Rufus Scrimger

Nutrition impact symptoms: Key determinants of reduced dietary intake, weight loss, and reduced functional capacity of patients with head and neck cancer before treatment

Our aim was to evaluate the prevalence and relationship of symptoms with reduced dietary intake, weight, and functional capacity in patients with head and neck cancer.

A pilot study of a randomized controlled trial to evaluate the effects of progressive resistance exercise training on shoulder dysfunction caused by spinal accessory neurapraxia/neurectomy in head and neck cancer survivors

Shoulder dysfunction remains a frequent complication after neck dissection procedures for head and neck cancer.

Muscle-invasive transitional cell carcinoma of the urinary bladder : A population-based study of patterns of care and prognostic factors

PURPOSE Population-based cancer registries can permit the study of the survivorship of all patients with a particular diagnosis regardless of patterns of referral and practice within a specific geographic distribution. The purpose of this study is to describe the patterns of care, outcome, and prognostic factors for bladder cancer in the northern region of the province of Alberta, Canada, between 1984 and 1993. METHODS AND MATERIALS Between 1984 and 1993, 184 patients from northern Alberta were identified from the Alberta Cancer Registry as having undergone curative treatment for biopsy-proven muscle-invasive transitional cell carcinoma of the bladder. Data were obtained, by retrospective chart review, regarding the staging, pathology, treatment, and outcome of patients treated in the northern Alberta cities of Edmonton, Grande Prairie, and Red Deer, regardless of the responsible treating institution. The prognostic significance of patient-, tumor-, and treatment-related variables were tested using univariate and multivariate analysis using the Cox proportional-hazard model. RESULTS As the primary treatment modality, 74 patients (40%) received radical radiotherapy (RT) without surgery; surgery was used alone in 81 patients (44%), and was combined with preoperative or postoperative radiotherapy in 29 patients (16%). Seventy-three (40%) patients also received concurrent, neoadjuvant, or adjuvant chemotherapy. The Kaplan-Meier estimate of median survival was 2.2 years, and the 5-year overall survival was 30%. Univariate analysis demonstrated the prognostic significance of T classification (p < 0.001), lymph node involvement (p < 0.001), complete response to RT (p = 0.001), hydronephrosis (p = 0.017), and vascular/lymphatic involvement (p = 0.035). Multivariate analysis revealed the following to have a significant association with survival: T classification (p = 0.001), lymph node involvement (p = 0.004), complete response to RT (p = 0.054), hydronephrosis (p = 0.019), and use of chemotherapy in the treatment regimen (p = 0.025). CONCLUSION The strongest prognostic factors in this study were tumor related, and no significant differences in survival were detected between patients treated with primary surgery vs. organ-preservation approaches. A survival advantage associated with the incorporation of chemotherapy into the management schema was detected on multivariate, but not univariate, analysis. Stratification of patients based on tumor characteristics is imperative in clinical trials for invasive bladder cancer. Novel treatment approaches are required to improve survival further in patients with apparently localized disease.

Adaptive radiotherapy using helical tomotherapy for head and neck cancer in definitive and postoperative settings: initial results.

AIMS To assess whether routine mid-treatment replanning in head and neck squamous cell carcinoma patients results in meaningful improvements in target or normal tissue dosimetry and to assess which patients derive the greatest benefit. MATERIALS AND METHODS Twenty patients treated with either postoperative chemoradiotherapy or definitive chemoradiotherapy with primary or nodal disease ≥3cm in size were included in this prospective pilot study. Seven patients received adjuvant chemoradiotherapy and 13 received definitive chemoradiotherapy. Patients were planned and treated on a helical tomotherapy system. All patients had a second computed tomography scan after 15 fractions and a new plan based on this was initiated from fraction 20. RESULTS Relative volume changes between computed tomography scans were: GTV 29%; CTV60 (adjuvant patients) 4%; parotid volume 17.5%; median reduction in neck separation 6-7 mm; weight loss 3%. For the group overall and for the definitively treated patient cohort, respectively, adapted plans resulted in reductions in PTV66 D(1) (0.3Gy, P=0.01 and 0.5Gy, P=0.01); PTV54 D(1) (0.6Gy, P<0.0001 and 0.9Gy, P=0.0002); spinal cord maximum (0.5Gy, P=0.004 and 0.6Gy, P=0.04) and volume of skin receiving ≥50Gy (16 cm(2), P=0.01 and 19 cm(2), P=0.001). Definitively treated patients also had a reduction in mean parotid dose (0.6Gy, P=0.046) and volume of normal tissue receiving ≥50Gy (67 cm(3), P=0.02). Patients with nasopharyngeal carcinoma received the greatest benefits with treatment adaptation with reduction in spinal cord maximum 1.2Gy, mean parotid dose 1.2Gy and parotid V(26) 6.3%. There was no significant benefit for adjuvant patients. Other factors associated with greater benefits were greater weight loss and greater reduction in neck separation and higher T stage. CONCLUSIONS There is minimal benefit to routine adaptive replanning in unselected patients, and no benefit in adjuvantly treated patients. Patients with nasopharyngeal carcinoma or with greater weight loss or reduction in neck separation did have clinically significant benefits. These patients should be targeted for adaptive strategies.

Clinical determinants of weight loss in patients receiving radiation and chemoirradiation for head and neck cancer: A prospective longitudinal view

We aimed to determine the effects of systemic inflammation and symptoms of head and neck cancer patients on dietary intake and weight in relation to mode of treatment.

Nutrition impact symptoms in a population cohort of head and neck cancer patients: multivariate regression analysis of symptoms on oral intake, weight loss and survival.

OBJECTIVES To evaluate the impact of 17 symptoms on reduced dietary intake, weight loss, and survival of patients with Head and Neck Cancer (HNC). METHODS 635 Consecutive patients were screened (Patient- Generated Subjective Global Assessment©, Head and Neck Symptom Checklist©) before radiation and/or chemotherapy. Multivariate regression analyses were used to relate severity of symptoms to reduced dietary intake and weight loss and identify prognostic individual symptoms impact on dietary intake. Cox proportional hazards model was used to find significant predictors of survival. RESULTS Aggregate burden of symptoms was a significant independent predictor of reduced intake, weight loss and survival. Patients with a highest total symptom scores survived significantly less (205days, 95% CI=146-264) compared to patients with lowest total symptom score (577days, CI=429-725), log-rank P<0.001). Loss of appetite, difficulty chewing, dry mouth, thick saliva and pain were individual symptoms that significantly associated with reduced dietary intake in the entire cohort. In subgroup analyses, tumor location, disease stage, performance status, and presence of dysphagia altered the profile of individual symptoms that predict intake. However across all subgroups loss of appetite had the highest impact (OR=4.6; 95% CI=3.1-6.8), followed by difficulty chewing (OR=2.5; 95% CI=2.0-3.9). CONCLUSION HNC patients experience significant symptom burden prior to radiation and chemotherapy. The nutritional impact of these symptoms on dietary intake is revealed by multivariate analysis and support the suggestion that unique individual symptom profiles require management to improve nutritional status.

Dose–volume analysis of locoregional recurrences in head and neck IMRT, as determined by deformable registration: A prospective multi-institutional trial

BACKGROUND AND PURPOSE Although IMRT for head and neck cancer is widely accepted, the implications of sparing normal tissue immediately adjacent to target volumes are not well known. MATERIALS AND METHODS Between 2002 and 2007, 124 patients with head and neck cancer were treated with surgery and postoperative IMRT (n=79) or definitive RT (n=45). Locoregional recurrences were analyzed for location relative to target volumes, and dosimetry. RESULTS With a median follow-up of 26.1months, a total of 16 locoregional recurrences were observed. The five-year actuarial locoregional disease-free survival was 82% [95% CI, 72-90%]. Analysis of 18 distinct sites of locoregional failure revealed that five of these failures were within the high dose clinical target volume (CTV), nine failures were at the margin of the CTV, and four recurrences were outside the CTV. The mean dose delivered to these recurrent volumes was 63.1 Gy [range: 57-68 Gy], while the mean dose to the coolest 1cc within each recurrence was 60.0 Gy [range: 51-67 Gy]. There were two periparotid recurrences observed. CONCLUSIONS We observed excellent locoregional control rates overall. The majority of recurrences occur within high dose regions of the neck and not near the spared parotid glands.

Making a Case for High-Volume Robotic Surgery Centers: A Cost-Effectiveness Analysis of Transoral Robotic Surgery

To evaluate the cost‐effectiveness of transoral robotic surgery (TORS) compared to intensity‐modulated radiotherapy (IMRT) for early stage (T1‐2, N0, M0) oropharyngeal squamous cell carcinoma (OPSCC).

A planning comparison of 3-dimensional conformal multiple static field, conformal arc, and volumetric modulated arc therapy for the delivery of stereotactic body radiotherapy for early stage lung cancer.

The primary objective of this study was to compare dosimetric variables as well as treatment times of multiple static fields (MSFs), conformal arcs (CAs), and volumetric modulated arc therapy (VMAT) techniques for the treatment of early stage lung cancer using stereotactic body radiotherapy (SBRT). Treatments of 23 patients previously treated with MSF of 48Gy to 95% of the planning target volume (PTV) in 4 fractions were replanned using CA and VMAT techniques. Dosimetric parameters of the Radiation Therapy Oncology Group (RTOG) 0915 trial were evaluated, along with the van׳t Riet conformation number (CN), monitor units (MUs), and actual and calculated treatment times. Paired t-tests for noninferiority were used to compare the 3 techniques. CA had significant dosimetric improvements over MSF for the ratio of the prescription isodose volume to PTV (R100%, p < 0.0001), the maximum dose 2cm away from the PTV (D2cm, p = 0.005), and van׳t Riet CN (p < 0.0001). CA was not statistically inferior to MSF for the 50% prescription isodose volume to PTV (R50%, p = 0.05). VMAT was significantly better than CA for R100% (p < 0.0001), R50% (p < 0.0001), D2cm (p = 0.006), and CN (p < 0.0001). CA plans had significantly shorter treatment times than those of VMAT (p < 0.0001). Both CA and VMAT planning showed significant dosimetric improvements and shorter treatment times over those of MSF. VMAT showed the most favorable dosimetry of all 3 techniques; however, the dosimetric effect of tumor motion was not evaluated. CA plans were significantly faster to treat, and minimize the interplay of tumor motion and dynamic multileaf collimator (MLC) motion effects. Given these results, CA has become the treatment technique of choice at our facility.

Salivary gland sparing in the treatment of head and neck cancer

Radiotherapy is an important component of the multimodality treatment of head and neck cancer. Although an effective treatment for many patients, it can have significant long-term sequelae. In particular, xerostomia – or dry mouth – caused by salivary gland injury is a serious problem suffered by most patients and leads to problems with oral comfort, dental health, speech and swallowing. This article explores the mechanisms behind radiation injury to the major salivary glands, as well as different strategies to minimize and alleviate xerostomia. This includes technical approaches to minimize radiation dose to salivary tissue, such as intensity-modulated radiotherapy and surgical transfer of salivary glands, as well as pharmacologic approaches to stimulate or protect the salivary tissue. The scientific literature will be critically examined to see what works and what strategies have been less effective in attempting to minimize xerostomia in head and neck cancer patients.