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

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

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

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

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

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

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

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

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

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

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

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

September, 2009|Oral Cancer News|

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

Source: www.oncologynursingnews.com
Author: Delicia Yard

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

From the August 2009 Issue of Oncology Nursing News.

August, 2009|Oral Cancer News|

Intensity-modulated radiotherapy reduces xerostomia in head and neck cancer

Source: www.oncologystat.com
Author: staff

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Taste, odor intervention

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

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

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

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

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

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

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

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

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

Acupuncture relieves radiation-induced xerostomia in head and neck cancer

Source: www.medscape.com
Author: Roxanne Nelson

Acupuncture can improve subjective symptoms of dry mouth in patients with radiation-induced xerostomia, according to the results of a pilot trial. When treated twice a week for 4 weeks with acupuncture, oncology patients who received radiation treatments to the head and neck area reported significant improvements in physical well being and quality of life.

The results of the trial, published online April 17 in Head & Neck, showed that acupuncture relieved symptoms as early as 2 weeks after starting therapy, with the benefits lasting for at least 1 month after treatment ended.

Although this was a pilot study, the results appear quite encouraging; little or no recovery is generally seen in these patients after they reach the damaging threshold of radiation. But all patients in this study had reached the damaging threshold, explained senior author William Chambers, DMD, MS, chief of the Section of Oncologic Dentistry and Prosthodontics at the University of Texas MD Anderson Cancer Center in Houston. “They all received over 50 Gy of definitive external-beam radiation therapy,” he said.

However, the data did not find a change in measured stimulated or unstimulated salivary flow, even though the patients reported symptom relief. “There was no statistically significant increase in saliva flow from baseline, but there was a positive trend, with a spike for unstimulated saliva [P = .08],” Dr. Chambers told Medscape Oncology.

The researchers also note that basal and salivary flow rates vary significantly among individuals, and therefore, subjective perceptions and objective measurements do not always correlate. A definitive threshold of increased saliva output that results in a clear clinical benefit has not been established, so even a small increase can provide relief to the patient.

Improvements Seen in Subjective Symptoms, Not Objective Differences
In this study, Dr. Chambers and colleagues evaluated the efficacy of acupuncture in alleviating xerostomia in 19 patients with head and neck cancer who had undergone radiation treatment.

All study participants completed the Xerostomia Inventory and the Patient Benefit Questionnaire at baseline and then throughout the study period. Objective measurements of salivary flow were collected with the subjective data, and unstimulated whole salivary flow rate and stimulated salivary flow rate were assessed.

At weeks 4 and 8, patients reported symptom improvement, reflected in both the Xerostomia Inventory and the Patient Benefit Questionnaire scores. The mean response rate, measured by the Xerostomia Inventory, was 40%, and at the end of the fourth week of treatment, 44.4% had achieved a partial response. This percentage rose to 55.6% by week 8.

Unlike subjective measures, there were no differences in the unstimulated whole salivary flow rate or the stimulated salivary flow rate between baseline and the end of the follow-up period (week 8). A small elevation in both the unstimulated whole salivary flow rate and the stimulated salivary flow rate was seen 1 week after acupuncture treatment.

Patient Benefit Seen, Larger Trials Needed
It appears that there was a clear clinical benefit to patients, even if it could not be quantified using current measuring tools, explained Dr. Chambers, and even small changes in salivary flow can result in increased oral comfort.

It is also possible that the results could be attributed to a placebo effect, at least in some patients. However, the researchers do note that patients who have had major salivary glands irradiated do not spontaneously improve after 4 months, so the improvements in this trial “were most likely attributable to the acupuncture treatment rather than spontaneous recovery.”

None of the patients in the study experienced adverse events related to their treatment, and complications resulting from acupuncture are rare. Based on the relative safety of the procedure and the fact that patients experienced relief, Dr. Chambers feels that acupuncture is an intervention that can be considered for this population. “As long as patients are interested and understand these results are preliminary,” he said.

Larger placebo-controlled trials are needed for more definitive results, and the researchers write that they plan on conducting these trials in the future, but this project is a “first step in verifying promising reports from previous research.”

Head Neck. published online before print April 17, 2009. Abstract

Parotid gland sparing IMRT for head and neck cancer improves xerostomia related quality of life

Source: Radiation Oncology, December 9, 2008; 3(1): 41.
Authors: C M van Rij, W D Oughlane-Heemsbergen, A H Ackerstaff, E A Lamers, A Jm Balm, and C Rn Rasch

ABSTRACT: Background and purpose: To assess the impact of intensity modulated radiotherapy (IMRT) versus conventional radiation on late xerostomia and Quality of Life aspects in head and neck cancer patients. Patients and methods: Questionnaires on xerostomia in rest and during meals were sent to all patients treated between January 1999 and December 2003 with a T1-4, N0-2 M0 head and neck cancer, with parotid gland sparing IMRT or conventional bilateral neck irradiation to a dose of at least 60 Gy, who were progression free and had no disseminated disease (n= 192). Overall response was 85 % (n = 163); 97 % in the IMRT group (n = 75) and 77 % in the control group (n = 88) the median follow-up was 2.6 years. The prevalence of complaints was compared between the two groups, correcting for all relevant factors at multivariate ordinal regression analysis. RESULTS: Patients treated with IMRT reported significantly less difficulty transporting and swallowing their food and needed less water for a dry mouth during day, night and meals. They also experienced fewer problems with speech and eating in public. Laryngeal cancer patients in general had fewer complaints than oropharynx cancer patients but both groups benefited from IMRT. Within the IMRT group the xerostomia scores were better for those patients with a mean parotid dose to the “spared” parotid below 26 Gy. CONCLUSIONS: Parotid gland sparing IMRT for head and neck cancer patients improves xerostomia related quality of life compared to conventional radiation both in rest and during meals. Laryngeal cancer patients had fewer complaints but benefited equally compared to oropharyngeal cancer patients from IMRT.

December, 2008|Oral Cancer News|

GlaxoSmithKline to acquire the leading dry mouth brand, Biotene

Source: www.marketwatch.com
Author: press release

GlaxoSmithKline Consumer Healthcare announced today that it has reached an agreement with Laclede, a privately held company, to purchase the leading Dry Mouth brand Biotene(R) for $170 million. The transaction is subject to regulatory review by competition authorities in the United States and Europe, and is expected to complete by early 2009.

“The acquisition of Biotene extends our portfolio in therapeutic oral healthcare to include a proven treatment for Dry Mouth,” said John Clarke, President, GSK Consumer Healthcare. “This opportunity leverages our global capability with dental and medical professionals and is a further step towards our goal in GSK of building and growing a diversified healthcare business.”

Biotene is the world’s number one dentist and hygienist-recommended Dry Mouth product for the growing population that suffers from this condition. Biotene is a brand in strong growth, with global sales in 2007 of around $50 million up 17%. Approximately 65% of the brand’s current sales are in the United States.

Dry Mouth, a condition known as Xerostomia, is a significant health issue associated with chronic medical conditions that include diabetes, rheumatoid arthritis, Sjogren’s syndrome and Parkinson’s disease. Additionally, cancer chemotherapy or radiation treatment, as well as any of more than 400 medications that, as a side-effect, can cause Dry Mouth. Globally, Dry Mouth is as prevalent as dental sensitivity, affecting around one-in-five adults.

Biotene joins a world-class portfolio of Oral Healthcare Brands, including:

– Aquafresh(R), Odol-med(R), Binaca(R), a leading range of toothpastes, toothbrushes, mouthwashes and whitening products
– Corsodyl(R), Chlorhexamed(R) gingivitis treatment
– Paradontax, a toothpaste for healthy gums
– Polident(R), Corega(R), a range of denture cleansers
– PoliGrip(R), Corega(R), a range of denture adhesives
– Sensodyne(R), the leading toothpaste to treat dental hyper-sensitivity

How Biotene works
Biotene is a proprietary system founded on three enzymes: glucose oxidase, lactoperoxidase and lysozme, each found in healthy saliva. The augmentation of these enzymes through the introduction of Biotene into an oral healthcare regimen aids the symptomatic relief of Dry Mouth. The Biotene range includes mouthwash, toothpaste, gel, spray and gum formulations for convenient, effective relief. New innovation in 2008 added additional enzymes that attack and breakdown plaque biofilm.

GlaxoSmithKline – one of the world’s leading research-based pharmaceutical and healthcare companies — is committed to improving the quality of human life by enabling people to do more, feel better and live longer. For further information please visit http://www.gsk.com.

October, 2008|Oral Cancer News|