Predictors of acute grade 4 swallowing toxicity in patients with stages III and IV squamous carcinoma of the head and neck treated with radiotherapy alone.
ABSTRACT The purpose of the study was to investigate the predictive factors for acute grade 4 swallowing toxicity in an attempt to identify which patients may benefit from early intervention with enteral feeding during curative radiation treatment for localised Stages 3-4 squamous cell carcinoma of the head and neck. It was hypothesised that craniocaudal length of the treatment field to the upper neck and pharynx would correlate with grade 4 swallowing toxicity due to the increased volume of pharynx irradiated.
Toxicity data were collected prospectively as part of a phase III randomised trial (TROG 91:01) that assigned patients to either conventional (CRT) or accelerated radiotherapy (ART). Patients were randomly assigned to either CRT, using a single 2 Gy per day to a dose of 70 Gy in 35 fractions in 49 days or to ART, using 1.8 Gy twice a day to a dose of 59.4 Gy in 33 fractions in 24 days. Treatment allocation was stratified for site and stage. Accrual commenced in 1991 and the trial was closed in 1998 when the target of 350 patients was reached. Potential factors were analysed that predicted for Grade IV swallowing toxicity.
The treatment field lengths >82mm for the second phase increased the probability of requiring intervention with percutaneous endoscopic gastrostomy (PEG) or Nasogastric tube (NGT). The probability of grade 4 swallowing was 36% if the phase 2 treatment length was >82mm vs 16% for less < or = 82mm(p=0.0001). A predictive enteral grading score (PEG score) was derived using the Cox regression coefficients: Field length of the boost volume >82mm scored 3 points, Stage grouping greater than 1 scored 1 point, altered fractionation scored 2 points, ECOG greater than 1 scored 1 point. The PEG score was 45% if the score was 6 and 19% if the score was <6 (p=0.0).
More attention needs to be focused on developing robust dose and volume constraints for the pharyngeal mucosa and the musculature in order to reduce the need for enteral feeding. Patients with PEG score of 6 or greater are at high risk of requiring enteral feeding during radiation treatment and should be considered for prophylactic PEG or NG feeding.
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ABSTRACT: PURPOSE: The purpose was to examine the effect of pretreatment weight status on loco-regional progression for patients with squamous cell carcinoma of the head and neck (SCCHN) after receiving definitive concurrent chemoradiation therapy (CCRT). METHODS: In an expanded cohort of 140 patients, we retrospectively reviewed weight status and loco-regional progression of SCCHN patients treated with CCRT between 2004 and 2010. RESULTS: Pretreatment ideal body weight percentage (IBW%) was statistically significantly different for patients with disease progression than for those without progression (p = 0.02) but was not an independent predictor of progression. Median pretreatment IBW% was 118 (72-193) for the progression-free group and was 101.5 (73-163) for the group with progression. Both groups suffered clinically severe weight loss of approximately 9 % from baseline to end treatment. CONCLUSIONS: Pretreatment weight status, a very crude indicator of nutrition status, may have prognostic value in patients with SCCHN undergoing definitive CCRT. Inadequate nutritional status in these patients has been associated with poor clinical outcomes and decreased quality of life. Based on this report and others, the best next steps include routine validated malnutrition screening and the testing of evidence-based nutrition care protocols with the goals of minimizing weight loss and improvement of quality of life.Supportive Care in Cancer 06/2013; · 2.09 Impact Factor
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ABSTRACT: La prise en charge nutritionnelle des patients porteurs d’un cancer des voies aérodigestives est indispensable du diagnostic aux séquelles éventuelles. Avant tout traitement, le dépistage d’une dénutrition sévère repose sur des examens cliniques et biologiques simples permettant d’individualiser une population à risque nutritionnel propre nécessitant une prise en charge spécifique. La nutrition entérale en postopératoire doit couvrir les besoins du patient: 35 kcal/kg par jour et 0,2 g d’azote/kg par jour, apports encore souvent mal respectés. Les bénéfices de l’immunonutrition sont encore à démontrer en carcinologie ORL tant en chirurgie qu’en radiochimiothérapie. Tout patient recevant de la radiothérapie doit bénéficier d’un suivi diététique dès le repérage: conseils alimentaires, compléments oraux peuvent éviter ou retarder la mise en place d’une gastrostomie pour nutrition entérale à domicile. Celle-ci est indispensable dès l’amorce d’une perte de poids pour assurer la faisabilité du programme thérapeutique. Enfin, les troubles fonctionnels à retentissement nutritionnel sont fréquents dans les suites avec répercussion importante sur la qualité de vie. Des études prospectives sont en cours pour mieux les gérer, voire les prévenir. The nutritional care of patients suffering from cancer of the aerodigestive tract is essential from diagnosis through to any possible sequellae. Before treatment, screening for severe malnutrition must take place, based on simple clinical and biological tests, so as to identify patients presenting nutritional risk factors, which require special care. Enteral nutrition during the postoperative period should cover the needs of the patient: 35 kcal/kg per day including 0.2 g of nitrogen/kg per day, but often these guidelines are not properly followed. The benefits of immunonutrition are yet to be demonstrated in head and neck cancer, both in surgery and radiochemotherapy. All patients treated with radiotherapy should be monitored with respect to diet from the very beginning: food tips and oral supplements can prevent or delay the necessity for a gastrostomy tube for enteral nutrition at home, without which treatment program is not feasible if there is any weight loss. Finally, functional disorders resulting from treatment, with nutritional impact and significant consequences on quality of life, can persist once treatment ends and lasts for long periods, sometimes even indefinitely. Prospective studies are underway to improve their management or even prevent these repercussions.Oncologie 11(3):128-132. · 0.10 Impact Factor
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ABSTRACT: In our randomized trial on hyperbaric oxygen (HBO), it was shown that HBO could reduce dysphagia and xerostomia, which are frequently encountered after (chemo-) radiotherapy (RT) and/or surgery for head and neck cancer (HNC). A risk model and nomogram are developed to select those patients who most likely will respond to HBO treatment. A total of 434 HNC patients treated from 2000 to 2008 were analyzed and filled out the EORTC QLQC-30 and H&N35 questionnaires. Age, gender, chemotherapy, T and N stages, site, radiotherapy technique, RT boost, surgery of the primary tumor and neck, bilateral RT, and dose were analyzed in a statistical model. The discriminative value of the model was evaluated based on receiver operating characteristics (ROC), the area under the curve (AUC), sensitivity, specificity, and proportion of correctly classified measures. Significant factors in predicting swallowing problems are age, follow-up duration, tumor site, chemotherapy, surgery of the primary tumor and neck, and dose. For dry mouth, the significant factors are age, gender, tumor site, N stage, chemotherapy, and bilateral irradiation. For dysphagia and xerostomia, the area under the ROC curve is 0.7034 and 0.7224, respectively, with a specificity of 89/77 %, sensitivity of 27/58 %, and a positive predictive value of 83/67 % for dysphagia and xerostomia, respectively. The developed predictive risk model could be used to select patients for costly hyperbaric oxygen treatment to prevent or reduce severe late side effects of HNC treatment. Our model serves as a guideline for the Department of Radiation Oncology to reduce costs by excluding patients not amenable to hyperbaric oxygen protocols. The nomogram presented is a useful tool for clinicians in assessing patient risks when deciding on follow-up strategies (e.g., hyperbaric oxygen treatment) after RT or surgery for HNC.Dysphagia 01/2013; · 1.94 Impact Factor