xerostomia

Acupuncture prevents radiation induced dry mouth

Source: www.healthcmi.com/
Author: staff

Acupuncture reduces the frequency and severity of xerostomia (dry mouth). University of Texas MD Anderson Cancer Center (Houston) and Fudan University Cancer Center (Shanghai) researchers conducted a randomized controlled clinical trial. The phase-three patient and assessor blinded investigation of acupuncture’s effects on head and neck cancer patients receiving radiation therapy demonstrated groundbreaking results. The researchers concluded that acupuncture “resulted in significantly fewer and less severe RIX [radiation-induced xerostomia] symptoms 1 year after treatment vs SCC [standard care control].” [1]

Salivary glands may be temporarily or permanently damaged by radiation therapy. There is a high-incidence of RIX, which may lead to complications including difficult or painful swallowing, impairment of the sense of taste (dysgeusia), and dental problems. Other RIX complications may include insomnia and difficulty speaking.

The study compared true acupuncture, sham acupuncture, and standard care control groups. True acupuncture produced significantly greater positive patient outcomes than the other groups. Outcome measures were based on a questionnaire, salivary flow, incidence of xerostomia, salivary contents, and quality of life scores. One year after completion of all acupuncture treatments, the true acupuncture group maintained significantly higher patient outcome rates over the standard care and sham groups.

All acupuncture treatments were provided by credentialed acupuncturists. The researchers note that their findings are consistent with several prior investigations. True acupuncture patients that received acupuncture three times per week during their six to seven week course of radiation therapy had significantly less dry mouth a year after completion of treatments than standard care control patients. No adverse effects occurred at University of Texas MD Anderson. One adverse effect was reported at the Fudan study location.

The researchers find that acupuncture is superior to standard care for the relief of radiation induced xerostomia. They comment that acupuncture is “minimally invasive” and “has a very low incidence of adverse effects.” [2] Based on the evidence, further research is warranted.

All participants in the study were at least 18 years of age, provided informed consent, had a diagnosis of head and neck carcinoma, and were scheduled for radiation therapy at a mean dose of 24 Gy to a minimum of one parotid gland. An extensive list of exclusion criteria was used to prevent variables created by comorbidity.

All acupuncturists providing treatment during the course of the study were licensed and were prepared and trained at the University of Texas MD Anderson Cancer Center. The acupuncture point prescription chosen for the study was the following:

  • CV24
  • LU7
  • KD6
  • Auricular: Shenmen, Point Zero, Salivary Gland 2 Prime, Larynx

Standard needle depths were used and the elicitation of deqi at the acupoints was at the discretion of treating acupuncturists. Notably, once deqi was elicited, needles were no longer manually stimulated (with the exception of displaced needles). Electroacupuncture was not used at any point.

Body-style acupuncture needles were of 0.25 mm diameter and 40 mm length. Auricular acupuncture needles were of 0.16 diameter and 15 mm length. Acupuncture treatments were provided a total of three times per week for the duration of the 6-7 week radiation treatment period.

The researchers chose to avoid the use of local points other than CV24 with the intent of preventing disturbance of tissues damaged by radiation. All patients were treated on the day of radiation therapy in a semisupine or supine position. Acupuncture was applied either before or after radiation therapy. Based on the data, the researchers note that acupuncture “should be considered for the prevention of radiation-induced xerostomia.” [3]

The investigators note that prior research indicates that acupuncture regulates blood flow at the parotid glands. In addition, a variety of other studies find acupuncture effective for the treatment of xerostomia. One of the studies cited in the investigation finds acupuncture effective for up to three years after treatment. Two pilot studies by the research group prior to this phase three clinical trial find acupuncture effective for the prevention of RIX if provided with radiation therapy.

The study employed strict controls and researchers monitored treatment facilities and licensed acupuncturists during the investigation. Further research will help to support standardization of acupuncture protocols for the prevention and treatment of RIX for inpatient and outpatient settings.

References:
1. Garcia, M.K., Meng, Z., Rosenthal, D.I., Shen, Y., Chambers, M., Yang, P., Wei, Q., Hu, C., Wu, C., Bei, W. and Prinsloo, S., 2019. Effect of True and Sham Acupuncture on Radiation-Induced Xerostomia Among Patients With Head and Neck Cancer: A Randomized Clinical Trial. JAMA Network Open, 2(12), pp.e1916910-e1916910.
2. Ibid.
3. Ibid.

December, 2019|Oral Cancer News|

Reducing RT toxicity in head and neck cancer: recent research context

Source: www.medpagetoday.com
Author: Kristin Jenkins, contributing writer, MedPage Today

In patients with head and neck malignancies, studies show that the significant acute and long-term toxicities and poor quality of life (QOL) associated with postoperative radiation therapy (PORT) can be improved by selectively reducing larger radiotherapy volumes. This includes treating just one side of the neck.

In patients with locally advanced head and neck squamous cell carcinoma (HNSCC), however, locoregional failure rates with the omission of PORT to the pathologically uninvolved neck (PN0) have been less clear. As a result, PORT has historically been delivered to the PN0 neck, with several studies showing high rates of regional control ranging from 95% to 100%. Notably, consensus clinical practice guidelines continue to recommend the use of bilateral irradiation of node-negative necks.

However, results from a prospective phase II study in 72 patients with primary HNSCC and high-risk pathology features now suggest that PORT to the PNo neck can be eliminated without sacrificing excellent disease control or QOL. At a median follow-up of 53 months, absolute regional control in the unirradiated neck was 97%, even though 67 patients (93%) had stage III/IV disease and 71% of tumors involved or crossed midline.

No patient received contralateral neck PORT, and 17 patients (24%) were treated for the primary neck tumor only, said Wade Thorstad, MD, of Washington University in St. Louis, and colleagues. The 5-year rates of local control, regional control, progression-free survival, and overall survival (OS) were 84%, 93%, 60%, and 64%, respectively, they reported in their study in the Journal of Clinical Oncology.

The study also showed that QOL measures were not significantly different from baseline at 1 year and 2 years post-completion of PORT (P>0.05).

“Our study demonstrated that this approach is safe and results in excellent control in a high-volume center where physicians are sub-site specialists,” Thorstad told the Reading Room. “All patients had complete preoperative staging and were discussed in a multidisciplinary setting. In this context, we feel this approach is reasonable, although confirmatory studies are needed.”

Has Been Ongoing Challenge
Achieving optimal disease control using the smallest volumes of QOL-destroying radiotherapy remains an ongoing clinical challenge for clinicians managing various subgroups of patients with HNSCC. What’s more, uncertainty about how to find the right balance between survival and QOL may have been seeded almost 50 years ago.

In October 1971, results from a seminal review of metastasis in previously untreated patients with HNSCC were presented at the annual meeting of ASTRO, then called the American Society of Therapeutic Radiologists and now the American Society for Radiation Oncology. In that presentation, Robert Lindberg, MD, of the University of Texas MD Anderson Cancer Center in Houston, included detailed maps of the seven common regions of metastasis seen on admission in 2,044 previously untreated patients.

Meanwhile, evidence for the impact of larger radiotherapy volumes on patients’ QOL has continued to accumulate. In 2009, a review of dysphagia related to treatment for HNSCC confirmed that the severity of radiation-associated effects on the tongue, larynx, and pharyngeal muscles is directly related to dosimetry.

The review authors noted that in addition to dysphagia and aspiration — recognized as potentially devastating complications of irradiation of the head and neck — the acute side effects of radiotherapy in HNSCC include xerostomia, hoarseness, erythema, and desquamation of the skin. Potential late sequelae include osteonecrosis, dental decay, trismus, hypogeusia, subcutaneous fibrosis, thyroid dysfunction, esophageal stenosis, hoarseness, and damage to the middle or inner ear.

Although radiation-induced xerostomia is also the most commonly reported late side effect, swallowing problems and the risk of aspiration remain the dose-limiting toxicity.

In the last 2 decades, advances in treatment technology have made significant strides towards improved survival that does not forfeit QOL. The widespread adoption of three-dimensional intensity-modulated radiation therapy (IMRT) in locally advanced HNSCC has made it possible to selectively restrict treatment volumes, sparing normal tissue.

A 2014 analysis of 50 consecutive survivors of locally advanced HNSCC at the University of California-Davis Comprehensive Cancer Center provided evidence for improved long-term QOL with IMRT. Five years after bilateral neck IMRT, the vast majority of patients reported being satisfied with their QOL. Using the University of Washington Quality of Life (UW-QOL) questionnaire, 41 of 50 patients (82%) rated their overall QOL as “outstanding” or “very good.”

At 5 years, the lowest domain score on the UW-QOL questionnaire was salivary function. Nevertheless, 42 patients (84%) reported saliva “of normal consistency” or “less saliva than normal but enough.” Although eight patients (16%) said they had “too little saliva,” none reported having “no saliva.”

In a 2017 study, Thorstad and colleagues reported that unilateral IMRT delivered oncologic outcomes similar to those of bilateral IMRT in 154 patients with surgically treated squamous cell carcinoma of the palatine tonsil. There were no contralateral neck recurrences in the unilateral IMRT group. In addition, patient self-reports indicated that those treated unilaterally had less acute toxicity, less need for use of gastrostomy tubes, and better QOL than patients treated bilaterally.

“Significant controversy remains regarding the use of unilateral RT in some subgroups of patients with palatine tonsillar cancer, particularly in those with N2b neck disease,” the study authors noted. “[Although] the 2011 American College of Radiology (ACR) appropriateness criteria recommended bilateral RT for this subgroup of patients, some authors challenged this recommendation.”

As far back as 1999 — the year that IMRT was introduced — the Brazilian Head and Neck Cancer Study Group reported that radiotherapy volumes could be safely reduced using unilateral rather than bilateral neck treatment in patients with PN0 necks. The findings showed that the rates of 5-year OS, neck recurrence, and complications were similar in both groups. When PORT was omitted in 83 patients with PN0 necks, there were only three treatment failures.

In Australia, experience at the Peter MacCallum Cancer Center at the University of Melbourne also appears to support the potential use of unilateral radiation therapy for lateralized tonsil primaries, even with advanced ipsilateral nodal disease. Results from a 2013 retrospective review of all 167 tonsillar cancer patients treated with curative intent (1990-2002) showed that the 5-year rates for local, nodal, locoregional, and distant failures were 14%, 4%, 18%, and 8%, respectively. The majority (58%) of patients had stage IV disease, and 86% were current or ex‐smokers. There were no contralateral nodal failures in 58 patients treated unilaterally, even though 33% had N2a, N2b, or N3 nodal disease.

Evidence for improved morbidity with IMRT restricted to the ipsilateral neck is also growing. In 2011, the phase III randomized controlled PARSPORT study demonstrated significant functional and overall QOL benefits in pharyngeal squamous cell carcinoma (T1-4, N0-3, M0) with the use of parotid-sparing IMRT compared with conventional radiotherapy.

In 94 patients treated at six radiotherapy centers in the U.K., significant recovery of saliva secretion was seen at 12 and 24 months with IMRT compared with conventional radiotherapy. Clinically significant improvements in dry mouth-related and global QOL scores were also reported. At 2 years, there were no significant differences in non-xerostomia late toxicities, locoregional control, or OS between the groups.

In 2007, results from a Danish study in patients with cancer of the oropharynx showed that ipsilateral radiotherapy of curative intent did not negatively influence locoregional control or survival compared with bilateral radiotherapy. In fact, the researchers found that the only factors that differed between the two treatment groups were primary tumor extension outside the tonsillar fossa and T stage.

However, the significant difference in adverse effects seen in patients who received ipsilateral treatment were compelling. These patients experienced a 50% reduction in moderate to severe treatment side effects compared with those treated with bilateral radiotherapy. This included all radiotherapy-induced morbidity — xerostomia, dysphagia, hoarseness, atrophy, and edema — with the exception of fibrosis.

Note:
Thorstad reported a financial relationship with Elekta; several co-authors also disclosed financial relationships with industry.

November, 2019|Oral Cancer News|

How dental professionals can help patients with xerostomia

Source: www.dentistryiq.com
Author: Jennifer Pettit, CRDH

Xerostomia affects up to 65% of the population, according to the American Academy of Oral Medicine.1 Many patients might experience dry mouth and accept it as a part of their life without seeking treatment or mentioning it to a health-care professional. It is important to recognize the signs of xerostomia to help reduce patients’ symptoms and prevent the consequences it carries.

Xerostomia is the reduction of salivary flow. The majority of saliva is produced by the parotid gland, followed by the lingual and submandibular glands. Saliva plays multiple roles in the oral cavity. It carries enzymes to help us digest food. It moistens food to create a bolus for easy passage through the esophagus. It also carries buffering agents to neutralize the pH of the oral environment, which can help prevent demineralization of tooth structure and caries lesions. It protects the oral mucosa and tongue from irritants such as bacteria and fungus. Lastly, it cleanses the teeth of small food particles.1

Hyposalivation is associated with many factors. According to the American Dental Association, more than 400 medications cause dry mouth as a side effect.2 The most well-known prescriptions to cause dry mouth are antipsychotics, anticonvulsants, bronchodilators, and certain hypertension medications.2 Other factors contributing to low saliva flow are aging, smoking, radiation therapy to the neck and head, and some diseases and conditions such as HIV/AIDS, diabetes, rheumatoid arthritis, thyroid dysfunctions, and Sjögren’s syndrome, just to mention a few.2

Oral manifestations of xerostomia include dry or chapped lips, mouth sores, fissured tongue and mucosa, salivary threads while talking, enamel erosion, and rampant caries. Symptoms described by patients are a burning or tingling sensation of the mucosa and tongue, difficulty swallowing dry foods, bad breath, altered taste buds, thirst, and cotton mouth.3

Once you have reviewed a patient’s medical history and medication list, there are many products you can recommend. To start off, a wide variety of over-the-counter medications can treat the symptoms of xerostomia. The most popular brands are Biotene (GSK), Act, Colgate, and TheraBreath, and they are available as mouthwashes, lozenges, xylitol mints and gums, gels, and sprays. Most over-the-counter products help to stimulate salivary flow or are used as a saliva substitute. These are typically used as needed throughout the day.

Prescription saliva substitutes, such as Caphosol (Eusa Pharma), NeutraSal (OraPharma), and SalivaMax (Forward Science), are available as well. The FDA has approved two systemic medications that need to be prescribed by a medical professional.2 One of them is pilocarpine, known by its brand name Salagen, which is a tablet to treat oral dryness associated with radiation therapy. The second is cevimeline, also known by its brand name Evoxac, a pill used to treat oral dryness associated with Sjögren’s syndrome. The newest prescription spray available on the market is 3M Xerostomia Relief Spray, which is the only lipid-based solution that coats the mucosa, throat, and tongue to prevent water loss and restore elasticity. All medications, both over-the-counter and prescription, should be taken with caution, as they may have their own side effects and contraindications.

Patients should be encouraged to receive an in-office application of 5% fluoride varnish. Home care should include a prescription-strength fluoride toothpaste, such as Colgate Prevident 5000 or 3M Clinpro 5000. GC America also offers two at-home treatments: GC Dry Mouth Gel to lessen symptoms and MI Paste to be applied as a topical tooth cream after brushing and flossing. MI Paste contains calcium, phosphate, and fluoride to remineralize teeth. A formula without fluoride is also available. Other recommendations you can make include using lip balm, sipping on water or licking ice cubes, and avoiding tobacco, alcohol, and salty or spicy foods.3

Dental professionals should keep an eye out for dry mouth signs as a preventive measure and guide patients through the many options available to reduce their symptoms. Over-the-counter medications might not be a cookie-cutter solution for everyone, and some trial and error might be necessary for patients to find the best product to treat their symptoms without causing any additional side effects.

References

1. Sankar V, Rhodus N; AAOM Web Writing Group. Xerostomia. American Academy of Oral Medicine website. https://www.aaom.com/index.php%3Foption=com_content&view=article&id=107:xerostomia&catid=22:patient-condition-information&Itemid=120. Updated October 15, 2015.

2.Center for Scientific Information; American Dental Association Science Institute. Xerostomia (Dry Mouth). American Dental Association website. https://www.ada.org/en/member-center/oral-health-topics/xerostomia. Updated August 27, 2018.

3Sankar V, Rhodus N; AAOM Web Writing Group. Dry Mouth. American Academy of Oral Medicine website. https://www.aaom.com/dry-mouth. Updated October 15, 2015.

Author:
Jennifer Pettit, CRDH, is a full-time dental hygienist at HQ Dontics, a prosthodontics office in Miami, Florida. She graduated from Miami Dade College in 2010 and has always had a passion for dental health. She takes pride in educating patients to prevent disease and finding the best solutions to suit their needs.

Ask the Dentist: Cancer patients should be aware how radiotherapy can affect saliva

Source: www.irishnews.com
Author: Lucy Stock

SALIVA – we normally give little thought to our spit but we definitely notice when it’s not there. Every day in the UK 31 people are diagnosed with a head and neck cancer. With increasing numbers of people undergoing radiotherapy for head and neck cancers there are more people living with the side-effects of not having enough saliva.

Dry mouth, termed xerostomia, is common after radiotherapy. It’s not only extremely uncomfortable, it makes speaking and swallowing more difficult and alters how things taste. Food can taste saltier, metallic; you can lose your sense of taste totally; and perhaps even worse, foods can taste foul, like sour milk.

Not being able to chew and swallow easily can reduce how much you eat and how well you eat, leading to weight loss and poor nourishment.

Saliva performs numerous jobs. It starts digestion by breaking down food and flushes food particles from between the teeth. Crucially, saliva contains minerals such as calcium and phosphate that keep teeth strong. So no saliva means that teeth decay rapidly and extensively. Even voice quality can change.

Without enough saliva, bacteria and other organisms in the mouth take the opportunity to grow uncontrollably. Nasty sores and mouth infections, including yeast thrush infections, are run-of-the-mill.

Luckily a dry mouth is usually a temporary nuisance that clears up in about two to eight weeks but it can take six months or longer for the salivary glands to start producing saliva again after radiotherapy ends.

In a 2017 study, out of several treatments tested, the drug pilocarpine gave the most significant improvement in dry mouth following radiotherapy. However, you may experience a side effect, albeit short lived, from this medication and it can take a couple of months to work.

Artificial salivas are available as lozenges, sprays and gels, the downside being that their benefits last only a few hours. The Biotene range is specially designed to help relieve dry mouths and includes toothpastes, mouthwashes and gels to give comfort and protect the teeth.

You can buy small atomiser spray bottles from most chemists and fill them with water or fluoride mouthwash. If you cannot swallow, your nurse or doctor can give you a nebuliser to moisten your mouth and throat. Always visit your dentist before cancer treatments to maximise the health of your mouth.

Relieve a dry mouth by:

  • Sipping water often
  • Avoiding drinks with caffeine which dry out the mouth
  • Chewing sugarless gum
  • Avoiding spicy or salty foods, which may cause pain
  • Avoiding tobacco or alcohol
  • Using a humidifier at night.

Forgotten patients: New guidelines help those with head-and-neck cancers

Source: www.fredhutch.org
Author: Diane Mapes and Sabrina Richards

Stigma, isolation and medical complexity may keep patients from getting all the care they need; recommendations aim to change that.

Like many cancer patients, Jennifer Giesel has side effects from treatment.

There’s the neuropathy in her hands, a holdover from chemo. There’s jaw stiffness from her multiple surgeries: an emergency intubation when she couldn’t breathe due to the golf ball-sized tumor on her larynx and two follow-up surgeries to remove the cancer. And then there’s hypothyroidism and xerostomia, or dry mouth, a result of the 35 radiation treatments that beat back the cancer but destroyed her salivary glands and thyroid.

“I went to my primary care doctor a couple of times and mentioned the side effects,” said the 41-year-old laryngeal cancer patient from Cleveland, who was diagnosed two years ago. “She was great but she didn’t seem too knowledgeable about what I was telling her. She was like, ‘Oh really?’ It was more like she was learning from me.”

Patients like Giesel should have an easier time communicating their unique treatment side effects to health care providers with the recent release of new head-and-neck cancer survivorship guidelines. Created by a team of experts in oncology, primary care, dentistry, psychology, speech pathology, physical therapy and rehabilitation (with input from patients and nurses), the guidelines are designed to help primary care physicians and other health practitioners without expertise in head-and-neck cancer better understand the common side effects resulting from its treatment. The goal is that they’ll then be able to better make referrals or offer a holistic plan for patients to get the support they need.

“Head-and-neck cancer survivors can have enormous aftereffects from the disease and treatment by virtue of the location of the primary tumor,” said Dr. Gary Lyman, a public health researcher with Fred Hutchinson Cancer Research Center who helped create the guidelines. “There are functional interruptions, like losing the ability to talk, eat or taste. And some of the surgeries can be disfiguring.

“I’m really glad the American Cancer Society decided to take this on,” he said. “These guidelines are sorely needed, long overdue and will serve cancer patients who are incredibly affected — both physically and emotionally.”

Currently, there are more than 430,000 head-and-neck cancer, or HNC, survivors in the U.S., accounting for around 3 percent of the cancer patient population.

As with many other cancers, HNC is an umbrella term for a number of different malignancies, including cancers that develop in or around the mouth, tongue, throat, nose, sinuses or larynx. Brain, thyroid and esophageal cancer are not considered head-and-neck cancers.

HNC has traditionally been linked to tobacco and alcohol use, and about 75 percent of HNC are related to these risk factors. Increasingly, though, human papillomavirus, or HPV, is causing a significant number of head-and-neck cancers (another reason why the HPV vaccine is such an important prevention tool).

An isolating group of diseases
For some patients with HNC, there can be a certain amount of stigma and isolation, due to its association with drinking and smoking. Treatment can also isolate patients since it sometimes mars a person’s appearance or alters their speech.

Some patients, literally, have no voice.

HNC’s complicated nature — it’s not one disease but several, all of which behave and respond to treatment differently — also results in very small patient populations, which can hinder research.

“Head-and-neck cancer patients have historically been somewhat ignored,” said Lyman, an oncologist with Seattle Cancer Care Alliance, Fred Hutch’s treatment arm. “Many view this as a lifestyle-associated cancer, like lung cancer, heavily influenced by tobacco exposure and [drinking] alcohol to excess. And people may have difficulty dealing with the appearance of some of the more severely affected patients.”

t’s a sentiment echoed by Dr. Eduardo Méndez, a Fred Hutch clinical researcher and head-and-neck cancer surgeon at SCCA.

“It’s in a location that affects your appearance, it affects your ability to speak and to swallow, and those are all things that you need to interact with others,” he said. “It can have an effect of shutting you down from the rest of society. Even the treatment for head-and-neck cancer can have consequences that affect those very same things that the tumor was affecting — swallowing, speech, appearance.”

Not surprisingly, many HNC survivors suffer from depression and/or body image and self-esteem issues after diagnosis and treatment.

“I struggle with body image issues every day,” said Beci Steelman, a 42-year-old court clerk from Bushnell, Illinois, who went through radiation and eight surgeries, including a total right maxillectomy (a surgery of the upper jaw), after being diagnosed with a rare head and neck tumor in 2010.

“You can see that my eye looks like someone’s pulling it halfway down my cheek,” she said. ”My mom and I just call it my googly eye and joke that I have ‘really good face days’ and others that are just ‘face days.’ Clearly something’s not right. When I smile, you can see a bit of metal from the obturator, this weird rubbery dental piece that plugs the hole in the roof of my mouth. Some days I just feel like I’m so ugly.”

Holistic approach benefits patients
There is good news with these cancers: most patients are diagnosed with HNC in its early, most curable stages.

“The majority will be completely functional and normal [after treatment],” said Dr. Christina Rodriguez, the medical oncologist who oversees the majority of HNC patient care at SCCA.

According to the National Comprehensive Cancer Network, around 80 to 90 percent of early stage patients (stage 1 and 2) go into remission after receiving surgery or radiation. Advanced stage patients (stage 3 and 4) receive more aggressive treatment and have lower cure rates, with the exception of patients with HPV-related head-and-neck cancers. Their 5-year cure rates are close to 90 percent.

But even those who go into remission may have to contend with a constellation of difficult side effects.

The head and neck area is “like a fine-tuned machine,” said Dr. Keith Eaton, a medical oncologist at SCCA and Fred Hutch who specializes in lung cancer and HNC. “There are so many dedicated structures that we can’t do without. If you get rid of half your liver, not a problem. If your epiglottis doesn’t work, you aspirate.”

In addition to trouble with swallowing and speech, stiffness in the jaw and problems with shoulder and neck mobility, HNC patients can be left with hypothyroidism, hearing loss, taste issues, periodontitis and lymphedema, the swelling that comes after lymph nodes are surgically removed, a common step in cancer treatment. Because of this complexity, patients need a holistic approach, said Méndez.

Steelman’s cancer extended to the orbital floor of her right eye which meant she had to undergo extensive surgery to her face including the removal of four back teeth, an incision to the roof of her mouth and the shortening of a jaw muscle.

“They got the tumor out and then put me back together,” she said. “I feel like Humpty Dumpty.”

She now wears a prosthetic (which requires daily maintenance) and has had injectable fillers to help with the atrophy around her right eye (an implant in the area became infected and had to be removed). She’s lost hearing in her right ear, her speech is sometimes “a little marble-y,” she has dry mouth from damage to her salivary glands and her jaw will not open as wide as it once did.

Steelman tapped a number of specialists to help her deal with these issues, including an otolaryngologist (ear, nose and throat doctor), speech pathologist, a prosthodontist (an expert in the restoration and replacement of teeth) and a plastic surgeon.

“You have to be your own advocate,” she said. “You learn that very quickly.”

Get help early
Physical therapists, speech pathologists, dietitians and providers with expertise in palliative and pain care (also called supportive care) can improve survivors’ quality of life enormously, especially when therapy is started early.

“Careful — and early — attention to side effects and treatment-related complications can help optimize survivors’ quality of life,” said Eaton, the SCCA oncologist.

Dr. Elisabeth Tomere, a physical therapist at SCCA, said she and her colleagues prescribe exercises that help patients regain strength, range of motion and tissue flexibility that surgery and/or radiation may have diminished. Some patients, for instance, need help building up their trapezius muscle to improve shoulder function they have lost after neck surgery. Others need to learn movements that strengthen the front of their necks and the muscles needed to maintain posture.

Patients with lymphedema in the face and neck — a common side effect from HNC treatments — can also benefit from early intervention by a physical therapist, said Tomere.

“These issues are all helpful to address as quickly as possible so they’re not ongoing,” she said, adding that it may take up to two years for patients to mentally and physically recover from treatment.

“We try to give people a realistic timeline,” she said.

The new ACS guidelines should help providers without expertise in head-and-neck cancers find the right specialists for their patients, she said.

Cancer physical therapy, while new, is becoming more standard. Both the American Physical Therapy Association and the Lymphology Association of North America allow providers or patients to search for specialized physical therapists near them — a boon to primary care providers who are not “connected to that world,” said Tomere.

Dietitians can play a key role, too, since many HNC patients struggle to eat. Treatments can cause dry mouth, taste changes or make chewing difficult. Food can become unappetizing or difficult to ingest.

“There’s an emotional component. Food becomes medicine,” said Linda Kasser, an SCCA dietitian and specialist in oncology nutrition. Patients must eat to keep their weight up, “but it can become exhausting … Sometimes they need to force themselves to eat. They feel pressured, which can contribute to family tensions and even food aversions.”

Dietitians can offer approaches to help patients maintain their weight and strength, from using new cooking strategies to make food more palatable to recommending temporary feeding tubes inserted into the stomach that help patients avoid the pain of chewing and swallowing altogether. They also help alleviate patients’ worries about food and separate “nutrition fallacy from fact,” said Kasser.

Not surprisingly, communication is strongly emphasized in the guidelines.

“We wanted to make sure that there is open communication between the providers and caregivers,” said Lyman. “That there’s a care plan that the patient understands and the caregiver understands. All the different specialists involved in the care should be on the same page.”

The new guidelines also emphasize lifestyle choices that will help to reduce the risk of HNC recurrence and secondary cancers: smoking cessation, limiting use of alcohol, regular exercise and good oral hygiene.

Exciting new research
Chemotherapy, radiation and surgery remain the standard of care for HNC — and drive many of the side effects covered by the new ACS care guidelines — but recent advances are making researchers like Méndez very optimistic for future care.

Thanks to advances in genomics, researchers now know that the mutations found in head and neck tumors vary widely.

“One size will not fit all,” said Méndez. “Treatment will have to be individualized.”

Méndez is leading efforts at Fred Hutch to develop tailored therapies based on the cancer’s genomic mutations, zeroing in on cancer cells’ “Achilles heels” — molecular pathways that tumor cells rely on to survive but that normal cells can do without. The approach is already paying dividends: Méndez is currently leading a clinical trial of a drug he and his team identified that exploits a vulnerability unique to head and neck tumors missing a key gene called p53.

“Once we understand the genotype driving tumor growth, strategies [for treatment] can become more targeted, more effective and less toxic,” he said.

New robotic-assisted surgery has also transformed the procedure for certain patients with tumors in the larynx and at the base of the tongue, allowing surgeons to perform fewer incisions and better preserve functions like swallowing and speech, he said.

Immunotherapy also looks like a very promising path to better HNC treatments.

“New immunotherapy drugs are getting FDA approval for head and neck cancer,” said Méndez. “I think in the next few years we will see it moving to a first-line therapy. It’s a very exciting time for head and neck cancer.”

For patients like Steelman and Giesel, that’s great news.

“I had a social worker who helped me get through the thick of [treatment], but nobody talked about what it would be like when treatment was over,” said Giesel, who had to teach herself how to swallow food a new way (she no longer has an epiglottis). “I thought I’d be returned to myself and I’d be fine, but it was not like that in any way.”

These new guidelines, she said, will help patients like her get the help they truly need.

“Primary care doctors need to know about the physical and emotional effects,” she said. ”I have a lot of good support and know how to ask for help, but I can’t imagine how [patients] who don’t know how to ask for help explain how they’re feeling.”

Do you or someone you love have a head-and-neck cancer? Join the conversation about treatment challenges and how the new guidelines might help on our Facebook page.

About the authors:
Diane Mapes is a staff writer at Fred Hutchinson Cancer Research Center. She has written extensively about health issues for NBC News, TODAY, CNN, MSN, Seattle Magazine and other publications. A breast cancer survivor and patient advocate, she writes the breast cancer blog doublewhammied.com and tweets @double_whammied. Reach her at dmapes@fredhutch.org.

Sabrina Richards is a staff writer at Fred Hutchinson Cancer Research Center. She has written about scientific research and the environment for The Scientist and OnEarth Magazine. She has a Ph.D. in immunology from the University of Washington, an M.A. in journalism and an advanced certificate from the Science, Health and Environmental Reporting Program at New York University. Reach her at srichar2@fredhutch.org.

Note:
1. Original article available at: http://www.fredhutch.org/en/news/center-news/2016/04/new-survivorship-guidelines-spotlight-head-and-neck-cancers.html

April, 2016|Oral Cancer News|

Improving QOL in head and neck cancer as survival improves

Source: www.medscape.com
Author: Zosia Chustecka

In patients undergoing radiation treatment for head and neck cancer, reducing the radiation to organs not affected by cancer is key to improving quality of life post-treatment.

Several studies presented here at the 2014 Multidisciplinary Head and Neck Cancer Symposium described new approaches to sparing radiation delivered to the salivary glands and to the voice box, without any loss of cancer control, but with a reported reduction in adverse effects, such as xerostomia (dry mouth), and an anticipated reduction in loss of voice and speech quality.

Improvements in such outcomes are becoming increasingly important as the epidemiology of head and neck cancer is changing, and the increase in human papillomavirus-positive disease means that patients are being diagnosed their 50s and will, in many cases, go on to live for decades after their definitive cancer treatment, researchers commented at a press briefing.

Xerostomia can make it difficult to speak, as well as chew and swallow, and can lead to dental problems. “Dry mouth might seem trivial, but it actually has a significant effect on quality of life,” commented Tyler Robin, PhD, an MD candidate in his final year at the University of Colorado Medical School in Denver.

To reduce this adverse effect, intensity-modulated radiation techniques are already directing the beam away from the parotid gland, which is responsible for stimulated saliva production, for example during eating. But for the rest of the time, saliva is produced unstimulated from the submandibular gland. “This gland actually produces the majority of saliva for the majority of the day,” he said.

“Historically, however, there had been hesitation to spare the submandibular gland from radiation because there are lymph nodes near the gland that also end up not getting treated,” he said. “While this seems worrisome because head and neck cancer spreads through the lymph nodes, it is well established that the risk of cancer involvement in the lymph nodes near the submandibular gland is exceedingly low, yet the benefit of sparing the gland for a patient’s quality of life is high.”

Dr. Robin presented data from 71 patients with advanced head and neck cancer who were treated with radiation that spared the contralateral submandibular gland in a collaborative study conducted at the University of Colorado and the Memorial Sloan-Kettering Cancer Center in New York City. The mean radiation dose delivered to the contralateral gland was 33.04 Gy./p>

At a median follow-up of 27.3 months, none had had cancer recurrences in the spared area.

This is preliminary evidence that submandibular gland-sparing radiotherapy is feasible technically, and that it is safe even in advanced-stage node-positive cancers, the researchers conclude. They suggest that these outcomes data “offer significant promise for decreasing morbidity.”

More data on this submandibular gland-sparing approach were presented at the meeting by Moses Tam, BS, an MB candidate in his final year at New York University School of Medicine in New York City, who was also an author on the previous presentation.

He reported data from 125 patients (median age, 57 years) with oropharyngeal cancer (53% base of tongue, 41% tonsil, 6% other), all of whom had node involvement (16% N1, 8% N2A, 48% N2B, and 28% N2C).

All patients underwent chemoradiation, but some patients had sparing radiation, with a reduction of radiation treatment volume to the submandibular (level 1B) lymph nodes, while the remainder had radiation without sparing.

The sparing approach significantly reduced the dose of radiation to the submandibular salivary glands (from 70.5 Gy to 63.9 Gy in the ipsilateral gland, and from 56.2 Gy to 43.0 Gy in the contralateral gland), and also to the oral cavity (from 45.2 Gy to 36.1 Gy; all P < .001).

Both groups of patients had a similar 2-year local regional control rate — 97.5% with sparing radiation and 93.8% with nonsparing radiation — indicating a low rate of tumor recurrence at the original tumor site.

However, those who received the sparing radiation had significant improvement in both patient-reported xerostomia summary scores ( P = .021) and observer-rated xerostomia scores ( P = .006), compared with the other group.

“Our data show that it is safe to spare the lymph nodes in oropharyngeal cancer from radiation,” Tam commented. This approach reduces the radiation dose to several nearby salivary organs, and therefore causes less damage to a patient’s post-treatment salivary function.

Effects on Voice and Speech Under-recognized

In contrast to the attention that has been focused on chronic mouth dryness and swallowing difficulties as complications of radiotherapy, relatively little attention has been paid to treatment-related changes in voice and speech quality, commented Jeffrey Vainshtein, MD, chief resident in the Department of Radiation Oncology at the University of Michigan in Ann Arbor.

In fact, physicians tend to underestimate the detrimental effects of head and neck radiation on this aspect of patients’ quality of life, he commented, and presented data showing a wide discrepancy between the reports from patients as compared to physicians on a voice and speech quality assessment tool.

The finding comes from a study conducted in 91 patients with stage III or IV oropharyngeal cancer who had participated in trials at the University of Michigan and been treated with definitive concurrent chemotherapy (weekly carboplatin and paclitaxel) and organ-sparing intensity-modulated radiation therapy (IMRT).

Patient-reported results show a maximal decrease in voice and speech quality at 1 month, with 41% to 68% of patients (using 2 different questionnaires) reporting worse quality than pretreatment baseline levels. Voice and speech quality returned to baseline levels by 12 to 18 months, but not in all patients. At 12 months, 28% to 33% of patients continued to report lower voice and speech quality.

In contrast, physicians reported that larynx toxicity was rare, and reported grade 1 toxicity in 5% of patients at 6 months, and in none at 1 and 2 years.

“It’s interesting to see this physician and patient disconnect,” commented Mitchell Machtay, MD, chair of radiation oncology at Case Western Reserve University in Cleveland, who moderated the press conference.

Dr. Vainshtein said that the degree of disconnect was “quite surprising,” but added that this is not unique to this study or to oncology, and indeed is seen throughout medicine. He suggested that physicians may miss the subtleties of changes in quality of life, and also some patients may not mention symptoms when talking with their doctor, but once they are asked in detail in a structured questionnaire, the results can be quite informative. He also said that more emphasis should be, and in fact is already being, placed on patient-reported outcomes in clinical trials.

Further analysis showed that the mean radiation dose to the voice box (glottic larynx) was independently associated with poor voice quality, while patient-perceived speech difficulties were related to the radiation dose received by both the voice box and the oral cavity.

These findings, from the largest prospective study of this issue to date, support limiting the mean radiation dose to the glottic larynx to less than 20 Gy during whole-neck IMRT for head and neck cancer when the larynx is not a target, the researchers conclude.

Minimizing the radiation dose is likely to reduce voice and speech problems, and thus improve post-treatment quality of life, Dr. Vainshtein commented.

Notes: The authors have disclosed no relevant financial relationships.
Source: 2 2014 Multidisciplinary Head and Neck Cancer Symposium (MHNCS): Abstracts 12 (Robin), 121 (Vainshtein), 139 (Tam). Presented February 21, 2014.

February, 2014|Oral Cancer News|

Effects of Chemoradiation on Voice and Speech Quality of H&N Cancer Patients

Source: Med Page Today
Published: February 23, 2014
By: Charles Bankhead
 

 

SCOTTSDALE, Ariz. — Patients with oropharyngeal cancer reported significant voice and speech impairment for up to 2 years after chemoradiation therapy, but most of their doctors saw no evidence of it, data from a prospective study showed.

Two years after treatment, a fourth of patients said their voice and speech remained below baseline levels, whereas none of their clinicians noted any impairment. At no time did as many as 10% of clinicians report patients with speech and voice issues, whereas the proportion of patients reporting problems ranged as high as 56%.

The likelihood of patient-reported difficulties with oral communication increased with the radiation dose to the glottic larynx, reported Jeffrey M. Vainshtein, MD, and colleagues at the Multidisciplinary Head and Neck Cancer Symposium.

“Our findings highlight the critical role of patient-reported outcomes in identifying areas of improvement of our current therapies, which may ultimately translate into improvements in quality of life for our patients,” Vainshtein, of the University of Michigan in Ann Arbor, said during a press briefing.

Dysphagia and xerostomia are recognized adverse effects of chemoradiation for head and neck cancer and have been studied extensively in recent years. In contrast, a paucity of information exists relative to the effects of chemoradiation on voice and speech quality, Vainshtein said.

To examine the issue, investigators assessed voice and speech outcomes in 93 patients who underwent chemoradiation for oropharyngeal cancer, using intensity-modulated radiation therapy (IMRT). At baseline, and then every 3 to 6 months after finishing treatment, patients completed two validated questionnaires: Head and Neck Quality of Life (HNQOL) and University of Washington Quality of Life (UWQOL).

At the same intervals, the patients’ physicians reported their assessments in accordance with the Common Terminology Criteria for Adverse Events.

All of the patients had locally advanced stage III/IV oropharyngeal cancer and received treatment in two clinical trials of organ-sparing IMRT. Radiation therapy protocols were designed to minimize the radiation dose to the pharyngeal constrictors, salivary glands, oral cavity, glottic larynx, supraglottic larynx, and esophagus.

Vainshtein and colleagues analyzed patient questionnaires to identify factors associated with voice and speech impairment, in addition to the frequency of impairment.

By the HNQOL communication domain and speech impairment domain of the UWQOL, radiotherapy-induced speech impairment reached a maximum in the first month after treatment. Impairment then decreased in subsequent assessments, stabilizing at 12 to 18 months.

The proportion of patients reporting post-treatment speech and voice impairment followed a time pattern consistent with speech impairment reflected in answers to the questionnaires. By the HNQOL, 68% of patients said their voice and speech quality were impaired versus baseline, decreasing to 56% at 3 months, 46% at 6 months, 33% at 12 months, 31% at 18 months, and 24% at 24 months.

By the UWQOL, the proportion of patients reporting worsening of voice and speech quality after treatment was 41%, 26%, 29%, 28%, 15%, and 22% at the assessments from 1 to 24 months after finishing therapy.

In contrast, few physicians included voice and speech impairment in their adverse event reports. Vainshtein said 7% of physicians reported grade 1 toxicity with respect to worsening of voice and speech at 3 months, 5% at 6 months, and 0% thereafter.

Comparing treatment characteristics and patient-reported voice quality worsening, investigators found an association between radiation dose to the larynx and patient-reported impairment at 6 and 12 months. Reported impairment at 6 months increased from 25% with a cumulative radiation dose of <20 Gy to 59% at >30-40 Gy, 50% at 40-50 Gy, and 64% with laryngeal doses >50 Gy (P=0.02).

A similar pattern emerged from the analysis of 12-month outcomes, as the proportion of patients reporting worsening of voice quality from baseline increased from 10% for laryngeal radiation doses <20 Gy to 63% of patients for cumulative doses >50 Gy (P=0.011).

“We observed similar findings for patient-reported voice quality worsening and speech impairment,” Vainshtein said. “The results were independent of other patient and treatment factors.”

Press briefing moderator Mitchell Machtay, MD, said he found the study eye opening.

“If you looked at radiation dose to larynx, not the area where the tumor was, I was struck by how doses of 20 to 30 Gy, which we don’t normally consider as very toxic high doses that can damage the voicebox, still caused a fair amount of damage,” said Machtay, of University Hospitals Case Medical Center in Cleveland.

The magnitude of disconnect between patient and physician assessments was one of the more surprising findings in the study.

“I don’t think it’s unique to head and neck cancer. I don’t think it’s unique to our study. I don’t think it’s unique to medicine,” Vainshtein said. “I think physicians tend to underestimate the effect of their treatment — whatever it is — on our patients.”

Some adverse effects can be subtle and do not become apparent during conversations with physicians, he continued. When the patients express their sentiments in a more formal manner, such as a questionnaire, the effects do emerge.

Some of the disconnect reflects differences in patients’ approaches to their illness and adverse effects of treatment, said Wade Thorstad, MD, of Washington University in St. Louis.

“There’s a group of patients, when you’re interviewing them about their symptoms, will tell it like it is and really explain things well,” said Thorstad, another participant in the press briefing. “There’s another group that is stoic, and they really underplay their issues before [their physician]. However, when they are filling out a questionnaire about their feelings about quality of life, I think you get a more honest assessment.”

 

* This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

 

February, 2014|Oral Cancer News|

Positive results for Acacia in cancer drug trials

Source: http://www.businessweekly.co.uk/
Author: staff

Positive results from a Phase II study of APD515 – a drug to treat xerostomia (dry mouth) in advanced cancer patients – have been reported by Cambridge UK medical technology business Acacia Pharma.

The study showed that APD515 significantly reduced the symptoms of dry mouth compared to placebo.

Dr Julian Gilbert, Acacia Pharma’s CEO said: “Dry mouth is a common and distressing issue in advanced cancer patients that is significantly under-recognised.

“It is associated with a wide range of oral and systemic complications and can contribute to a greatly reduced quality of life. Our market research indicates that a locally delivered, liquid formulation of a suitable salivary stimulant would be of major benefit to many cancer sufferers, and these data indicate that APD515 should meet this profile.”

The trial was conducted in 11 centres in the UK and Denmark and enrolled 32 patients with advanced cancer and a persistently dry mouth http://kodu.ut.ee/~roma1956/images/phocagallery2/gallery/generic-cialis.html.

The study met its primary endpoint of a significant improvement in the subjective scoring of mouth dryness after one week of treatment with APD515 compared to placebo.

Dr. Gabriel Fox, Acacia Pharma’s chief medical officer, added: “This was a robust trial, whose cross-over design allowed us to compare the effects of APD515 and placebo in the same patient.

“The study has shown an unequivocal benefit for APD515 in advanced cancer patients suffering with a dry mouth. APD515 is the first product opportunity to be developed in this hitherto poorly managed patient group.”

Initially, Acacia Pharma intends to develop APD515 in advanced cancer patients, up to 80 per cent of whom suffer from some degree of xerostomia, either as a direct result of their disease or as a consequence of their chemotherapy or other medicines they are taking.

APD515 also has the potential to be developed for other xerostomic patient populations. The company will be optimising the formulation and presentation in preparation for Phase III testing in an advanced cancer population.

October, 2013|Oral Cancer News|

IMRT plus chemotherapy offers high locoregional control in advanced nasopharyngeal carcinoma

Source: www.healio.com

Treatment with intensity-modulated radiotherapy and concurrent weekly chemotherapy improved xerostomia and dysphagia in patients with advanced nasopharyngeal carcinoma, according to study results presented at the WIN Symposium.

Researchers in China recruited 310 patients with stages III to IVb nasopharyngeal carcinoma. All patients received curative IMRT plus weekly chemotherapy with cisplatin (40 mg/m2). Patients received doses of 66 to 70.4 Gy to the gross tumor volume, 60 Gy to the first clinical target, and 54 to 56 Gy to the second clinical target.

“The medial group retropharyngeal nodes were never contoured as clinical target volume, aiming to spare the pharyngeal constrictors unless they were involved,” the researchers wrote. “[The] level 1b node was selectively contoured as clinical target volume in order to spare the submandibular glands and oral cavity.”

Patient-reported and observer-related scores assessed swallowing and salivary gland function at baseline and periodically up to 3 years after treatment.

Median follow-up was 39 months. At 3 years, researchers reported a local RFS rate of 93.6%, a regional RFS rate of 95.8% and a distant metastases-free survival rate of 80%.

Researchers reported no marginal or out-of-field relapses.

Patients’ dysphagia and xerostomia worsened during late courses of treatment, as well as after treatment, yet scores gradually improved after therapy. Dysphagia was minimal or absent at 9 months post radiotherapy, whereas xerostomia improved from 3 to 15 months post radiotherapy and remained steadily until the conclusion of follow-up.

“IMRT concurrent with weekly chemotherapy aiming to reduce xerostomia and dysphagia can be safely performed for locally advanced [nasopharyngeal carcinoma] and has high locoregional control rates,” researchers wrote. “Distant metastasis remains the main failure pattern. Long-term patient-reported and observer-rated swallowing and salivary glands function were only slightly worse than baseline.”

Note:
1. Wang XS. Abstract #P6.17. Presented at: WIN Symposium; July 10-12, 2013; Paris.

July, 2013|Oral Cancer News|

Lower radiation reduces xerostomia in head/neck cancer patients

Source: www.drbicuspid.com
Author: DrBicuspid Staff

Lowering the radiation dose to the submandibular gland of patients with head and neck cancer decreases xerostomia, according to a study presented on April 20 at the European Society for Radiotherapy and Oncology (ESTRO) meeting in Geneva.

Radiation oncologists at University Medical Center Utrecht (UMCU) showed for the first time that it is possible to reduce xerostomia in patients treated with radiotherapy for head and neck cancer if the radiation dose to a salivary gland (the submandibular gland) on the opposite side to the tumor is minimized, stated a university press release.

It is the largest study yet to show a correlation between radiation doses to the submandibular glands and their output of saliva. Guidelines for the recommended maximum dose could potentially be issued for use in clinical practice to benefit patients, according to the researchers.

Approximately 40% of head and neck cancer patients suffer from xerostomia in the long term, which causes problems with eating, sleeping, speech, tooth loss, and oral hygiene, leading to diminished quality of life, social isolation, and difficulty in the ability to work. Attempts to treat xerostomia and its consequences can be costly and are not very effective, the study noted.

Therefore, the UMCU researchers looked at using intensity-modulated radiotherapy (IMRT) to treat the tumors and spare the submandibular gland on the opposite side of the tumor and both parotid glands. They also wanted to determine the maximum radiation dose and how the treatment would affect patients’ xerostomia.

They analyzed 50 patients with throat cancers in which cancer cells had not migrated into the contralateral lymph nodes and had not metastasized to other parts of the body. The patients were treated with the contralateral submandibular IMRT and compared with a historical group of 52 patients who had received radiotherapy that had spared only the parotid glands.

After six weeks and after one year, the researchers measured saliva flow objectively from the submandibular and parotid glands by stimulating saliva with citric acid on the tongue and catching the resulting saliva in specially designed cups. They also used a questionnaire to measure the patients’ subjective experience of xerostomia.

Saliva flows from the contralateral submandibular glands were significantly higher at six weeks and at one year in patients who received a dose to the submandibular gland of less than 40 Gy, which translated into fewer complaints of xerostomia, the researchers reported. Using the new technique, they were able to keep the dose to less than 40 Gy in half of the patients.

All but one of the patients who could be treated with radiation doses of less than 40 Gy to the submandibular gland had small tumors (less than 4 cm in diameter). These patients consequently had fewer problems with xerostomia after a year.

The study could lead to guidelines recommending a maximum dose of 40 Gy for the submandibular gland, the researchers noted.

April, 2013|Oral Cancer News|