Physician With a Mission
Network - Summer 2008
By Sandi Stromberg
When David I. Rosenthal, M.D., arrived at
M. D. Anderson six years ago, he brought with him a deep concern about the symptom burden his patients experienced as a result of cancer treatment.
While successful advances have been made in the treatment of head and neck cancers over the last 10-15 years, the acute toxicity can be significant and also cause long-term functional impairment.
This is true for several types of cancer patients, including those with oropharynx (the base of the tongue and tonsils) cancers, many of whom underwent operations in the past. Today, standard treatment for them consists of adding chemotherapy as a sensitizer to intensify the effect of radiation on the tumor and to kill more cancer cells.
While cancer control and survival rates are excellent, and the organs are preserved numerically, many patients experience worse symptoms with chemoradiation than with radiation therapy alone, and certain functions, such as swallowing, may be impaired.
“I was looking for some instrument to assess the side effects they deal with,” Rosenthal says. “But most instruments were concerned only with ‘quality of life.’ While this is important, the tools to measure it often miss many of the most relevant symptoms that our patients suffer. Of the 30 to 40 questions, I would find that only one or two were relevant.”
Where to start?
Rosenthal wanted a general symptom screening instrument for all patients with head and neck cancers that would be valid before, during and after treatment, independent of whether they had surgery, radiation, chemotherapy or any combination.
To develop the specific content for the patient questionnaire, he worked with Cleeland and other head and neck specialists, including medical, dental and surgical oncologists, speech-swallowing-language pathologists and patient and family focus groups. Together they identified symptoms and functionality issues.
From his years of experience, Rosenthal knew one of the most common symptoms for patients with head and neck cancers is dry mouth, which can have both functional and comfort implications.
“Another important toxicity is mucositis, sometimes called ‘the sun-burn effect’ of radiation given with or without chemotherapy, on the mouth, throat and esophagus,” he says. “This can lead to the inability to eat or swallow.”
He wanted to make sure the questionnaire was very sensitive to mucositis symptoms.
What they learned
“One thing we noticed in our trials is that some patients get a lot of mucus in their throat when they have bad mucositis,” Rosenthal says. “It’s a significant symptom that hadn’t been reported before. Yet, mucus in the throat can be so copious that some patients focus on management of secretions all the time. They’re constantly gargling, suctioning. They can’t sleep. They gag and regurgitate.”
In all, the study identified nine head and neck cancer-specific symptoms, separate from the 13 core MDASI.* They are mouth and throat sores, problems with tasting food, constipation, problems with teeth or gums, skin pain, burning or rash, difficulty with voice or speech, choking or coughing, difficulty chewing or swallowing, and excess mucus in the mouth and throat.
Not only were they able to validate the MDASI-HN, but also in a subsequent study where they compared it with the quality-of-life Functional Assessment of Cancer Therapy-Head and Neck, it proved to be more predictive of the severity of radiation-induced mucositis.
Since validation, the tool has been incorporated into some clinical trials, including a Phase III, Radiation Therapy Oncology Group trial. However, hopes are that when technology allows, the MDASI-HN will become an integral part of a patient’s electronic medical record as M. D. Anderson researchers work toward understanding symptom burden and finding interventions to treat and ultimately prevent debilitating side effects for cancer survivors.
* For a review of the 13 core MDASI symptoms that may be experienced by any cancer patient, see the spring 2007 issue of Network.