Bilateral Elective Nodal Radiation Increases Narcotic Requirement But Not Patient-Reported Pain During Head and Neck Cancer Radioation Therapy

Abstract

Oral mucositis occurs in the majority of patients (pts) undergoing radiation therapy (RT) for head and neck cancer (HNC). The Oral Mucositis Daily Questionnaire (OMDQ) is a validated survey for HNC patient pain. This analysis was undertaken to report the course of patient-reported pain and associated narcotic use throughout the duration of RT for pts with HNC. Hypothesis: We hypothesized pts with bilateral elective nodal RT (BL-RT) treatment vs. unilateral elective nodal RT (UL-RT), with or without concurrent chemotherapy (CRT), would have significantly worse pain that coincided with increasing narcotic requirement. Pts with Stage I-IV HNC who were treated with either adjuvant or definitive RT at our institution from 2015 to 2017 were included for analysis. At baseline and weekly on-treatment visits, clinical data including narcotic use was recorded and OMDQ was administered. Pain was treated with either our institution’s standard of care (SOC) analgesic regimen using hydrocodone-acetaminophen +/- transdermal fentanyl as needed, or according to an outside provider (OP). Average daily narcotic use was converted to oral morphine milligram equivalents and reported as a cumulative requirement (dMME). Pts were dichotomized by either unilateral or BL-RT and +/- concurrent chemotherapy (RT vs CRT). To evaluate Mouth/Throat Soreness (MTS) OMDQ score response, the difference between baseline and week 3 (W3D) and at end-of-treatment (EoTD) was calculated for each pt. All other elements of the OMDQ were also analyzed. Two way ANOVA was performed and associations over time were quantified with a random coefficient mixed model. A total of 98 patients were eligible for analysis (42% SOC and 59% OP). The median age was 61.2y (IQR: 55.4-70.1y). Median dose to the primary was 70Gy (Range:50-70Gy). Overall, pts were treated: 44% adjuvantly, 56% definitively, 56% BL-RT, 39% UL-RT, 82% CRT, 18% RT alone. SOC vs. OP had no change in weekly MTS and no significant difference in dMME. There was no difference in overall pain scores, W3D or EoTD when comparing elective nodal RT; however, there was increased narcotic requirement for BL-RT (p<0.001). CRT vs. RT-alone had greater weekly MTS (p=0.03) and an increased dMME (p=0.047). There were no significant differences in all other OMDQ questions. We report on the use of narcotics and mucositis-related pain throughout the course of RT. Surprisingly, BL-RT did not increase MTS scores compared to UL-RT. Not surprisingly, CRT did increase weekly MTS scores. Both BL-RT and CRT increased narcotic requirements. Implications for research: This study suggests that narcotic use as measured by dMME, rather than OMDQ, may be a better metric for quantifying mucositis during radiation.