Clinical Investigation
Quality of Life and Survival Outcome for Patients With Nasopharyngeal Carcinoma Receiving Three-Dimensional Conformal Radiotherapy vs. Intensity-Modulated Radiotherapy—A Longitudinal Study

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Purpose

To investigate the changes of quality of life (QoL) and survival outcomes for patients with nasopharyngeal carcinoma (NPC) treated by three-dimensional conformal radiotherapy (3D-CRT) vs. intensity-modulated radiotherapy (IMRT).

Methods and Materials

Two hundred and three newly diagnosed NPC patients, who were curatively treated by 3D-CRT (n = 93) or IMRT (n = 110) between March 2002 and July 2004, were analyzed. The distributions of clinical stage according to American Joint Committee on Cancer 1997 were I: 15 (7.4%), II: 78 (38.4%), III: 74 (36.5%), and IV: 36 (17.7%). QoL was longitudinally assessed by the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and the EORTC QLQ-H&N35 questionnaires at the five time points: before RT, during RT (36 Gy), and 3 months, 12 months, and 24 months after RT.

Results

The 3-year locoregional control, metastasis-free survival, and overall survival rates were 84.8%, 76.7%, and 81.7% for the 3D-CRT group, respectively, compared with 84.2%, 82.6%, and 85.4% for the IMRT group (p value > 0.05). A general trend of maximal deterioration in most QoL scales was observed during RT, followed by a gradual recovery thereafter. There was no significant difference in most scales between the two groups at each time point. The exception was that patients treated by IMRT had a both statistically and clinically significant improvement in global QoL, fatigue, taste/smell, dry mouth, and feeling ill at the time point of 3 months after RT.

Conclusions

The potential advantage of IMRT over 3D-CRT in treating NPC patients might occur in QoL outcome during the recovery phase of acute toxicity.

Introduction

Over the past decade, the advances of modern radiotherapy (RT) techniques for treating nasopharyngeal carcinoma (NPC) have emerged with the development of conformal RT, such as the three-dimensional conformal radiotherapy (3D-CRT) or, more recently, the intensity-modulated RT (IMRT). The reliance of 3D-CRT on computed tomography or magnetic resonance imaging–guided 3D planning allows better delineation of tumor target and organs at risk with clearer radiologic visualization of their spatial relations, thus providing a potentially therapeutic benefit of dose escalation to tumor tissue with reduced toxicity to normal tissues (1). IMRT represents an advanced form of 3D-CRT. It employs inverse planning algorithms and iterative computer-driven optimization to generate treatment fields with varying beam intensity. Combinations of intensity-modulated fields produce custom-tailored conformal dose distributions around the tumor, with steep dose gradients at the transition to adjacent normal tissues.

Growing reports have shown that the technical and dosimetric superiority of conformal RT over conventional two-dimensional RT (2D-RT) can translate into clinical benefits, such as reduced normal tissue toxicity or improved quality of life (QoL) 2, 3, 4, 5, 6, 7. Investigations regarding the comparison of 3D-CRT with IMRT were still confined to the analysis of dose distribution between them 8, 9, 10. As far as we know, it has not been reported whether the dosimetric advantage of IMRT over 3D-CRT could improve the tumor control, patient survival, or QoL in treating NPC. In current study, longitudinal results of QoL from NPC patients treated by 3D-CRT or IMRT at a single institution were presented. The data pertaining to QoL were collected using the questionnaires of the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-H&N35 at five time points: before RT (ti1), during RT (36 Gy, ti2), and 3 months (ti3), 12 months (ti4), and 24 months after RT (ti5). We compared the locoregional control rate (LRCR), metastasis-free survival rate (MFSR), and overall survival rate (OSR), as well as the changes of the EORTC QoL scales at the five time points for patients treated by 3D-CRT with those by IMRT.

Section snippets

Patients

In our institution, radical RT for treating NPC was routinely delivered by 2D-RT before the introduction of 3D-CRT in April 1996. Between April 1996 and March 2002, 3D-CRT was gradually used to replace 2D-RT in the boost phase for curable NPC cases or in salvage of recurrent disease. After becoming familiar with the techniques of 3D-CRT and implementation of the IMRT system by March 2002, our physicians and physicists began to use the two techniques as a standard strategy in treating NPC for

Tests of potential selection bias

In consideration of the potential selection bias between the two groups, we compared the components of their age, gender, clinical stage, histology, RT dose, combination with C/T, and completions of QoL at each time point. As shown in Table 1, no statistically significant difference was found (p > 0.05). To study whether patients who dropped out because of noncompliance or death at each time point introduced bias, we compared the QoL and medical data for those with and without dropouts

Discussion

Conventional RT with 2D treatment planning has been the standard treatment for NPC for many years. Over the past decade, much progress has been made in improving the therapeutic index of RT in treating NPC. The technique evolution of conformal RT has emerged with 3D-CRT followed by IMRT, which has gained increasing popularity in the treatment of NPC. Compared with 2D-RT, conformal RT have, in some research, translated clinically into better tumor control and patient survival with reduced organ

Acknowledgments

The authors thank to Yang Wei-Jiuan, Su Ching-Ju, and Huang Mei-Yueh for their assistance of data collection.

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    Supported by the grant NSC 90-2320-B-182A-006 from the National Science Council, Taiwan; and CMRP610 from the Chang Gung Memorial Hospital, Taiwan.

    Conflict of interest: none.

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