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ORIGINAL ARTICLE
Year : 2017  |  Volume : 54  |  Issue : 1  |  Page : 31-34
 

An audit and analysis of different causes of defaults in patients receiving radiation for head and neck cancers: A tertiary regional cancer center experience


Department of Radiation Oncology, Acharya Harihar Regional Cancer Centre, Cuttack, Odisha, India

Date of Web Publication1-Dec-2017

Correspondence Address:
Dr. S Padhi
Department of Radiation Oncology, Acharya Harihar Regional Cancer Centre, Cuttack, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_114_17

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 » Abstract 

CONTEXT: Strict adherence and timely completion of the external beam radiation therapy (EBRT) schedule is an important prognostic factor in the survival of head and neck cancer patients. However, many patients are unable to complete the radiation treatment due to various reasons resulting in a poor outcome. AIMS: This study aims to study the pattern and various possible causes of defaults for possible intervention. SETTINGS AND DESIGN: A retrospective epidemiological analysis. SUBJECTS AND METHODS: Patients receiving EBRT for head and neck cancers with curative intent from January 2015 to December 2015 but did not complete the prescribed treatment were included. Unplanned treatment breaks in the treatment was not taken into consideration. STATISTICAL ANALYSIS USED: SPSS version 21. RESULTS: Out of 458, 92 (20.08%) patients did not complete the EBRT (P = 0.06). Fifty-six out of total 92 patients (60.9%) who defaulted stopped taking treatment within halfway of the treatment (15 fraction) and 12 out of total 92 patients (13%) just at the 22nd/23rd fraction. Defaulter rates in patients from different places are in the range of 12.8% to 33.0% but was statistically not significant (P = 0.224). There was no particular age (P = 0.966), disease site (P = 0.354) preponderance among defaulters. Use of concurrent chemo-radiation in radical or adjuvant settings was also not related to defaults (P = 0.406). CONCLUSIONS: Radiation-induced acute toxicity, socioeconomic status and distance plays minimal role as a cause of patients who stop taking EBRT. There is no particular relation between age, disease site, treatment received before radiotherapy, intent of treatment, and concurrent chemoradiation-induced acute reactions with defaults among patients. Loss of income and work in the poor population during the treatment may be an important possible cause of defaults.


Keywords: Causes of defaults, head and neck cancer, treatment defaulters


How to cite this article:
Pujari L, Padhi S, Meher P, Tripathy A. An audit and analysis of different causes of defaults in patients receiving radiation for head and neck cancers: A tertiary regional cancer center experience. Indian J Cancer 2017;54:31-4

How to cite this URL:
Pujari L, Padhi S, Meher P, Tripathy A. An audit and analysis of different causes of defaults in patients receiving radiation for head and neck cancers: A tertiary regional cancer center experience. Indian J Cancer [serial online] 2017 [cited 2020 Jul 6];54:31-4. Available from: http://www.indianjcancer.com/text.asp?2017/54/1/31/219530



 » Introduction Top


Globally, cancer has become one of the leading causes of death. In developed countries, cancer comes as the second most common cause of death, and in developing countries, it comes as the third leading cause of death.[1]

In developing countries, head and neck cancer comes as second most common cancer in male and third most common cancer in female. Overall head and neck cancers are the most common cancer among male and third most common cancer among female in India. In India, more than 2.5 lakh new patients of head and neck cancer are diagnosed every year, of whom about three-fourths are in an advanced stage.[2]

Radiotherapy forms an important constituent in multimodality treatment approach in the treatment of head and neck cancers along with chemotherapy and surgery. In many cases, radiotherapy is the primary treatment modality also. Timely completion of radiotherapy with appropriate doses is one of the important factors in overall prognosis and survival of the patients being treated with both radical and adjuvant intent.

Although there are rapid progress and popularity of modern radiotherapy machines and techniques in India with advanced methods still a large population of Indian patients, depend on conventional treatment by Co-60 machines.

Radiotherapy facilities in India are awfully short when compared to the demand. Many patients are unable to receive treatment due to lack of facilities and different logistic problems.[3]

Among the patients coming to a radiotherapy center for treatment, many do not complete the treatment as per the treatment protocol and schedule which adversely affects the outcome in these patients.

This study is an attempt to identify various patterns and causes of defaults in patients receiving radiotherapy in a center treating patients by conventional modalities with Co-60.


 » Subjects and Methods Top


The study was conducted in a tertiary cancer center in Eastern India treating patients by Co-60 radiotherapy machine.

It was a retrospective observational study including all patients who were receiving radiotherapy for head and neck cancers during January 2015–December 2015 with curative intent. Patients receiving radiotherapy in palliative intent were excluded from the study. Unscheduled treatment breaks and gaps in treatment were not taken into consideration. Only the patients who did not complete their treatment at all were included in the study.

All data such as epidemiological characteristics, disease sites, treatment modalities, and previous treatments were obtained from radiation treatment records.

All data were collected, summarized, and analyzed by SPSS version 21 IBM SPSS Statistics for Windows, version 21.0 (IBM Corp., Armonk, N.Y., USA). All proportions were analyzed and compared by Chi-square test and level of statistical significance was considered as P < 0.05.


 » Results Top


A total of 458 patients have received external beam radiation to head and neck region in curative intent in this study period of 1 year. Of this 458 patients, 111 (24.2%) were female and 347 (75.8%) were male [Table 1].
Table 1: The age group and gender distribution

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Mean age of presentation of head and neck cancer is 52 years in a range of 13–89 years.

Maximum disease burden is found in 50–59 years of age group (26.4%) followed by 40–49 years age group (24%) and 60–69 years age group (19.9%). These three age groups from 40 to 69 years constitute 70% of the disease burden in our institute [Table 1].

There is no difference in age of incidence of head and neck cancer between male and female patients as both are comparable across all age groups (P = 0.995) [Table 1].

Majority of the patient (67%) at our institute are from the nearby area, i.e., from the Eastern part of our state [Table 2] and [Figure 1].
Figure 1: Geographic regions of the Odisha

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Table 2: Distribution of various parameters like age group, locality, disease site, intent of radiotherapy, and addition of chemotherapy among the two groups

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Out of 458 patients, 92, i.e., 20.1% did not complete their scheduled radiotherapy treatment at all. Fifty-six patients out of 92 (60.8%) dropped out of treatment even before completing 15 fraction of radiation. An interesting finding is that 12 patients (13%) out of total 92 defaulters have stopped receiving their treatment just at the time of field reduction to spare the spinal cord at 22–23 fraction [Table 3].
Table 3: Percentage of defaulters at various fractionations

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Oral cavity is the most common site (41%) among patients with head and neck cancer followed by the oral tongue (19%), laryngopharynx (13.5%) oropharynx (6.3%), and nasopharynx (5.5%) [Table 2].

Two hundred and sixty-eight (58.5%) patients received radiation in adjuvant setting with 184 of them receiving concurrent chemotherapy with radiation. Rest of 190 patients (41.5%) received radiation in radical intent with 117 of them receiving concurrent chemoradiotherapy. Around 60% of the patients received concurrent chemoradiation in both adjuvant and radical settings [Table 2].

Sixty-three patients out of 347 male (18.2%) and 29 out of 111 female (26.0%) patients did not complete their treatment (P = 0.068) [Table 2].

Maximum patients who default are in age group of 70-79 years (23.5%) followed by 22% in 60-69 years and 20.7% in 40-49 years age group (P = 0.966) [Table 2].

Patients from different regions coming to our institute have default rates in the range of minimum 12.9% for Northern area of the state to maximum 33% from far-flung KBK districts (P = 0.225) [Table 2].

Among various disease sites default rates are in the range of 12%–27.8%. For thyroid malignancies, it is in tune of 50% (P = 0.335) [Table 2].

Default rates among patients treated with different intents like adjuvant or radical also have similar default rates of 18.7% and 22.1%, respectively, (P = 0.364) [Table 2]. Default rates of patient receiving concurrent chemotherapy with radiation is 18.6% which is similar to patients receiving only radiotherapy (22.1%) (P = 0.273) [Table 2].


 » Discussion Top


Tobacco chewing and smoking are known risk factors for head and neck cancers. In our part of the country, chewing tobacco is common among men and women. However, it is more so in case of men.[4] The incidence of head and neck cancers are more in male patients as compared to female patients. Head and neck cancers are seen across a spectrum of age groups. In this study, the range was 13–89 years with mean age of presentation 52 years. Maximum disease burden of the head and neck cancer is found in 40–69 years of age group, i.e., the middle to early old age group constituting of about 70% of the total disease burden. It is similar to the data presented by Mehrotra et al.[5] Considering that the 40–59 years age group is economically productive it poses as huge health as well as an economic challenge.

Most of the patients presenting to our institute are from the Eastern region and from the rest part of the state the patients constitute only 33%. This again reflects the need to establish adequate and qualitatively sound cancer treatment facilities in other parts of the state and rest of the country which has not been possible till date.[3] Many of the patients are not coming to the hospital due to the distance from home and economic factors and lack of awareness that “cancer is curable in its early stages.”

Oral cavity and oral tongue are the most common sites which correlate with the practice of chewing tobacco in the Eastern part of India. It is in agreement with the data published by Sherin et al.[6]

Around one in every five patients did not complete their radiation treatment at all leaving aside the patients who had unscheduled treatment breaks during their radiotherapy. In that case, the number of patients not receiving their radiotherapy properly will be far more. The analysis of different causes of such unscheduled treatment breaks was beyond the scope of this study. Quite a high number of patients are even unable to complete their treatment.

Among the treatment defaulters, 61% of patients defaulted within the first 15 fraction. The use of concurrent chemoradiation in head and neck cancer is not related to defaults (P = 0.273). Both of these observations indicate that radiation-related acute reactions like mucositis are not the cause of default on the contrary to the popular notion. As radiation-related toxicities like mucositis develop usually after 2nd–3rd week. Although with the use of concurrent chemotherapy, it develops a little earlier and with a more severe form. Still with the use of concurrent chemoradiation also the severe form of acute radiation reactions are seldom seen with in first 15 fraction.

There is no difference in the pattern of defaults all most across all age groups (P = 0.996). There is no statistically significant relation between sex of the patients and tendency to default (P = 0.068). However, still female are more likely to default in treatment as compared to male. This can be attributed to still prevalent negligence toward a womens' health in our society.

Distance of the radiotherapy center from home of the patients who have come to our institute is also not a significant factor in patients who default (P = 0.225). It may be a factor in the patients not seeking treatment at all but not a factor in patients who stop receiving the treatment midway.

There was no statistically significant difference between default rates among patients receiving radiotherapy in adjuvant or radical setting (P = 0.364).

Use of chemotherapy concurrently with radiotherapy and possible resultant more acute adverse effect with the use of concurrent chemotherapy are not a cause of defaults in patients as the default rates were not significant in these groups (P = 0.273).


 » Conclusions Top


Total defaults from treatment is an issue in patients with head and neck cancers in our center and so may be the case in other parts of the country and other developing nations. From this study, no definite cause and predisposing factor or risk group can be identified among patients who tend to default from their treatment, but it can be safely said that radiation-related toxicities, distance of the treatment facility from home, age of the patient, and particular disease sites are not related to defaults by the patients. Financial constraints may not be important also as radiotherapy is free for below poverty line patients and for other population under various insurance schemes of the government. Moreover, radiotherapy treatment is highly subsidized at our center for the patients who do not come under the various government sponsored schemes.

There must be some other reasons for which patients are defaulting in treatment. Around 13% patients defaulting just at the time of field reduction to spare the spinal cord indicated toward a possible communication gap between treating radiation oncologist and the patients. Although radiotherapy treatment at government set up are highly subsidized still there is a significant loss of productive man days when the patients have to travel a long way from their home or in most cases have to stay away from home due to unavailability of radiotherapy treatment facility near to their home. The patients have to spend whole day for a radiotherapy treatment which hardly takes 5–10 min. This has got very high financial implications for the patients who are mostly poor people in most of our government set up and feed hand to mouth. Besides this there may be some reasons unique for that particular radiation treatment facility which needs to be explored. We radiation oncologist need to develop a mechanism to actively follow the patient up during the radiation treatment in high volume centers and also keep in mind all aforesaid factors while treating a patient.

Limitations

Patients were neither examined prospectively nor were they followed up after they defaulted from the treatment. The patients were not interviewed to ascertain the exact cause of default in each of them.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

1.
Mohsen N. The global burden of cancer 2013. JAMA Oncol 2015;1:505-27.  Back to cited text no. 1
    
2.
Desai C. Squamous cell carcinoma of the head and neck region: insights from the American Society of Clinical Oncology 2008 presentations. Indian J Cancer 2008;45:90-2.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Murthy NS, Chaudhry K, Rath GK. Burden of cancer and projections for 2016, Indian scenario: gaps in the availability of radiotherapy treatment facilities. Asian Pac J Cancer Prev 2008;9:671-7.  Back to cited text no. 3
[PUBMED]    
4.
Chadda R, Sengupta S. Tobacco use by Indian adolescents. Tob Induc Dis 2002;1:111-9.  Back to cited text no. 4
[PUBMED]    
5.
Mehrotra R, Pandya S, Chaudhary AK, Kumar M, Singh M. Prevalence of oral pre-malignant and malignant lesions at a tertiary level hospital in Allahabad, India. Asian Pac J Cancer Prev 2008;9:263-5.  Back to cited text no. 5
[PUBMED]    
6.
Sherin N, Simi T, Shameena P, Sudha S. Changing trends in oral cancer. Indian J Cancer 2008;45:93-6.  Back to cited text no. 6
[PUBMED]  [Full text]  


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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