The nomogram uses the patient's age, chemotherapy regimen, baseline hearing level, and location of the tumor to predict hearing after treatment, principal author Dr. Jay Piccirillo of Washington University School of Medicine in St. Louis told Reuters Health by email. "An app has been created but it is not yet available, as ongoing testing and validation has been slowed by the COVID pandemic."
"Ultimately, the nomogram could be provided within standard audiometry software for use in the clinic," said Dr. Piccirillo, who is Editor of JAMA Otolaryngology-Head and Neck Surgery. "This will require additional software work to integrate the app and instructional information to help clinicians correctly engage in risk discussions with the patient."
As reported in that journal, Dr. Piccirillo and colleagues conducted a validation study of a previously created predictive model and nomogram for use in general practice for patients newly diagnosed with head and neck cancer.
The team compared 105 patients (208 ears; mean age, 61; 78% men) diagnosed and treated between 2018-2019 with the development cohort. The ratio of women, proportion difference and average age were similar in both cohorts, as were comorbidity scores. The validation group had more current smokers (24% vs. 36%) and significantly fewer stage-4 cancers (52% vs. 71%).
Treatment was also similar between cohorts. Patients in the validation cohort underwent radiation therapy; 48% received cisplatin-based chemotherapy, and 64% had a surgical resection. The mean cochlear dose of radiation was 13 Gy, and the mean total cisplatin dose was 238 mg/m2.
The main outcome was hearing, defined by the audiometric pure-tone average (PTA) of 1, 2, and 4 kHz. A calibration curve demonstrated that predicted and observed post-treatment PTA were not significantly different.
The model showed good discrimination, predicting a posttreatment pure-tone PTA greater than 35 dB - a common threshold for hearing aid consideration - with a sensitivity of 73% and specificity of 67%, with an area under the curve of 0.71.
Specifically, compared with no cisplatin treatment, induction and high-dose therapy were associated with a mean hearing threshold PTA increase of 19.38 dB, whereas all other cisplatin regimens were associated with a mean increase of 4.56 dB.
Baseline average 1-, 2-, and 4-kHz PTA and age divided by 10 were both predictors of increased post-treatment PTA. Tumor location showed a position-dependent increase in post-treatment effect, with lesions closer to the cochlea having a more pronounced effect on post-treatment PTA.
Interviews with six participating clinicians suggested the nomogram requires careful integration into patient counseling to clarify risks and benefits for treatment.
Dr. Madhur Garg, Clinical Director, Radiation Oncology at Montefiore Health System in New York City and a professor at Albert Einstein College of Medicine, commented in an email to Reuters Health that the tool could be useful for risk-assessment in this population. "Patients deemed at high risk for hearing loss can be counseled upfront, followed up closely post-treatment for possible interventions, and we can explore if there are alternative treatment modalities. The tool can also be used to research novel treatment and protective modalities."
"There is some mention about dosing/regimen of chemotherapy and radiation therapy; however more information will be helpful," he said. "For example, how easily can the nomogram be implemented in a clinical workflow daily?"
"Additional research in a larger patient population with longer follow up beyond two months post-treatment is needed to see if this nomogram can predict for long-term hearing outcomes," he noted.
"The paper raises the issue of a debilitating yet ignored side effect of head and neck cancer treatment," he said. "With technological advances such as image-guided adaptive radiation therapy and proton therapy, there is a higher likelihood of avoiding higher radiation dose to normal structures and therefore reducing chances of hearing loss."
SOURCE: https://bit.ly/389JR3Z JAMA Otolaryngology-Head and Neck Surgery, online December 10, 2020
By Marilynn Larkin
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