Hi All,

Check out one of the recent posts on the Oral Cancer on the News page:

http://www.oralcancerfoundation.org/news/story.asp?newsId=954

This study examined outcomes for 151 head and neck patients given IMRT. Bottom line was that IMRT offered excellent outcomes in local-regional control and overall survival. Oropharyngeal cancer patients (base of tongue, soft palate, and tonsils) did the best with a 2-year local-regional control rate of 98%.

From what I've read, there are few studies that have completed that document the outcomes of IMRT. The Anderson MD study from 2004 was one of the first and reviewed 74 patients. Unlike the Anderson study, this one found no significant advantage with patients receiving postoperative radiation versus definitive radiation, nor did it find that the T or N stage had a significant effect on local-regional control. Like the Anderson study, this study found no significant difference in whether the patient had chemotherapy or not.

It seems that when I compare the stats on these two IMRT studies to several of the older conventional radiation studies, the survival outcomes are quite a bit better. And what is up with the chemo results with IMRT -this seems to be showing that chemo doesn't make the survival difference with IMRT that it did with conventional radiation.

Does anyone have any further insight into this?

Connie

I wonder if any of the newer studies on conventional radiation offer better survival rates? Maybe they are outdated?? Not sure but let us know what you find out.

Spoke to our radiation oncologist at Hopkins the other day and asked what they were finding re local control etc. for the tomo-IMRT vs. regular IMRT (they no longer use the older "conventional" radiation for head/neck cancer patients, and all but a few HNC patients are getting tomo). He said that the initial comparisons of tomo vs. regular IMRT is that the tomo is as good or better for disease control and far fewer side effects. BUT -- he said that they still need long-term data -- 36 to 56 months out. They have only had the tomo a year.

Virtually everyone at Hopkins is getting some concurrent chemo so can't address that issue.

Gail

radiation seems to be the gift that keeps giving for a couple of my friends, both about 12 yr head/neck cancer survivors.

george is in great shape, a heavy weight lifter. however a few months ago, he was getting short of breath from going up a flight of stairs. so the docs put a pigs' heart valve into him...they said the original valve showed signs of radiation burn.

max had bypass surgery today. he had been having very low blood pressure. then one day last week he felt badly, measured his bp and found it was over 200. the docs checked him out and got him in for bypass asap... docs told him the problem was due to his cancer radiation.

what i learned from these guys, we survivors need to really pay attention to our health and if something changes, find out why.

as for newer radiation being more effective than older styles, i think that it maybe years (or decades) before there is enough data to really know. till then, let's enjoy the day.

cheers,
cu,
larry

Larry --

Your friend's heart was radiated when he was treated for HNC? Wow. All I can say is thank goodness for IMRT.

On the other hand, our ENT had HNC 18 years ago and is fine now -- although the conventional radiation of the day has left her with dry mouth and very poor sense of taste, & also (when you look for it) a slight difference in color of skin on the sides of her neck vs. back and front where beam was blocked to protect her spinal cord. (Her successful treatment was the reason she went into the field).

Gail

Yes, I wouldn't have expected heart problems from radiation.

Just for the heck of it, I purchased this full 11 page study. It does state that long-term outcome data of IMRT in H&N cancer is limited, that there is great variation in IMRT delivery technique, including target delineation and dose prescriptions, and that its important to confirm that long-term favorable outcomes can be reliably reproduced.

It doesn't break the results down by stage but 85% of patients in the study were Stage III/IV (most of those Stage IV).

I always wonder when I read these studies, how they come up with the survival stats that are in general use. A few studies that I've read really slice and dice the numbers in many different ways producing quite different results for different subsets of the patient population.

When they come up with these often used general stats, do they take the average stats of all the studies done over time and extrapolate that out to the general patient population? Or, do they get data from hospitals? When you read a few of these things, its really clear that general statistics don't mean a whole lot to a specific individual (as has been said on the site many times before).

I do like to think that progress is being made with this disease though. Maybe the tomo-IMRT is another step in that direction.

Connie

Connie,

Did they just look at all kinds of chemo lumped together when they used that as a variable? Because, as has been discussed here before, there is much better data on the added benefits of chemo for some types of chemo than others, so I wonder if that could be part of the issue. I also suspect that the effects of stage and chemo may have gotten confounded -I assume this wasn't a study where patients were randomly assigned to receive chemo or not so it seems likey that, for example, the 15% of people who were not stage III or IV probably mostly did not have chemo. So you would expect frm previous data that they as a group would do better anyway, even without chemo, which might wipe out real effects of chemo in the data for people who were at more advanced stages.

And did they use random assignment for whether the people in the research got IMRT or not? because if not, as I've seen reading about other people's experienes here, it seems that there is a tendency (among some doctors anyway) to believe that more advanced cancer is more likely to be effectively treated my non-IMRT, ie. general field, radiation. If that tendency happened for patients in this study, what it means is that there would be a greater likelihood that patients with more advanced symptoms (which are only partly measured by the TNM system as far as I can tell, there are things like whether there was perineural invasion or not that is completely outside of that system) would be more likely to be in the non-IMRT group which measn that any differences between the two groups could partly be due to that pre-existing difference.

Anyway, those are just some things that occur to me in interpreting the results. I do think it's interesting that in general the two year rate of local or regional recurrence was much less than other stats you have seen. I wodner why that is, and it certainly seems very hopeful.

Nelie

oops, my bad about the what type of chemo question. Reading that again, I see that they did all get cisplatin. I do still wodner if that was confounded with stage though--I bet there were very few if any stage I and IIs getting concurrent chemo.

Nelie, In the M.D. Anderson 2004 study involving 74 patients with oropahyngeal cancer (BOT, tonsils, or soft palate) , 43 patients (88% St III/IV) were given postoperative IMRT (of whom only 3 were given chemo). 31 patients (100% St III/IV) were given definitive (no surgery) IMRT (of whom 17 were given chemo). The postoperative group had such good results, it would have been hard to get an improvement from chemo I think (4 yr disease free survival 92%, 4-yr locoregional control 95%, distant metastis-free survival (94%). The definitive IMRT group had worse rates overall (66%,78%,84%) but within that the chemo group had better DMFS survival (by 13%) though the others ratings were about the same.

The Univ of Iowa study covered all head-and-neck cancer of which the oropharyngeal patients had the best outcomes (2-yr 98% local-regional control rate). They say that IMRT has been shown to potentially improve local-regional control, reduce side effects, and improve QOL - but that long-term outcome data of IMRT are limited. It goes on to talk about differences in IMRT delivery techniques, which make it hard to reliably reproduce the same results.

In both studies, they compared a group having post-operative IMRT who didn't get chemo with a definitive IMRT group of whom about 50% got chemo.

It seems very promising to me. I'd like to think progress is being made.

Connie

I spoke to our radiation physicist Thursday at Hopkins (he was looking ragged after 5 days' of trying to get the tomo-therapy machine back up, working until 3:30 am) BUT he always will take time to answer a few questions. He said that the radiation planning is a major factor in outcome of any radiation (tomo, IMRT or conventional) and that comparing numbers from different ROs who might have different approaches complicates the statistics. Hopkins compares in-house, as do the other larger institutions, to minimize this problem. But it does come into play when you get large retrospective studies which take data from a variety of sources.

He was quite blunt that the expertise of the senior RO planning Barry's therapy, as well as the use of the tomo machine, was a major factor in his getting through with relatively reduced side-effects. By chance I met our original RO in the hall (he's now retired, was in to give a talk) and spoke with him briefly as well. He said they are achieving very high rates of control with both IMRT (older data thus fairly long-term) and tomo-IMRT in cancers of Barry's extent (Stage IV technically but sort of a 3 1/2 according to both Hopkins and Sloan-Kettering as one lymph node was enlarged slightly and thus suspicious, but never biopsied). Barry was the last patient he did a plan for.

Gail