Objectives This report is an update of a Comparative Effectiveness Review (CER) published in final form in May 2010 on the benefits and harms of radiotherapy (RT) to treat patients with head and neck cancer (CER No. 20). RT modalities included two-dimensional RT (2DRT), three-dimensional conformal RT (3DCRT), intensity-modulated RT (IMRT), and proton-beam RT (PBT). In this CER update we included 3DCRT, IMRT, PBT, and stereotactic body RT (SBRT). We used the same Key Questions as for CER No. 20, asking whether any of these modalities is more effective than the others (1) in reducing normal tissue toxicity and adverse events, and improving quality of life (QOL); (2) in improving local tumor control, time to disease progression, and survival; or (3) when used in certain anatomic locations or patient subpopulations; and, finally, whether (4) there is more variation in patient outcomes with any modality secondary to user experience, treatment planning, or target volumes. The main finding of CER No. 20 was that late xerostomia was reduced and QOL domains related to xerostomia were improved in patients treated with IMRT compared with those who received either 3DCRT or 2DRT. Evidence was insufficient to draw conclusions on survival or tumor control, adverse events other than late xerostomia (e.g., mucositis, dysphagia, skin toxicities, or osteoradionecrosis of the jaw), whether patient and tumor characteristics affected relative outcomes, or whether physician experience and treatment characteristics affected relative clinical outcomes such as survival or treatment-associated adverse events. Data sources A medical librarian searched MEDLINE®, Embase®, and the Cochrane Controlled Trials Registry for English-language articles. The overall search was performed for a period dating 12 months before the final literature search in CER No. 20 (September 28, 2009) through April 2013. For SBRT, the literature was searched for the period January 1, 1990, through April 2013. The search was updated May 1, 2014. A search of the gray literature included clinical trial registries and information from manufacturers if available. Review methods We sought only comparative studies that reported clinical outcomes and QOL among our populations of interest. In preparing CER No. 20, we found noncomparative studies to be uninformative due to substantial heterogeneity in methods and populations, so we excluded them from the update. Data were abstracted for each Key Question by one reviewer, with independent data verification. The study limitations of randomized controlled trials (RCTs) and other comparative studies were assessed using the U.S. Preventive Services Task Force (USPSTF) criteria. The strength of the body of evidence for specific outcomes was assessed according to the latest guidance in the Agency for Healthcare Research and Quality “Methods Guide for Effectiveness and Comparative Effectiveness Reviews.” Results In two searches, we identified 7,130 unique titles and screened 284 in full text. Of the latter, 14 unique studies (N=1,781) in 15 reports met the inclusion criteria, including one RCT (N=60). In the updated search, we identified a second citation to an RCT. However, the latter included the same patients as the previously identified RCT. Therefore, it was not double-counted in the total number of patients; however, because it reported additional, different outcomes, it was reviewed. In 13 unique studies (14 reports, including the RCT), 3DCRT and IMRT were compared. One study compared 3DCRT and SBRT; none compared IMRT and SBRT. As in CER No. 20, no evidence was identified on PBT. Key outcomes of therapy included overall survival, local control, adverse effects, and QOL. According to USPSTF criteria, the RCT was deemed fair quality, whereas the other 13 studies were graded as poor quality. Conclusions New evidence on the comparative effectiveness of RT modalities for head and neck cancer is limited and heterogeneous for each comparison of 3DCRT versus IMRT or SBRT. We did not identify any evidence for PBT. New moderate-strength evidence enhances the CER No. 20 finding of reduced late xerostomia with IMRT compared with 3DCRT, with no relative change in other conclusions on adverse events or QOL. New evidence was insufficient to draw conclusions about the relative effects of IMRT and 3DCRT on overall survival or locoregional tumor control. New evidence is insufficient to draw conclusions on the comparative effectiveness of 3DCRT or IMRT versus SBRT or PBT.

Radiotherapy Treatments for Head and Neck Cancer Update [Internet]

Radiotherapy Treatments for Head and Neck Cancer Update

Purpose To identify from the current literature when is the right time to replan and to assign thresholds for the optimum process of replanning. Nowadays, adaptive radiotherapy (ART) for head and neck cancer plays an exceptional role consisting of an evaluation procedure of the prominent anatomical and dosimetric variations. By performing complex radiotherapy methods, the credibility of the therapeutic result is crucial. Image guided radiotherapy (IGRT) was developed to ensure locoregional control and thus changes that might occur during radiotherapy be dealt with. Materials and methods An electronic research of articles published in PubMed/MEDLINE and Science Direct databases from January 2004 to October 2020 was performed. Among a total of 127 studies assessed for eligibility, 85 articles were ultimately retained for the review. Results The most noticeable changes have been reported in the middle fraction of the treatment. Therefore, the suggested optimal time to replan is between the third and the fourth week. Anatomical deviations > 1 cm in the external contour, average weight loss > 10%, violation in the dose coverage of the targets > 5%, and violation in the dose of the peripherals were some of the thresholds that are currently used, and which lead to replanning. Conclusion ART may decrease toxicity and improve local-control. Whether it is beneficial or not, depends ultimately on each patient. However, more investigation of the changes should be performed in future prospective studies to obtain more accurate results.

Adaptive radiation therapy: When, how and what are the benefits that literature provides?

The goal of this study was to investigate if daily dose recalculations are necessary or if less time-consuming approaches can be used to identify dose differences to the planned dose in patients with head and neck cancers (H&N). For 12 H&N patients treated with helical tomotherapy, daily dose calculations were performed retrospectively. Four different summation doses (SuDo) were calculated: DayDo (daily dose calculation), MVCTx2, MVCTx5, and MVCTx10 (dose calculations every second, fifth, and tenth fraction). Dose recalculations were depicted on the last contoured mega voltage CT (MVCT). The DayDo was compared to the planned dose and to the less time-consuming SuDo scenarios. The doses were assessed for the planning target volume (PTV) and the organs at risk (OARs): mandible (mand), spinal cord (SC), spinal cord +5 mm (SC+5 mm), parotid glands (PG). The ipsilateral PG, contralateral PG, and PTV volume decreased by −22.5% (range: −34.8 to 5.2%), −19.5% (−31.5 to 15.8%), and −2.6% (−16.7 to 0.2%), respectively. There was a significant median mean dose (Dmean) dose difference for DayDo compared to the planned dose for PG total of 1.9 Gy (−3.3 to 7.3 Gy). But less time-consuming SuDo compared to DayDo showed statistically significant but not clinically relevant (<2%) dose differences for several organs. Hence the small dose difference to the gold standard (DayDo), we recommend dose recalculations every fifth MVCT in order to identify the occurrence of dose differences compared to the planned dose. Daily dose calculations are the most precise to assess dose differences between actual and planned dose. Dose recalculations on every fifth MVCT (i. e., weekly control CTs) are an applicable and time-saving way of identifying patients with significant dose differences compared to the planned dose.

CT-based dose recalculations in head and neck cancer radiotherapy: comparison of daily dose recalculations to less time-consuming approaches

Purpose To investigate the effects of interfractional variation, such as anatomical changes and setup errors, on dose delivery during treatment for prostate cancer (PC) and head and neck cancer (HNC) by courses of volumetric modulated arc therapy (VMAT) aided by on-treatment electronic portal imaging device (EPID) images. Methods Seven patients with PC and 20 patients with HNC who had received VMAT participated in this study. After obtaining photon fluence at the position of the EPID for each treatment arc from on-treatment integrated EPID images, we calculated the differences between the fluence for the first fraction and each subsequent fraction for each arc. The passing rates were investigated based on a tolerance level of 3% of the maximum fluence during the treatment courses and the correlations between the passing rates and anatomical changes. Results In PC, the median and lowest passing rates were 99.8% and 95.2%, respectively. No correlations between passing rates and interfractional variation were found. In HNC, the median passing rate of all fractions was 93.0%, and the lowest passing rate was 79.6% during the 35th fraction. Spearman's correlation coefficients between the passing rates and changes in weight or neck volume were - 0.77 and - 0.74, respectively. Conclusions Analyses of the on-treatment EPID images facilitates estimates of the interfractional anatomical variation in HNC patients during VMAT and thus improves assessments of the need for re-planning or adaptive strategies and the timing thereof.

https://aapm.onlinelibrary.wiley.com/doi/epdf/10.1002/acm2.12805

Analyses of integrated EPID images for on-treatment quality assurance to account for interfractional variations in volumetric modulated arc therapy.

A quantitative assessment of volumetric and anatomic changes of the parotid gland during intensity-modulated radiotherapy for head and neck cancer using serial computed tomography.

Background

The purpose of this study was to evaluate how gross tumor volume (GTV) affects treatment outcome among different race/ethnic groups in patients with head and neck cancer receiving definitive radiotherapy (RT).



Methods

Ninety-one patients with head and neck cancer were treated to a median RT dose of 69.96 Gy in 33 fractions. The patient's self-reported race/ethnicity, primary tumor, and nodal GTV were obtained. Two-year actuarial local, nodal, and distant control, and overall and disease-free survival were calculated.



Results

The patients were categorized as white (n = 43) or non-white (n = 48), which included 29 African Americans, 11 Hispanics, 5 Asians, and 3 others. The mean primary GTV was 21.0 cc and 39.9 cc for whites and non-whites, respectively (p = .011). White patients reported improved overall survival of 85.4% compared to non-whites (65.8%; p = .006). Improvements in local and nodal control and disease-free survival rates were also observed.



Conclusion

White patients demonstrated improved treatment outcomes compared with non-whites, which may be reflective of tumor volume. © 2014 Wiley Periodicals, Inc. Head Neck, 2015

Race disparities attributed to volumetric tumor burden in patients with head and neck cancer treated with radiotherapy.

Purpose/Objective(s): This study included 165,226 individuals diagnosed with colorectal cancer between 1988 and 2001. Colorectal cancer cases were identified from 16 population-based registries of the National Cancer Institute’s Surveillance, Epidemiology, and End Results program. Materials/Methods: Survival probabilities were compared among white and black patients. Kaplan-Meier curves and proportional hazard ratios from Cox regression analysis were calculated accounting for marital status, age, gender, stage at diagnosis and year of diagnosis. Patients lacking complete information were excluded from analysis. Results: Multivariate analysis demonstrated that older age, male gender, non-recent year of diagnosis, and advanced stage at diagnosis were associated with worse survival. Black race independently predicted for a worse survival compared with whites. Marital status was a greater predictor of survival when analyzed in conjunction with race: compared to married white patients, black single/separated/divorced (unmarried) and black married patients were found to have hazard ratios (HR) of 1.63 (1.56-1.71) and 1.21 (1.17-1.25), respectively. While stage I patients experienced better survival, when compared to white married patients, the HR for black unmarried and black married patients was 2.11 (1.84-2.41) and 1.35 (1.241.47), respectively. Conclusions: Marital status and race are independent predictors of colorectal cancer survival. Additional strategies must be defined that address the social factors that account for disparities in cancer outcome. Author Disclosure: A. Blackstock: E. Research Grant; NIH/NCI P30 CA012197-36. B. Lally: None. S. Isom: None. E. Paskett: None.

Gross Tumor Volume Presentation in Different Race/Ethnic Groups as a Determinant of Treatment Outcome in Head-and-Neck Cancer Patients Treated With Definitive Radiation Therapy

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A quantitative assessment of volumetric and anatomic changes of the parotid gland during intensity-modulated radiotherapy for head and neck cancer using serial computed tomography.

Race disparities attributed to volumetric tumor burden in patients with head and neck cancer treated with radiotherapy.

Gross Tumor Volume Presentation in Different Race/Ethnic Groups as a Determinant of Treatment Outcome in Head-and-Neck Cancer Patients Treated With Definitive Radiation Therapy