Comment on “The spectrum of late radiation sequelae in head and neck cancer”

Dear Editor, We read with great interest the study by Vashistha and colleagues,[1] which analyzed the spectrum, prevalence, and severity of late radiation-induced toxicities in patients with head and neck cancer (HNC) who underwent radical external beam radiotherapy. This retrospective study comprised a total of 100 HNC patients, of whom 49% were diagnosed with oral cavity (OCC) or oropharyngeal cancer (OPC). All eligible patients were diagnosed with squamous cell HNCs, and they all received radical radiation therapy (RT) alone or definitive chemoradiotherapy (CRT). RT technique was three-dimensional conformal RT(3D-CRT) in most patients. A follow-up period of at least 12 months was reported for each patient. Vashistha et al.[1] concluded that the most prevalent late toxicity encountered by survivors of HNC was related to salivary gland function, resulting in xerostomia and dysphagia, which was followed by dental caries (P = 0.03) and subcutaneous fibrosis (P = 0.01). The authors noted that the spectrum of adverse events was affected mainly by the patient’s Eastern Cooperative Oncology Group (ECOG) performance status and the disease’s location and stage. This study enhances our understanding of the late toxicities experienced by patients with HNC following RT or CRT. However, we would like to emphasize the significance of several additional toxicities that are often overlooked despite their considerable occurrence rates in these patient groups. Vashistha and colleagues[1] reported that the main late toxicities associated with RT/CRT included xerostomia, dental caries, dysphagia, subcutaneous fibrosis, hoarseness, and trismus in their study. Notably, the majority of patients underwent highly toxic 3D-CRT, and nearly half of the study population consisted of OC or OPC patients. The use of the 3D-CRT technique, along with these specific tumor locations, presents significant challenges in protecting periodontal tissues, teeth, and jaws from exposure to high doses of RT.[2] Hence, it is surprising that the authors did not observe any cases of periodontitis, tooth loss, or osteoradionecrosis of the jaws (ORN), which are frequently reported in such patients. Although more advanced intensity-modulated RT is now more commonly used, studies indicate that periodontitis, tooth loss, and ORN rates in HNC patients can reach up to 61.5%,[3] 67 %,[4] and 9.2%,[5] respectively. Unfortunately, these severe late-onset toxicities can significantly impact the affected patient’s quality of life, response to treatment, and disease prognosis, potentially more so than the toxicities that are frequently reported,[3-5] Periodontitis, tooth loss, and ORN might independently or jointly result in such adverse outcomes by causing malnutrition, exacerbating the cancer cachexia process, impairing immunological function, and inducing or intensifying inappropriate chronic local and systemic inflammatory responses.[5-8] As a result, it is imperative to provide data concerning these toxicities and their severity whenever available. However, stressing the significance of these frequently overlooked but considerably debilitating toxicities in patients with HNC is essential for facilitating multidisciplinary evaluations and the prompt implementation of preventive or therapeutic measures against them. Such initiatives will undoubtedly enhance patients’ quality of life and improve their prognosis. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.