Prevention and Management of Osteoradionecrosis in Patients With Head and Neck Cancer Treated With Radiation Therapy: ISOO-MASCC-ASCO Guideline

Abstract

ASCO Guidelines provide recommendations with comprehensive review and analyses of the relevant literature for each recommendation, following the guideline development process as outlined in the ASCO Guidelines Methodology Manual . ASCO Guidelines follow the ASCO Conflict of Interest Policy for Clinical Practice Guidelines . Clinical Practice Guidelines and other guidance (“Guidance”) provided by ASCO is not a comprehensive or definitive guide to treatment options. It is intended for voluntary use by providers and should be used in conjunction with independent professional judgment. Guidance may not be applicable to all patients, interventions, diseases, or stages of diseases. Guidance is based on review and analysis of relevant literature and is not intended as a statement of the standard of care. ASCO does not endorse third-party drugs, devices, services, or therapies and assumes no responsibility for any harm arising from or related to the use of this information. See complete disclaimer in Appendix 1 and Appendix 2 (online only) for more. PURPOSE To provide evidence-based recommendations for prevention and management of osteoradionecrosis (ORN) of the jaw secondary to head and neck radiation therapy in patients with cancer. METHODS The International Society of Oral Oncology-Multinational Association for Supportive Care in Cancer (ISOO-MASCC) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials and observational studies, published between January 1, 2009, and December 1, 2023. The guideline also incorporated systematic reviews conducted by ISOO-MASCC, which included studies published from January 1, 1990, through December 31, 2008. RESULTS A total of 1,539 publications were initially identified. There were 487 duplicate publications, resulting in 1,052 studies screened by abstract, 104 screened by full text, and 80 included for systematic review evaluation. RECOMMENDATIONS Due to limitations of available evidence, the guideline relied on informal consensus for some recommendations. Recommendations that were deemed evidence-based with strong evidence by the Expert Panel were those pertaining to best practices in prevention of ORN and surgical management. No recommendation was possible for the utilization of leukocyte- and platelet-rich fibrin or photobiomodulation for prevention of ORN. The use of hyperbaric oxygen in prevention and management of ORN remains largely unjustified, with limited evidence to support its practice. Additional information is available at www.asco.org/head-neck-cancer-guidelines .

Gaps in Access to Medically Necessary Dental Care for Patients Living With and Beyond Cancer: We Must Do Better

“…The psychosocial impact of this collective burden of illness can be sufficiently severe to result in severe anxiety, depression, societal withdrawal, and even increased risk of suicide in a subset of head and neck cancer survivors. 26 Despite high-quality evidence, implementation of guidelines into practice has languished. A primary barrier is that coverage benefits for these services have not been provided across private dental insurance payers and by Medicare and Medicaid and therefore many oral health services require individuals to pay out of pocket.…”

“…Treatment-related side effects affecting the oral cavity and oral function include xerostomia/salivary hypofunction, mucositis, pain, soft tissue fibrosis, osteonecrosis of the jaw, dysphagia, nutritional deficiencies, dysarthria, trismus, and surveillance for disease recurrence or new primary cancers. 25,26 Individuals with advanced cancer may require extensive surgical jaw reconstruction, oral prosthetics, and/or voice simulation devices. These costly procedures are medically necessary to improve disease treatment tolerability and enable outcomes that assure basic human functions such as speech and swallowing.…”

Financial Burden of Dental Care Among Patients With Head and Neck Cancer

“…Most patients reported that their oncologist recommended dental screening at the start of cancer care (67 of 85 [79%]). Patient adherence to that recommendation was high (71 of 85 Less than high school diploma (1) [9] High school diploma or GED (7) [28] Some college (13) [15]…”

“…Associate's degree (12) [10] Bachelor's degree (40) [23] Master's degree (20) [11] PhD or other doctoral degree (5) [3] Prefer not to say Total household income, $ (n = 81) ≤30 000 (9) [20] 30 001-45 000 (9) [11] 45 001-65 000 (19) [13] 65 001-80 000 (14) [10] 80 001-100 000 (12) [10] 100 001-150 000 (19) [16] 150 001-200 000 (9) [9] >200 000 (11) [12]…”

“…4 Given the risk of opportunistic infections and development of severe oral complications, such as extensive dental caries, oral mucositis, and osteoradionecrosis of the jaw, it is recommended to treat any underlying dental pathology before commencing an antineoplastic treatment regimen. 8,9 After cancer therapy, the prevalence of dental caries has been found to be 28%, and patients had greater plaque and gingival indexes compared with healthy control individuals. 10 Traditionally, treatments for dental complications have not been covered by medical insurers, and patients pay for this care using either dental insurance (either public or private) or out-of-pocket payment.…”