Neurological complications of modern radiotherapy for head and neck cancer.

Radiotherapy is one of the mainstay treatment modalities for the management of non-metastatic head and neck cancer (HNC). Notable improvements in treatment outcomes have been observed in the recent decades. Modern radiotherapy techniques, such as intensity-modulated radiotherapy and charged particle therapy, have significantly improved tumor target conformity and enabled better preservation of normal structures. However, because of the intricate anatomy of the head and neck region, multiple critical neurological structures such as the brain, brainstem, spinal cord, cranial nerves, nerve plexuses, autonomic pathways, brain vasculature, and neurosensory organs, are variably irradiated during treatment, particularly when tumor targets are in close proximity. Consequently, a diverse spectrum of late neurological sequelae may manifest in HNC survivors. These neurological complications commonly result in irreversible symptoms, impair patients' quality of life, and contribute to a substantial proportion of non-cancer deaths. Although the relationship between radiation dose and toxicity has not been fully elucidated for all complications, appropriate application of dosimetric constraints during radiotherapy planning may reduce their incidence. Vigilant surveillance during the course of survivorship also enables early detection and intervention. This article endeavors to provide a comprehensive review of the various neurological complications of modern radiotherapy for HNC, summarize the current incidence data, discuss methods to minimize their risks during radiotherapy planning, and highlight potential strategies for managing these debilitating toxicities.

Cost-effectiveness of dabigatran compared with warfarin for stroke prevention in patients with atrial fibrillation--a real patient data analysis in a Hong Kong teaching hospital.

BACKGROUND: To compare the management cost and cost-effectiveness of dabigatran with warfarin in patients with nonvalvular atrial fibrillation (AF) from the hospital's and patients' perspectives. HYPOTHESIS: Dabigatran is more cost-effective than warfarin for stroke prevention of AF in Hong Kong. METHODS: The analysis was performed in conjunction with a drug utilization evaluation of dabigatran study in a teaching hospital in Hong Kong. The study recruited 244 patients who received either dabigatran or warfarin for stroke prevention of AF. A cost-effectiveness analysis was performed and was expressed as an incremental cost-effectiveness ratio (ICER) in averting a cardiac event or a bleeding event. A sensitivity analysis was used on all relevant variables to test the robustness. RESULTS: From the hospital's perspective, the dabigatran group had a lower total cost of management than that of the warfarin group (median: US$421 vs US$1306, P < 0.001) (US$1 = HK$7.75) and was dominant over warfarin. From the patients' perspective, the total cost of management in the dabigatran group was higher than that in warfarin group (median: US$1751 vs US$70, P < 0.001), and the ICER in preventing a cardiac or bleeding event of dabigatran vs warfarin was estimated at US$68,333 and US$20,500, respectively. If dabigatran was subsidized by the hospital, a higher cost would be incurred by the hospital (median: US$1679 vs US$1306, ICER (cardiac and bleeding events): US$15,163 and US$4549, respectively). CONCLUSIONS: The study favored dabigatran for stroke prophylaxis in patients with nonvalvular AF in Hong Kong under the current hospital's perspective and provided a reference for further comparisons under patient and subsidization perspectives.

Dabigatran compared with warfarin for stroke prevention with atrial fibrillation: experience in Hong Kong.

BACKGROUND: Dabigatran is an oral direct thrombin inhibitor recently approved for stroke prevention in atrial fibrillation (AF) as an alternative to warfarin. The primary advantages of dabigatran are freedom from monitoring and less interaction with other drugs and food. It is ideal for patients who are unwilling to adhere to regular coagulation monitoring or whose therapeutic effect using warfarin is not optimal despite adequate monitoring and management. However, the impact of dabigatran on health-related quality of life (HRQoL) and drug compliance has been less evaluated. This study aimed to evaluate the clinical and humanistic outcomes of dabigatran use in Hong Kong. HYPOTHESIS: Dabigatran 110 mg twice daily was non-inferior in stroke prophylaxis in AF patients compared to adjusted-dose warfarin; while dabigatran 150 mg twice daily was superior to adjusted-dose warfarin in the real world data in Hong Kong. METHODS: We retrospectively analyzed 244 patients with newly diagnosed AF and prescribed dabigatran (n = 122) or warfarin (n = 122) for stroke prophylaxis from the Prince of Wales Hospital between January 2010 to November 2011. Clinical outcomes including death, stroke, bleeding, and HRQoL using the EuroQol EQ-5D-5L were compared between patients on dabigatran and warfarin. RESULTS: The median duration of follow-up was 310 days. Stroke occurred in 2 patients (1.64%) in the dabigatran group and 4 in the warfarin group (3.28%) (adjusted hazard ratio [HR]: 0.53, P = 0.47). Bleeding of any degree occurred in 28 patients on dabigatran and 38 patients on warfarin (adjusted HR: 0.76, P = 0.28), with age over 70 years and renal impairment being significant positive predictors of bleeding (P = 0.01 and 0.02, respectively). Dyspepsia was the most common adverse event of dabigatran over warfarin (19.7% vs 8.2%, P = 0.01). Rate of discontinuation of dabigatran was 25.4%, with dyspepsia being the most common cause for discontinuation (6 patients, 4.92%). There was no significant difference in drug compliance or HRQoL at 1 year between the 2 groups (utility score 0.77 [dabigatran] vs 0.74 [warfarin], P = 0.28). CONCLUSIONS: In Hong Kong, the clinical efficacy and safety of dabigatran were comparable to that of warfarin, and drug compliance and HRQoL of using dabigatran and warfarin were similar after 1 year of use.