IMRT

A ‘new gold standard’ for head and neck cancer radiotherapy.

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Phase III trial results on a precision radiotherapy technique support a ‘new gold standard’ for treating head and neck cancer patients.

The research suggests the new approach can reduce the risk of swallowing problems after radiotherapy, without impacting the success of treatment. The Dysphagia-Aspiration Related Structures (DARS) trial, which was sponsored by The Royal Marsden and coordinated by the Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, with funding from Cancer Research UK, compared dysphagia-optimised intensity modulated radiotherapy (DO-IMRT) with standard IMRT. 

Final results from the trial were published in The Lancet Oncology.

Oncologists and physicists spend some additional time designing the treatment based on the size and position of the tumour. A computer will then plan the dose and route[…]. These tweaks to the treatment can significantly improve quality of lifeChris Nutting

DO-IMRT optimises IMRT to reduce the risk of swallowing difficulties, known as dysphagia. This common side effect of radiotherapy for head and neck cancer can, in some cases, leave patients needing a permanent feeding tube. DO-IMRT lowers the risk of dysphagia by reducing radiation to the pharyngeal muscles, which support swallowing. The DARS study included 112 newly diagnosed participants with oropharyngeal and hypopharyngeal cancers (tumours of the throat) from centres across the UK and Ireland. Half received standard IMRT and half received DO-IMRT for six weeks. 

The trial revealed that: 

  • After two years, patients treated with DO-IMRT were more likely to report better swallowing function than those treated with IMRT. 
  • After a year, around three fifths (62%) of DO-IMRT patients reported high normalcy of diet – meaning they were still able to eat at least some foods that require chewing – and over 8 in 10 (85%) said they felt comfortable eating in public, compared with just under 45% and 75% of those treated with standard IMRT respectively.  
  • After just over three years of follow up, there was no evidence of a difference in survival rates between the two approaches.

Study lead Professor Chris Nutting, Consultant Clinical Oncologist at The Royal Marsden NHS Foundation Trust and Professor of Radiation Oncology at The Institute of Cancer Research, London, said: “The final results from this study support a new gold standard for treating head and neck cancer patients with radiotherapy. We have demonstrated that this targeted form of radiotherapy can spare the swallowing muscles of patients without impacting the success of their treatment. This approach involves oncologists and physicists spending some additional time designing the treatment based on the size and position of the tumour. A computer will then plan the dose and route which turns the radiation into lots of smaller, more precise beams that help to protect the throat where possible. As these tweaks to the treatment can significantly improve quality of life, we hope more centres will implement this practice.”  

We’re delighted our trial has shown it is possible to tailor how we deliver cutting-edge radiotherapy to minimise damage to key muscles and structures involved in swallowingEmma Hall

Professor Justin Roe, Consultant Speech and Language Therapist and Joint Head of the Department of Speech, Voice and Swallowing at The Royal Marsden NHS Foundation Trust, said: “The vast majority of patients I support have had a head and neck cancer diagnosis and many unfortunately experience swallowing problems during and following treatment, which often includes radiotherapy. I regularly see people who no longer enjoy food and drink, or feel too embarrassed to consume them around others, which can lead to depression and isolation. Dysphagia can also cause other serious medical problems such as malnutrition, dehydration and, in some cases, respiratory complications. It has been a privilege to support this study and I hope to see many more patients benefit from this tailored form of radiotherapy in the future.”

Professor Emma Hall, Co-Director of the Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, which coordinated the trial, said: “Maintaining the ability to eat and drink normally following treatment for head and neck cancer is incredibly important for patients’ wellbeing. We’re delighted our trial has shown it is possible to tailor how we deliver cutting-edge radiotherapy to minimise damage to key muscles and structures involved in swallowing, and help more people continue to enjoy eating and drinking following therapy. This is just one example of how advanced radiotherapy techniques like Do-IMRT can help more patients live well, with fewer side effects, after receiving cancer treatment.” 

Martin Ledwick, Cancer Research UK’s head nurse, said: “Behind the results of each clinical trial, there are real people who deserve the best possible quality of life. It’s important the interventions not only work, but can be kinder so they are still able to enjoy life’s pleasures. It’s difficult for many of us to imagine not being able to swallow properly, but this can be the reality for head and neck cancer patients post-treatment. These promising results could make life after treatment brighter for head and neck cancer patients, and we look forward to seeing this kinder form of radiotherapy make its way to the clinic.”

Is IMRT Before Surgery of Benefit in Patients With Centrally Located Liver Cancer?

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The use of neoadjuvant intensity-modulated radiotherapy (IMRT) before surgical resection of hepatocellular carcinoma with a hepatectomy may be an efficacious and tolerable treatment option for patients with centrally located disease, according to a study published in JAMA Surgery. However, additional investigative efforts are warranted to determine the extent of this approach’s efficacy, suggested Jianxiong Wu, MD, of the Peking University Cancer Hospital and Institute, China, and colleagues.

From 2014 to 2019, a total of 38 patients with centrally located hepatocellular carcinoma were recruited for the nonrandomized, controlled study. All patients had Child-Pugh class A liver function and had not received any previous treatment. They received liver-directed neoadjuvant IMRT over a 5- to 6-week period, and their status was subsequently discussed at a multidisciplinary team meeting to determine the best surgical approach.

The study findings revealed that 34.2% of patients reached a major pathologic response after treatment. From this cohort, 13.2% of patients reached a complete pathologic response. In addition, there was a 94.6%, 75.4%, and 69.1% overall survival rate at 1-, 3-, and 5-year intervals, respectively. A 45.8-month median disease-free survival rate was reported, with patients achieving 70.3%, 54.1%, and 41.0% disease-free survival rates at 1-, 3-, and 5-year intervals.

Moreover, 7.9% of patients experienced grade 3 radiotherapy-related adverse effects. Furthermore, complications from surgical intervention were observed in 34.2% of patients. They included grade 1 to 2 complications (31.6%) and grade 3a complications (2.6%). More severe complications were not observed in any patients, according to the investigators.

Source: JNCCN

Toxicity of Proton Beam Therapy vs Intensity-Modulated Radiation for Prostate Cancer.

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TAKE-HOME MESSAGE

  • In this case-matched study, toxicity of proton beam therapy (PBT) was compared with that of intensity-modulated radiation therapy (IMRT) for treatment in 394 patients with localized prostate cancer. There were no differences between therapies in the risk for grade ≥2 acute GI, grade ≥2 acute GU, grade ≥2 late GI, and grade ≥2 late GU toxicities.
  • Toxicity is not variable between PBT and IMRT treatments in men with localized prostate cancer.

ABSTRACT

BACKGROUND

The authors assessed whether proton beam therapy (PBT) for prostate cancer (PCa) was associated with differing toxicity compared with intensity-modulated radiation therapy (IMRT) using case-matched analysis.

METHODS

From 2010 to 2012, 394 patients who had localized PCa received 79.2 Gray (Gy) relative biologic effectiveness (RBE) delivered with either PBT (181 patients) or IMRT (213 patients). Patients were case-matched on risk group, age, and prior gastrointestinal (GI) and genitourinary (GU) disorders, resulting in 94 matched pairs. Both exact matching (risk group) and nearest-neighbor matching (age, prior GI/GU disorders) were used. Residual confounding was adjusted for by using multivariable regression. Maximum acute and late GI/GU Common Terminology Criteria for Adverse Events-graded toxicities were compared using univariate and multivariable logistic and Cox regression models, respectively.

RESULTS

Bladder and rectum dosimetry variables were significantly lower for PBT versus IMRT (P ≤ .01). The median follow-up was 47 months (range, 5-65 months) for patients who received IMRT and 29 months (range, 5-50 months) for those who received PBT. On multivariable analysis, which exploited case matching and included direct adjustment for confounders and independent predictors, there were no statistically significant differences between IMRT and PBT in the risk of grade ≥2 acute GI toxicity (odds ratio, 0.27; 95% confidence interval [CI], 0.06-1.24; P = .09), grade ≥2 acute GU toxicity (odds ratio, 0.69; 95% CI, 0.32-1.51; P = .36), grade ≥2 late GU toxicity (hazard ratio, 0.56; 95% CI, 0.22-1.41; P = .22), and grade ≥2 late GI toxicity (hazard ratio, 1.24; 95% CI, 0.53-2.94; P = .62).

CONCLUSIONS

In this matched comparison of prospectively collected toxicity data on patients with PCa who received treatment with contemporary IMRT and PBT techniques and similar dose-fractionation schedules, the risks of acute and late GI/GU toxicities did not differ significantly after adjustment for confounders and predictive factors.

IMRT role confirmed in head and neck cancer.

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How have recent studies added to our understanding of the appropriate use of intensity modulated radiotherapy in head and neck cancer?

Important data concerning the use of intensity modulated radiotherapy (IMRT) in patients with head and neck cancer were recently published, confirming the potential of the technique to effectively treat tumors while minimizing adverse events.

The French Oncology and Radiotherapy Group for Head and Neck Cancer (known as GORTEC) set up the prospective GORTEC 2004-03 study in response to a request from the French National Authority for Health. The authority had stated in 2003 that IMRT appeared to be of major benefit in the irradiation of head and neck cancer, and called for it to be evaluated further in prospective trials.

IMRT enables specialists to spare sensitive structures (such as the parotid gland, irradiation of which can lead to xerostomia and a reduced quality of life) without compromising on the coverage of tumor target volumes.

In the prospective GORTEC 2004-03 study, specialists at 8 centers in France evaluated IMRT in a total of 208 patients. The tumor sites were the orophyarynx (56% of patients), nasopharynx (18%), oral cavity (12%), pharyngo-larynx (12%), and cervical lymph node from an unknown primary (2%). Of these, 29% were stage I-II tumors, and 71% were stage III-IV tumors.

Overall, almost half of the patients had surgery then postoperative IMRT, while just over a third of patients received concurrent chemotherapy.

Analysis of 2-year follow-up data showed that the locoregional progression-free survival rate was 86%, the metastatic progression-free survival rate was 92.7%, the recurrence-free survival rate 80%, and the overall 2-year survival rate was 86.7%.

At 18 months, xerostomia of grade 2 or above was seen in 16.1% of patients. The researchers found that a mean IMRT dose to the spared parotid below 28 Gy was associated with a significantly lower incidence of xerostomia (8.5% with grade 2 or above, compared to 24% in patients who received 28 Gy or more).

The researchers calculated that the rate of xerostomia (grade 2 or above) increased by about 3% per Gy of the mean parotid dose up to 28 Gy, then increased by 7% per Gy above 33 Gy.

In their paper describing the study findings, published in the journal Radiotherapy and Oncology, the researchers concluded that IMRT for head and neck cancer “seems to reduce late toxicities without jeopardising local control and overall survival”.

They added that “the results of the GORTEC 2004-03 prospective cohort study confirm the benefit of IMRT in the treatment of head and neck cancers”.1

References:
1. Toledano I, et al. Radiother Oncol. 2012;103:57-62.

 

Source: www. getinsidehealth.com