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Year : 2019  |  Volume : 15  |  Issue : 3  |  Page : 696-699

Head-and-neck cancer patients beyond 2 years of disease control: Preliminary analysis of intensity-modulated radiotherapy late-effect assessment scale

Division of Radiation Oncology, Medanta – The Medicity, Gurgaon, Haryana, India

Date of Web Publication29-May-2019

Correspondence Address:
Dr. Trinanjan Basu
Division of Radiation Oncology, Medanta – The Medicity, Gurgaon - 122 001, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_1459_16

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 > Abstract 

Over a decade of intensity-modulated radiotherapy (IMRT) improved the toxicity profile among head-and-neck cancer patients and also improved the quality of life (QOL). Several parameters' few subjective and few objectives have documented various aspects related to QOL. Patients surviving beyond a certain period will have few unattended concern. A single questionnaire-based evaluation might answer few untouched issues. This brief communication formulated such an indigenous single-institution scale named IMRT late-effect assessment scale (ILEA). The preliminary analysis identified concerns related to dryness of mouth, swallowing habit change, and fear of disease recurrence. Future large-scale prospective evaluation is needed.

Keywords: Head-and-neck cancer, intensity-modulated radiotherapy, quality of life, survival

How to cite this article:
Basu T, Goyal S, Kataria T, Gupta D. Head-and-neck cancer patients beyond 2 years of disease control: Preliminary analysis of intensity-modulated radiotherapy late-effect assessment scale. J Can Res Ther 2019;15:696-9

How to cite this URL:
Basu T, Goyal S, Kataria T, Gupta D. Head-and-neck cancer patients beyond 2 years of disease control: Preliminary analysis of intensity-modulated radiotherapy late-effect assessment scale. J Can Res Ther [serial online] 2019 [cited 2021 Nov 27];15:696-9. Available from: https://www.cancerjournal.net/text.asp?2019/15/3/696/244203

 > Introduction Top

An established practice of intensity-modulated radiotherapy (IMRT) in head-and-neck cancer (HNC) management ushered new hope among the compromised quality of life (QOL) in both acute and long term. The randomized data also supported its clinical benefit regarding long-term side effects of radiotherapy. However, patients controlled on their disease for more than 2 years and expecting probable cure still has concerns to take care off. This study aims at assessing these concerns through an indigenous ILEA scale combining QOL and organs at risk (OAR)-specific late toxicities together. We believed that our preliminary assessment albeit just an observation could hint at future well-constructed studies.

 > Materials and Methods Top

This single-institution study was conducted over 6 months upon HNC patients coming for routine follow-up and has been disease free for at least 2 years after IMRT. This was an observational study. An indigenous ILEA questionnaire was developed comprising ten major topics and subtopics highlighting OAR-specific late toxicities and QOL issues as perceived from day-to-day patient assessment [Table 1]. The responses were recorded, and among the subtopics, the most bothersome one was selected. A total of 18 patients were analyzed based on the ten topics such as skin over the irradiated region, oral cavity, dental status including jaws, swallowing, speech, nutrition, general physical aspects, questions on personal life, professional life, and any other specific aspects not addressed through these questions. The study was carried out only those patients who are disease controlled beyond 2 years, and study period was just 6 months to assess whether at all any need to document toxicities at such a late phase at all.
Table 1: ILEA scale

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Since this was a random evaluation, thus no sample size calculation or statistical method was used.

The group of radiation oncologist evaluating these patients on OPD basis was recruited from department to collect the data. This was a dedicated group of four radiation oncologists and they only presented the data.

 > Results Top

There were 18 patients (15 male and 3 female) with median age 62.5 years having various subsites of primary malignancies (nasopharynx: 2, oral cavity: 3, oropharynx: 5, larynx: 5, and hypopharynx: 3) comprising both early (7) and advanced (11) stages. This small number was within the stipulated analysis time for 6 months. We actually are planning a bigger prospective well-constructed protocol.

As perceived from the ILEA scale, major responses from different topics were subcutaneous edema (skin), dryness of mouth and sticky saliva (oral cavity), dental sensitivity (dental status including jaws), increased time to swallow (swallowing), change in voice quality (speech), dietary modifications (nutrition), and fatigue (personal life).

Topics such as general physical status and professional life responses were mostly positive as majority were working and had no issues with looks or appearance.

Among the different topics, the most bothersome was still the questions related to oral cavity either dryness or sticky saliva and these even after 2 years resulted in modifications in diet, swallowing, and speech abilities. Secondarily, these had an impact on nutritional, social, and interpersonal relationships [Table 2].
Table 2: Major concerns in ILEA scale - individual patient

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 > Discussion Top

QOL among HNC patients is of paramount importance. In early stages where the chances of cure are high as well as in advanced stages for effective palliation. There are several definitions in literature and most highlight the composition of physical, emotional, and social well-being.[1],[2] The European organization (EORTC) has been instrumental in documenting simple Likert type scales in addressing these issues both in the early and late stage after treatment.[3],[4] The radiotherapy techniques have also improvised over the years, and randomized data suggested a benefit of IMRT over conventional techniques.[5] Parallel to this, the QOL scales have also been validated in favor of IMRT.[6]

There have always been difference between the way a doctor assesses the QOL and the way patient perceives it. For radiation oncologist, the long-term xerostomia prevention and also diminishing its sequels are important, but for a patient, the change in dietary and social habits and seclusion might be of higher importance.

There has been recent publication correlating Patient-Reported Outcomes Measurement Information System (PROMIS) in HNC by assessing the associations of the PROMIS instruments with the responses to the different EORTC scales. The study could identify few unmet needs as well.[7] These have been validated also and the importance of patient-related outcome highlighted.[8]

In advanced stage HNC also, previous mucous, skin, and salivary damages have a strong influence on QOL. The treatment paradigm should be tailored so as not to compromise with these issues.[9]

We, in our preliminary analysis, tried to encompass both felt need as part of QOL for a physician and also patient in a simple combined scale. ILEA scale was simple to use, addressed several issues which are pertinent for a patient who has disease controlled beyond 32-year posttreatment. The initial results are encouraging and are in lieu with available data.[10]

There is always a perception difference in QOL among physician and a patient. A Latin American study long back although concluded very good concordance between satisfaction level among both parties, we think Indian scenario would be different. A future prospective study would answer many such issues.[11]

 > Conclusion Top

The study with small sample size and indigenous ILEA scale could indicate major concerns with HNC IMRT beyond 2 years of disease control. To emphasize that even after 2 years, xerostomia and its various sequels keep on troubling patients either directly or indirectly. As we gain experience with IMRT, various new OARs such as dysphagia structures, minor salivary glands, laryngeal architecture, central nervous system structures, or brachial plexus have become equally important in reducing late toxicities and a better QOL. We would like to put forward that late toxicities are bothersome and yet it is subjective. This varies person to person, and in future studies, this should be evaluated with numerical objective scoring.

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Conflicts of interest

There are no conflicts of interest.

 > References Top

Bottomley A. The cancer patient and quality of life. Oncologist 2002;7:120-5.  Back to cited text no. 1
Gotay CC, Korn EL, McCabe MS, Moore TD, Cheson BD. Quality-of-life assessment in cancer treatment protocols: Research issues in protocol development. J Natl Cancer Inst 1992;84:575-9.  Back to cited text no. 2
Carrillo JF, Carrillo LC, Ramirez-Ortega MC, Ochoa-Carrillo FJ, Oñate-Ocaña LF. The impact of treatment on quality of life of patients with head and neck cancer and its association with prognosis. Eur J Surg Oncol 2016;42:1614-21.  Back to cited text no. 3
Hammerlid E, Taft C. Health-related quality of life in long-term head and neck cancer survivors: A comparison with general population norms. Br J Cancer 2001;84:149-56.  Back to cited text no. 4
Nutting CM, Morden JP, Harrington KJ, Urbano TG, Bhide SA, Clark C, et al. Parotid-sparing intensity modulated versus conventional radiotherapy in head and neck cancer (PARSPORT): A phase 3 multicentre randomised controlled trial. Lancet Oncol 2011;12:127-36.  Back to cited text no. 5
Rathod S, Gupta T, Ghosh-Laskar S, Murthy V, Budrukkar A, Agarwal J, et al. Quality-of-life (QOL) outcomes in patients with head and neck squamous cell carcinoma (HNSCC) treated with intensity-modulated radiation therapy (IMRT) compared to three-dimensional conformal radiotherapy (3D-CRT): Evidence from a prospective randomized study. Oral Oncol 2013;49:634-42.  Back to cited text no. 6
Stachler RJ, Schultz LR, Nerenz D, Yaremchuk KL. PROMIS evaluation for head and neck cancer patients: A comprehensive quality-of-life outcomes assessment tool. Laryngoscope 2014;124:1368-76.  Back to cited text no. 7
Garcia SF, Cella D, Clauser SB, Flynn KE, Lad T, Lai JS, et al. Standardizing patient-reported outcomes assessment in cancer clinical trials: A patient-reported outcomes measurement information system initiative. J Clin Oncol 2007;25:5106-12.  Back to cited text no. 8
Airoldi M, Garzaro M, Raimondo L, Riva G, Pecorari G, Giordano C. Quality of life, physical, and psychologic functioning in patients affected by end-stage head and neck cancer. J Clin Oncol 2011;29 15 Suppl:5537.  Back to cited text no. 9
Bairati I, Meyer F. Health-related quality of life (HRQOL) of patients 3 years after radiation therapy (RT) for early head and neck cancer (HNC). J Clin Oncol 2011;29 15 Suppl:9077.  Back to cited text no. 10
Morgenfeld EL, Rivarola E, Cataldi C, Gil Deza E, Tognelli F, Polo S. Comparison between patient's (pt) and doctor's (dr) expectation about the efficacy of cancer treatment (tx). A prospective blind mis-match analysis. J Clin Oncol 2004;22 14 Suppl:8248.  Back to cited text no. 11


  [Table 1], [Table 2]


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