To better identify the patients who are unlikely to have good functional outcomes following CRT, Dr. Gourin and her colleagues at the Medical College of Georgia in Augusta, where she was previously on the faculty, performed fiberoptic endoscopy evaluation of swallowing (FEES) exams on patients prior to treatment. They found that 40% of their patients showed signs of aspiration, and in 25% the aspiration was silent. I suspect those cases will do poorly with CRT, she said. We are in the process of collecting the post-treatment data to correlate [the outcomes with FEES results], but this may be one way of predicting who will do poorly or not.
Explore This IssueApril 2008
Similarly, Dr. Johnson pointed out that in patients in whom the tumor has destroyed the organ, surgery may be the best choice. I believe that there does exist a cohort of patients with advanced primary tumors who are probably better served with resection and reconstruction and then adjuvant therapy, because the advanced primary tumor has so disrupted function that it can not possibly be expected to fix itself, Dr. Johnson said. So even though the CRT might conceivably cure the tumor, it doesn’t fix the problem.
Coping with Toxicity
Although organ preservation therapy may prevent the need for a disfiguring surgery, it causes significant side effects of its own. One of the most significant side effects of CRT is mucositis and stenosis. The majority of patients have swallowing problems following CRT. Some patients are unable to eat solid foods and thus have trouble maintaining their weight. And aspiration is a big problem. The exact rate of such complications is not clear because different groups report different numbers, but Dr. Gourin noted that recent studies have reported as many as 75% of patients become reliant on a feeding tube long-term.
Unfortunately, there aren’t a lot of data that compare the two options head to head, said Dr. Wax. And explaining the potential problems to patients isn’t always straightforward. People can very easily conceptualize the problems they are going to have when they have surgery. But I don’t think people can conceptualize what radiation or chemotherapy does.
There are a large number of ongoing clinical trials designed to test new drug regimens, including some molecularly targeted agents. Thus, less-toxic regimens might be identified that would make the use of CRT more advantageous.
I think we are becoming more concerned with their quality of life, Dr. Wax concluded. How well can we get these patients to be able to eat in public, so they think that they have a life instead of thinking ‘Okay, you cured my cancer, but what in life is there worth me living for?’ I think we need to start to examine those types of issues.