Author: Fran Lowry

Most patients with locoregionally advanced head and neck cancer who were successfully treated with intensive chemoradiotherapy had no residual deficits in speaking or swallowing after their treatment, according to the results of a study done by University of Chicago researchers.

The study appears in the December issue of the Archives of Otolaryngology–Head & Neck Surgery.

Of 163 patients with head and neck cancer who were assigned a speaking score an average of 35 months after completing treatment, 84.7% were found to have no lasting difficulties and were given a score of 1 on a scale of 1 to 4, with 1 being the best and 4 being the worst function.

In addition, among 166 patients who were assigned a swallowing score an average of 35 months after treatment, 63.3% were found to have no lasting difficulties swallowing and were given a score of 1.

“We weren’t surprised by our findings,” senior author Joseph K. Salama, MD, told Medscape Medical News. “However, it was nice to quantify formally our clinical impressions—that most patients in the long run do well.”

Dr. Salama was with the University of Chicago, Illinois, at the time the study was conducted and is now at Duke University Medical Center in Durham, North Carolina.

Expert Disagrees
However, Robert L. Ferris, MD, PhD, professor and vice chair of the Department of Otolaryngology at the University of Pittsburgh Medical Center in Pennsylvania, disagreed with the view that so many patients with head and neck cancer retain good speech and swallowing function after such intensive treatment.

Pointing out that the study’s results are from a single institution, Dr. Ferris told Medscape Medical News that “the problem is there are good data on the other side. Speech and swallowing outcomes are clearly negatively affected by chemoradiation.”

He pointed out that a paper by Machtay et al (J Clin Oncol. 2008;26:3582-3589) showed the opposite results. “This has multicenter data from 3 prospective clinical trials that showed a 43% rate of long-term side effects and toxicities—data that conflict with this study,” he said.

Those With Hypopharyngeal and Laryngeal Cancers Fared the Worst
The aim of the study was to identify factors that influenced long-term speech and swallowing outcomes after organ-preserving therapy. The cohort was drawn from a multi-institutional phase 2 study of 222 patients with locoregionally advanced head and neck cancer (stage IV nonmetastatic or stage III base of tongue or hypopharyngeal tumors) who received treatment between 1998 and 2002.

Patients enrolled in this trial received induction chemotherapy consisting of carboplatin and paclitaxel, followed by chemoradiotherapy with paclitaxel, fluorouracil, hydroxyurea, and 1 of 3 radiation dose levels. Of the original cohort, 184 were alive and free of locoregional recurrence at the outset of the current study.

In addition to the finding that most patients maintained normal or near-normal speaking and swallowing function after treatment, the authors found that female sex, smoking history, hypopharyngeal or laryngeal primary sites, and poor response to induction chemotherapy were factors associated with worse speaking outcomes. Factors that were associated with worse swallowing outcomes included advanced patient age, poor performance status, primary site, and neck dissection.

Patients who had hypopharyngeal or laryngeal tumors had significantly worse speaking outcomes than patients with primary sites in other locations (P < .001), and they also exhibited a trend toward worse swallowing outcomes (P = .17).

“These results were in line with prior work from our group which showed that pretherapy swallowing evaluation was worse for hypopharyngeal patients, and early posttherapy swallowing evaluation was worse for those sites as well,” Dr. Salama told Medscape Medical News.

“This work is really the first step that defines what our outcomes at minimum should be,” he added. “Further work needs to be done to identify ways to further improve swallowing and speech with modifications in radiation [and] surgical techniques, as well as methods to assist patients during and shortly after treatment with exercises.”

Results Reflect the Work of a Group at the Top of Its Game

The stellar study results are most likely because the University of Chicago group comprises world-class experts in what they do, Dr. Ferris said. In their hands, the results would be excellent, but Dr. Ferris was skeptical that similar results would be the norm in community centers throughout the United States.

“I think a generic statement that people just do great with chemo and radiation would generate a lot of argument at our meetings,” he said. “Their good outcome could be a reflection of a group who is at the top of their game.

“But do community oncology centers read this and say, ‘OK, I can give that regimen and my patients will all do great’? That would be a concern,” he added. “I think there is skepticism that aggressive, 3-drug chemo followed by combined chemo and radiation for 16 weeks can be managed by less experienced individuals who see a lower volume of these patients. There is skepticism that they could get the same good results in speaking and swallowing.”

The University of Chicago team, “because of their long-term experience and expertise, their multidisciplinary, team-oriented approach, may be more capable of managing the speaking and swallowing and optimizing those outcomes,” Dr. Ferris noted. “Whereas we see results not being the same when translated out into less experienced, community-based oncology practices.”

The study was supported by the Robert and Valda Svendsen Foundation. Dr. Salama and Dr. Ferris have disclosed no relevant financial relationships.

Source: Arch Otolaryngol Head Neck Surg. 2010;136:1226-1234. Abstract