Radiation Therapy for the Management of Oral Cavity and Oropharyngeal Cancers Samir Narayan, M.D. 9/9/2016

Introduction Indications for Radiation Therapy Radiation Therapy Principles and Techniques Managing side effects Pre-treatment evaluation Acute Effects Late Effects Survivorship Restoring Function

Cancers of Oral Cavity and Oropharynx 48,000 cases estimated in U.S. 9500 deaths Twice as common in men Average age at diagnosis is 62 Risk factors: Tobacco Alcohol HPV Betel nut chewing American Cancer Society

Radiation as a Treatment Modality: Indications Adjuvant (postoperative) Decreases locoregional recurrence after surgery Concurrent chemotherapy for high risk features Organ preservation (definitive) Avoids surgery for anatomic and functional preservation Surgery reserved for salvage of primary or neck dissection Stage I/II- RT can be used as an alternative to surgery Stage III/IV- Combined modality (RT + concurrent chemotherapy or cetuximab) Palliative (symptom control)

Radiation Dose and Prescription Total Dose: Definitive treatment of HN SCCA: 70 Gy Adjuvant 60-66 Gy Microscopic areas need 50-60 Gy Dose Per Fraction: Conventional fractionation is 1.8 - 2 Gy per fraction, once daily, 5 days/week. Duration: 70 Gy/35 fx/7 weeks Accelerated fractionation: Decreases the total time for radiation therapy Ex. 70 Gy in 6 weeks, one day of B.I.D.

Radiation Therapy Simulation Process Positioning and Immobilization CT image acquisition and reference marking

Radiation Therapy Treatment Planning Image Fusion Target Delineation Normal Tissue Contouring Treatment Plan Optimization

Radiation Treatment Plan Design and Evaluation

Radiation Treatment Delivery

Managing Side Effects Acute effects: Occur during treatment Manifest in varying degrees Resolve after recovery period May result in treatment breaks Late effects: Occur months to years after treatment Result from sublethal injury repair and host response Injury to stromal elements or supporting tissues such as the vasculature

Pre-Treatment Evaluation Dental Assessment Nutritional Assessment and counseling Psychosocial Evaluation and Support smoking cessation financial caregiver education Speech/Swallow Evaluation Audiometry

Acute effects Dermatitis Mucositis Odynophagia Dysphagia Hoarseness Taste alteration Thick saliva Weight loss

Oral Mucositis Develops two to three weeks after starting RT. The incidence of mucositis is variable depending upon the field, total dose and duration of RT. No proven benefit for pharmacologic prevention of radiation-induced mucositis Cochrane review 2013 Chlorhexidine mouth rinse is not effective

Managing Mucositis Oral hygiene protocol Dietary modification Mouthwashes: Baking soda +salt 2% viscous lidocaine, Maalox, diphenhydramine with or without nystatin. Opiate pain meds Mucoprotective devices Careful attention to radiation technique

Late effects Dry mouth Dental Decay Osteoradionecrosis Taste alteration Fibrosis Swallowing impairment Hypothyroidism

Survivorship Care Dental Care Speech/Swallow/Physical Therapy Psychosocial support Nutritional support Reinforce healthy lifestyle

References

References http://www.mascc.org/isoo-publications http://www.nidcr.nih.gov/OralHealth/Topics/CancerTreatme nt/ReferenceGuideforOncologyPatients.htm http://www.cancer.gov/about-cancer/treatment/side- effects/mouth-throat/oral-complications-pdq http://www.cancer.org/cancer/oralcavityandoropharyngealc ancer/detailedguide/oral-cavity-and-oropharyngeal-cancer- treating-radiation-therapy

Summary Radiation therapy is an integral treatment of Oral Cavity and Oropharynx CA. An experienced and multidisciplinary team of providers optimizes outcomes for patients.