Optimising Radiation Therapy Dose to the Swallowing Organs at Risk: An In Silico Study of feasibility for Patients with Oropharyngeal Tumours.

Recent evidence suggests that reducing radiotherapy dose delivered to specific anatomical swallowing structures [Swallowing Organs at Risk (SWOARs)] may improve swallowing outcomes post-treatment for patients with head and neck cancer. However, for those patients with tumours of the oropharynx, which typically directly overlap the SWOARs, reducing dose to these structures may be unachievable without compromising on the treatment of the disease. To assess the feasibility of dose reduction in this cohort, standard IMRT plans (ST-IMRT) and plans with reduced dose to the SWOARs (SW-IMRT) were generated for 25 oropharyngeal cancer patients (Brouwer et al. in Radiother Oncol 117(1):83-90, https://doi.org/10.1016/j.radonc.2015.07.041 , 2015; Christianen et al. in Radiother Oncol 101(3):394-402, https://doi.org/10.1016/j.radonc.2011.05.015 , 2011). ST-IMRT and SW-IMRT plans were compared for: mean dose to the SWOARs, volume of pharynx and larynx receiving 50 Gy and 60 Gy (V50 and V60 respectively) and overlap between the tumour volume and the SWOARs. Additionally, two different SWOARs delineation guidelines (Brouwer et al. in Radiother Oncol 117(1):83-90, https://doi.org/10.1016/j.radonc.2015.07.041 , 2015; Christianen et al. in Radiother Oncol 101(3):394-402, https://doi.org/10.1016/j.radonc.2011.05.015 , 2011) were used to highlight differences in calculated volumes between existing contouring guidelines. Agreement in SWOARs volumes between the two guidelines was calculated using a concordance index (CI). Despite a large overlap between the tumour and SWOARs, significant (p < 0.05) reductions in mean dose to 4 of the 5 SWOARs, and V50/V60 for the pharynx and larynx were achieved with SW-IMRT plans. Low CIs per structure (0.15-0.45) were found between the two guidelines highlighting issues comparing data between studies when different guidelines have been used (Hawkins et al. in Semin Radiat Oncol 28(1):46-52, https://doi.org/10.1016/j.semradonc.2017.08.002 , 2018; Brodin et al. in Int J Radiat Oncol Biol Phys 100(2):391-407, https://doi.org/10.1016/j.ijrobp.2017.09.041 , 2018). This study found reducing dose to the SWOARs is a feasible practice for patients with oropharyngeal cancer. However, future prospective research is needed to determine if the extent of dose reduction achieved equates to clinical benefits.

Treatment toxicities and their impact on oral intake following non-surgical management for head and neck cancer: a 3-year longitudinal study.

PURPOSE: Patients who receive (chemo)radiotherapy [(C)RT] for head and neck cancer (HNC) experience multiple treatment effects. However, the presence and recovery of treatment toxicities and how these impact on oral intake over time post-treatment are not fully understood. The primary aim of this study was to examine patient perceptions of the toxicities present and which are barriers to oral intake, up to 3 years post (C)RT. The secondary aim was to identify mealtime strategies used to optimise oral intake. METHODS: A prospective cohort of 96 patients after completion of (C)RT for HNC reported the presence of toxicities, if they were barriers to oral intake, and use of any mealtime strategies at the end of treatment (EoT), and at 3, 6, 12, 24, and 36 months post-treatment. RESULTS: All toxicities and reported barriers changed over time (p < 0.05) except trismus. Odynophagia, reduced appetite, and fatigue improved (p < 0.05) by 3 months. Significantly less patients reported xerostomia and dysgeusia as barriers to oral intake at 3 months despite no improvement in their presence. No change in the presence of any toxicity or its impact on oral intake occurred from 12 to 36 months, with exception of dentition problems which significantly increased at 36 months. Alternating food/fluids was the most frequently used mealtime swallowing strategy at all time points beyond the EoT. CONCLUSIONS: The dysphagia and associated toxicities HNC patients experience are chronic in nature. Rehabilitation should include mealtime strategies and support with adjusting to the changing presence and impact of toxicities on oral intake.

Total laryngectomy with primary tracheoesophageal puncture: Intraoperative versus delayed voice prosthesis placement.

BACKGROUND: Studies support using intraoperative voice prosthesis insertion performed at the time of primary tracheoesophageal puncture (TEP) during laryngectomy. However, none have compared intraoperative voice prosthesis insertion with delayed voice prosthesis insertion. The purpose of this study was to prospectively examine patient, services, and cost benefits of intraoperative versus delayed voice prosthesis placement. METHODS: Voice prosthesis use, duration to the first voice prosthesis change, early communication, and costs were compared between 14 patients who underwent a laryngectomy and who received intraoperative voice prosthesis placement, and 10 patients who underwent initial catheter stenting and then delayed voice prosthesis insertion. RESULTS: Intraoperative voice prosthesis placement was associated with significantly fewer early device changes (1.4 vs 2), voice prosthesis changes because of resizing (8% vs 80%), longer durations to initial voice prosthesis change (159.7 vs 24.5 days), earlier commencement of voice rehabilitation (13.2 vs 17.6 days), reduced length of hospital stay (17.2 vs 24.5 days), and cost savings of $559.83/person. CONCLUSION: Superior clinical and patient benefits are associated with intraoperative voice prosthesis placement during primary TEP. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1138-1144, 2017.

Pretreatment factors associated with functional oral intake and feeding tube use at 1 and 6 months post-radiotherapy (+/- chemotherapy) for head and neck cancer.

A proportion of patients with head and neck cancer (HNC) experience significant swallowing difficulty during and post-radiotherapy/chemoradiotherapy (RT/CRT). Identifying patients during the pretreatment period who are anticipated to have compromised oral intake would allow for early and accurate patient education, and prioritisation of their management. Ascertaining a clear set of pretreatment predictors from the literature is challenging due to heterogeneity in study designs and patient cohorts, with minimal prospective data available (especially at 1-month post-treatment). The objectives of this study were to investigate which pretreatment factors predicted compromised oral intake and feeding tube use at 1 and 6 months post-RT/CRT. Prospective data were collected on 80 consecutive HNC patients receiving RT/CRT from 2011 to 2014. The primary outcome was to identify predictors of a modified diet at 1 and 6 months post-RT/CRT. Secondary outcomes were to identify predictors of feeding tube use at these time intervals, and <6 vs. >6 week duration of feeding tube use. Multivariate analysis revealed bilateral neck radiotherapy treatment was a strong predictor of modified diets at 1 month (p < 0.001), and T-stages T3/T4 a predictor of modified diets at 6 months (p = 0.03). Patients treated with concurrent CRT (p = 0.02) and bilateral neck treatment (p = 0.02) predicted feeding tube use at 1 month, and concurrent CRT predicted feeding tube use for >6 weeks (p = 0.04). Therefore, patients receiving bilateral neck treatment and/or CRT are at greatest risk of requiring modified diets and feeding tube use early post-treatment, and should be prioritised for intervention and ongoing support.