Patient-Reported Outcomes-Guided Adaptive Radiation Therapy for Head and Neck Cancer

Sarah Weppler; Harvey Quon; Colleen Schinkel; Adam Yarschenko; Lisa Barbera; Nabhya Harjai; Wendy Smith

doi:10.3389/fonc.2021.759724

Patient-Reported Outcomes-Guided Adaptive Radiation Therapy for Head and Neck Cancer

Front Oncol. 2021 Oct 19:11:759724. doi: 10.3389/fonc.2021.759724. eCollection 2021.

Authors

Sarah Weppler^{1

2}, Harvey Quon^{3

4}, Colleen Schinkel^{2

4}, Adam Yarschenko^{2

5}, Lisa Barbera^{3

4}, Nabhya Harjai⁶, Wendy Smith^{1

2

4}

Affiliations

¹ Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada.
² Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada.
³ Department of Radiation Oncology, Tom Baker Cancer Centre, Calgary, AB, Canada.
⁴ Department of Oncology, University of Calgary, Calgary, AB, Canada.
⁵ Department of Mechanical Engineering, University of Calgary, Calgary, AB, Canada.
⁶ Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.

Abstract

Purpose: To identify which patient-reported outcomes (PROs) may be most improved through adaptive radiation therapy (ART) with the goal of reducing toxicity incidence among head and neck cancer patients.

Methods: One hundred fifty-five head and neck cancer patients receiving radical VMAT (chemo)radiotherapy (66-70 Gy in 30-35 fractions) completed the MD Anderson Symptom Inventory, MD Anderson Dysphagia Inventory (MDADI), and Xerostomia Questionnaire while attending routine follow-up clinics between June-October 2019. Hierarchical clustering characterized symptom endorsement. Conventional statistical approaches indicated associations between dose and commonly reported symptoms. These associations, and the potential benefit of interfractional dose corrections, were further explored via logistic regression.

Results: Radiotherapy-related symptoms were commonly reported (dry mouth, difficulty swallowing/chewing). Clustering identified three patient subgroups reporting: none/mild symptoms for most items (60.6% of patients); moderate/severe symptoms affecting some aspects of general well-being (32.9%); and moderate/severe symptom reporting for most items (6.5%). Clusters of PRO items broadly consisted of acute toxicities, general well-being, and head and neck-specific symptoms (xerostomia, dysphagia). Dose-PRO relationships were strongest between delivered pharyngeal constrictor Dmean and patient-reported dysphagia, with MDADI composite scores (mean ± SD) of 25.7 ± 18.9 for patients with Dmean <50 Gy vs. 32.4 ± 17.1 with Dmean ≥50 Gy. Based on logistic regression models, during-treatment dose corrections back to planned values may confer ≥5% decrease in the absolute risk of self-reported physical dysphagia symptoms ≥1 year post-treatment in 1.2% of patients, with a ≥5% decrease in relative risk in 23.3% of patients.

Conclusions: Patient-reported dysphagia symptoms are strongly associated with delivered dose to the pharyngeal constrictor. Dysphagia-focused ART may provide the greatest toxicity benefit to head and neck cancer patients, and represent a potential new direction for ART, given that the existing ART literature has focused almost exclusively on xerostomia reduction.

Keywords: adaptive radiation therapy; dysphagia; head and neck cancer; patient-reported outcomes; xerostomia.