Preservation of swallowing function with de-intensified chemoradiation therapy for HPV-associated oropharyngeal squamous cell carcinoma

Abstract

PurposeThis study aimed to compare the swallowing function in patients with human papillomavirus–associated oropharyngeal squamous cell carcinoma treated with de-intensified chemoradiation therapy (6 weeks, 60 Gy) versus those receiving standard-of-care chemoradiation therapy (7 weeks, 70 Gy).Methods and materialsA retrospective review was conducted of 78 patients with human papillomavirus–associated oropharyngeal squamous cell carcinoma with modified barium swallow studies pretreatment and 6 to 8 weeks posttreatment. The swallowing function was objectively scored for penetration, aspiration, and pharyngeal residue. Forty patients received de-intensified chemoradiation therapy (60 Gy image guided radiation therapy with weekly cisplatin 30 mg/m2) and 38 patients received standard-of-care chemoradiation therapy (70 Gy image guided radiation therapy with chemotherapy of the medical oncologist's choosing). Univariate and multivariate analyses were performed to detect differences between the cohorts with regard to laryngeal penetration, aspiration, and pharyngeal residue. A multivariate logistic regression was used to determine the overall effect of treatment on the swallowing function. Patient-reported swallowing outcomes in de-intensified cohort were assessed with the European Organisation for Research and Treatment of Cancer Quality of Life Module for Head and Neck Cancer and the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events questionnaires.ResultsPatients treated with de-intensified chemoradiation therapy were associated with a suggestion of lower risk of developing overall swallowing dysfunction (odds ratio [OR], 0.62; P = .07), laryngeal penetration (OR, 0.63; P = .12), and pharyngeal residue (OR, 0.61; P = .08). The mean pre- and 2-year post-European Organisation for Research and Treatment of Cancer Quality of Life scores pertaining to swallowing (1-4 scale, higher worse) in the de-intensified cohort were 1.4 and 1.2 for liquids; 1.2 and 1.1 for purees; 1.5 and 1.7 for solids, 1.0 and 1.3 for choked when swallowing; and 9.0 and 10.8 for composite score, respectively. The mean pre- and 2-year post-Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events swallowing difficulty scores (1-5 scale, with higher scores being worse) were 1.5 and 1.8, respectively.ConclusionsCompared with 7 weeks of 70 Gy, 6 weeks of 60 Gy de-intensified chemoradiation therapy appears to better preserve the baseline swallowing function (per objective modified barium swallow assessment). Patients treated with de-intensified chemoradiation therapy reported minimal changes in swallowing function.

Factors associated with swallowing dysfunction in patients with head and neck cancer

“…The number of WST failures increased over time to almost 12% three months after treatment, and the reason for failure changed from “not being able to drink the 100 ml of water,” to “coughing or choking post‐swallow.” Coughing or choking post‐swallow was found to have a specificity of up to 91.7% in predicting aspiration, and the WST is therefore a useful tool for early detection of swallowing dysfunction (Wu et al, 2004). Previous research found dysphagia and aspiration rates between 12% and 21%, similar to the results found in this study (Judy et al, 2018; Patterson et al, 2018). Especially, patients that received surgery with adjuvant treatment have a higher prevalence of dysphagia in comparison with patients that receive RT alone, as also seen in this research by the higher number of swallows (Hutcheson et al, 2019).…”

“…Coughing or choking post-swallow was found to have a specificity of up to 91.7% in predicting aspiration, and the WST is therefore a useful tool for early detection of swallowing dysfunction (Wu et al, 2004). Previous research found dysphagia and aspiration rates between 12% and 21%, similar to the results found in this study (Judy et al, 2018;Patterson et al, 2018).…”

The course of health-related quality of life from diagnosis to two years follow-up in patients with oropharyngeal cancer: does HPV status matter?

“…The findings in this study may contribute to the current discussion about treatment deescalation. Efforts to improve treatment outcome in this patient group should also focus on preventing HRQOL deterioration during and shortly after treatment when possible [31][32][33][34]. Furthermore, the results of this study are helpful in further advancing supportive care by providing information on the impact of OPSCC and its treatment on HRQOL and referring patients to supportive care, tailored to the needs of OPSCC patients with HPV-positive and those with HPV-negative tumors.…”

Reduced-dose radiation in human papillomavirus-associated oropharyngeal carcinoma can improve outcome: a systematic review and meta-analysis

“…The systematic review conducted in this study showed that lower doses could reduce post-treatment AEs, either the incidence of decreased quality of life ( 40 ) or late adverse reactions ( 25 ). Some studies ( 28 , 41 - 43 ) have shown that, after dose reduction, the symptoms of dry mouth, hypogeusia, and dysphagia continue to improve, and gastrostomy tube (PEG) placement rates and late toxicity were also lower ( 43 - 45 ). It has also been reported ( 46 ) that the target volume of OPC could combine dose reduction with unilateral irradiation for improving mild to moderate acute swallowing dysfunction.…”