Palliative radiotherapy in locally advanced head and neck cancer-A prospective trial
AIM: To evaluate the role of palliative radiotherapy for symptom control in patients with locally advanced head and neck cancer. MATERIALS AND METHODS: 25 patients with stage 3 and stage 4 head and neck cancer were treated with a short course of palliative radiotherapy (30 Gray (Gy) in 10 fractions over 2 weeks). Baseline symptoms were assessed using a 11 point numerical scale for pain, dysphagia, cough, insomnia and dyspnoea. The primary end point was relief of symptoms in the fourth week after radiotherapy. Percentage symptom relief was quantified by the patient using a rupee scale. RESULTS: All 22 patients with pain and 90% of patients with dysphagia, dyspnoea and disturbed sleep had greater than 50% relief in symptoms after radiotherapy. Cough was relieved in sixty percent of cases. CONCLUSION: A short course of radiation can be an effective method of symptom palliation in head and neck cancers.
Keywords: Radiotherapy, palliation, head and neck carcinoma
Seventy five to eighty percent of cancer patients in India present with advanced disease and are considered incurable. The goal of treatment is to palliate symptoms and improve quality of life. Radiotherapy and chemotherapy can be useful modalities for symptom management and should be judiciously used in palliative care. The present study was undertaken to evaluate the role of palliative radiotherapy in patients with advanced head and neck cancer who were not fit for radical treatment.
This prospective single arm study was conducted at the Postgraduate Institute of Medical Education and Research, Chandigarh between July and December 2002. The study population consisted of 25 biopsy proven and previously untreated cases of squamous cell carcinoma of the head and neck region. All patients had locally advanced disease and their Karnofsky performance status ranged from 50 to 70.
The primary end point of the study was symptom relief in the fourth week after the end of radiotherapy. Baseline symptoms were assessed using a questionnaire incorporating a 11 point numerical scale for scoring pain, dysphagia, cough, insomnia and dyspnoea. Symptoms were scored on a scale of 0-10 and graded as mild (score 1-3), moderate (4-6) and severe (>6). Analgesics were prescribed in accordance with the WHO pain ladder. Cough sedatives and anxiolytics were prescribed for relief of cough and insomnia. External radiation was delivered to the primary site and draining lymph nodes to a dose of 30Gy/2 weeks in 10 fractions. Percentage symptom relief was quantified by the patient using a rupee scale in the fourth week after completion of radiation.
The study group had 19 male and 6 female patients with a mean age of 58 years and mean KPS of 60. More than half the patients had travelled over fifty kilometres to come to hospital. 7 patients had Stage III disease and 18 had Stage IV. The primary tumour was located in the larynx in 9 patients, oropharynx in 8, hypopharynx in 7 and alveolus in 1 patient.
Pain and generalised weakness were present in 88% while dysphagia and disturbed sleep were reported by 80%. Cough and dyspnoea were present in 13 and 8 patients respectively. Five patients required naso-gastric intubation for absolute dysphagia.
Pain was graded as mild in 9 patients, moderate in 10 and severe in 3 patients [Table - 1].
At the end of radiation therapy 17 patients had grade 1 and 8 patients had grade 2 mucositis. No patient had grade 3 mucositis.
[Table - 2] depicts symptom relief in the fourth week after completion of radiation. All 22 patients had greater than 50% pain relief. No patient required narcotic analgesics. All 8 patients with dyspnoea had >75% relief and 8/13 patients had >50% relief of cough. As a result of symptom relief, 18/20 patients could sleep better.
Long term follow up was difficult since many patients were from distant areas. The follow up period ranged from 1 to 7 months with a median duration of 3 months. Of the 16 patients who returned for follow up, relief of pain and other symptoms persisted for at least 3 months. During this period 2 patients developed new complaints; one had cough and the other had seizures. Two patients came back with progression of disease 6 months after completion of radiation.
In the developing world, approximately 75% of patients with head and neck malignancies present with locally advanced disease. When patients with stage III or stage IV disease are treated with conventional treatment i.e. definitive surgery and/or radiation, local recurrence and distant metastases lead to poor long- term results. Recent trials have demonstrated that the addition of systemic chemotherapy to loco-regional definitive therapy significantly increases local control with some survival benefit; but with significant increase in toxicity.
The incidence of grade 3 or worse toxicity is increased when concurrent chemotherapy is combined with conventional radical radiation. Such toxic treatment compromises the quality of life in these patients. Treatment related toxicities are even greater when chemotherapy is given concomitantly with altered fractionation radiotherapy as reported by List et al. In this study, acute treatment toxicities were severe, with decline in virtually all QOL and functional domains. List et al concluded that pretreatment quality-of-life level was the best predictor of quality of life during and after chemo-radiation.
Careful case selection is therefore very important when treating patients with aggressive chemotherapy and radiotherapy. Many Indian patients have advanced disease, poor nutritional and performance status and are found unfit for radical therapy. A short course of radiation is often effective in palliating symptoms in such patients.
The dose prescribed for palliative radiation varies. A single fraction of 8 Gy or a short course of 20Gy/5fractions or 30Gy/10fractions have been found cost-effective when compared with continued need for analgesics in patients with metastatic bone pain.,, Similarly, short courses of radiation have been used for palliation of symptoms in head and neck cancer. In a recent study, Mohanti et al used 20 Gy/5fractions/1 week for advanced head and neck cancer patients. Paris et al administered 14.8Gy/four fractions/ 2 days initially. If the patient showed improvement, up to three such courses were given at three-week intervals for a final tumor dose of 44.4Gy in twelve fractions over 8-9 weeks.
The present prospective study tried to quantify the benefit of a short course of radiation for locally advanced head and neck cancer. We chose a regimen of 30Gy in 10 fractions which is a commonly used and well tolerated regimen in palliative radiotherapy. It was not thought ethical to include a control arm because palliative radiotherapy reduces the risk of fungation, bleeding and obstruction in head and neck tumours.
In Mohanti's study effective symptom relief was observed in half of all patients. Radiation toxicity was mild (grade 1- 2). One third of patients showed greater than 50% reduction in tumour size and went on to complete radical RT up to 70Gy.
Paris et al found their schedule of four fractions over two days, repeated at three weekly intervals, obtained palliation in 80% of cases with minimal acute reactions and no long-term complications. Eleven of 39 lesions in this study had complete response; 19 lesions had a partial response; 4 lesions had no response; 3 lesions progressed under treatment. Response could not be assessed in two patients. The mean survival after completion of therapy was 4.5 months ranging from 2 weeks to 31 months.
The two-week schedule used in this study provided greater than 50% symptom relief in 90% of patients who had pain, dysphagia, dyspnoea and disturbed sleep. Cough was relieved in sixty percent of cases.
Patients in this study were unfit to undergo a protracted course of chemo-radiotherapy. A short course of radiation can effectively relieve symptoms in locally advanced head and neck cancers and reduce the need ongoing analgesic therapy and hospital visits. Where facilities of radiotherapy are available and accessible, palliative radiation should be offered for patients with locally advanced head and neck cancer.
[Table - 1], [Table - 2]