Differences between planned and delivered dose for head and neck cancer, and their consequences for normal tissue complication probability and treatment adaptation.

BACKGROUND AND PURPOSE: Anatomical changes induce differences between planned and delivered dose. Adaptive radiotherapy (ART) may reduce these differences but the optimal implementation is insufficiently clear. The aims of this study were to quantify the difference between planned and delivered dose in HNC patients, assess the consequential difference in normal tissue complication probability (ΔNTCP) and to explore the value of ΔNTCP as an objective selection strategy for ART. MATERIALS AND METHODS: For 52 patients, daily doses were accumulated to estimate the delivered dose. The difference from planned dose was analyzed for CTVs and 9 organs-at-risk (OAR). ΔNTCP was calculated for xerostomia, dysphagia, parotid gland dysfunction and tube feeding dependency at 6 months. ART was deemed necessary if ΔNTCP was >5%. The positive predicted value (PPV) was calculated for identification of ART-patients by clinical judgement, and ΔNTCP at fraction 10 and 15. RESULTS: ΔNTCP >5% was seen five times for dysphagia and twice for the other toxicities. Only 5/9 patients with any ΔNTCP >5% clinically received ART, although ART had been done for 13/52 patients (PPV: 0.38). PPV was 0.86 and 0.75 for accumulated dose at fraction 10 and 15, respectively, using a ΔNTCP cut-off for the allocation of ART of 5%. Using other ΔNTCP cut-offs did not substantially improve PPV. With this cut-off the negative predictive value was 0.93 for ΔNTCP method of fraction 10 and fraction 15, and 0.90 for clinical judgement. CONCLUSION: To identify patients accurately for ART, NTCP calculations based on the dose differences between planned and delivered dose at fraction 10 are superior to clinical judgement.