S P O H N C VOL. 14 NO. 1 PUBLISHED BY SUPPORT FOR PEOPLE WITH ORAL AND HEAD AND NECK CANCER, INC. SEPTEMBER PDF

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NEWS FROM S P O H N C VOL. 14 NO. 1 PUBLISHED BY SUPPORT FOR PEOPLE WITH ORAL AND HEAD AND NECK CANCER, INC. SEPTEMBER 2004 S P O H N C A PROGRAM OF SUPPORT FOR PEOPLE WITH ORAL AND HEAD AND NECK CANCER
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NEWS FROM S P O H N C VOL. 14 NO. 1 PUBLISHED BY SUPPORT FOR PEOPLE WITH ORAL AND HEAD AND NECK CANCER, INC. SEPTEMBER 2004 S P O H N C A PROGRAM OF SUPPORT FOR PEOPLE WITH ORAL AND HEAD AND NECK CANCER Oral Complications of RadiationTherapy: The Dentists Role ERIC G. D HONDT D.D.S. In 2003 there were an estimated 27,700 newly reported cases of oral-pharyngeal cancer in the United States resulting in an estimated 7,200 deaths. Many of the patients treated for these types of cancers will receive head and neck radiation as part of their treatment. The goal of radiation therapy is to eradicate the tumor without causing significant damage to normal tissues. Currently, many of the radiation techniques used in the treatment of head and neck cancers have serious and detrimental side effects to the oral cavity (Table 1). Oral complications of head and neck radiation have been cited as the single most common cause of interruption and discontinuation of treatment regimens for cancer patients. Therefore, these complications can have the potential to adversely affect treatment outcomes, cancer prognosis and quality of life. To help manage the oral complications associated with head and neck radiation a dentist should be involved as an integral part of the treatment planning team. Unfortunately, dentists are oftentimes overlooked. This can be a result of physicians and patients not understanding the role of dentists or dentists not feeling comfortable treating head and neck cancer patients due to lack of education. Dentists need to be involved in all aspects of cancer therapy including treatment planning for patients prior to the start of radiation treatment and during radiation treatment, and follow- up with patients after treatment is completed. TABLE 1 Oral Complications of Head and Neck Radiation Xerostomia: Dryness of mouth as a result of reduced or absent salivary flow which increases the risk of infection and dental disease and compromises speaking, chewing and swallowing Infection: Viral, bacterial, or fungalresulting from xerostomia and/or damage to mucosa Mucositis/stomatitis: Inflammation and ulceration of mucous membranes associated with pain Dental decay: Rapid decay and/or erosion of the tooth as a result of changes in both quality and quantity of saliva. Increases lifetime risk of dental decay Taste alterations: Changes in taste perception, ranging from unpleasant to tasteless. Functional disabilities: Impaired ability to eat, speak and swallow. Nutritional compromise: Poor nutrition secondary to eating difficulties cause mucositis, dry mouth, trismus or infection. Trismus: Loss of elasticity/scarring of chewing muscles that restricts normal ability to open the mouth. Osteoradionecrosis (ORN): Blood vessel compromise and destruction of bone exposed to therapeutic doses of radiation resulting in a decreased ability to heal if traumatized with increased susceptibility to infection Source: National Institutes of Health Prior to the start of radiation therapy a full dental and oral examination should be scheduled. During this visit, a full series of x-rays should be taken to identify any potential pathology, decay, gum disease or infected teeth. A dental cleaning and all necessary fillings should be completed. Dental impressions are also needed for the fabrication of custom fluoride trays to be used during radiation. The dentist should also use this opportunity to discuss with the patients the potential side effects of head and neck radiation. (Table 1). Teeth that are infected or have the potential to become infected during or after treatment need to be addressed. If traditional dental treatments (i.e. root canals) cannot be completed prior to the start of treatment, or if the tooth cannot be saved, it must be removed prior to the start of treatment. This is important because of the potential for osteoradionecrosis if the tooth has to be removed following radiation therapy. Osteoradionecrosis is a very serious potential complication of head and neck radiation that can occur when a tooth is removed in an area that has been irradiated. The pretreatment evaluation also gives the dentist and patient the opportunity to discuss the oral complications that can be expected or avoided during treatment. There are multiple See ORAL COMPLICATIONS on next page Page 2 September 2004 SUPPORT FOR PEOPLE WITH ORAL AND HEAD AND NECK CANCER S P O H N C, INC. P. O. BOX 53 BOARD OF DIRECTORS Nancy E. Leupold, MS, President James J. Sciubba, D.M.D, Ph.D., Vice President Jean O. Cashin, Secretary Walter E. Boehmler, Treasurer Louis Frillmann Karrie Zampini, CSW David M. Brizel, M.D. Duke University Medical Center Linda K. Clarke, MS, RN, CORLN Greater Baltimore Medical Center David W. Eisele, M.D. University of California San Francisco Keith Heller, M.D., F.A.C.S. North Shore-LIJHealth System Alex Keller, M.D., F.A.C.S. Jesus E. Medina, MD University of Oklahoma Health Sciences Eugene N. Myers, M.D., F.A.C.S. University of Pittsburgh School of Medicine David Myssiorek, M.D. MEDICAL ADVISORY BOARD Karrie Zampini, CSW NEWSLETTER EDITOR Nancy E. Leupold, MS WEBMASTER Barry Sebastian Herman Oliver, M.D., F.A.P.A. David G. Pfister, M.D. Memorial Sloan-Kettering Cancer Center Jed Pollack, M.D. James J. Sciubba, D.M.D., Ph.D. Johns Hopkins Medicine Elliot W. Strong, M.D., F.A.C.S., Emeritus Memorial Sloan-Kettering Cancer Center Denise M. Vey Voda, M.A., D.D.S Everett E. Vokes, M.D. University of Chicago Medical Center David P. Wolk, M.D., F.A.C.S. News From SPOHNC is a publication of Support for People with Oral and Head and Neck Cancer, Inc. Copyright DISCLAIMER: Support for People with Oral and Head and Neck Cancer, Inc. does not endorse any treatments or products mentioned in this newsletter. Please consult your physician before using any treatments or products. IN THIS ISSUE ASCO Data Related to H & N Cancer...3 A Time for Sharing...4 Maintaining Your Emotional Health...5 COMING IN OCTOBER, 2004 Reconstructive Surgery for the Narrowing of the Throat Following Nonsurgical Therapy of Laryngopharngeal Primary Cancers Mark L Urken, MD, FACS ORAL COMPLICATIONS continued from page 1 treatment modalities, both prescription and non-prescription, that can help minimize the complications of radiation therapy (Table 2). The success of these medications and products varies depending on the person and dose of radiation received but most patients find them helpful. Please note that there are other modalities that are available that may also be helpful During treatment, patients should perform normal oral hygiene at least twice a day. As radiation treatment progresses, oral hygiene may become painful as a result of xerostomia and mucositis. A TABLE 2. Medications and Products For Patients Undergoing Radiation Therapy Rx Fluoride: In custom trays filled with prescription 1.1% neutral sodium fluoride gel. Worn for 5 minutes each night prior to bedtime. Nothing to eat or drink following. Rx Chlorohexdine rinse: Antimicrobial rinse used twice a day AS TOLERATED. Has a high alcohol content that may irritate tissues. Rx Stanford Mouthwash (Nystatin/Tetracycline/ Hydrocortisone/Chlorpheniamine): Antimicrobial. Pain associated with mucositis Rx KBX rinse (Kaopectate, Benadryl, Xylocaine): For pain associated with mucositis Rx Gelclair rinse: For pain associated with mucositis Xylitol products: gums and candies which promote saliva flow that do not cause decay Physical therapy: to help with elasticity of the chewing muscles and to maintain opening. supersoft toothbrush is recommended in these situations. Prescription mouth rinses (KBX, Stanford, Gelcair) can be prescribed your dentist and used as needed to help coat the mucosa and soothe the pain caused mucositis. Custom fluoride trays should be worn every night for 5 minutes prior to bedtime. It is important not to eat or drink after using the trays. The fluoride will help protect the teeth and make them more resistant to decay. Recall appointments with the dentist should be scheduled at least every 3 months. This more frequent recall interval allows dentists to assess how the oral cavity is responding to radiation treatment and make suggestions for treatment. Following the completion of treatment, patients can expect some of the side effects of radiation to improve. Some patients may notice an improvement in mucositis and return of taste within a few weeks. This will improve their ability to speak, eat, and swallow. Trismus, the inability to open the mouth, takes longer to improve. The muscles that open and close the mouth lose elasticity and can take months to regain full function. Physical therapy can be helpful both during and after treatment to maintain muscle function and opening. The most permanent side effect of radiation therapy is xerostomia. The salivary glands are extremely sensitive to ORAL COMPLICATIONS continued on page 7 S P O H N C P.O. Box 53 Locust Valley, NY Page 3 September 2004 SCIENTIFIC DATA RELATED TO HEAD AND NECK CANCER PRESENTED AT ASCO S ANNUAL MEETING IN JUNE 2004 New Orleans, June 5, A large international phase III study has found that adding the drug, cetuximab (Erbitux), to radiation therapy can nearly double the median survival in patients with head and neck cancer that has not spread to other parts of the body. James A. Bonner, MD., Chairman of the Department of Radiation at the University of Alabama at Birmingham, and Merle M. Salter professor of radiation oncology, presented the findings at the 40th Annual Meeting of the American Society of Clinical Oncology on June 5, The use of cetuximab and radiation therapy may become an excellent choice of therapy for this group of patients, said Dr. Bonner, the study s principal investigator. Future studies should be performed to examine combinations of chemotherapy, radiation therapy, and cetuximab. Head and neck cancers account for three to four percent of all cancers in the United States. Cancers of the head and neck comprise several sites including the nasal cavity, the sinuses, oral cavity, nasopharynx, oropharynx and other sites in the head and neck region. Most of these cancers begin in squamous cells found in the lining of structures in the head and neck. Standard treatment options for locally advanced head and neck cancer include radiation therapy, chemotherapy combined with radiation treatment, or surgery followed radiation and/or chemotherapy plus radiation for patients whose tumors can be surgically removed. Many head and neck cancer cells overexpress (make too much of) a protein called the epidermal growth factor receptor (EGFR), which may help cancer cells to grow more aggressively. One targeted therapeutic approach includes the agent cetuximab, which is a monoclonal antibody that attaches to and blocks EGFRs. Early studies suggested that treatment with cetuximab would boost the effectiveness of radiation therapy in patients with head and neck cancer. Erbitux is currently approved for the treatment of advanced colorectal cancer and is presently in several clinical trials to evaluate its efficacy in the treatment of other cancers. A total of 424 patients in the United States and Europe were enrolled in this study. All had tumors in their tonsils, tongue, or voicebox that may have involved lymph nodes but had not spread to other parts of the body. Patients were randomly assigned to receive either radiation therapy alone or radiation plus weekly cetuximab. Patients were followed up for a median of just over three years. Results of the trials indicated that median survival for patients treated with cetuximab was 54 months, compared with 28 months for patients who received radiation therapy alone. Fifty-seven percent of the cetuximab-treated patients survived for three years, compared with 44 percent of those in the radiation-only group. The researchers concluded that the addition of Erbitux to high-dose radiation therapy significantly improves survival compared to high-dose radiation therapy alone in the treatment of locally advanced head and neck cancer. Mucositis (inflammation in the mouth), causing pain and difficulty swallowing, is a common side effect of radiation therapy for head and neck cancer. In this study, patients in both groups suffered from this side effect in roughly equal numbers. It is particularly encouraging that the increase in survival achieved with cetuximab was attained with no worsening of radiationinduced adverse effects, said Bonner. Patients treated with cetuximab suffered more frequently from a skin rash on the face and body, but this did not appear to reduce the effectiveness of the treatment. The addition of chemotherapy to radiation has also previously been shown to improve outcomes in patients with locally advanced head and neck cancer, says Scott Saxman, M.D., of the National Cancer Institute s Cancer Therapy Evaluation Program. Follow-up studies will be necessary to determine the relative benefit of cetuximab compared to chemotherapy, he adds, and to determine whether combining cetuximab with chemotherapy will provide even greater benefit. New Orleans, June 6, 2004 Data presented today from a Phase III clinical trial involving 303 head and neck cancer patients showed that Ethyol (amifostine) reduced the incidence of moderate-to-severe dry mouth (xerostomia) in patients receiving radiation therapy for their disease. The data also showed that two years after treatment, patients treated with Ethyol retained the ability to produce saliva. Further, the data showed no evidence of tumor protection for the 24-month period of the study. The data were presented today at the American Society of Clinical Oncology s (ASCO) 40 th Annual Meeting. We found that two years after treatment, amifostine continues to diminish xerostomia induced radiation therapy for head and neck cancer without evidence of any compromise in the efficacy of the radiotherapy, said David M. Brizel, MD, Professor of Radiation Oncology, Duke University Medical Center and principal investigator of the study. Xerostomia is the medical term for chronic and severe dry mouth. It is a debilitating and sometimes permanent condition caused a reduction in salivary gland function, commonly caused radiation therapy to treat cancer of the head and neck region. The salivary glands are very sensitive to radiation and may be exposed during treatment resulting in a reduction in the production of stimulated and unstimulated saliva in the mouth. The Phase III clinical trial was conducted at 40 centers in North America and Europe. Patients were randomized to one of two groups: group 1 (the control group) received 1.8 to 2.0 gamma rays (Gy) of radiation to treat their cancer; group 2 were given the same dose of radiation, but also received Ethyol intravenous infusion 15 to 30 minutes prior to each of their radiation treatments. Both groups received treatment for five to seven weeks for a total dose of Gy. The Ethyol group received the drug at 200 milligrams per meter squared (mg/m 2 ). Xerostomia was assessed at 12, 18 and 24 months after radiotherapy Radiation Therapy Oncology Group (RTOG) criteria. Radiotherapy efficacy was assessed See SCIENTIFIC DATA on page 6 S P O H N C -- Page 4 September 2004 A TIME FOR SHARING Cycling and Cancer The First Cancer Experience Cycling had been an integral part of my life since I began cycling seriously in Plano, Texas in The spring of 1996 in Atlanta was no different from previous springs. I had been putting in a ton of training miles in preparation for the summer and had achieved a high level of fitness. All of my plans for the summer changed suddenly when, one week after completing the 1996 Bike Ride Across Georgia, I discovered a tumor on the base of my tongue. The diagnosis was a stage III squamous cell carcinoma with metastasis to an adjacent lymph node. Up until that time, I had assumed that cancer was not a disease of highly fit, health-conscious people. My perceptions quickly changed. I did not know at the time of my diagnosis if I would be able to return to a normal and healthy life, or if I would even survive. I also did not know that cycling would play a key role in my return to fitness and health, or that another cyclist and cancer survivor, who happened to be from Plano, Texas, would inspire my return. An aggressive treatment regimen that included three cycles of chemotherapy (Cisplatin and 5-FU) and twice daily radiation for 31 days had drained my energy, and my weight had dropped from 170 to 148 pounds. I had continued to ride during my treatment. My oncologist was very surprised when I asked him if I could ride my bike with my chemo pump attached to my infusion port. After replying God love you!, he went running down the hall of the medical complex shouting, You are not going to believe what Mr. Chambers just asked me! He seemed to be quite pleased that I was trying to maintain a normal and active life in the midst of coping with a serious illness. As I was recovering from the effects of the disease and the treatment, I wondered if I would ever again have the stamina to complete the Six-Gap Century in the north Georgia mountains, a 100 mile ride with over 10,000 ft. of vertical climbing. As my weight and energy began to return, I was on the bike more and riding a little stronger, but still nowhere near the fitness level required to complete Six- Gap. In the summer of 1999, after watching Lance Armstrong win the Tour De France, I decided that if Lance could win the Tour after cancer treatment, I could ride Six-Gap. That summer I joined a local bike club in the Chicago area, Velo Club Roubaix. I got dropped a lot on the club training rides during that first summer, but the next summer I was hanging on longer and getting stronger and fitter. During the summer of 2001, I was training and riding 200 miles per week in preparation for Six-Gap, and I was no longer being dropped on the club training rides. In the fall of 2001 I rode Six-Gap again for the first time since I completed the ride in 6 hours and 10 minutes, only 10 minutes longer than my previous, fastest time of 6 hours. It was an unbelievable feeling to complete Six-Gap. I felt a great since of accomplishment in finishing the ride that day, five years after wondering if I would ever complete the ride again. It also felt great to have achieved the same level of fitness and stamina that I had experienced before cancer. I have been able to sustain my fitness and stamina, and completed Six-Gap in 2002 and I also completed el Tour de Tucson in 2001 and 2002, riding with the Platinum group in el Tour. The 2001 el Tour was a special event for me because it occurred at my five-year post-treatment anniversary. In the 2002 el Tour, I was fortunate to start the ride with the cyclists in the VIP group, including Robbie Ventura, Greg LeMond, Jeannie Longo, and the T-Mobile women s team. Six years earlier I wondered if I would survive, and there I was at the starting line of el Tour with some of the top cyclists in the world. Role Reversal and Shared Experiences Cancer Returns (but does not recur) After I returned from el Tour in November of 2001, my wife, Kathy, discovered a knot in her neck and a growth of tissue on her tonsillar fossa. When I felt the knot in her neck and saw the growth, I felt that same sense of dread that I had experienced five years earlier. The enlarged lymph node and the abnormal tissue growth were ominous signs. I tried to be optimistic and assure her that it was probably just a benign re-growth of her tonsillar tissue, but deep down, I had the feeling that this all looked too familiar. How could this be happening? Oropharyngeal cancer is not a common form of cancer and it usually occurs in smokers. How could two non-smokers in the same family end up with throat cancer? We hoped that the enlarged node and growth were benign anomalies, but when the growth and node were surgically removed and the biopsy performed, the diagnosis was can
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