In Response to “Acute Oral Mucositis During Hypo-Fractionated Radiation in Squamous Cell Carcinoma of Oral Cavity”

By Muhammad Shahid Iqbal, Josef Kovarik, Charles Kelly

Affiliations

1. Department of Oncology, Northern Centre for Cancer Care, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom

doi: 10.29271/jcpsp.2024.05.629

Sir,

We read Hammad et al.¹ on their experience of acute oral mucositis (OM) during hypofractionated radiation in squamous cell carcinoma of the oral cavity with interest.  Although this study contains a small number of patients (n = 11), it provides useful information, as hypofractionated radiotherapy is gaining popularity in head and neck cancer (HNC), especially in developing countries as it can be more cost-effective.²

Hammad et al.¹ reported 36% grade (G) III OM and 64% GII OM. After 1-month post-completion of treatment, the severity of OM was improved (9% GIII, 18% GII, and 46% GI). At 3-month follow-up, there is no GII/III OM and only 18% patients had G1 OM. None of the patients developed GIV OM. All patients who developed GIII OM had stage ≥ III (large radiotherapy volume including ipsilateral neck) and received concomitant weekly cisplatin. All patients had surgery and 3D conformal radiotherapy.

The authors report that 3 patients (27%) received this high dose, 55 Gy in 20 fractions with palliative intent. Can the authors shed light on their approach in using a higher, potentially more toxic dose in a palliative situation? We acknowledge that there is no standard palliative radiotherapy regimen for HNC.^3,4 However, life expectancy in such patients is limited, with a median survival of about 6 months⁴ and therefore, is the use of radical radiotherapy appropriate? Although the use of “radical dose with palliative intent” has been a longstanding concept in HNC and may prove, especially useful where palliative systemic resources are limited.

Secondly, the authors reported that 73% patients had “addiction” but did not specify what type or whether having this addiction made the acute toxicity worse. There is evident that smoking during radiotherapy increases toxicity.

In general, the use of hypofractionated radiotherapy (>2.4 Gy/fraction) with concomitant chemotherapy in HNC is not recommended⁵ although a recent large phase III trial shows similar 3-year survival and toxicity outcomes.² There remain concerns regarding late toxicity with hypofractionated radiotherapy in HNC and we would encourage the authors to consider publishing the long-term survival and toxicity outcomes in their particular patient population. Also, 55 Gy in 20 fractions can be considered radical dose, compatible with normo-fractionated (chemo)-radiotherapy regimens in HNC⁶ and would the authors consider using slightly lower dose/fraction in adjuvant settings e.g. 50 - 52.5 Gy in 20 fractions? Such information and results would widen the HNC treatment world experience and be a useful addition to the present published literature.

COMPETING INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTION:
MSI, JK, CK: Conception, design and drafting of the manuscript.
All authors approved the final version of the manuscript to be published.

REFERENCES

1. Hammad AM, Abrar S, Tahseen R, Qureshi BM, Hafiz A, Abbasi AN. Acute oral mucositis during hypo-fractionated radiation in squamous cell carcinoma of oral cavity. J Coll Physicians Surg Pak 2023; 33(12):1460-2. doi: 10.29271/ jcpsp.2023.12.1460.
2. Bentzen SM, Rosenblatt E, Gupta T, Agarwal JP, Ghosh Laskar S, Jacinto AA, et al. randomized controlled trial of hypofractionated vs. normofractionated accelerated radiation therapy with or without cisplatin for locally advanced head and neck squamous cell carcinoma (HYPNO). IJROBP 2023; 117(415):e2. doi: 10.1016/j.ijrobp. 2023.08.026.
3. Iqbal MS, Kelly C, Kovarik J, Goranov B, Shaikh G, Morgan D, et al. Palliative radiotherapy for locally advanced non-metastatic head and neck cancer: A survey of UK national practice. Radiother Oncol 2018; 126(3):568-9. doi: 10. 1016/j.radonc.2017.11.017.
4. Shahid Iqbal M, Kelly C, Kovarik J, Goranov B, Shaikh G, Morgan D, et al. Palliative radiotherapy for locally advanced non-metastatic head and neck cancer: A systematic review. Radiother Oncol 2018; 126(3):558-67. doi: 10.1016/j. radonc.2017.12.011.
5. Thomson DJ, Palma D, Guckenberger M, Balermpas P, Beitler JJ, Blanchard P, et al. Practice recommendations for risk-adapted head and neck cancer radiation therapy during the COVID-19 Pandemic: An ASTRO-ESTRO consensus statement. Int J Radiat Oncol Biol Phys 2020; 107(4):618-27. doi: 10.1016/j.ijrobp.2020.04.016.
6. Vreugdenhil M, Fong C, Sanghera P, Hartley A, Dunn J, Mehanna H. Hypofractionated chemoradiation for head and cancer: Data from the PET NECK trial. Oral Oncol 2021; 113:105112. doi: 10.1016/j.oraloncology.2020.105112.