xerostomia

Acupuncture can prevent radiation-induced chronic dry mouth

Source: http://www.virtualmedicalcentre.com
Author: staff

When given alongside radiation therapy for head and neck cancer, acupuncture has shown for the first time to reduce the debilitating side effect of xerostomia, according to new research from The University of Texas MD Anderson Cancer Center and Fudan University Shanghai Cancer Center.

The study, published in the journal Cancer, reported findings from the first randomised controlled trial of acupuncture for the prevention of xerostomia.

Xerostomia, or severe dry mouth, is characterised by reduced salivary flow, which commonly affects patients receiving radiotherapy for head and neck cancer. Most current treatments are palliative and offer limited benefit, according to Lorenzo Cohen, Ph.D., professor in MD Anderson’s Departments of General Oncology and Behavioral Science and director of the Integrative Medicine Program.

The condition impairs quality of life for patients, as it creates difficulties eating, speaking and sleeping, while also increasing the risk for oral infections.

“There have been a number of small studies examining the benefits of acupuncture after xerostomia develops, but no one previously examined if it could prevent xerostomia,” said Cohen, who is also the study’s principal investigator. “We found incorporating acupuncture alongside radiotherapy diminished the incidence and severity of this side effect.”

Cohen and his colleagues examined 86 patients with nasopharyngeal carcinoma, treated at Fudan University Shanghai Cancer Center. Forty patients were randomised to acupuncture and 46 to the standard of care. Those in the treatment arm received acupuncture therapy three times per week during the seven-week course of radiotherapy. Patients were evaluated before radiotherapy, weekly during radiotherapy, and then again one and six months later.

The results were based on data derived from two self-report questionnaires and measuring actual saliva flow. Patients completed the Xerostomia Questionnaire (XQ), an eight-item survey which assessed symptoms consistent with the condition. XQ scores under 30 corresponded to mild or no symptoms of xerostomia.

The second measure, MD Anderson Symptom Inventory Head and Neck (MDASI-HN), ranked the severity of cancer-related symptoms, other than xerostomia, and their interference with quality of life. The team also measured saliva flow rates using standardised sialometry collection techniques.

Benefits Noticed Quickly

“What was quite remarkable was that we started to see group differences as early as three weeks into radiotherapy for the development of xerostomia, cancer-related symptoms that interfere with quality of life, and saliva flow rates – an important objective measure,” said Zhiqiang Meng, M.D., Ph.D., co-principle investigator of the study and deputy chair of the Department of Integrative Oncology, Fudan University Shanghai Cancer Center.

The largest group differences in XQ scores were seen by the end of radiotherapy, but the differences persisted over time. By one month after the end of radiotherapy, 54.3 percent of the acupuncture group reported XQ scores greater than 30, compared to the control group at 86.1 percent. By six months after radiotherapy, the numbers dropped to 24.1 percent in the acupuncture group and 63.6 percent of the control group still reporting symptoms of xerostomia. Saliva flow rates were also greater in the acupuncture group, starting at three weeks into radiotherapy and persisting through the one and six month follow-up.

Acupuncture also helped cancer-related symptoms, other than xerostomia, as measured by the MDASI-HN questionnaire, with differences that emerged in week three and continued through six months.

“The medical implications are quite profound in terms of quality of life, because while chronic dry mouth may sound benign, it has a significant impact on sleeping, eating and speaking,” Cohen said. “Without saliva, there can be an increase in microbial growth, possible bone infection and irreversible nutritional deficits.”

Additional studies are needed to determine the mechanisms for the benefits of acupuncture, and while the study didn’t examine this issue, Cohen said it may have an impact on local blood flux, specifically at the parotid gland.

Further research is planned, including a large trial conducted at MD Anderson in collaboration with Fudan University Shanghai Cancer Center. Both centers will enroll 150 patients undergoing radiotherapy for head and neck cancer: 50 will receive acupuncture, 50 sham acupuncture and 50 will be enrolled in a control group. Researchers will also examine saliva constituents and a number of other measures to better determine the mechanisms of acupuncture.

Source: MD Andersen Cancer Center: Cancer

November, 2011|Oral Cancer News|

Proper dental care for cancer patients: why it is important

Source: newcanaan.patch.com
Author: Alan B. Sheiner DDS

Common side effects from radiation therapy are not stressed enough in dental schools, but they can be managed and even prevented.

A few weeks ago, I was contacted by a retired physician with whom I had not spoken for a number of years since he retired from practice to become a “gentleman farmer” in the country. While I was happy to hear from him, his news was not so good. He was calling because he had been treated for base of tongue cancer and his teeth were “coming apart”. His cancer treatment consisted of chemotherapy and radiation therapy. Unfortunately, he somehow “slipped through the cracks” and his oral cavity was now suffering from some of the side effects of the cancer therapy – fortunately he is currently cancer free.

The oral cavity, one of the most complex and visible organ systems in the body, is invariably compromised as a result of treatment for head and neck cancer. Whether the malignancy is to be treated by surgery, radiation therapy, chemotherapy or a combination of these modalities, the function, if not also the form, of the oral cavity will be impacted. Aside from the obvious physical changes after cancer surgery to the head and neck region, there are issues which usually accompany radiation therapy to the head and neck region.

There may be side effects from cancer therapy, some of which can be devastating, but preventable or manageable with proper precautions and care. The most common side effects for head and neck cancer patients who undergo radiation therapy are:

Dry Mouth (xerostomia)
Post Radiation Tooth Decay
Inability to open the mouth wide (Trismus)
Necrosis of soft tissue and bone (osteoradionecrosis)
Impaired ability to heal from wounds in the oral cavity

Prior to commencement of active treatment, each patient should be thoroughly evaluated by a dentist well versed in the management and care of the irradiated head and neck cancer patient. Unfortunately, this subject has not been stressed in dental school. Even if a dentist has had some instruction, his or her clinical experience might be quite limited. A real life example of this is a lady irradiated for a parotid gland tumor. The parotid gland (we have two) is a major salivary gland. Her general dentist provided her with fluoride applicators, but unfortunately this practitioner did not appreciate the importance of using a neutral pH fluoride gel. The acidulated fluoride gel, normally used when a dentist or hygienist gives a fluoride treatment, literally ate into the surfaces of this woman’s porcelain crowns. Now, in addition to having a dry mouth from radiation, she also has multiple crowns with surfaces like sandpaper. These expensive restorations could not be salvaged and required replacement. In short, the dentist remembered that radiated patients should have daily fluoride treatment. He just did not have a genuine understanding of how to accomplish the task properly.

The most common and profound side effects of irradiation to the head and neck region are: dry mouth (since the major salivary glands are almost always damaged by the therapy), post-irradiation dental caries (a preventable situation), the risk of osteoradionecrosis (non-healing chronic bone death in irradiated bone which has a compromised blood supply) and trismus (an inability to open the mouth fully).

As always, your dentist is the best resource and first person you should see for consultation.

October, 2011|Oral Cancer News|

New Guidelines for Reirradiation of Head and Neck Cancer

Source: Medscape News Today

When head and neck cancer recurs and surgery is not an option, reirradiation provides the only potentially curative option. However, because the tumor often recurs in the same place or very close to tissue that has already been irradiated, this treatment approach represents a “significant challenge.”

For this reason, it should be handled at a tertiary-care center, according to a new guideline issued by the American College of Radiology. Specifically, it stipulates that the tertiary center should have a head and neck oncology team that is equipped with the resources and the experience to manage the complexities and toxicities of retreatment.

In the guideline, published in the International Journal of Radiation Oncology, Biology and Physics, a panel of experts outline appropriateness criteria for various clinical scenarios that arise with such patients.

It provides a consensus on how patients should be managed.

“This is an important document because it is the first set of guidelines for the potentially curative treatment of patients who have regrowth of head and neck tumors. It provides a consensus on how patients should be managed,” coauthor Madhur Kumar Garg, MD, said in a statement. Dr. Garg is from the Department of Radiation Oncology at Montefiore Medical Center, in the Bronx, New York, where about a dozen reirradiation procedures are performed annually.

Commitment to Retreatment

Retreatment is justified because clinical trial results have shown that local treatment improves overall survival, the panel of experts notes.

However, they emphasize that, before a commitment to retreatment is made, patients presenting with recurrent or second primary tumors need to undergo careful restaging evaluation. In addition to computed tomography (CT) or magnetic resonance imaging to evaluate the extent of the recurrent tumor, the panel urges that strong consideration be given to positron emission tomography with CT to evaluate for metastatic disease, or “at a minimum, a CT scan of the chest should be performed.”

In addition, a detailed history and assessment is needed, which includes documentation of the sequelae of previous treatment, such as fibrosis, carotid stenosis, dysphagia, xerostomia, and osteoradionecrosis.

Retreatment options include surgical resection and palliative chemotherapy — both are regarded as standard of care, the panel writes. But for patients with unresectable disease, reirradiation is the “only potentially curative treatment,” they add.

Two phase 2 clinical trials conducted by the Radiation Therapy Oncology Group (RTOG) have shown survival outcomes with reirradiation plus chemotherapy that appear to be superior to those seen with chemotherapy alone in other studies. However, “whether this apparent improvement is the result of selection bias is uncertain,” the panel explains. A larger phase 3 comparing reirradiation plus chemotherapy with chemotherapy alone was closed because of poor accrual.

In terms of the dose of radiation delivered in the second treatment course, it appears that at least 50 to 60 Gy is needed, the experts report. Both of the phase 2 studies conducted by the RTOG delivered a total dose of 60 Gy, using an accelerated hyperfractionated regimen delivering 1.4 Gy twice daily in 4 week-on/week-off cycles. Multiple single-institution reports of reirradiation have used once-daily standard fractionation in a planned continuous treatment course with less toxicity, they note. However, differences in study designs and in the chemotherapy regimens make it difficult to discern what independent effect, if any, differences in radiation fractionation had on the toxicity that was seen.

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

October, 2011|Oral Cancer News|

Palifermin Decreases Severe Oral Mucositis of Patients Undergoing Postoperative Radiochemotherapy for Head and Neck Cancer: A Randomized, Placebo-Controlled Trial

Source: OncologyStat.com

TAKE-HOME MESSAGE

This randomized, placebo-controlled trial found that weekly palifermin was associated with decreased incidence and duration of severe oral mucositis in patients undergoing postoperative chemoradiotherapy for head and neck cancer.

SUMMARY

OncologySTAT Editorial Team

Combined chemoradiotherapy (CRT) offers improved outcomes after resection of locally advanced head and neck cancer but also increases the risk of oral mucositis, a debilitating and potentially dose-limiting toxicity of locoregional treatment. Palifermin, an analogue of keratinocyte growth factor, is FDA approved to prevent and treat mucositis in patients undergoing high-dose myelotoxic therapy for hematologic malignancies. In this multicenter, randomized, placebo-controlled trial, Henke et al evaluated whether palifermin reduces severe oral mucositis in patients undergoing CRT after surgical resection of locally advanced head and neck cancer.

Adult patients receiving postoperative CRT for high-risk stage II to IVB head and neck squamous cell carcinoma and with an ECOG performance status of 0 to 2 were enrolled from 38 centers in Europe, Australia, and Canada. Eligible study patients were stratified by tumor location (oral cavity/oropharynx or hypopharynx/larynx) and residual tumor (R0 [complete resection] or R1 [incomplete resection]). Study patients received a radiation dose of 60 Gy (R0 group) or 66 Gy (R1 group) plus cisplatin 100 mg/m2 on days 1 and 22, with the study drug administered 3 days prior to starting CRT and then weekly for 6 weeks. Patients who underwent radiotherapy after 6 weeks received an additional 100 mg/m2 of cisplatin and study drug. Oral saline rinses, topical anesthetics, feeding tubes, and hematopoietic growth factors were permitted; oral anti-inflammatory, antifungal, or antibiotic solutions were not permitted.

Patients initially were randomized to three treatment arms: weekly palifermin 180 µg/kg throughout CRT, weekly palifermin 180 µg/kg for 4 doses followed by weekly placebo through the remainder of CRT, or weekly placebo throughout CRT. However, adverse event monitoring led to a restart of the study after enrollment of the first 17 patients, with subsequently enrolled patients randomized to receive weekly palifermin 120 µg/kg (n = 92) or weekly placebo (n = 94) throughout CRT (for a minimum of 7 weeks); efficacy analyses were based on these 186 patients. The primary endpoint was the incidence of severe oral mucositis (WHO grade 3 or 4). Oral mucosa assessments occurred twice weekly throughout CRT and until resolution of oral mucositis to WHO grade ≤ 2 or week 15, whichever occurred first. Among secondary endpoints were duration of and time to onset of severe oral mucositis, incidence of grade ≥ 2 xerostomia at month 4, and incidence of treatment breaks (≥ 5 missed consecutive radiation fractions; chemotherapy delays or discontinuation). Time to disease progression and overall survival (OS) also were assessed.

Of 186 patients randomized to weekly palifermin 120 µg/kg or placebo, 79 in the palifermin arm (86%) and 82 in the placebo arm (87%) completed all oral evaluations. Patients in the palifermin group received a mean radiation dose of 59.7 Gy in a mean of 43.5 days and a mean cumulative cisplatin dose of 217.1 mg/m2. Patients in the placebo group received a mean radiation dose of 59.8 Gy in a mean of 43.2 days and a mean cumulative cisplatin dose of 206.4 mg/m2. Severe oral mucositis was observed in 47 patients (51%) in the palifermin group and 63 patients (67%) in the placebo group (P = .027). The median duration of severe oral mucositis was 4.5 days in the palifermin group vs 22.0 days in the placebo group (P = .037), and the median time to develop severe oral mucositis was 45 vs 32 days (P = .022), respectively. Incidence of grade ≥ 2 xerostomia at month 4, incidence of treatment breaks, time to disease progression, and OS did not differ significantly between the two groups.

In conclusion, weekly palifermin at a dose of 120 µg/kg was associated with reduced incidence, increased time to development, and decreased duration of severe oral mucositis in patients undergoing postoperative CRT for locally advanced head and neck cancer. However, differences in other efficacy endpoints were not statistically different in patients receiving palifermin. Further study of palifermin in this patient population is needed.

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

September, 2011|Oral Cancer News|

Cannabis use and oral diseases

Source: Nature.com

Questions: What is the effect of cannabis usage on the oral environment?

Data sources
Medline and the Cochrane Central register of controlled trails (CENTRAL).

Study selection
Randomised Controlled Trials, Controlled Clinical Trials and Cohort Studies conducted on humans investigating cannabis usage were included. Screening was performed independently by two reviewers. Only English language studies were included. Case reports, letters and historical reviews were excluded.

Data extraction and synthesis
A narrative synthesis was conducted.

Results
Seven studies were included and a range of cannabis-associated oral side effects identified.

Conclusions
Based on the limited data, it seems justified to conclude that with increasing prevalence of cannabis use, oral health care providers should be aware of cannabis-associated oral side effects such as xerostomia, leukoedema and an increased prevalence and density of Candida albicans.

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

U of A study finds ways to help end dry mouth in cancer patients

Source: e! Science News

For patients suffering from cancer in the mouth or throat, a recent study shows that a treatment called submandibular gland transfer will assist in preventing a radiation-induced condition called xerostomia. Also known as dry mouth, xerostomia occurs when salivary glands stop working. University of Alberta researcher Jana Rieger likens the feeling of xerostomia to the experience of the after-effects of having surgery and anesthetic—but the feeling is permanent.

While the importance of healthy saliva glands may be an afterthought for some patients when battling cancer, the long-lasting effects create a number of problems for them when they are in remission.

“We need saliva to keep our mouths healthy,” said Rieger. “Without saliva, people can lose their teeth, dentures don’t fit properly and the ability to swallow and speak is severely altered.”

The study conducted by Rieger, a speech language pathologist in the Faculty of Rehabilitation Medicine, looked at functional outcomes—speech changes, swallowing habits and the quality of life of patients with mouth and throat cancers—as they received two different types of treatments prior to and during radiation.

The first group of patients underwent the submandibular gland transfer. This method was pioneered by Hadi Seikaly and Naresh Jha at the University of Alberta in 1999. The transfer involves moving the saliva gland from under the angle of the jaw to under to the chin. Prior to this procedure, the saliva gland was in line for the radiation. Seikaly says, “Most patients, when they are cured from cancer, complain of one major thing: dry mouth.”

The second group in the study took the oral drug salagen. Rieger says, “Studies have shown in the past that if this drug was taken during radiation, it might protect the cells in the salivary glands.”

According to the study findings, both groups had the same results in terms of being able to speak properly but where the main difference was in swallowing. The group taking the drug had more difficulty.

Rieger said, “This group needed to swallow more, and it took a longer time to get food completely out of their mouth and into the esophagus. Because they had trouble eating, they may become nutritionally comprised.”

This leads to a host of other problems. Dry mouth causes one to drink large volumes of water, which leads to numerous trips to the bathroom. Difficulty swallowing causes issues with eating food while it’s still hot and it takes the patients a long time to complete a meal.

As a result of these problems, Rieger found the quality life for most patients decreased significantly. “People suffering from xerostomia no longer want to go out eat and be in social settings. Consuming water to quench dry mouth means they have difficulty in getting a good night’s sleep. Some become depressed and avoid going out.”

Based on this study, the authors hope to encourage patients to have the submandiublar gland transfer as a preventative treatment for xerostomia prior to radiation for mouth and throat cancers.

 

Reirradiation with intensity-modulated radiotherapy in recurrent head and neck cancer.

Source: HighWire- Stanford University

In this retrospective investigation we analyzed outcome and toxicity after intensity-modulated reirradiation of recurrent head and neck cancer. METHODS: Thirty-eight patients with local recurrent head and neck cancer were evaluated. The median dose of initial radiotherapy was 61 Gy. Reirradiation was carried out with step-and-shoot intensity-modulated radiotherapy (median dose: 49 Gy). RESULTS: Median overall survival was 17 months, and the 1- and 2-year overall survival rates were 63% and 34%. The 1- and 2-year local control rates were 57% and 53%. Distant spread occurred in 34%, and reirradiation induced considerable late toxicity in 21% of the patients. Thirty-two percent showed increased xerostomia after reirradiation. The risk for xerostomia was significantly higher for cumulative mean doses of ?45 Gy to parotid glands. Considering median cumulative maximum doses of 53 Gy to the spinal cord and 63 Gy to the brainstem, no late toxicities were observed. CONCLUSIONS: Reirradiation with intensity-modulated radiotherapy in recurrent head and neck cancer is feasible with acceptable toxicity and yields encouraging rates of local control and overall survival.

� 2011 Wiley Periodicals, Inc. Head Neck, 2011.

February, 2011|Oral Cancer News|

Parotid-sparing intensity modulated versus conventional radiotherapy in head and neck cancer (PARSPORT): a phase 3 multicentre randomised controlled trial

Source: www.thelancet.com
Authors: Dr Christopher M Nutting FRCR et al.

Background:
Xerostomia is the most common late side-effect of radiotherapy to the head and neck. Compared with conventional radiotherapy, intensity-modulated radiotherapy (IMRT) can reduce irradiation of the parotid glands. We assessed the hypothesis that parotid-sparing IMRT reduces the incidence of severe xerostomia.

Methods:
We undertook a randomised controlled trial between Jan 21, 2003, and Dec 7, 2007, that compared conventional radiotherapy (control) with parotid-sparing IMRT. We randomly assigned patients with histologically confirmed pharyngeal squamous-cell carcinoma (T1—4, N0—3, M0) at six UK radiotherapy centres between the two radiotherapy techniques (1:1 ratio). A dose of 60 or 65 Gy was prescribed in 30 daily fractions given Monday to Friday. Treatment was not masked. Randomisation was by computer-generated permuted blocks and was stratified by centre and tumour site. Our primary endpoint was the proportion of patients with grade 2 or worse xerostomia at 12 months, as assessed by the Late Effects of Normal Tissue (LENT SOMA) scale. Analyses were done on an intention-to-treat basis, with all patients who had assessments included. Long-term follow-up of patients is ongoing. This study is registered with the International Standard Randomised Controlled Trial register, number ISRCTN48243537.

Findings:
47 patients were assigned to each treatment arm. Median follow-up was 44·0 months (IQR 30·0—59·7). Six patients from each group died before 12 months and seven patients from the conventional radiotherapy and two from the IMRT group were not assessed at 12 months. At 12 months xerostomia side-effects were reported in 73 of 82 alive patients; grade 2 or worse xerostomia at 12 months was significantly lower in the IMRT group than in the conventional radiotherapy group (25 [74%; 95% CI 56—87] of 34 patients given conventional radiotherapy vs 15 [38%; 23—55] of 39 given IMRT, p=0·0027). The only recorded acute adverse event of grade 2 or worse that differed significantly between the treatment groups was fatigue, which was more prevalent in the IMRT group (18 [41%; 99% CI 23—61] of 44 patients given conventional radiotherapy vs 35 [74%; 55—89] of 47 given IMRT, p=0·0015). At 24 months, grade 2 or worse xerostomia was significantly less common with IMRT than with conventional radiotherapy (20 [83%; 95% CI 63—95] of 24 patients given conventional radiotherapy vs nine [29%; 14—48] of 31 given IMRT; p<0·0001). OCF. At 12 and 24 months, significant benefits were seen in recovery of saliva secretion with IMRT compared with conventional radiotherapy, as were clinically significant improvements in dry-mouth-specific and global quality of life scores. At 24 months, no significant differences were seen between randomised groups in non-xerostomia late toxicities, locoregional control, or overall survival.

Interpretation:
Sparing the parotid glands with IMRT significantly reduces the incidence of xerostomia and leads to recovery of saliva secretion and improvements in associated quality of life, and thus strongly supports a role for IMRT in squamous-cell carcinoma of the head and neck.

Funding:
Cancer Research UK (CRUK/03/005).

Authors:
Dr Christopher M Nutting FRCR, James P Morden MSc, Kevin J Harrington FRCR, Teresa Guerrero Urbano PhD, Shreerang A Bhide FRCR, Catharine Clark PhD, Elizabeth A Miles MPhil, Aisha B Miah FRCR, Kate Newbold FRCR, MaryAnne Tanay MSc, Fawzi Adab FRCR, Sarah J Jefferies FRCR , Christopher Scrase FRCR, Beng K Yap FRCR, Roger P A’Hern MSc, Mark A Sydenham BSc, Marie Emson BSc, Emma Hall PhD, on behalf of the PARSPORT trial management group.

Source:
The Lancet Oncology, Volume 12, Issue 2, Pages 127 – 136, February 2011

February, 2011|Oral Cancer News|

Reducing xerostomia through advanced technology

Source: The Lancet Oncology

Radiation-related xerostomia has been the most significant and disabling side-effect of radiotherapy for head and neck cancer for more than 50 years. With the PARSPORT trial, reported in The Lancet Oncology, the largest and best designed of several randomised trials focusing on xerostomia, radiation oncologists and their partners in physics and dosimetry should take pride that significant progress has been made. Before the introduction of intensity-modulated radiotherapy (IMRT), more than 80% of survivors experienced substantial dry mouth syndrome and associated effects on dental health, swallowing, taste, and quality of life. By contrast, Nutting and colleagues report about 25% of 2-year survivors had significant clinician-rated xerostomia. Taken together with two randomised trials of IMRT for nasopharyngeal cancer, there is now compelling evidence of the power of advanced technology in reducing toxicity from head and neck radiotherapy.

Can even better use of technology help us to further reduce xerostomia? The parotid glands provide watery saliva during eating, which is largely replaceable by consuming more water or lubricants. The submandibular, sublingual, and minor salivary glands provide mucinous saliva, associated with the resting sense of moisture and dry mouth symptoms. Future work should systematically explore the prioritisation of different components of the salivary gland system. A clinical benefit from sparing the submandibular glands may be seen, beyond that seen by sparing the parotid glands. The mean dose delivered to the minor salivary glands within the oral cavity has also been reported to be a significant factor in patient-reported xerostomia. Further possibilities include gland repair or regenerative strategies with stem cells, acupuncture, or acupuncture-like stimulation. The promise of intensity-modulated protons provides even more optimism for reducing xerostomia and other acute and late effects.

Another important aspect of PARSPORT is the evolution of quantitative methods to assess xerostomia—eg, pre and post stimulation salivary flow, quality of life, clinical grading, and diet tolerance scales. While there is no agreement on which is the gold standard, we should use multiple measures which reflect different aspects and perspectives (patient clinician) on the issue. One must recognise an inherent weakness in technology-based xerostomia trials: neither patients nor clinicians are blinded. However, for those practicing radiotherapy for head and neck cancer, and for our patients, the improved outcomes are empirically obvious every day. Xerostomia is now an uncommon first complaint among survivors more than 3 months from treatment. This concern has been replaced by the next most bothersome issues: swallowing, taste, and fatigue. Reduction in the burden of treatment-related side-effects is especially important given the increasing number of patients presenting with oropharyngeal cancer (85% of patients in PARSPORT had disease at this site), related to the surge in cases of HPV infection. Considering the excellent prognosis of patients with oropharyngeal cancer with no or minimal smoking history (>80% 3-year survival), the potential for striking reductions in duration and magnitude of symptom burden is clear. Several ongoing studies are examining strategies to reduce treatment intensity for these patients, including radiation dose reduction, and substitution of cytotoxic drugs with targeted agents (eg, the recently approved RTOG-1016 for HPV-positive cancers).

Lastly, a recent report suggests that surgical relocation of a submandibular gland might be an effective way to reduce the sense of dry mouth at rest. This intervention can be applied anywhere surgeons are trained for this procedure, in collaboration with two-dimensional radiotherapy, and demands further investigation. Some of us may under-appreciate that IMRT technology is available to less than 10% of the global population. Salivary gland transfer thus may have a more immediate and long-term effect on the global burden of radiation-related xerostomia than all the beam modulation done for many decades.

January, 2011|Oral Cancer News|

Less xerostomia occurs with IMRT in head and neck cancer

Source: www.medscape.com
Author: Roxanne Nelson

Intensity-modulated radiotherapy (IMRT) might be a better treatment option for patients with squamous cell carcinoma of the head and neck. Compared with conventional radiation therapy, IMRT significantly decreases the incidence of xerostomia and improves quality of life, according to a study published online January 13 in the Lancet Oncology.

British researchers report that at 12 months, grade 2 or higher xerostomia was significantly lower with IMRT than with conventional radiotherapy (38% vs 74%; P = .0027). At 2 years, the incidence of grade 2 or higher xerostomia continued to be significantly less common with IMRT than with standard radiotherapy; 9 patients (29%) reported xerostomia in the IMRT group, compared with 20 (83%) in the conventional therapy group.

The authors note that there were no significant differences in locoregional control or overall survival between the 2 patient groups.

Lead author Christopher M. Nutting, MD, FRCR, consultant and honorary senior lecturer in clinical oncology at the Royal Marsden Hospital and Institute of Cancer Research, London, United Kingdom, and colleagues note that their results “strongly support a role for IMRT in squamous cell carcinoma of the head and neck.”

Spares the Parotid Gland, Similar Outcomes
Head and neck oncology expert Ted Teknos, MD, agrees. “One of the advantages of IMRT is that you can deliver radiation very accurately and you can spare normal structures to a much higher degree than conventional radiation therapy,” said Dr. Teknos, director of the Division of Head and Neck Surgery at Ohio State University Medical School in Columbus.

“With IMRT, you can typically spare the opposite parotid gland, so that patients can have better salivary flow posttreatment,” said Dr. Teknos, who was approached by Medscape Medical News for independent comment. “Dry mouth is difficult to live with, and really affects quality of life.”

IMRT is commonly used. In fact, any facility that has the equipment will attempt to do parotid-sparing radiotherapy, he explained. It is the standard of care at his own institution, he said, adding that “it is the standard at many centers. The problem is that you need the technology to do IMRT. A lot of smaller medical centers may not have IMRT at their disposal. It is important for patients to ask the radiation oncologist if they have IMRT capability.”

Another important point is that IMRT is most effective in reducing xerostomia if the cancer is unilateral. “It is difficult to spare the parotid on both sides if there’s a midline lesion or the tumor originates in the nasopharynx,” Dr. Teknos explained.

The use of IMRT produces cancer outcomes similar to those observed with conventional radiation therapy. “That was seen in this paper and has been confirmed in many other studies,” he said. “There isn’t a trade-off in survival, but using IMRT can give a marked improvement in salivary flow and quality of life.”

Fewer Report Xerostomia
In this study, Dr. Nutting and coauthors evaluated the hypothesis that parotid-sparing IMRT will reduce the incidence of severe xerostomia. They randomized 94 patients with histologically confirmed pharyngeal squamous cell carcinoma (T1 to T4, N0 to N3, M0) from 6 British radiotherapy centers to treatment with either IMRT or conventional radiotherapy (47 in each treatment group).

In both study groups, the primary tumor and involved lymph nodes were treated with 65 Gy in 30 daily fractions, 5 days a week. Among postoperative patients, 60 Gy in 30 fractions was given unless there was macroscopic residual disease. Measurements of salivary flow were conducted prior to radiotherapy, at week 4 of treatment, and at 2 weeks and 3, 6, 12, 18, and 24 months after radiotherapy.

The median follow-up was 44 months (interquartile range, 30·0 to 59·7); 6 patients in each group died within 12 months.

At each time point from 3 to 24 months, the authors note that a smaller proportion of patients receiving IMRT than conventional radiotherapy reported grade 2 or higher subjective xerostomia. The proportion of patients reporting grade 2 or higher xerostomia at the 12 month time point did not differ by tumor site, radiotherapy indication, disease stage, or use of neoadjuvant chemotherapy.

At both 12 and 24 months, there were significant benefits in the recovery of saliva secretion with IMRT, compared with conventional radiotherapy. At 12 months, there was unstimulated saliva flow from the contralateral parotid gland in 47% of patients in the IMRT group, compared with none in the conventional radiotherapy group (P < .0001). Results were similar at 24 months (44% vs 0%; P < .0068).

There were also clinically significant improvements in dry-mouth-specific and global quality-of-life scores among patients who received IMRT.

At 24 months, there were no significant differences observed in nonxerostomia late toxicities. Fatigue was the only recorded acute adverse event of grade 2 or higher that differed between the 2 groups, and was more prevalent in the IMRT group (74% vs 41%; P = .0015).

Source: Lancet Oncol. Published online January 13, 2011.
Note: The study was funded by Cancer Research UK. The authors have disclosed no relevant financial relationships.

January, 2011|Oral Cancer News|