Palliative radiotherapy in advanced head and neck cancers: A pragmatic experience from a high volume tertiary care centre

INTRODUCTION

Head and neck cancers often present at an advanced stage, as an inoperable disease requiring palliation, particularly in developing countries like India, where access to early detection and curative treatment may be limited. In such settings, palliative radiotherapy plays a critical role in symptom relief and improving quality of life. Given the high patient burden and resource constraints at tertiary care centres, it becomes essential to tailor radiotherapy strategies that balance symptom relief, treatment compliance, and toxicity. Hypofractionated regimens, offering shorter treatment durations, are commonly employed to minimize hospital visits while maximizing clinical benefit. However, there is limited consensus on the optimal regimen.

This study seeks to address this gap by comparing four commonly used hypofractionated radiotherapy (HRT) schedules in terms of tumour response, symptom relief, toxicity, and follow-up outcomes, while incorporating radiobiological parameters in patients treated at our high-volume tertiary care centre.

MATERIAL AND METHODS

This retrospective study included 102 patients with histologically confirmed squamous cell carcinoma of the head and neck, treated at our institution between 2021 and 2023. Patients were grouped according to the radiotherapy regimen received: 20 Gy in 5 fractions weekly, 20 Gy in 5 fractions daily, 30 Gy in 10 fractions daily, and 50 Gy in 16 fractions daily. Daily fractions were delivered five days a week(Monday to Friday). Baseline characteristics, Eastern co-operative oncology group (ECOG) performance status, tumour site, grade, and differentiation were recorded. Symptom burden before and after the treatment was documented, and tumour response at 4 weeks post-treatment was assessed clinically based on symptom resolution and examination.

Treatment-related toxicity was assessed using Radiation Therapy Oncology Group (RTOG) version 5.0 criteria.

Biologically effective dose (BED) and equivalent dose in 2 Gy fractions (EQD2) were calculated using the linear-quadratic model with an α/β ratio of 10 for tumour tissue. Coding was applied to categorize variables appropriately (e.g., response: complete, partial, stable, or progressive; performance status as ECOG 0–1 vs. 2–3; histology by differentiation and grade; symptom responses as improved or not) was assessed using CTCAE v5.0.

Statistical analysis was performed using JAMOVI software (version 2.4). Descriptive statistics were used, presented as frequencies and percentages. Chi-square tests were used for categorical comparisons across regimens, and multinomial logistic regression was conducted to identify significant predictors of tumour response. A p-value of <0.05 was considered statistically significant.

RESULTS

A total of 102 patients were included in this retrospective analysis, with a male predominance (90.2%) and a mean age of 53.5 years. The most common primary tumour sites were the oral cavity (53.9%) and the larynx (24.5%). ECOG performance status was 2–3 in 65.7% of patients. The majority of tumours were moderately differentiated squamous cell carcinomas, 67.6%. Stage IVA or IVB disease was observed in 61% of cases [Table 1].

Across treatment regimens, the 50 Gy in 16 fractions group had the older patients, with a mean age of 60.4 years, and 50% of patients were above the age of 60. This group had the lowest proportion of ECOG 2–3 (45%), indicating better baseline performance status. In contrast, the 30 Gy in 10 fractions group had 80% of patients with an ECOG score of 2–3, suggesting a worse overall performance status [Table 2].

The best tumour response was observed in the 50 Gy group, with a 95% response rate, followed by 84% in the 30 Gy group, 80% in the 20 Gy daily group, and the lowest at 66% in the 20 Gy weekly group. Symptom relief followed a similar trend. Patients receiving the 50 Gy regimen experienced the highest symptom palliation, including 100% relief from pain, hoarseness, and bleeding, as well as 95% improvement in dysphagia and 85% in trismus. The 30 Gy regimen also showed substantial improvement, with 84% pain relief, 82% hoarseness improvement, and 80% dysphagia relief. The 20 Gy daily group demonstrated moderate symptom control, while the weekly regimen consistently showed the lowest rates across all symptom domains [Table 3].

Statistical analysis using the chi-square test revealed several significant associations. Tumour response was significantly associated with treatment regimen (p = 0.005), as was trismus response (p = 0.023). Toxicity outcomes such as mucositis (p <0.001), xerostomia (p = 0.035), and dermatitis (p = 0.050) also varied significantly across treatment groups.[Table 4]

The highest grade 3/4 mucositis was observed in the 50 Gy group (60%), while it was absent in the 30 Gy and 20 Gy daily regimens. Similarly, xerostomia and dermatitis were least frequent in the 20 Gy daily group. Treatment interruptions showed a strong association with regimen type (p <0.001), with the 50 Gy group experiencing gaps in 85% of patients, in contrast to only 4% in the 20 Gy daily group [Table 4].

Site distribution and age group were also significantly associated with treatment regimen. The 50 Gy regimen was more commonly administered to patients with laryngeal primaries and those older than 60 years, with p-values of 0.010 for both site and age group. However, ECOG performance status, tumour grade, stage, and differentiation did not show statistically significant associations with tumour response.

Median follow-up duration varied among groups, with the 50 Gy group having the longest median follow-up at 10.9 months, closely followed by the 30 Gy group at 10.5 months. The 20 Gy daily and weekly regimens had shorter follow-up durations, at 9.4 months and 7.6 months, respectively.

DISCUSSION

Palliative radiotherapy (RT) remains a cornerstone in managing locally advanced head and neck squamous cell carcinoma (LAHNSCC), especially in patients who are unsuitable for radical therapy due to advanced disease, comorbidities, or poor performance status. In our prospective analysis of 102 patients treated with four commonly used HRT regimens, we observed distinct patterns of tumour response, symptom relief, toxicity, and treatment feasibility. These real-world findings from a tertiary care centre in India mirror global experience, particularly those of the developing nations, and emphasize the importance of individualized, context-aware treatment planning.

The 50 Gy in 16 fractions regimen showed the highest tumour response (95%) and maximal symptom palliation for pain, bleeding, hoarseness, and dysphagia. Our results align with those of Srivastava et al.^[1] and Al-Mamgani et al.^[2], both of whom documented high response rates and improved disease control with the “Christie” regimen. AlMamgani reported an 87% symptom relief rate and a median survival of 12.7 months. However, our study also highlights a key limitation, that is an increased acute toxicity, with 60% experiencing grade 3/4mucositis and 85% treatment interruptions, emphasizing the need for close monitoring and supportive care. Similarly, Soni et al.^[3] reported high acute toxicity with this regimen, but reported better disease control even at 6 months, suggesting a better progression-free survival.

In contrast, 30 Gy in 10 fractions demonstrated a favourable response rate (84%) with minimal toxicity, despite being used in patients with poorer performance status (80% ECOG 2–3). These outcomes corroborate the findings of Ali et al.^[4] and Ghoshal et al.^[5], where this schedule achieved combined complete and partial response rates of ~74% with effective relief of pain and dysphagia. Ali et al.^[4] further noted that a subset of patients could proceed to curative treatment post-palliation, positioning this regimen as both a palliative and potential bridging option.

Short-course regimens, including 20 Gy in 5 fractions (daily or weekly), were well tolerated, with no reported grade 3 mucositis and low treatment interruption rates, especially 4% in the daily arm. However, tumour responses were modest (80% and 66%, respectively), and symptom control, particularly in pain, trismus, and hoarseness, was comparatively inferior. Mohanti et al.^[6] and Paliwal et al.^[7] in their studies reported partial responses ranged from 37% to 92% with negligible toxicity, further supporting our findings. Our experience advocates their utility in patients with poor performance status, limited life expectancy, or logistical constraints.

Zingeta et al.^[8] evaluated a 44.4 Gy in 12 fractions protocol and reported a high partial response rate (70–75%), with strong symptom relief and low toxicity, highlighting the advantage of moderate hypofractionation in balancing efficacy and tolerability. Veluthattil et al.^[9] found that 52.5 Gy in 15 fractions improved quality of life in advanced oral cavity cancers despite a 72% incidence of grade 3 mucositis. Though we did not compare these regimens, our data with 50 Gy/16# parallels these benefits, especially in patients with good performance status. These patients experienced superior symptom relief but also the highest toxicity, indicating that such regimens may be appropriate for highly motivated patients with good support systems.

Spartacus et al.^[10] evaluated 25 Gy in 4 weekly fractions, showing symptom relief with minimal toxicity. This supports the idea that weekly schedules can be particularly effective for patients unable to attend daily sessions. Our weekly 20 Gy/5# arm demonstrated similar feasibility, particularly in patients with travel limitations or poor tolerance and compliance issues.

Another pivotal contribution comes from Chen et al.^[11], who assessed the Quad Shot regimen of 14.8 Gy over 2 consecutive days, repeated every 3–4 weeks. They reported an 83% symptom palliation rate with very low grade ≥3 toxicity (9%), supporting its use in frail patients seeking rapid relief with minimal toxicity burden. We did not evaluate the Quad Shot regimen, but the excellent tolerance and efficacy seen with our lower-dose regimens (20–30 Gy) offer parallel advantages. This emphasizes that low-intensity regimens can offer meaningful palliation of symptoms without compromising patient comfort.

Radiobiological assessment using biologically effective dose (BED) and equivalent dose in 2 Gy fractions (EQD2) further contextualises these findings [Table 5]. The 50 Gy/16# regimen had the highest BED (65.63 Gy) and EQD2 (54.7 Gy), correlating with better tumour control but increased mucosal toxicity. In contrast, 20 Gy regimens had BEDs of 30 Gy and achieved meaningful symptom relief with minimal toxicity, supporting their role in low-burden palliation. These findings are consistent with those of Das et al.^[12], who emphasized tailoring schedules to both patient and institutional logistics using twice-weekly 40 Gy in 10 fractions to reduce resource strain while maintaining efficacy.

The statistically significant associations between HRT regimen and tumour response (χ² = 23.7, p = 0.005), trismus response (χ² = 19.3, p = 0.023), and hoarseness relief (χ² = 14.9, p = 0.038) in our study emphasize the importance of symptom-specific outcomes when selecting palliative schedules. Grewal et al.^[13] similarly, advocate for a performance status and intent-based approach for regimen selection.

Finally, the incorporation of patient-reported outcome measures (PROMs), as highlighted by Fortin et al.^[14], is essential in evaluating palliative RT. In their study, 71% of patients reported meaningful symptom relief even when objective tumour shrinkage was modest. In our cohort, similar subjective improvements were evident even in patients receiving lower-dose regimens, emphasizing that clinical benefit cannot be measured solely by imaging but must account for perception of their symptoms and their quality of life.

TAKE HOME MESSAGE

The study contributes to the growing body of evidence on hypofractionated palliative radiotherapy in offering a symptomatic benefit in the palliative setting. The regimen choice significantly influences tumour response, symptom relief, toxicity, and compliance. The 50 Gy/16# protocol offers superior tumour control and symptom resolution, but at the cost of high toxicity and associated treatment interruptions. In contrast, 30 Gy in 10# offers an optimal therapeutic index while striking a balance between efficacy and tolerability. Shorter courses like 20 Gy in 5# provide rapid symptom relief with minimal toxicity and remain a practical choice for frail patients. Our findings reinforce the need for an adaptable, patient-centered approach that incorporates radiobiological principles, symptom burden, and institutional logistics to evaluate true palliative benefit.