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.

Background The purpose of this study was to assess aspiration pneumonia (AsPn) rates and predictors after chemo-irradiation for head and neck cancer. Methods The was a prospective study of 72 patients with stage III to IV oropharyngeal cancer treated definitively with intensity-modulated radiotherapy (IMRT) concurrent with weekly carboplatin and paclitaxel. AsPn was recorded prospectively and dysphagia was evaluated longitudinally through 2 years posttherapy by observer-rated (Common Toxicity Criteria version [CTCAE]) scores, patient-reported scores, and videofluoroscopy. Results Sixteen patients (20%) developed AsPn. Predictive factors included T classification (p = .01), aspiration detected on videofluoroscopy (videofluoroscopy-asp; p = .0007), and patient-reported dysphagia (p = .02–.0003), but not observer-rated dysphagia (p = .4). Combining T classification, patient reported dysphagia, and videofluoroscopy-asp, provided the best predictive model. Conclusion AsPn continues to be an under-reported consequence of chemo-irradiation for head and neck cancer. These data support using patient-reported dysphagia to identify high-risk patients requiring videofluoroscopy evaluation for preventive measures. Reducing videofluoroscopy-asp rates, by reducing swallowing structures radiation doses and by trials reducing treatment intensity in patients predicted to do well, are likely to reduce AsPn rates.

Purpose Doses actually delivered to the parotid glands during radiotherapy often exceed planned doses. We hypothesized that the delivered doses correlate better with parotid salivary output than the planned doses, used in all previous studies, and that determining these correlations will help decisions regarding adaptive re-planning (ART) aimed at reducing the delivered doses. Methods and Materials Prospective study: oropharyngeal cancer patients treated definitively with chemo-irradiation underwent daily cone beam CT (CBCT) with clinical set-up alignment based on C2 posterior edge. Parotid glands in the CBCTs were aligned by deformable registration to calculate cumulative delivered doses. Stimulated salivary flow rates were measured separately from each parotid gland pretherapy and periodically posttherapy. Results 36 parotid glands of 18 patients were analyzed. Average mean planned doses was 32 Gy and differences from planned to delivered mean gland doses were −4.9 to +8.4 Gy, median difference +2.2 Gy in glands whose delivered doses increased relative to planned. Both planned and delivered mean doses were significantly correlated with post-treatment salivary outputs at almost all post-therapy time points, without statistically significant differences in the correlations. Large dispersions [on average, standard deviation (SD) 3.6 Gy] characterized the dose/effect relationships for both. The differences between the cumulative delivered doses and planned doses were evident already at first fraction (r=0.92, p<0.0001) due to complex set-up deviations, e.g. rotations and neck articulations, uncorrected by the translational clinical alignments. Conclusions After daily translational set-up corrections, differences between planned and delivered doses in most glands were small relative to the SDs of the dose/saliva data, suggesting that ART is not likely to gain measurable salivary output improvement in most cases. These differences were observed already at first treatment, indicating potential benefit for more complex set-up corrections or adaptive interventions in the minority of patients with large deviations detected very early by CBCT.

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