Aspiration pneumonia (AP) is a common late adverse effect of chemoradiotherapy (CRT) and bioradiotherapy for head and neck cancer (HNC). Evaluating the long-term risk factors of AP is difficult because patients’ characteristics vary according to the multimodal therapies they receive, say researchers from Shizuoka Cancer Center in Japan. They conducted a study (the first to their knowledge) to identify specific factors that might help predict which patients have the highest risk of infection.
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The researchers’ retrospective analysis covered nearly 9 years of data. Of the 305 patients in the study, 65 (21%) developed AP after CRT or bioradiotherapy. The median time from end of treatment to AP was 161 days. Nearly all (95%) the patients had Eastern Cooperative Oncology Group performance status of 0 to 1. Most had received standard chemotherapeutic regimens with platinum or cetuximab with supportive care.
The researchers found 5 independent risk factors: habitual alcoholic consumption, poor oral hygiene, coexisting malignancies, hypoalbuminemia before treatment, and use of sleeping pills at the end of treatment. Of those, only hypoalbuminemia was a familiar factor consistent with previous reports.
The finding that oral hygiene predicted AP was unexpected, because at the study hospital, HNC patients who undergo radiotherapy are routinely referred to dentists and receive systematic oral care during the treatment. Of 193 patients with poor oral hygiene before treatment, 135 had been followed up by dentists 3 months after the treatment. Of the 135 patients, 87 whose oral hygiene had improved had a significantly lower frequency of AP than did the 48 patients who had poor oral hygiene (18% vs 54%). The researchers say this suggests that continuous oral management is required in high-risk patients even after treatment.
The researchers also say unnecessary posttreatment administration of sleeping pills might increase the risk of AP. “Notably,” they say, of the 94 patients who used sleeping pills at the end of treatment, 83 continued to use them after the treatment. However, the researchers point to a study that found 31% of patients who had received radiotherapy or CRT had insomnia during the treatment, but about half of them recovered after the treatment.
Seven of 11 patients who had multiple HNCs or coexisting cervical esophageal cancers developed AP. So did 6 of 18 patients who underwent surgical or endoscopic resection for esophageal and gastric cancer. Three of those 6 developed AP within 1 week postresection. The researchers suggest that postsurgical immunosuppression and anesthesia or sedation before endoscopy might impair swallowing function. They also suggest that clinicians may want to consider swallowing exercises for high- or moderate-risk patients to improve swallowing function.
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The researchers note that AP has been found to be a “significant prognostic factor,” citing a study that found that AP accounted for 19% of noncancer-related deaths of patients with HNC who received CRT. Therefore, they expected AP to be strongly associated with patient survival in their study. However, it wasn’t—perhaps because of the relatively low number of deaths during the follow-up period. Nonetheless, AP “tended to be associated” with increased risk of death.
Source:
Kawai S, Yokota T, Onozawa Y, et al. BMC Cancer. 2017;17:59.
doi: 10.1186/s12885-017-3052-8.