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Background: Facemasks accurately immobilise patients with head and neck cancer (HNC) receiving radiotherapy (RT). However, such masks are associated with treatment related distress, a prognostic factor for poorer survival. Open masks offer increased comfort and patient satisfaction. We investigated whether open masks could immobilise patients without affecting treatment accuracy. Materials and methods: Over an 18-month period, all HNC RT patients with anxiety were offered open masks. Once 30 patients had completed treatment, set-up data was compared to patients in closed masks. The mean displacement and one-dimensional standard deviations (SD) of the mean, systematic and random set-up errors were calculated for translational directions: anterior-posterior (x), superior-inferior (y), medial-lateral (z). The mean and SD of the mean was calculated for rotational displacements. Mann-Whitney U was used to determine any significant differences between set- up data. Results: Sixty patients were included (30 open & 30 closed masks). There was no statistically significant difference found in the x (p = 0.701), y (p = 0.246) or z (p = 0.535) direction for the SD of the mean displacements between both masks. No statistically significant difference was found in the SD of means for rotational displacements. The calculated planning target volume (PTV) margin requirements were minimally less for the closed masks 3.5, 2.6, and 2.7 mm (x, y, z, respectively) versus 4.2, 3.2, and 3.7 mm, respectively, for open masks. Conclusion: Our study demonstrates that open masks maintain accuracy at levels comparable to closed masks in patients with anxiety. The minor difference in the calculated PTV margin could be rectified with daily on-line imaging or surface guided imaging. [ABSTRACT FROM AUTHOR]

Introduction: Adjuvant radiotherapy is proven to prevent lymph node field relapse after therapeutic lymphadenectomy for melanoma, but does not improve overall survival based on current data. There remains a high rate of distant relapse. This study reports patterns of failure in patients treated with adjuvant radiotherapy, looking at factors associated with distant metastasis and comparing this to recent literature.Methods: This retrospective study included patients treated with adjuvant nodal irradiation after lymphadenectomy between June 2012 and March 2015.Results: Twenty-one patients were treated during this period. Median follow-up was 13.5 months. There were no lymph node field recurrences. Distant metastasis (DM) rate was 48%. DM rate was significantly higher (P = 0.027) in patients with extracapsular extension (ECE) (71%) than those without ECE (0%). DM rate was higher in those with a maximum tumour size of >3 cm (71%) than those with tumour size <3 cm (30%) (P = 0.160). Number of nodes, BRAF status or nodal site did not correlate with rate of DM. The median time to DM was 16 weeks after completion of radiotherapy.Conclusion: Radiotherapy is well tolerated and effective in regional control. However, patients are at risk of early distant relapse, particularly those with ECE or large tumour size. There are currently no useful prognostic markers to differentiate the risk of regional versus distant recurrence, and the optimal treatment paradigm remains undefined. Research on adjuvant systemic therapies and abscopal effects of radiotherapy have shown improved management of distant metastasis; creating an even greater need for effective regional control strategies. [ABSTRACT FROM AUTHOR]

Oropharyngeal squamous cell cancers have a locoregional recurrence rate range of 17.3-32.5% and a distant metastatic rate of 6.5-17% at 3 years (ref1). Structured follow up is of paramount importance to facilitate early diagnosis and salvage treatment. We examined a cohort of patients with oropharyngeal cancer treated radically within a large Irish tertiary referral centre with diagnosed recurrence in order to better understand the clinical presentation and to optimise outpatient follow up following radical treatment. An existing database of 259 new oropharynx cancer patients treated radically between 2012 and 2020 was assessed to identify any patient with established recurrence. For those with recurrence: details of clinical presentation and diagnosis were recorded. Of the 259 patients assessed 70 experienced recurrence: 12 with locoregional failure, 12 with both local and distant failure, 25 with distant only failure and 21 with persistent disease post treatment. Of the 12 locoregional failures- 92% were symptomatic: pain (83%) and neck lump (8%). One recurrence was identified during routine outpatient review, the remainder following patient contact after onset of symptoms. 75% of the patients with locoregional failure had non-HPV related cancers, and 85% of the group were stage 3 or stage 4 at initial presentation. In terms of timeline to presentation, 50% had been identified within 9 months and 80% within 2 years following treatment. Of the 12 local + distant failures- 75% were symptomatic: pain (67%) and neck lump (8%). 2 patient recurrences were identified during routine outpatient review, the remainder following patient contact. 50% of the patients in this group had HPV related tumours and 50% of this group were stage 3 or stage 4 at initial presentation. 80% of these recurrences had been identified within 2 years following treatment. Of the 25 distant failures: 61% were identified on post treatment imaging, 15% presented with respiratory symptoms, 12% presented with pain or palpable lump and 12% were identified on routine imaging. 70% of the patients in this group had HPV related tumours and 57% of this group were stage 3 or 4 at presentation. 80% of these recurrences has been identified within 2 years following treatment. 21 patients were found to have persistent disease following treatment- all were identified on post treatment imaging. Locoregional recurrence of oropharynx cancer is associated with patient symptoms in over 90% of cases, most commonly pain. These symptoms are rarely discovered during routine review. Of the 12 patients found to have locoregional recurrence, 75% of the group were non HPV related tumours, 85% were stage 3 or 4 at initial presentation and 80% of the recurrences were identified within 2 years of treatment. This study highlights the importance of both patient and staff education and the importance of outpatient communication pathways that facilitate prompt review and investigation of new symptoms. [ABSTRACT FROM AUTHOR]

To investigate if tumour volume (primary, nodal and combined) predicts recurrence free (RFS) and overall survival (OS) in p16+ oropharyngeal squamous cell carcinoma. Study design We conducted a retrospective analysis of patients with OPSCC treated with curative radiotherapy in SLRON from 2013 - 2021. TNM 8th edition definition of stage was applied. Participants Eligible participants had OPSCC and received radiotherapy as definitive, radical treatment. Diagnosis was based on clinical assessment, histological sampling and PET imaging. p16 status was available for all patients. Clinical examination and PET imaging were used to assess response to treatment. Treatment Patients received 65-70Gy over 30-35 fractions, delivered using Intensity-Modulated Radiotherapy (IMRT). Endpoints Primary endpoints: 1. To investigate if GTVp predict RFS & OS in p16+ OPSCC 2. To investigate if GTVn predict RFS & OS in p16+ OPSCC 3. To investigate if GTVcomb predict RFS & OS in p16+ OPSCC Secondary endpoints: 1. To investigate if GTVp &/or GTVn predict RFS & OS in p16- OPSCC 2. To investigate if GTVp &/or GTVn predict RFS & OS in OPSCC 3. To investigate if use of concomitant chemotherapy improves outcomes in OPSCC in this cohort 4. To estimate RFS and OS Statistical Analysis All analyses were performed in IBM SPSS Statistics ver 29.0, and involved descriptive statistics, survival analyses by Kaplan-Meier method, and linear regression by Cox Proportional Hazards (univariate & multivariate). OS was evaluated from date of final RT. RFS was evaluated from date of final RT to the date of first local or distant recurrence, death, or last clinical assessment/investigation. Baseline Characteristics From January 2013 to April 2021, 246 patients were eligible for this review. Median age at first RT was 59.6. 187 (76%) were male. 179 (73%) had p16+ disease. 218 (88.6%) received chemotherapy. Median follow up was 25.5 months (0.5 - 96). Disease stage & Tumour volumes Patients with p16+ disease were diagnosed with earlier stage disease (86% stage 1 or 2), in comparison with those with p16- disease (3% stage 3 or 4; p<.001). Treatment Treatment was delivered using IMRT. 235 (95.5%) received 70Gy in 35 fractions and 11 (4.5%) received 65Gy in 30 fractions. Overall Survival 61 out of 246 patients (25%) died. Median survival for the total population was not reached. 3, 4 and 5 year overall survival was 75% (95%CI: 69 to 81%), 69% (95%CI: 61 to 76%) and 64% (95%CI: 55 to 73%) respectively. There was a significant difference in OS between those with P16- and P16+ (p<.001). Median survival for the P16- population was 34.9 months (95%CI 13 to 56 months). Median survival for the P16+ population was not reached. Recurrence Free Survival Median recurrence free survival for the total population was not reached.3, 4 and 5 year RFS survival was 65% (95%CI: 59 to 72%), 63% (95%CI: 56 to 70%) and 58% (95%CI: 49 to 66%) respectively. There was a significant difference in RFS between those with P16- and P16+ (p<.001). Median survival for the P16- population 23.6 months (95%CI 11 to 37 months). Median survival for the P16+ population was not reached. Survival based on Gross Tumour Volume For the total population (p16+ & p16-): • GTVp greater or less than median GTVp (dichotomized) was a statistically significant predictor of OS (p=.004) • GTVp based on Adrian et al volume brackets <6 cm3, 6–12 cm3, 12–24 cm3, 24–48 cm3, 48–96 cm3, and>96cm3 (as suggested by Adrian et al, 2022) was a statistically significant predictor of OS (p<.001) • GTVp greater or less than 40cm3 (as suggested by Adrian et al, 2022) was a statistically significant predictor of OS (p<.001) • GTVcomb based on volume brackets <15cc, 15-70cc, >70cc (as suggested by Panje et al, 2017) was a statistically significant predictor of OS and RFS (p=.001 and p <.001 respectively). When looking only at those with P16+, neither age, gender nor stage 1-2, were predictive of OS. The following variables were predictive of OS: GTVp, GTVp >18.3cc, GTV as per Adrian et al volume brackets, GTVp 15-70cc, GTVp>40cc, GTVn, GTVcomb and total dose. [Display omitted] [Display omitted] We demonstrate that GTV (primary, nodal and combined) predict outcome in p16+ OPSCC. This metric is readily available to the Radiation Oncologist at tumour delineation, and therefore may aid dose de-escalation decision making, without added delay. Future work may investigate cautious dose de-escalation in a cohort with smaller GTVs. [ABSTRACT FROM AUTHOR]

All head and neck cancer (HNC) patients receiving radiotherapy should have access to Speech and Language Therapy (SLT) for management of speech and swallowing(1). A pilot SLT education group programme, was delivered over a 10-week-period in a radiation-oncology (RO) service in 2023 as part of a waiting-list initiative. The purpose was to increase timely access to SLT for HNC patients. We aimed to evaluate the SLT pilot education group and make recommendations for future service delivery models. HNC patients receiving radical radiotherapy (n=22) prioritised as low-risk SLT patients, attending for RO, were identified and invited to attend an SLT education session. High-risk patients requiring intensive SLT intervention e.g. hypo-pharyngeal cancer, advanced laryngeal cancer and T4 tumours were excluded. Topics covered included an introduction to eating, drinking and swallow (ED&S) mechanisms, side-effects of radiotherapy and potential impact on ED&S, management strategies and prophylactic swallowing exercises. Sessions were interactive and patient information leaflets were provided. Invitations to attend additional sessions were extended; individual appointments were available on patient request. Swallowing outcomes (The MDADI global score, EAT-10) and patient satisfaction levels were completed at the time of attendance. Data was collected on patient demographics, treatment plans, attendance rates, admissions, patient self-report of dysphagia and impact on quality of life. Waiting-list times and cost savings were calculated. The results demonstrated that 14 patients attended (64%) the offered education session (9 males; mean age 66.5, range 46-84 years) The majority of patients had disease staging as ≤T2 (57%; 8/14). Attendees were heterogeneous with regard to tumour location (Table 1). No patients requested individual appointments. Of 14 attendees, 5 required inpatient admission (36%), compared to 6 (75%) patients who were invited and did-not-attend the education session. Reason for admission analysis revealed all 5 attendees required admission for symptom control, chiefly pain management, nausea, constipation and weight loss. Requirement for NG feeding was stated in 3/5 (60%) cases. Inpatient NG insertion requirement in the non-attender cohort was 67% (4/6). Treatment for pneumonia was required in 0% of cases. Attendees were admitted later into their treatment (mean fraction at time of admission 32; range 28-35) when compared to non-attendees (mean fraction at time of admission 23.5; range 13-35). The presence of oropharyngeal dysphagia as per self-report was identified in 8 (57%; EAT-10 score ≥3) attendees. However, the majority of attendees did not consider dysphagia as affecting quality-of-life (Mean MDADI global-question score of 3). All attendees reported the education session as helpful, they planned to implement advice given and would recommend attendance to fellow-patients. Seven patients received SLT input within local departmental standards (KPI of by 5 fractions). An additional 7 patients accessed SLT who would not have been seen due to service constraints. A further 8 patients would have received SLT guidance if they had attended the education session offered. When comparing costings for individual versus group interventions, a saving of €482.46 could be made per group programme for a similar patient cohort(2). [Display omitted] This waiting-list group initiative provided access to SLT for a cohort of low-risk HNC patients who would not have received guidance due to departmental service constraints. This pilot study has shown that group interventions can be an effective way to introduce the role of SLT, deliver general patient education and introduce swallowing rehabilitation to this specific client group. Preliminary findings suggest that this pilot waiting-list initiative was an effective medium to enhance patient experience and encourage patient autonomy and empowerment for HNC patients during their radiation-oncology journey. However, this pilot programme was delivered to a low-risk HNC patient cohort and a similar approach may not be appropriate for HNC patients with more extensive disease where an individualised treatment programme is the gold-standard (3). Group intervention can be a necessary solution to address service delivery demands in the existence of resource constraints. Nevertheless, the value, impact and effectiveness of tailored face-to-face SLT interventions with HNC patients who present with acute, chronic and complex ED&S needs cannot be underestimated(4, 5). This initiative will continue and facilitate further analysis regarding admission avoidance, alternative feeding requirement and swallow function outcomes. Further analysis exploring rationale for nonattendance will assist with future programme design. Data will also be used to assist with future service development, resource allocation and staff planning. [ABSTRACT FROM AUTHOR]

The onset of the COVID-19 outbreak caused major interruptions to the entire healthcare network affecting most oncological referral, diagnosis and treatment pathways. Oropharyngeal cancer patients were a particularly vulnerable group during this period as many were reluctant to present to hospital due to their concerns of contracting the virus. This created a potential for delayed presentation in keeping with more advanced disease with potential for worsened outcomes. We designed a retrospective study to analyse differences in patient presenting stage, treatment encountered, delays encountered and treatment outcomes for patients with oropharyngeal cancer treated before and during the COVID pandemic. All patients receiving radical radiotherapy for oropharyngeal cancer pre-COVID (July 17–July 18= GROUP 1) and during COVID (Mar 20–Mar 21= GROUP 2) in a large Irish tertiary referral network were included. Patient and disease characteristics, diagnostic timelines, treatment delays and disease outcomes were extracted from patient records. Patients were excluded if performance status was not suitable for curative treatment, if evidence of metastatic disease or if any history of prior head and neck radiotherapy. [Display omitted] 159 patients were suitable for assessment, 76 in Group 1 and 83 in Group 2. Median follow up was 48 months in Group 1 and 23 months in Group 2. When comparing Group 1 and 2: TNM overall stage were as follows: Stage 1: (25% vs 45.8%), Stage 2: (28.9% vs 18%), Stage 3:(21% vs 15.7%), Stage 4:(25% vs 20.5%). When grouped by stage we found no statistically significant difference in presentation stage between Group 1 and 2 (p=0.268). Use of hypofractionated regimen (65Gy/30fr) increased during the pandemic (2.6% to 10.8%) in keeping with international guidelines. There was no change in numbers of patients experiencing significant treatment delays between groups, with COVID related sepsis accounting for one significant delay and one death during treatment. There was a small but non-significant reduction in the use of concomitant chemotherapy from 93.4% in group 1 to 85.5% in group 2 (p=0.269). Overall survival assessed at 2 years was 77% in Group 1 and 85% in Group 2 (p=0.350). Disease free survival assessed at 2 years was 69% in Group 1 and 76% in Group 2 (p=0.567). [Display omitted] In spite of challenges related to the COVID-19 pandemic, this study has demonstrated that oropharyngeal cancer patients' treatment standards and outcomes were maintained within a large tertiary referral centre in Ireland. This study is one of the largest assessing the impact of the COVID-19 pandemic on head and neck radiotherapy patients. We did not demonstrate any difference in overall survival and disease free survival at 2 years when compared to a similar group prior to the pandemic. Furthermore we did not demonstrate any worsening of presenting stage related to delayed presentations during the pandemic. [ABSTRACT FROM AUTHOR]

This study investigates whether spinal deviations exceeding 5mm from the planned position during Head & Neck cancer radiotherapy, detected using a rigid registration IGRT approach, warrant rescans or replans. Varian's Velocity™ software package was employed to perform Deformable Image Registration (DIR) on ten radical H&N cases which required re-scanning and re-planning when evaluated using a rigid registration approach. The deformation field was used to generate Synthetic CT's (sCT) using Velocity to evaluate the dosimetric impact of the spinal deviations in Eclipse™. Our findings revealed that 6 out of the 10 plans (60%) exhibiting spinal deviations >5mm and evaluated using a rigid registration approach did not necessitate a replan or rescan, maintaining a dosimetric impact of <2% and adhering to institutional Dose Volume Constraint (DVC) tolerances. Conversely, only 4 of the 10 cases required a rescan and replan when deformation was utilised for evaluation. Rigid registration cannot always account for the anatomical deviations in spinal positions noted during Head & Neck Radiothearpy. The substantial workflow implications of unnecessary rescans and replans accentuate the need for effective adaptive workflows like DIR in making informed decisions in Head & Neck radiotherapy. [ABSTRACT FROM AUTHOR]

Background: The incidence of human papillomavirus (HPV)-positive oropharyngeal cancer, a disease affecting younger patients, is rapidly increasing. Cetuximab, an epidermal growth factor receptor inhibitor, has been proposed for treatment de-escalation in this setting to reduce the toxicity of standard cisplatin treatment, but no randomised evidence exists for the efficacy of this strategy.Methods: We did an open-label randomised controlled phase 3 trial at 32 head and neck treatment centres in Ireland, the Netherlands, and the UK, in patients aged 18 years or older with HPV-positive low-risk oropharyngeal cancer (non-smokers or lifetime smokers with a smoking history of <10 pack-years). Eligible patients were randomly assigned (1:1) to receive, in addition to radiotherapy (70 Gy in 35 fractions), either intravenous cisplatin (100 mg/m2 on days 1, 22, and 43 of radiotherapy) or intravenous cetuximab (400 mg/m2 loading dose followed by seven weekly infusions of 250 mg/m2). The primary outcome was overall severe (grade 3-5) toxicity events at 24 months from the end of treatment. The primary outcome was assessed by intention-to-treat and per-protocol analyses. This trial is registered with the ISRCTN registry, number ISRCTN33522080.Findings: Between Nov 12, 2012, and Oct 1, 2016, 334 patients were recruited (166 in the cisplatin group and 168 in the cetuximab group). Overall (acute and late) severe (grade 3-5) toxicity did not differ significantly between treatment groups at 24 months (mean number of events per patient 4·8 [95% CI 4·2-5·4] with cisplatin vs 4·8 [4·2-5·4] with cetuximab; p=0·98). At 24 months, overall all-grade toxicity did not differ significantly either (mean number of events per patient 29·2 [95% CI 27·3-31·0] with cisplatin vs 30·1 [28·3-31·9] with cetuximab; p=0·49). However, there was a significant difference between cisplatin and cetuximab in 2-year overall survival (97·5% vs 89·4%, hazard ratio 5·0 [95% CI 1·7-14·7]; p=0·001) and 2-year recurrence (6·0% vs 16·1%, 3·4 [1·6-7·2]; p=0·0007).Interpretation: Compared with the standard cisplatin regimen, cetuximab showed no benefit in terms of reduced toxicity, but instead showed significant detriment in terms of tumour control. Cisplatin and radiotherapy should be used as the standard of care for HPV-positive low-risk patients who are able to tolerate cisplatin.Funding: Cancer Research UK. [ABSTRACT FROM AUTHOR]

Background: Osteoradionecrosis is a long-term, serious side effect of head and neck radiation therapy and is associated with significant morbidity and quality of life issues., Methods: This paper sought to determine consensus on the prevention and management of osteoradionecrosis by an international panel of multidisciplinary professionals expert in the management of patients with head and neck cancer using a Delphi methodology. Unique to this work is our direct inclusion of the views of patients and carers in our findings., Results: This study reached consensus on the importance of pre and post oral health assessment and education for patients with head and neck cancer. This was also noted by the patients and carers who took part in the study., Conclusions: This work highlights the need for a standardized oral health assessment tool and multidisciplinary care of patients to prevent and manage osteoradionecrosis., (© 2024 The Author(s). Head & Neck published by Wiley Periodicals LLC.)

Introduction: Despite the benefits of quitting smoking for those who have cancer, including improved health outcomes and reduced therapeutic toxicities, it is unclear how many people are supported in quit attempts during this time. Variations in the availability and provision of smoking cessation (SC) services are reported, with little understanding of the challenges and solutions. This co-designed study aimed to understand the perspectives of health care professionals (HCPs) working in oncology settings to engage in SC practices and identify recommendations for developing an SC pathway., Methods: This was a qualitative study. Eighteen HCPs participated in semi-structured interviews from July 2021 to May 2022. We used thematic analysis approaches to code data and present four emergent themes and SC strategies at micro, meso and organizational levels., Results: Four themes emerged specifically: 1) timing and knowledge, 2) building a relationship, 3) frequent asking with infrequent action, and 4) removing the barriers and tailoring the system. While HCPs discuss SC, there are variations in documentation and when conversations occur. Primarily, HCPs value the time to build therapeutic relationships with patients and thus may limit SC discussions in preference to treatment in clinical interactions. The role of structural barriers, including prescriptive authority for nurses, hinders active SC processes, as it is the lack of continuity and embedding of services supported by a clinical champion for SC., Conclusions: The study suggests re-evaluating the status quo in SC service, highlighting service gaps and suggesting opportunities at organizational levels to reduce structural barriers., Implications: Variations in smoking cessation services exist in designated cancer centres. The data from this study can be used to inform a real time health systems approach for SC services in oncology settings. Developing tailored smoking cessation services and interventions that are patient-centred and informed by their experiences are required. The data in this study suggests developing specialist education and training to upskill HCPs for equitable engagement if we are to meet EU and Moonshot goals for cancer reduction., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)