GOLEZ, Steffi Gabrielle R.

August 27, 2019

4NUR-2 RLE 2 Ma’am Dyan Dee Tiongco

Title: Radiation therapy for nasopharyngeal carcinoma: the predictive value of interim survival
assessment
Authors: Ryo Toya, Ryuji Murakami, Tetsuo Saito, Daizo Murakami,Tomohiko Matsuyama,
Yuji Baba, Ryuichi Nishimura, Toshinori Hirai, Akiko Semba, Eiji Yumoto, Yasuyuki
Yamashita, and Natsuo Oya
APA: Toya, R., Murakami, R., Saito, T., Murakami, D., Matsuyama, T., Baba, Y.,Oya, N. et al.
(2016). Radiation therapy for nasopharyngeal carcinoma: the predictive value of interim survival
assessment. Journal of Radiation Research, 57(5), 541–547.

1.) Using the PICO format, formulate your questions.

a. What is the population of interest?
- A total of 63 patients having nasopharyngeal cancer.

b. What is the intervention implemented or the interest?

- Of the 63 patients, 52 received chemoradiotherapy, whereas 11 underwent RT alone.
Elective nodal irradiation was delivered to the upper or whole neck; Interim MR
Assessment was performed before boost irradiation. Based on this assessment, boost
irradiation was delivered to the primary lesion and suspicious metastatic lymph
nodes. Of the 63 patients, 43 underwent 3D-CRT and 20 received IMRT. Post-RT
neck dissection, defined as neck dissection within 6 months after RT, was performed
in 9 patients with suspicious residual LN metastases, despite a complete response of
the primary lesion.
- After treatment completion, patients were evaluated every 1–2 months during the first
year, every 3 months during the second year, and every 6 months thereafter. All
patients underwent physical and endoscopic examinations at each follow-up visit.
Post-treatment, MRI, and CT studies were performed within 1–2 months after
treatment completion and every 6 months thereafter or when clinically indicated. A
diagnosis of treatment failure was based on the results of follow-up studies or neck
dissection specimens indicating persistent disease, relapse, or disease progression.
Failures were classified as involving the primary lesion (local), neck LN metastases
(regional), or distant metastases (distant).

c. What is the comparison? Or the current applicable practice or status?

- Nasopharyngeal carcinoma (NPC) is a malignant entity distinct from other head and
neck cancers and may be associated with Epstein–Barr virus infection. Most NPCs
are poorly differentiated or undifferentiated radiosensitive carcinomas. Because of its
 anatomic characteristics, NPC is rarely treated surgically; radiation therapy is
generally delivered with or without chemotherapy. In patients with head and neck
cancer, radiotherapy elicits substantial anatomic changes due to tumor shrinkage,
decreased salivary gland volume, and body weight loss.

d. What is the outcome of interest?

- Our study, which was based on long-term follow-up data, revealed that the LN size
measured during the interim assessment was predictive of treatment outcomes in
patients with NPC. Interim assessment could be used as a predictive surrogate
imaging marker of survival in patients with NPC. Findings similarly suggest a
significant association between large LNs and poor DC. The use of chemotherapy
might be essential for reduced distant metastasis, which improves the survival of NPC
patients.

2.) Discuss your process of evidence search.

a. Identify key words used
- Journal articles for cancer of respiratory system
b. Identify data bases used
- Google, Journal of the Radiation Research
c. Identify at least 5 potential articles relevant to your problem

1) Schwartz DL, Garden AS, Shah SJ, et al. Adaptive radiotherapy for head and neck
cancer—dosimetric results from a prospective clinical trial. Radiother Oncology (2013).
2) shimura Y, Shibata T, Nakamatsu K, et al. A two-step intensitymodulated radiation
therapy method for nasopharyngeal cancer: the Kinki University experience. Jpn J Clin
Oncol (2010).
3) Toya, R., Murakami, R., Saito, T., Murakami, D., Matsuyama, T., Baba, Y.,Oya, N. et al.
(2016). Radiation therapy for nasopharyngeal carcinoma: the predictive value of interim
survival assessment. Journal of Radiation Research, 57(5), 541–547.
4) Lai V, Khong PL. Updates on MR imaging and F-FDG PET/CT imaging in
nasopharyngeal carcinoma. Oral Oncol 2013;50:539–48.
5) Toh CK, Heng D, Ong YK, et al. Validation of a new prognostic index score for
disseminated nasopharyngeal carcinoma. Br J Cancer 2005;92:1382–7.
Rate the identified articles according to the level of evidence.
1) Level I: Evidence from a systematic review of all relevant randomized controlled trials
(RCT's), or evidence-based clinical practice guidelines based on systematic reviews of RCT's
2) Level V: Evidence from systematic reviews of descriptive and qualitative studies (meta-
synthesis)
3) Level I: Evidence from a systematic review of all relevant randomized controlled trials
(RCT's), or evidence-based clinical practice guidelines based on systematic reviews of RCT's
4) Level I: Evidence from a systematic review of all relevant randomized controlled trials
(RCT's), or evidence-based clinical practice guidelines based on systematic reviews of RCT's
5) Level V: Evidence from systematic reviews of descriptive and qualitative studies (meta-
synthesis)
d. Choose ONE (1) article to appraise.
- Toya, R., Murakami, R., Saito, T., Murakami, D., Matsuyama, T., Baba, Y.,Oya, N. et al.
(2016). Radiation therapy for nasopharyngeal carcinoma: the predictive value of interim survival
assessment. Journal of Radiation Research, 57(5), 541–547.
e. Assess the available evidence for its appropriateness and applicability for our
practice
 Appropriateness of the research questions
- There were no research questions indicated in the article.

 Appropriateness of the research design

- It is appropriate because in a retrospective study, in contrast to a prospective study,
the outcome of interest has already occurred at the time the study is initiated. This
retrospective study was performed between February 1996 and October 2012, 66
patients with pathologically diagnosed NPC who had undergone pretreatment
physical, endoscopic and radiological examinations were treated with RT with or
without chemotherapy.

 Rigors of the study/validity and reliability issues

- The study has some limitations, including the retrospective design, relatively small
number of patients, and variability in RT doses, radiation types, and chemotherapy
regimens. Also, the authors cannot rule out physician bias with respect to post-RT
neck dissection and these factors may affect treatment outcomes.

 Validity of the interventions (internal and external validity) (if applicable)

- The method is helpful in determining the pretreatment characteristics and may be
suggested as predictive and/or prognostic factors for nasopharyngeal carcinoma.

 Adequacy of the sample

- The sample size was valid and enough to be a basis in order to come up with a result.

 Validity and reliability of the instruments, data collection activities and

measures
- All tools, data collection activities and measures were not questionable and were all
valid to be a reliable source

 Appropriateness of statistical treatments or analysis measures

- All statistical treatments and analysis measures are appropriate and reliable.
  Findings and conclusions
- In conclusion, the interim assessment of LNs provides information that may serve as
a surrogate imaging marker predictive of treatment outcomes in patients with NPC,
specifically that a large LN size at interim assessment is predictive of an unfavorable
survival outcome.

3.) Give your general comment on the study identified

- I can say that this study has a great method of predicting survival is easy and practical
because it does not require the evaluation of multiple target lesions or the addition of
imaging studies to routine MR studies for boost planning. They also said in this study
the recommendation needs to do for further research. Accordingly, interim
assessment could be used as a predictive surrogate imaging marker of survival in
patients with NPC. In addition, the risks of distant failure and poor survival have been
more strongly correlated with LN metastasis than with the primary lesion. Based on
the interim assessment findings, RT dose escalation and/or adjuvant chemotherapy
should be considered for patients with NPC who have a poor prognosis.

4.) Give your recommendation for Evidence based practice

- I recommend this research because this may help or benefit a lot of patients and also
this is very essential because a lot of people encounter cardiovascular cases. This may
guide our healthcare providers to have this kind of assessment and this research can
help them update the management of nasopharyngeal cancer. Through patient’s
cooperation in giving the accurate information of their feelings and condition, the
healthcare providers can make a right assessment, diagnosis, planning, interventions,
management and evaluation throughout the patient’s stay.