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Need for objective patient selection criteria for palliative radiotherapy in advanced head and neck cancer
Radiotherapy and Oncology 87 (2008) 308–309 www.thegreenjournal.com
Letters to the Editor Need for objective patient selection criteria for palliative radiotherapy in advanced head and neck cancer To the Editor We congratulate Porceddu et al. [1] for their efforts in trying to evolve a regimen to address one of the most commonly encountered problems i.e. an effective palliative fractionation in the management of advanced and incurable head and neck cancers. The Hypo regimen seems to be effective, safe and logistically advantageous. As mentioned by the authors, there has been a scarcity of prospective studies evaluating the role of palliative radiotherapy and despite the small number of patients in the Hypo trial, it provides evidence for the effectiveness of shorter palliative fractionation. We, being from a tertiary care cancer centre (where a significant percentage of head and neck cancer patients are not suitable for radical treatment), have some comments and difference of opinion to put forward: 1. Patient selection. The criteria for patient selection in this study are largely subjective. The authors have chosen patients who were (a) Unsuitable for curative treatment based on the presence of either surgically unresectable disease, (b) Not being suitable for definitive radiotherapy due to extensive locoregional disease, (c) Poor general medical condition and/or (d) Presence of distant metastatic disease. Of the 37 patients in the study, 13 patients (35%) had stages I–III and 26 patients (70%) had WHO performance score of 0 and 1. Despite the above facts, these patients were not suitable for radical or curative treatment. There is a large variation in selecting patients for palliative treatments among oncologists in routine practice. Despite most such decisions being increasingly taken in multi-disciplinary joint clinics, there are no rigid guidelines for patient selection. For example, an advanced and unresectable oral cavity primary in a patient with a performance score of 1 may not be suitable for radical radiotherapy for some, suitable for neoadjuvant chemotherapy for some and definitive chemoradiotherapy for some. With the emergence of effective neoadjuvant chemotherapeutic regimens, all patients with good performance status could be offered this option. In this study, 7/37 (20%) patients survived beyond 12 months and probably those were the group of patients suitable for more aggressive therapy. The patient selection criteria need to be defined more tightly since this is the same group of patients who may in the case of ‘unsuitability’ for surgery still be the candidates for chemoradiotherapy protocols. Several times in addition to the disease various other parameters like performance status, age and
affordability determine the final choice of treatment. The criteria need to be more objective for wider applicability for the above mentioned reasons, since in the absence of well-defined criteria a proportion of patients (20% in this study) may do better than the rest and live longer to express the late sequelae of hypo fractionated treatment. 2. In patients with extensive locoregional disease whose expected survival is 4–9 months, CT planning in our setting would probably amount to excessive efforts. We usually plan such patients on a conventional simulator immobilized with the help of Plaster of Paris mould. In a resource limited setting like most of the developing world, the simulation time is as significant and valuable as the machine time. 3. The boost volume of <3 cm seems to be too low when we speak of palliative radiotherapy for extensive locoregional disease. Our policy of boosting residual disease is most often based on tolerance in addition to response. 4. Another point, which the authors accept was not documented, was the analgesic requirement. This is an important endpoint in evaluating the efficacy of the palliative regime. Though the main aim of the study was response assessment, the endpoint of symptom palliation would have been better as it would establish the efficacy of this regime whose main aim was palliation.
References [1] Porceddu SV, Rosser B, Burmeister BH, et al. Hypofractionated radiotherapy for the palliation of advanced head and neck cancer in patients unsuitable for curative treatment ‘‘Hypo trial’’.
Srinivas Chilukuri Sarbani Ghosh Laskar* Vedang Murthy Jai Prakash Agarwal Ashwini Budrukkar Ketayun A. Dinshaw Tata Memorial Hospital, Radiation Oncology, Patrel, Mumbai, Maharashtra 400012, India E-mail address: [email protected] *
Corresponding author. Received 24 February 2008; accepted 7 March 2008;
Available online 15 April 2008
0167-8140/$ - see front matter c 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.radonc.2008.03.014
Letters to the Editor Need for objective patient selection criteria for palliative radiotherapy in advanced head and neck cancer To the Editor We congratulate Porceddu et al. [1] for their efforts in trying to evolve a regimen to address one of the most commonly encountered problems i.e. an effective palliative fractionation in the management of advanced and incurable head and neck cancers. The Hypo regimen seems to be effective, safe and logistically advantageous. As mentioned by the authors, there has been a scarcity of prospective studies evaluating the role of palliative radiotherapy and despite the small number of patients in the Hypo trial, it provides evidence for the effectiveness of shorter palliative fractionation. We, being from a tertiary care cancer centre (where a significant percentage of head and neck cancer patients are not suitable for radical treatment), have some comments and difference of opinion to put forward: 1. Patient selection. The criteria for patient selection in this study are largely subjective. The authors have chosen patients who were (a) Unsuitable for curative treatment based on the presence of either surgically unresectable disease, (b) Not being suitable for definitive radiotherapy due to extensive locoregional disease, (c) Poor general medical condition and/or (d) Presence of distant metastatic disease. Of the 37 patients in the study, 13 patients (35%) had stages I–III and 26 patients (70%) had WHO performance score of 0 and 1. Despite the above facts, these patients were not suitable for radical or curative treatment. There is a large variation in selecting patients for palliative treatments among oncologists in routine practice. Despite most such decisions being increasingly taken in multi-disciplinary joint clinics, there are no rigid guidelines for patient selection. For example, an advanced and unresectable oral cavity primary in a patient with a performance score of 1 may not be suitable for radical radiotherapy for some, suitable for neoadjuvant chemotherapy for some and definitive chemoradiotherapy for some. With the emergence of effective neoadjuvant chemotherapeutic regimens, all patients with good performance status could be offered this option. In this study, 7/37 (20%) patients survived beyond 12 months and probably those were the group of patients suitable for more aggressive therapy. The patient selection criteria need to be defined more tightly since this is the same group of patients who may in the case of ‘unsuitability’ for surgery still be the candidates for chemoradiotherapy protocols. Several times in addition to the disease various other parameters like performance status, age and
affordability determine the final choice of treatment. The criteria need to be more objective for wider applicability for the above mentioned reasons, since in the absence of well-defined criteria a proportion of patients (20% in this study) may do better than the rest and live longer to express the late sequelae of hypo fractionated treatment. 2. In patients with extensive locoregional disease whose expected survival is 4–9 months, CT planning in our setting would probably amount to excessive efforts. We usually plan such patients on a conventional simulator immobilized with the help of Plaster of Paris mould. In a resource limited setting like most of the developing world, the simulation time is as significant and valuable as the machine time. 3. The boost volume of <3 cm seems to be too low when we speak of palliative radiotherapy for extensive locoregional disease. Our policy of boosting residual disease is most often based on tolerance in addition to response. 4. Another point, which the authors accept was not documented, was the analgesic requirement. This is an important endpoint in evaluating the efficacy of the palliative regime. Though the main aim of the study was response assessment, the endpoint of symptom palliation would have been better as it would establish the efficacy of this regime whose main aim was palliation.
References [1] Porceddu SV, Rosser B, Burmeister BH, et al. Hypofractionated radiotherapy for the palliation of advanced head and neck cancer in patients unsuitable for curative treatment ‘‘Hypo trial’’.
Srinivas Chilukuri Sarbani Ghosh Laskar* Vedang Murthy Jai Prakash Agarwal Ashwini Budrukkar Ketayun A. Dinshaw Tata Memorial Hospital, Radiation Oncology, Patrel, Mumbai, Maharashtra 400012, India E-mail address: [email protected] *
Corresponding author. Received 24 February 2008; accepted 7 March 2008;
Available online 15 April 2008
0167-8140/$ - see front matter c 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.radonc.2008.03.014