Toxicities Affecting Quality of Life After Chemo-IMRT of Oropharyngeal Cancer: Prospective Study of Patient-Reported, Observer-Rated, and Objective Outcomes

Abstract

Purpose After conventional radiotherapy for head and neck cancer, xerostomia has traditionally been the major effector of patient-reported quality of life (QOL), and recent publications suggest that dysphagia has an even stronger effect. We hypothesized that IMRT aiming to spare the salivary glands and swallowing structures reduced, or eliminated, the effects of these toxicities on QOL. Methods and Materials Prospective longitudinal study: 72 patients with Stage III-IV oropharyngeal cancer treated uniformly with definitive chemo-IMRT sparing the salivary glands and swallowing structures. Overall QOL was assessed by summary scores of the Head Neck QOL (HNQOL) and University of Washington QOL (UWQOL) questionnaires, as well as HNQOL “Overall Bother” question. QOL, observer-rated toxicities (CTCAE v2), and objective evaluations (videofluoroscopy assessing dysphagia and saliva flow rates assessing xerostomia) were recorded pre-therapy through 2 years post-therapy. Correlations between toxicities/objective evaluations and overall QOL were assessed using longitudinal repeated measures of analysis and Pearson correlations. Results All observer-rated toxicities and QOL scores worsened 1-3 months after therapy and improved through 12 months, with minor further improvements through 24 months. At 12 months, dysphagia grades 0-1, 2, and 3, were observed in 95%, 4%, and 1% of patients, respectively. Using all post-therapy observations, observer-rated dysphagia was highly correlated with all overall QOL measures (p<0.0001), while xerostomia, mucosal, and voice toxicities were significantly correlated with some, but not all, overall QOL measures, with lower correlation coefficients than dysphagia. Late overall QOL (≥6 or ≥12 months post-therapy) was primarily associated with observer-rated dysphagia, and to a lesser extent with xerostomia. Videofluoroscopy scores, but not salivary flows, were significantly correlated with some of the overall QOL measures. Conclusion After chemo-IMRT, while late dysphagia was on average mild, it was still the major correlate of QOL. Further efforts to reduce swallowing dysfunction are likely to yield additional gains in QOL.

Functional outcomes after TORS for oropharyngeal cancer: a systematic review

“…More specifically, physiologic impairment quantified from the MBS study has been shown to predict quality of life, and MBS endpoints of aspiration and pharyngeal residue significantly predict post-treatment pneumonia after treatment for OPC (p=0.017, Se 80%, Sp 60%). 36,37 These data offer compelling support for inclusion of instrumental assessment, particularly the MBS, in TORS trials, as the data obtained from MBS cannot be reliably inferred from subjective, self-report of swallowing function obtained from PRO measures.…”

Microvascular Reconstruction

“…Adjuvant treatment reporting is also critical in outcomes analyses. Surgery with radiation and chemotherapy invariably affect patient function and QOL more than surgery or radiation alone 21,22,28,41 (level 4 evidence). Although pure comparison between modalities may not be feasible, acknowledging the effects of adjuvant treatments have on function and QOL is important.…”

“…Systematic reviews in head and neck reconstruction have increased in recent years, but a definitive review of the functional outcomes in reconstruction is lacking 20 (level 3 evidence). Although nonoperative management of head and neck cancers have well-designed, single-institution studies as well as systematic review to assess functional outcomes 21,22 (level 3 evidence), such rigor in examining the role of reconstruction in the operative management of this disease has not been employed. We asked the following question to guide our systematic review: what are the functional outcomes of head and neck reconstruction involving the oral cavity and oropharynx?…”

Head and Neck Cancer

“…Dysfunction of the swallowing structures is a common cause of severe acute and late toxicity after head and neck radiotherapy and is perhaps the strongest determinant of long-term quality of life in HNC survivors (Hunter et al 2013 ;Langendijk et al 2008 ;Machtay et al 2008 ;Terrell et al 2004 ). Radiotherapy dose to the swallowing structures, specifi cally the pharyngeal constrictor (PC) muscles, has been implicated as a primary treatment-related predictor of swallowing dysfunction after chemoradiotherapy (Eisbruch et al 2011 ;Popovtzer et al 2009 ).…”