A joint guideline from the International Society of Oral Oncology–Multinational Association for Supportive Care in Cancer and ASCO seeks to fill a gap in the clinical guidance for patients with head and neck cancers who develop osteoradionecrosis following their head and neck radiation therapy.1 Despite the potential severity of osteoradionecrosis, the literature currently lacks consensus-based recommendations to aid in the prevention and management of this painful and debilitating condition.
“The impetus has very much been to achieve consistency in clinical practice based on the state of the science, linked with interprofessional oncology care,” said Douglas E. Peterson, DMD, PhD, FDS, RCSEd, FASCO, of UConn Health, and Co-Chair of the guideline Expert Panel. “This modeling for the guideline is unique and hopefully offers important guidance for clinicians involved in osteoradionecrosis prevention and management.”
Douglas E. Peterson, DMD, PhD, FDS, RCSEd, FASCO
Setting a New Standard
Osteoradionecrosis is a side effect of radiotherapy for head and neck cancers, with reported incidence rates varying from about 6% to 20%.2,3 Characterized by the presence of nonhealing and exposed oral bone, patients with osteoradionecrosis may experience discomfort, facial deformity, impaired functioning (eg, difficulty chewing or swallowing), increased health-care utilization, and decreased quality of life.4
Osteoradionecrosis currently lacks standardized treatment protocols, resulting in patients receiving a wide range of therapies that differ by type and intensity.4 Inconsistencies in the definition of osteoradionecrosis, along with its uncertain pathophysiology, also have made the development of consistent grading, staging, and treatment approaches difficult.5
Another notable challenge concerns the need for robust data from clinical trials to guide decision-making. “We don’t have big phase III studies [to draw from], so it is a lot of gestalt,” said Shlomo Koyfman, MD, of the Cleveland Clinic, and Co-Chair of the guideline Expert Panel. “But [the Panel] figured if we could get expert consensus on how we practice, we could really help the field. Even though the data are there, [they are] not very strong data, and we don’t have a lot of it.”
Shlomo Koyfman, MD
The guideline addresses a large breadth of topics, including the definition of osteoradionecrosis and how to recognize it; prevention techniques (including preradiation dental care, attention to the mandible in radiation planning, and when and how to extract problematic teeth); grading and severity; and recommendations for medical treatment of mild-to-moderate cases and surgical treatment of moderate-to-severe cases.
Dr. Peterson noted that topics such as nonsurgical interventions, patient-reported outcomes, and provisions of supportive care are highly relevant to osteoradionecrosis prevention and management but require more evidence for future guidelines to offer definitive recommendations on implementation. The use of hyperbaric oxygen for both prevention and management of osteoradionecrosis remains largely unjustified and requires further evidence to support its practice; unfortunately, these studies are often resource-intensive and costly.6,7
“Another new frontier is [the] development of predictive tools, such as bone turnover markers and genetic markers, as potential candidates to predict a priori which patients are more likely to develop osteoradionecrosis than others,” Dr. Peterson added. “Success in this arena in the future could help guide preventive decision-making as well as grading and staging.”
Supporting Greater Collaboration
The guideline was developed jointly between the International Society of Oral Oncology–Multinational Association of Supportive Care in Cancer and ASCO to ensure recommendations had input and concurrence from international experts representing the interprofessional health-care team likely to encounter and care for patients with osteoradionecrosis. The guideline also received endorsement from the American Head and Neck Society, the American Society for Radiation Oncology, the American Academy of Oral Medicine, and other major organizations.
“The practitioners who deal with this problem are really varied, and it’s broader than typical cancer,” Dr. Koyfman said. “[They are] dentists, oral surgeons, radiation oncologists, head and neck surgeons, hyperbaric oxygen practitioners, medical oncologists, and primary care physicians. A readership from multiple different subspecialties will be converging on one common set of principles, which is the goal of trying to standardize how we think about this.”
Use of a multidisciplinary group of experts also reflects the Expert Panel’s desire to convey in the guideline the importance of interprofessional care for patients with osteoradionecrosis. “This guideline is an excellent example of how dentistry is linked with medicine and the management of certain oral complications,” said Deborah Saunders, DMD, of the Health Sciences North Research Institute, in Canada, and Co-Chair of the guideline Expert Panel.
For instance, she said, the collaboration between dentistry and medicine in the United States is often limited by barriers, such as a lack of physician knowledge about dentist-based procedures. Further, medical insurance carriers often decline to cover preradiotherapy dental screenings for patients with head and neck cancers because those are considered dental procedures. But more than one-third of these patients may be without dental insurance.8
“These [barriers] become limitations for physicians not referring patients with head and neck cancers to a dentist, which is a bit of a roadblock to us being able to create an ideal world of prevention [for osteoradionecrosis] that includes both dentistry and medicine,” Dr. Saunders added.
The National Comprehensive Cancer Network already recommends multiple providers from various subspecialties be involved in the care of patients with head and neck cancers.9 However, the Expert Panel hopes having a consensus-based guideline that articulates this specifically for osteoradionecrosis could help increase prevention efforts and inform better treatment selection.
“Osteoradionecrosis is a complicated problem that requires a multidisciplinary approach,” Dr. Koyfman said. “It’s not like one dentist or one radiation oncologist trying to figure this out. Bringing in a team, thinking about this together, is one of the main things that is going to improve outcomes.”
REFERENCES
1. Peterson DE, Koyfman SA, Yarom N, et al: Prevention and management of osteoradionecrosis in patients with head and neck cancer treated with radiation therapy: ISOO-MASCC-ASCO guideline. J Clin Oncol 42:1975-1996, 2024.
2. Aarup-Kristensen S, Hansen CR, Forner L, et al: Osteoradionecrosis of the mandible after radiotherapy for head and neck cancer: Risk factors and dose-volume correlations. Acta Oncol 58:1373-1377, 2019.
3. Kubota H, Miyawaki D, Mukumoto N, et al: Risk factors for osteoradionecrosis of the jaw in patients with head and neck squamous cell carcinoma. Radiat Oncol 16:1, 2021.
4. Somay E, Yilmaz B, Topkan E, et al: Chapter 3: Assessment of the impact of osteoradionecrosis on quality-of-life measures in patients with head and neck cancer, in Sergi CM (ed): Advancements in Cancer. Brisbane, Australia; Exon Publications; 2023.
5. Raj R, Nair AH, Krishnan NA, et al: Advances and controversies in the management of osteoradionecrosis after head and neck cancer treatment: A narrative review. J Maxillofac Oral Surg 21:836-844, 2022.
6. Forner LE, Dieleman FJ, Shaw RJ, et al: Hyperbaric oxygen treatment of mandibular osteoradionecrosis: Combined data from the two randomized clinical trials DAHANCA-21 and NWHHT2009-1. Radiother Oncol 166:137-144, 2022.
7. Sultan A, Hanna GJ, Margalit DN, et al: The use of hyperbaric oxygen for the prevention and management of osteoradionecrosis of the jaw: A Dana-Farber/Brigham and Women’s Cancer Center multidisciplinary guideline. Oncologist 22:1413, 2017.
8. Brennan MT, Treister NS, Sollecito TP, et al: Dental disease before radiotherapy in patients with head and neck cancer: Clinical Registry of Dental Outcomes in Head and Neck Cancer Patients. J Am Dent Assoc 148:868-877, 2017.
9. Pfister DG, Spencer S, Adelstein D, et al: Head and Neck Cancers, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 18:873-898, 2020.
Originally published in ASCO Daily News. © American Society of Clinical Oncology. ASCO Daily News, May 1, 2024. All rights reserved.
