group reproduced the excellent results that individual treatment centers had been reporting, namely, a 90% loco-regional progression-free survival with minimal grade 3 and no grade 4 xerostomia.”(6)

IMRT involves shaping radiotherapy treatment beams so that they deliver a dose pattern that matches the size and shape of a targeted tumor while minimizing exposure of surrounding healthy tissues and organs. This approach has been widely adopted by radiation oncologists for the treatment of diverse forms of cancer. Ongoing clinical studies are now maturing, allowing long term outcomes to be assessed and validating IMRT based on clinical data.

Improving IMRT Through Image-Guidance
Lei Dong, PhD, associate professor of medical physics at the MD Anderson Cancer Center in Houston, Texas, detailed how new image-guidance technologies further enhance the accuracy of IMRT treatments by enabling clinicians to correct for patient set-up uncertainties and anatomical changes over a course of treatment.

“Clinicians naturally want to take advantage of the more conformal dose distributions that IMRT makes possible by reducing the treatment margins around a tumor, to protect more healthy tissues,” said Dr. Dong. “When we do that, it is important to ensure that the treatments are targeted very precisely, so the tumor receives the high dose treatments, and the dose to surrounding tissues and organs is kept as low as possible.”

Dr. Dong discussed the issue of basing radiotherapy treatment plans on single CT scans taken during treatment simulation. “Internal motion can affect the accuracy of tumor definition if the CT scan is acquired while the patient is swallowing,” he said, referencing a study he worked on with colleagues from M. D. Anderson Cancer Center.(7)

According to Dr. Dong, stereoscopic X-ray imaging and volumetric cone-beam CT imaging, two imaging techniques enabled by Varian’s On-Board Imager® kV imaging device, make it possible to fine-tune patient positioning just prior to each daily treatment. In addition, frequent imaging can alert clinicians to changes in a patient’s anatomy over time, so that a new treatment plan can be developed part-way through a course of treatment whenever warranted–a process called adaptive radiotherapy.

“Preliminary studies have shown that combining IGRT and adaptive IMRT replanning can improve the overall quality of the treatment plan and, most importantly, reduce unnecessary doses to normal organs surrounding the tumor, such as the parotid glands and oral cavities,” Dr. Dong said.(8) “Combining IGRT with IMRT creates a powerful tool for high precision radiation therapy.”

November, 2009|Oral Cancer News|

Intensity-modulated radiation offers treatment advantages over conventional therapy for head and neck cancer

Source: www.docguide.com
Author: John Otrompke

Patients treated with simultaneously integrated boost treatment using intensity-modulated radiation therapy (IMRT) experience better overall survival, disease-free survival, and local recurrence rates, as well as decreased dermatitis and better postoperative salivary function that those treated with conventional radiation.

“IMRT treatment was described as ‘boosted’ because we use 2 different doses in the same patient, who gets a dose of 2.12 gy to 1 part of their anatomy, while another part gets 1.8 gy,” said Sebastien Clavel, MD, University of Montreal, Montreal, Quebec, on November 3 at the American Society of Therapeutic Radiology and Oncology (ASTRO) 51st Annual Meeting.

In the study, 249 patients with stage III and IV oropharyngeal carcinoma were treated between 2000 and 2007. Of these, 100 received IMRT, while 149 patients received conventional radiation therapy.

After a 33-month median follow-up, 95.4% of those treated with IMRT were still alive, compared with 75.8% of those in the conventional arm. Disease-free survival was 89.3% for the IMRT group, compared with 71.6% in the conventional radiation arm. In addition, local control was 92.4% in the IMRT patients, compared with 85.3% in the conventional group.

“With the old technique, the rays were shooting from both sides, whereas with IMRT, the rays come from all directions,” said Dr. Clavel. “When using IMRT, we also always give them a 3-mm margin with the skin, both of which result in fewer cases of dermatitis.” IMRT patients experienced a 20% decrease in dermatitis grades 3 and 4.

“If we are able to treat the tumour with IMRT while avoiding the structure of the parotid gland, which produces saliva, the patients can live better, because more saliva is useful to protect the teeth, to eat, and swallow,” he added, noting that only 8% of those treated with IMRT experience grade 3 or 4 xerostomia at 2 years following treatment, compared with 80% of those treated with conventional radiation.

Better salivary function was also associated with increased weight regain post operatively. “Patients lost 10% of their weight during treatment; while they did not gain all their weight back in the IMRT group, they were able to regain up to 50% more than those treated with conventional radiation,” said Dr. Clavel.

Notes:
1. presented at American Society of Therapeutic Radiology and Oncology (ASTRO)
2. presentation title: A Comparison of Simultaneously Integrated Boost Using Intensity-Modulated Radiation Therapy and Conventional Radiation Therapy in the Setting of Concomitant Carboplatin and 5-Fluorouracil for Locally Advanced Oropharyngeal Carcinoma. Abstract 69

November, 2009|Oral Cancer News|

Cepharanthin effect on radiation-induced xerostomia and taste disorder in patients with head and neck cancer

Source: Nippon Jibiinkoka Gakkai Kaiho, September 1, 2009; 112(9): 648-55
Author: R Shimazu et al.

In evaluating the effect of cepharanthin on and taste disorder in 40 patients undergoing radiotherapy for head and neck cancer, we administered cepharanthin intravenously during chemoradiotherapy to 22 patients, with 18 others as a control group. Cepharanthin did not significantly affect salivary secretion during and after chemoradiotherapy, although taste disorder and oral discomfort were alleviated. Cepharanthin may thus be effective in maintaining the quality of life of patients with head and neck cancer.

Authors:
R Shimazu, G Tanaka, R Tomiyama, Y Kuratomi, and A Inokuchi

Authors’ affiliation:
Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Saga University, Saga

November, 2009|Oral Cancer News|

Group acupuncture to relieve radiation induced xerostomia: a feasibility study

Source: Acupuncture in Medicine 2009;27:109-113
Author: Richard Simcock et al.

Background:
A distressing complication of radiotherapy treatment for head and neck cancer is xerostomia (chronic oral dryness). Xerostomia is difficult to treat conventionally but there are reports that acupuncture can help. We conducted a feasibility study to examine the acceptability of a standardised group acupuncture technique and adherence to group sessions, together with acceptability of the objective and subjective measurements of xerostomia.

Methods:
12 males with established radiation induced xerostomia were treated in three groups of four. Each received eight weekly sessions of acupuncture using four bilateral acupuncture points (Salivary Gland 2; Modified Point Zero; Shen Men and one point in the distal radial aspect of each index finger (LI1)). Sialometry and quality of life assessments were performed at baseline and at the end of treatment. A semi-structured interview was conducted a week after completing the intervention.

Results:
Adherence to and acceptability of the treatment and assessments was 100%. There were objective increases in the amounts of saliva produced for 6/12 patients post intervention and the majority also reported subjective improvements. Mean quality of life scores for domains related to salivation and xerostomia also showed improvement. At baseline 92% (11/12) patients reported experiencing a dry mouth “quite a bit/very much” as compared to 42% (5/12) after the treatment. Qualitative data revealed that the patients enjoyed the sessions.

Conclusion: The pilot study shows that a standardised group technique is deliverable and effective. The tools for objective and subjective assessment are appropriate and acceptable. Further examination in a randomised trial is now warranted.

Authors:
Richard Simcock1, Lesley Fallowfield2, Valerie Jenkins2

Authors’ affiliations:
1 Brighton & Sussex University Hospitals Trust, Brighton, East Sussex, UK
2 Cancer Research UK Psychosocial Oncology Group, Brighton & Sussex Medical School, University of Sussex, Brighton, East Sussex, UK

September, 2009|Oral Cancer News|

Ipsilateral irradiation for well lateralized carcinomas of the oral cavity and oropharynx: results on tumor control and xerostomia

Source: Radiation Oncology 2009, 4:33
Authors: Laura Cerezo et al.

In head and neck cancer, bilateral neck irradiation is the standard approach for many tumor locations and stages. Increasing knowledge on the pattern of nodal invasion leads to more precise targeting and normal tissue sparing.

The aim of the present study was to evaluate the morbidity and tumor control for patients with well lateralized squamous cell carcinomas of the oral cavity and oropharynx treated with ipsilateral radiotherapy.

Methods:
Twenty consecutive patients with lateralized carcinomas of the oral cavity and oropharynx were treated with a prospective management approach using ipsilateral irradiation between 2000 and 2007. This included 8 radical oropharyngeal and 12 postoperative oral cavity carcinomas, with Stage T1-T2, N0-N2b disease.

The actuarial freedom from contralateral nodal recurrence was determined. Late xerostomia was evaluated using the European Organization for Research and Treatment of Cancer QLQ-H&N35 questionnaire and the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE), version 3.

Results:
At a median follow-up of 58 months, five-year overall survival and loco-regional control rates were 82.5% and 100%, respectively.

No local or contralateral nodal recurrences were observed. Mean dose to the contralateral parotid gland was 4.72 Gy and to the contralateral submandibular gland was 15.30 Gy.

Mean score for dry mouth was 28.1 on the 0-100 QLQ-H&N35 scale. According to CTCAE v3 scale, 87.5% of patients had grade 0-1 and 12.5% grade 2 subjective xerostomia.

The unstimulated salivary flow was >0.2 ml/min in 81.2% of patients and 0.1-0.2 ml/min in 19%. None of the patients showed grade 3 xerostomia.

Conclusions:
In selected patients with early and moderate stages, well lateralized oral and oropharyngeal carcinomas, ipsilateral irradiation treatment of the primary site and ipsilateral neck spares salivary gland function without compromising loco-regional control.

Authors:
Laura Cerezo, Margarita Martin, Mario Lopez, Alicia Marin, Alberto Gomez

September, 2009|Oral Cancer News|

Taste and smell disorders caused by cancer or treatments add to patients’ problems

Source: www.oncologynursingnews.com
Author: Delicia Yard

Although the mechanisms underlying abnormalities in the senses of taste and smell in cancer patients are unknown, such disturbances clearly decrease quality of life for the majority of cancer patients—and clinicians need to be aware of the problem in order to help a person’s recovery.

This is the word from a study recently published in The Journal of Supportive Oncology (2009;7:58-65). Jae Hee Hong, PhD, Pinar Omur-Ozbek, PhD, Brian T. Stanek, and coinvestigators from Wake Forest University Comprehensive Cancer Center and Virginia Tech’s food science and technology department and biomedical engineering school conclude, “Oncologists who understand the types and causes of taste and olfactory abnormalities may be better prepared to discuss and empathize with these negative side effects.”

Altered sensory perception can undermine a person’s struggle against cancer by causing malnutrition and anxiety. One study cited by Dr Hong and colleagues found that malnutrition, not malignancy, was the primary cause of morbidity in 20% of cancer patients.

Dr Hong and colleagues explain that disorders of taste and odor can result from cancer itself or from cancer treatments, with 68% of chemotherapy patients reporting such problems. But the specific causes of these alterations often remain unidentified.

How Senses Go Bad
According to the researchers, problems with taste and smell break down into 3 categories: loss of sensitivity, distorted perception, and hallucination. The abnormalities may take the following forms:

• absence of taste perception (ageusia) or odor perception (anosmia)
• reduced sensitivity to taste perception (hypogeusia) or odor perception (hyposmia)
• distortion of taste perception (dysgeusia) or odor perception, with the person being unable to identify odors (dysosmia); in dysosmia, the person may think he or she smells something when no odor is present (phantosmia), be unable to tell the difference between perceived odors (agnosia), or have altered odor perception when 1 scent is present with another (parosmia)
• perception of taste even when no substance has been ingested (phantogeusia); although the perceived taste is often described as metallic or salty, some patients have described it as bitter, sweet, sour, peppery, greasy, soapy, powdery, or chemical.

Taste Complaints Common in Patients with Head-and-Neck Cancer
Changes in taste acuity—ageusia and hypogeusia— depend on the site of the tumor, but people with head and neck cancer report more problems than do people with breast cancer or lung cancer. According to studies cited by Dr Hong’s group, approximately 85% of patients undergoing radiation treatment of the head and neck experienced unpleasant taste changes.

“Irradiation of the taste buds frequently leads to partial or complete loss of taste or alteration of taste,” affirms Michele Y. Halyard, MD, in a commentary accompanying the Hong study (J Support Oncol. 2009;7:68-69). An associate professor of radiation oncology at the Mayo Clinic in Scottsdale, Ariz, Dr Halyard adds that taste recovery may take 6 to 12 months after head-and-neck radiotherapy.

Zinc and other heavy metals play a part in the physiology of taste function, and uncontrolled studies have shown zinc supplementation to improve taste abnormalities in people with head-and-neck cancer who were treated with external-beam radiation therapy. Dr Halyard and colleagues conducted a large randomized trial in which zinc did not help prevent or recover taste loss caused by radiation therapy, but, conflictingly, a small pilot trial demonstrated more promising results. Zinc’s specific role in taste perception is unknown, writes Dr Halyard, “but it is a recognized cofactor of alkaline phosphatase, which is the most abundant enzyme within the taste-bud membrane.”

Dr Halyard recommends that clinicians consider arranging a formal nutritional consultation for patients undergoing cancer treatment and initiating enteral feeding if necessary. “Nutritional intervention has been shown to improve not only quality of life in cancer patients but survival as well and should play an important role in the management of patients with alterations in taste and smell that impact oral intake,” she contends.

Odor Identification and Aversion
Sense of smell doesn’t appear to be as affected as sense of taste in cancer patients, note Dr Hong and colleagues. People with lung, ovarian, and breast cancers did not differ significantly from people without cancer in 1 test measuring smell sensitivity. In addition, radiotherapy administered to patients with oropharyngeal cancer did not significantly change their ability to recognize odors.

Nevertheless, chemotherapy and radiation have been found to be major causes of dysosmia. In 1 study of 40 individuals with breast cancer, most recovered their ability to identify odors and had increased smell acuity 6 to 9 months after radiotherapy treatment.

Abnormal taste and odor perception are building blocks to food aversion. Many cancer patients report that high-protein foods give off an unpleasant taste and odor. Red meat seems to be a particular culprit; patients appear better able to tolerate protein in the forms of fish, chicken, eggs, and cheese. High-fat foods, vegetables, chocolate, and caffeinated drinks also frequently make the food-aversion lists of people with cancer.

Another contributor to taste aversion is xerostomia, otherwise known as “dry mouth.” This condition occurs in cancer patients when radiation damage to the salivary glands diminishes saliva secretion. Xerostomia is strongly linked with taste alteration, particularly with the problem of metallic tastes or aftertastes.

Better Understanding Will Lead to Better Management
Dr Hong et al conclude that new management strategies are needed to help cancer patients resolve taste and odor malfunctions. In a separate statement announcing the study, coinvestigator Andrea Dietrich, professor of civil and environmental engineering at Virginia Tech and an expert on the taste and odor assessment of water among cancer patients, pointed out that one of the purposes of the study was to provide both researchers and clinicians with a better understanding of the types and causes of taste and odor dysfunctions so that they can develop treatments for these conditions and improve quality of life for their patients.

Source:
From the August 2009 Issue of Oncology Nursing News.

August, 2009|Oral Cancer News|

Intensity-modulated radiotherapy reduces xerostomia in head and neck cancer

Source: www.oncologystat.com
Author: staff

Intensity-modulated radiotherapy significantly reduces the risk of subjective xerostomia by about 50% in patients with pharyngeal tumors, according to the first results of the multicenter, phase III PARSPORT trial.

Cancer Research UK’s PARSPORT (Parotid-Sparing Intensity-Modulated Radiation Therapy Compared With Conventional Radiation Therapy in Treating Patients With Oropharyngeal or Hypopharyngeal Cancer Who Are at High Risk of Radiation-Induced Xerostomia) trial evenly randomized 94 patients with pharyngeal tumors to conventional radiotherapy (conventional radiotherapy ) or intensity-modulated radiotherapy (IMRT). A three-dimensional technique, IMRT produces highly conformal dose distributions that can reduce the radiation dose to the salivary glands and normal tissue.

At 12 months, the incidence of grade 2 or higher xerostomia was 74% in CRT patients vs. 39% in IMRT patients, based on the subjective portion of the LENT/SOM (Late Effects on Normal Tissue-Subjective/Objective Management) questionnaire (P = .004).

The benefit of IMRT appeared to continue over time, with an 18-month xerostomia incidence of 71% with conventional therapy vs. 29% with IMRT (P = .003), principal investigator Dr. Christopher Nutting reported in a late-breaking abstract presentation at the annual meeting of the American Society of Clinical Oncology.

A similar pattern was observed using the RTOG (Radiotherapy Oncology Group) scale. The incidence of at least grade 2 xerostomia was 64% with CRT vs. 41% with IMRT at 12 months (P = .05), and 81% vs. 20% at 18 months (P less than .001).

This is the first randomized IMRT trial in head and neck squamous cell carcinoma, although phase II data suggest that parotid gland-sparing IMRT maintains saliva production, said Dr. Nutting, head of the head and neck unit at the Royal Marsden Hospital in London.

Grade 2 or higher radiation fatigue during and up to 8 weeks post treatment was significantly higher in the IMRT arm than in the CRT arm (76% vs. 41%; P less than .01), possibly because of more irradiation of brain tissue, he said. No other significant differences in acute or late toxicities were seen between the two arms.

“These data support the adoption of IMRT as the standard of care for head and neck cancer patients,” Dr. Nutting said.

The importance of the PARSPORT trial is that it confirms findings from two prior randomized trials in nasopharyngeal carcinoma patients (who also have a high risk of xerostomia), and it “shows that an improvement in radiation technology can translate into a decrease in toxicity,” Dr. Anthony Cmelak, medical director of the Vanderbilt-Ingram Cancer Center at Franklin (Tenn.), said during a discussion of the study.

He applauded the study’s use of a centralized quality assurance program because, he said, there are no set standards of delivery or quality assurance for IMRT in the community. Radiotherapy was delivered according to protocol in 43 CRT patients and 46 IMRT patients. (The remaining five patients either refused or were ineligible for treatment, or deviated from the protocol.).

When given as primary treatment, the mean dosage in both arms was 65 Gy in 30 fractions over 6 weeks. The mean contralateral parotid dose was 60 Gy in the CRT arm, which is capable of producing long-term damage, compared with 26 Gy in the IMRT arm, Dr. Nutting said. Ipsilateral parotid mean doses were similar, at 59 Gy vs. 45 Gy.

When given postoperatively, the mean radiotherapy dose was 64 Gy in the CRT arm vs. 61 Gy in the IMRT arm, the mean contralateral parotid dose was 57 Gy vs. 27 Gy, and the mean ipsilateral parotid dose was 61 Gy vs. 50 Gy.

In all, 85% of patients had tumors arising in the oropharynx and 15% in the hypopharynx; 77% had AJCC (American Joint Committee on Cancer) stage III/IV disease, and about 40% received neoadjuvant chemotherapy. Their mean age was 58 years.

Dr. Nutting said that one of the concerns about not treating part of the anatomy of the head and neck region is that locoregional progression-free survival may be poorer with IMRT. No significant difference was observed in this outcome between the IMRT (87.3%) and CRT (88%) arms (hazard ratio, 1.59).

With a median follow-up of 32 months, 91% of CRT and 93.6% of IMRT patients were alive at 1 year, although the confidence interval of 0.38-2.90 (HR, 1.05) precludes any significant conclusions, he said.

Dr. Cmelak said outstanding questions are whether the use of concurrent chemotherapy that sensitizes tissue would influence xerostomia outcomes or the ability of IMRT to spare parotid parenchyma, and whether reduced xerostomia justifies the increased integral dose. It has been asserted that the large number of beams and monitor units used in IMRT leads to an increase in integral dose (that is, the total amount of energy absorbed by a patient during radiation).

He said that the future of radiation delivery lies in arc-modulated radiation technology, which is available on roughly 70% of machines being produced today and which can reduce the integral dose by about one-half and a 15-minute IMRT session to about 5 minutes.

Finally, Dr. Cmelak said that additional research should include a cost-benefit comparison, citing a substantial difference in Medicare global costs of $23,715 for IMRT vs. $12,850 for 3-D radiation. Quality-of-life data from PARSPORT will be forthcoming.

Note:
The investigators disclosed receiving honoraria from Elekta AB and Varian Medical Systems Inc.

Taste, odor intervention

Source: speech-language-pathology-audiology.advanceweb.com
Author: staff

Cancer and its therapies, including chemotherapy and radiotherapy, may directly alter and damage taste and odor perception, possibly leading to patient malnutrition, and in severe cases, significant morbidity, according to a Virginia Tech – Wake Forest University Comprehensive Cancer Center compilation of various existing studies [Journal of Supportive Oncology, 7(2): 58-65].

One of the purposes of the study, said Andrea Dietrich, PhD, professor of civil and environmental engineering (CEE) at Virginia Tech, is to provide researchers and physicians with a better understanding of the types and causes of taste and odor dysfunctions so that they can develop treatments for these conditions and improve the quality of life of their patients. According to Susan Duncan, PhD, RD, professor of food science and technology at Virginia Tech, a bad taste in the mouth can lead to poor nutrition because patients avoid eating.

Approximately two thirds of cancer patients who receive chemotherapy report altered sensory perception, such as decreased or lost taste acuity or metallic taste. Altered sensory perception causes psychological anxiety and malnutrition, and thus negatively impacts the chances of survival for cancer patients, as reported in an earlier study conducted by Duke University.

Dr. Dietrich, an expert on water quality and treatment, as well as the taste and odor assessment of water, has expanded upon her knowledge of this field to include such assessments in cancer patients. She worked with Jae Hee Hong, Dr. Duncan, and Brian T. Stanek of the Virginia Tech Food Science and Technology Department, Pinar Omur-Ozbek, also of CEE, Yong Woo Lee of Virginia Tech’s School of Biomedical Engineering and Glenn Lesser, a physician of hematology and oncology at Wake Forest.

Their joint paper reports the “alteration of taste and smell in (cancer) patients has been understudied compared with other aspects of cancer research.”

The researchers based their work on numerous previous studies that reported on changes in taste acuity, taste quality, odor perception, food aversion, and xerostomia (dry mouth) causing taste alteration. Findings from these studies showed changes in taste acuity are dependent on the site of the tumor with head and neck patients reporting more complaints than do patients with other types of cancer such as breast or lung. The most prevalent taste alteration reported is the perception of a metallic or bitter taste, with red meat often cited as a cause. Another earlier study showed aversion to food is now occurring in as much as 55 percent of the patients receiving chemotherapy or radiotherapy.

From their review of the literature, the research team put together a listing of management strategies to improve taste and odor abnormalities for cancer patients. These include: avoiding the use of metallic silverware and reducing the consumption of foods that have a metallic or bitter taste such as red meat, coffee or tea. On the positive side, patients should increase their consumption of high-protein foods, add seasonings and spices to enhance flavors in some cases, practice good oral hygiene, and use agents such as sugar free gums and sour tasting drops to stimulate salivary secretion.

Dr. Dietrich explained their study of the literature, and synopsis of it, is meant to increase the recognition by oncologists and physicians of the disturbances cancer patients experience in their ability to taste and smell. “Oncologists who understand the types and causes of taste and olfactory abnormalities may be better prepared to discuss and empathize with these negative side effects,” she and her colleagues concluded. And physicians could improve their relationships with their patients, sharing “possible mediation strategies,” and directly affecting the recovery of patients.