Trends in Reporting of Swallowing Outcomes in Oropharyngeal Cancer Studies: A Systematic Review.

Over the last two decades, dysphagia is increasingly recognized as a significant short-term and long-term issue in oropharyngeal cancer patients. However, there remains a lack of standardization and agreement about reporting swallowing outcomes in studies that assess treatment outcomes in this population. A systematic review was performed following PRISMA Guidelines by searching Pubmed (MEDLINE) and Scopus. The inclusion criteria used included (1) prospective and retrospective clinical studies involving adult patients with oropharyngeal cancer, (2) reports swallowing outcomes, (3) English studies or studies with English translation, (4) full text retrievable and (5) publication between 1990 and 2016. 410 unique studies were identified, and 106 were analyzed. A majority (> 80%) of studies that reported swallowing outcomes were published after 2010. While 75.4% of studies reported subjective outcomes (e.g., patient-reported or clinician-reported outcome measures), only 30.2% of studies presented results of objective instrumental assessment of swallowing. The majority (61%) of studies reported short-term swallowing outcomes at 1 year or less, and only 10% of studies examined 5-year swallowing comes. One study examined late-dysphagia (> 10 years) in the oropharyngeal cancer population. Considerable heterogeneity remains in the reporting of swallowing outcomes after treatment of oropharyngeal cancer despite its importance for quality of life. Studies reporting long-term swallowing outcomes are lacking in the literature, and objective measures of swallowing function remain underutilized and nonstandardized.

Head and Neck Cancer Survivorship Care: A Review of the Current Guidelines and Remaining Unmet Needs.

OPINION STATEMENT: A larger proportion of patients with head and neck cancers (HNC) are now surviving, constituting up to 3% of all cancer survivors. This is likely due in part to the increase in HPV-related oropharyngeal cancers affecting younger individuals and with a better prognosis and to the improved outcomes of other HNCs as well over the last two decades. Most studies have previously been focusing on improving risk stratification, treatment and disease-related outcomes. Over the last decade, there has been an evolving interest in the field of survivorship care. Despite the collaborative efforts from a multidisciplinary team in managing cancer and treatment-related side-effects and in improving survivors' overall quality of life (QOL), it has been reported that up to 60-65% of patients have at least one unmet need. The purpose of this article is to review current guidelines for HNC survivorship care and identify areas of unmet need. Over the last 5 years, multiple groups have published guidelines describing survivorship care issues and their possible management. Although a very comprehensive and informative first initiative, multiple issues need to be further evaluated. These include how to best support patients and their partners' fear of cancer recurrence, to provide coordinated care among all physicians, to identify and meet patients' needs in local multidisciplinary teams and to institute measures to ensure every individual's access to high-quality patient-centred care. Furthermore, experts may consider engaging in further dialog with primary care physicians (PCP) to improve sharing of survivorship care. More should be learned about PCPs' comfort levels in providing such care and whether further steps are required to facilitate a seamless. Transition of care and accessibility to specialized care as needed.

A Novel Neoadjuvant Therapy for Operable Locally Invasive Non-Small-Cell Lung Cancer. Phase I Study of Neoadjuvant Stereotactic Body Radiotherapy. LINNEARRE I (NCT02433574).

BACKGROUND: Despite improved staging and surgical techniques, the rate of incomplete resection (R1) of non-small-cell lung cancer (NSCLC) has not significantly decreased. Patients with R1 resection have worse survival compared with those with complete resection (R0). Stereotactic body radiotherapy (SBRT) is a rapid and convenient radiotherapy treatment that delivers high-dose radiotherapy to tumors with high precision while sparing normal organs. Although its efficacy in treating small lung tumors is documented, its use as neoadjuvant therapy for locally advanced (LA) NSCLC has not been examined. We hypothesized that a short course of preoperative SBRT is feasible and can be delivered safely as a neoadjuvant therapy in patients at risk for incomplete resection. METHODS: In this phase I study, 20 patients with cT3 to 4, N0 to 1, M0 NSCLC at risk for incomplete resection will be treated with neoadjuvant SBRT followed by surgery and adjuvant chemotherapy. Four groups of 5 patients will be treated with escalating doses (35, 40, 45, and 50 Gy) in 10 daily fractions. The primary outcome is feasibility (ie, the ability to complete SBRT and surgery as planned; within 7 weeks). Secondary outcomes include acute and late adverse events; R0, R1, and R2 rates; and secondary surrogates of feasibility and safety. RELEVANCE: This study is an important first step in introducing a new therapeutic modality to patients with LA NSCLC that could improve surgical outcomes in the future. If neoadjuvant SBRT is found to be feasible and safe for LA NSCLC, its effect in achieving R0 resection could be investigated in randomized trials.

Optimal detection of hypothyroidism in early stage laryngeal cancer treated with radiotherapy.

BACKGROUND: Hypothyroidism following radiation therapy (RT) for treatment of Head and Neck Cancer (HNC) is a common occurrence. Rates of hypothyroidism following RT for Early Stage Laryngeal Squamous Cell Carcinoma (ES-LSCC) are among the highest. Although routine screening for hypothyroidism is recommended; its optimal schedule has not yet been established. We aim to determine the prevalence and optimal timing of testing for hypothyroidism in ES-LSCC treated with RT. METHOD: We conducted a population-based cohort study. Data was extracted from a prospective provincial head and neck cancer database. Demographic, survival data, and pre- and post-treatment thyroid stimulating hormone (TSH) levels were obtained for patients diagnosed with ES-LSCC from 2008-2012. Inclusion criteria consisted of patients diagnosed clinically with ES-LSCC (T1 or 2, N0, M0) treated with curative intent. Patients were excluded if there was a history of hypothyroidism before the treatment or any previous history of head and neck cancers. RESULTS: Ninety-five patients were included in this study. Mean age was 66.1 years (range: 44.0-88.0 years) and 82.3% of patients were male. Glottis was the most common subsite at 77.9% and the average follow-up was 40 months (Range: 12-56 months). Five-year overall survival generated using the Kaplan-Meier method was 79%. Incidence of hypothyroidism after RT was found to be 46.9%. The greatest frequency of developing hypothyroidism was at 12 months. CONCLUSIONS: We found a high prevalence of hypothyroidism for ES-LSCC treated with RT, with the highest rate at 12 months. Consequently, we recommend possible routine screening for hypothyroidism using TSH level starting at 12 months. To our knowledge, this is the first study to suggest the optimal timing for the detection of hypothyroidism.

Endotracheal brachytherapy alone: An effective palliative treatment for tracheal tumors.

BACKGROUND: Tracheal tumors are rare. They are usually unresectable and treated primarily with external beam radiation. The use of palliative endotracheal brachytherapy (ETBT) alone in treating patients with tracheal tumors has not been reported. METHODS: Using a prospective database, demographic, treatment, and outcome data of patients with tracheal tumors treated palliatively with ETBT from 2006 to 2014 were analyzed. Tumor and symptom responses were evaluated based on response evaluation criteria in solid tumors criteria. Survival, in-field disease control, symptom response, and duration of symptom responses were evaluated using descriptive analyses. RESULTS: Sixteen ETBT (median, 2) treatments were delivered to 8 patients. Median age was 63.4 years old. Common symptoms were hemoptysis, cough, and dyspnea. Tracheal lengths of 3.5-11 cm were treated with 5-7 Gy/fraction, using 1-3 fractions. The mean overall survival was 5 months and symptom-free survival was 6.8 months, respectively. After ETBT, 88% of patients experienced symptomatic improvement (hemoptysis [n = 3/3], cough [n = 6/7], and dyspnea [n = 4/4]). One patient developed Grade 1 stenosis that did not require intervention. CONCLUSIONS: This is among the largest series of tracheal tumors treated palliatively with ETBT alone. ETBT provided effective palliation with symptom improvement and minimal toxicity.

Turn down the noise--a blinded evaluation of iterative image reconstruction in radiation therapy computed tomography simulation.

PURPOSE: The current standard reconstruction algorithm for computed tomography (CT) scans is filtered back projection. Alternative algorithms using iterative reconstruction (IR)-in our case, "sinogram affirmed iterative reconstruction"-have been increasingly implemented in diagnostic CT imaging. We studied its potential in improving radiation therapy planning images. METHODS AND MATERIALS: Raw planning CT data sets of patients from varied disease sites were reconstructed using filtered back projection and IR levels 1, 3, and 5 with equal radiation dose. For each site, 2-7 patient scans were selected; 2-3 physicians blindly evaluated the 4 3-dimensional image sets. Using a visual analogue scale, they rated the sharpness, noise, perceived ease in delineating gross tumor/clinical target volume and organs at risk, and overall appreciation of the images. Interobserver correlation was calculated with the Spearman correlation coefficient (ρ). Generalized estimating equations assessed the differences in the mean score for each criterion between reconstructions. When significant differences existed, pairwise comparisons compared the least-squares means. The preference for each reconstruction was rank ordered for each observer. The rank occurrences were computed; generalized estimating equations and pairwise comparisons were again calculated. RESULTS: Sixteen physicians reviewed 548 image sets. The sharpness had a ρ = -0.22-0.53, noise ρ = -0.34-0.38, delineating gross tumor/clinical target volume ρ = -0.28-0.53, delineating organs at risk ρ = -0.47-0.42, and overall appreciation ρ = -0.17-0.38, suggesting a low level of agreement among observers. IR 3 and 5 had consistently higher scores and ranks than filtered back projection (P = .02 and P = .015, respectively). Paradoxically, IR 5 scored both highest and worst the most frequently. IR 3 was more consistently well-ranked for all criteria. CONCLUSIONS: This report is the first to clinically evaluate IR in radiation therapy planning. When used to reduce noise in current CT simulation protocols, IR images were generally preferred. Although highly processed images polarized observers, the use of moderate IR was appreciated for most disease sites.

Skin elasticity as a measure of radiation fibrosis: is it reproducible and does it correlate with patient and physician-reported measures?

Current means of measuring RT-induced fibrosis are subjective. We evaluated the DermaLab suction cup system to measure objectively skin deflection as a surrogate for fibrosis. Sixty-nine patients with E-STS were treated with limb-sparing surgery and 50-66 Grays (Gy) of RT. Using a "scleroderma" DermaLab Suction Cup, the skin stiffness was measured by two clinicians. The National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) scale, the Musculoskeletal Tumor Rating Scale (MSTS) and Toronto Extremity Salvage Score (TESS) questionnaires were completed for each patient. Levels of agreement between measurers were estimated using the Kappa (k) coefficient and the concordance correlation coefficient (CCC). All sixty-nine patients were included. The level of agreement between measurers for NCI-CTCAE grading was moderate (range k = 0.41-0.59). The CCC for the elasticity measurements were higher, with CCC = 0.82 for fibrotic skin and CCC 5 0.84 for normal skin. The elasticity measurements were significantly higher when MSTS scores were <30 and or TESS scores were <90. Suction Cup measurement of skin elasticity is more reproducible than CTCAE grading and shows promise in generating reproducible measurements for radiation-induced skin fibrosis. Furthermore, it correlates well with the MSTS and TESS.