This evidence review focuses on cancers affecting the oral cavity and lip, larynx, hypopharynx, oropharynx, nasopharynx, paranasal sinuses and nasal cavity, salivary glands, and occult primaries in the head and neck region.
Radiation therapy may be administered externally (i.e., a beam of radiation is directed into the body) or internally (i.e., a radioactive source is placed inside the body, near a tumor). External radiotherapy (RT) techniques include "conventional" or 2-dimensional (2D) RT, 3-dimensional (3D) conformal RT, and intensity-modulated radiation therapy (IMRT).
Conventional External-Beam Radiotherapy
Methods to plan and deliver RT have evolved that permit more precise targeting of tumors with complex geometries. Conventional 2D treatment planning utilizes X-ray films to guide and position radiation beams. Bony landmarks bones visualized on X-ray are used to locate a tumor and direct the radiation beams. The radiation is typically of uniform intensity.
Three-Dimensional Conformal Radiotherapy
Radiation treatment planning has evolved to use 3D images, usually from computed tomography (CT) scans, to more precisely delineate the boundaries of the tumor and to discriminate tumor tissue from adjacent normal tissue and nearby organs at risk for radiation damage. Three-dimensional conformal RT (3D-CRT) involves initially scanning the individual in the position that will be used for the radiation treatment. The tumor target and surrounding normal organs are then outlined in 3D on the scan. Computer software assists in determining the orientation of radiation beams and the amount of radiation the tumor and normal tissues receive to ensure coverage of the entire tumor in order to minimize radiation exposure for at risk normal tissue and nearby organs. Other imaging techniques and devices such as multi-leaf collimators (MLCs) may be used to "shape" the radiation beams. Methods have also been developed to position the individual and the radiation portal reproducibly for each fraction and to immobilize the individual, thus maintaining consistent beam axes across treatment sessions.
IMRT is the more recent development in external radiation. Treatment planning and delivery are more complex, time-consuming, and labor-intensive for IMRT than for 3D-CRT. Similar to 3D-CRT, the tumor and surrounding normal organs are outlined in 3D by a scan and multiple radiation beams are positioned around the individual for radiation delivery. In IMRT, radiation beams are divided into a grid-like pattern, separating a single beam into many smaller "beamlets". Specialized computer software allows for "inverse" treatment planning. The radiation oncologist delineates the target on each slice of a CT scan and specifies the target's prescribed radiation dose, acceptable limits of dose heterogeneity within the target volume, adjacent normal tissue volumes to avoid, and acceptable dose limits within the normal tissues. Based on these parameters and a digitally reconstructed radiographic image of the tumor, surrounding tissues, and organs at risk, computer software optimizes the location, shape, and intensities of the beam ports to achieve the treatment plan's goals.
Increased conformality may permit escalated tumor doses without increasing normal tissue toxicity and is proposed to improve local tumor control, with decreased exposure to surrounding, normal tissues, potentially reducing acute and late radiation toxicities. Better dose homogeneity within the target may also improve local tumor control by avoiding under dosing within the tumor and may decrease toxicity by avoiding overdosing.
Other advanced techniques that may further improve RT treatment by improving dose distribution. These techniques are considered variations of IMRT. Volumetric modulated arc therapy delivers radiation from a continuous rotation of the radiation source. The principal advantage of volumetric modulated arc therapy is greater efficiency in treatment delivery time, reducing radiation exposure and improving target radiation delivery due to less individual motion. Image-guided RT involves the incorporation of imaging before and/or during treatment to more precisely deliver RT to the target volume.
Summary of Evidence
For individuals who have head and neck cancer who receive IMRT, the evidence includes systematic reviews, randomized controlled trials (RCTs), and nonrandomized comparative studies. Relevant outcomes are overall survival (OS), functional outcomes, quality of life, and treatment-related morbidity. Recently published systematic reviews compared IMRT to two (2)-dimensional radiotherapy (2D-RT) and conformal radiotherapy (CRT) in individuals with nasopharyngeal carcinoma (NPC). Results revealed a significant improvement in clinical oncologic outcomes (e.g., OS, progression-free survival, locoregional control/survival) and toxicities such as xerostomia with IMRT in this individual population. A 2014 systematic review concluded that IMRT, when compared with 2D-RT or 3D-CRT, had no significant impact on OS or locoregional control in previously untreated individuals with non-metastatic head and neck cancers; however, IMRT was associated with a significant improvement in xerostomia. One RCT compared two (2) fractionation schedules of IMRT for locally advanced head and neck cancer and found a survival benefit in using simultaneous modulated accelerated radiotherapy boost over simultaneous integrated boost-IMRT. Nonrandomized cohort studies have supported the findings that both short- and long-term xerostomia are reduced with IMRT. Overall, evidence has shown that IMRT significantly and consistently reduces both early and late xerostomia and improves quality of life domains related to xerostomia compared with 2D-RT or 3D-CRT. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have thyroid cancer in close proximity to organs at risk who receive IMRT, the evidence includes case series data. Relevant outcomes include OS, functional outcomes, quality of life, and treatment-related morbidity. High-quality studies that differentiate the superiority of any type of external beam RT to treat thyroid cancer are not available. However, the published evidence plus additional dosimetry considerations together suggest IMRT may be appropriate for thyroid tumors in some circumstances, such as for anaplastic thyroid carcinoma or thyroid tumors located near critical structures (eg, salivary glands, spinal cord), similar to the situation for head and neck cancers. Thus, when adverse events could result if nearby critical structures receive toxic radiation doses, the ability to improve dosimetry with IMRT might be accepted as meaningful evidence for its benefit. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.