Current Practice
Adjuvant Chemoradiation After Surgical Resection in Elderly Patients With High-Risk Squamous Cell Carcinoma of the Head and Neck: A National Cancer Database Analysis

https://doi.org/10.1016/j.ijrobp.2017.03.019Get rights and content

Purpose

To determine the patterns of adjuvant chemoradiotherapy use in elderly patients treated with definitive surgical resection for squamous cell carcinoma of the head and neck with extracapsular extension (ECE) or positive margins and determine whether an association with overall survival (OS) exists with adjuvant concurrent chemoradiotherapy (CRT).

Methods and Materials

The National Cancer Database was queried to identify patients with SCC of the oral cavity, oropharynx, larynx, and hypopharynx who were treated with primary definitive surgery and adjuvant radiation therapy between 2004 and 2012. For elderly patients (aged >70 years) with pathology revealing ECE or positive margin, the benefit of concurrent chemotherapy was explored using multivariable Cox proportional hazards modeling.

Results

A total of 7349 patients were identified meeting study criteria, of whom 1187 were elderly (aged >70 years) with a median follow-up of 30.6 months. Of these elderly patients, 445 had ECE or positive margin and represent the study population, of whom 187 (42%) received CRT. Delivery of CRT in this cohort increased over the study period, and intensity modulated radiation therapy was associated with increased use of CRT (odds ratio 2.07; P=.004). Increasing age was associated with reduced use of CRT (odds ratio 0.88; P<.001). Chemoradiotherapy was associated with a significant improvement in OS on multivariable analysis (hazard ratio 0.74; P=.04) and a trend toward significance on inverse propensity score analysis (hazard ratio 0.78; P=.051). Three-year OS was 53.8% in the CRT group, compared with 44.6% in the adjuvant radiation therapy–alone patients.

Conclusions

The use of adjuvant CRT is increasing among elderly patients with resected squamous cell carcinoma of the head and neck exhibiting ECE or positive margins. Chemoradiotherapy was associated with an improvement in OS on multivariable analysis but not propensity-weighted analysis. Among fit elderly patients with ECE or positive margins after definitive surgical resection, concurrent chemotherapy can be carefully considered.

Introduction

Patients with locally advanced squamous cell carcinoma of the head and neck are often treated with primary surgical resection. After surgical resection, pathologic factors are used to guide the application of adjuvant radiation therapy (RT) and concurrent chemotherapy. Since their initial publication in 2004, 2 phase 3 studies completed by the European Organization for Research and Treatment of Cancer (EORTC) and Radiation Therapy Oncology Group (RTOG) have defined the role of adjuvant chemoradiotherapy (CRT) for patients with resected squamous cell carcinomas of the head and neck 1, 2. A retrospective, unplanned subgroup analysis of pooled data from these studies identified extracapsular extension (ECE) or positive margins as the key features defining a high-risk group for which an association with overall survival was observed for adjuvant concurrent CRT with cisplatin (3).

The combination of trimodality therapy (surgery followed by adjuvant CRT) is an intensive form of treatment, and elderly patients may be at higher risk of toxicity from such a regimen. Only 25 patients older than 70 years were enrolled into the RTOG study, whereas such patients were excluded from the EORTC study. As such, it is not known whether extrapolation of the benefit of adjuvant CRT as seen in the pooled analysis of these seminal studies to this elderly population is valid. The purpose of the present study was to evaluate the patterns of practice in the United States regarding the use of adjuvant CRT in elderly patients and determine whether a survival benefit exists in this population.

Section snippets

Data source

To obtain an adequate number of subjects to understand patterns of use of adjuvant CRT in patients aged >70 years, we queried the National Cancer Database (NCDB), which is a nationwide de-identified oncology data set capturing data for roughly 70% of cancer patients in the United States (4). The NCDB is a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. Because the study uses de-identified data exclusively, it was exempt from

Results

From the NCDB participant user files a total of 368,208 patients were identified. From this initial number, 7349 patients of all ages with complete pathologic risk factors were identified meeting all the previously outlined criteria. A Consolidated Standards of Reporting Trials diagram for the final patient cohort is shown in Figure 1. Among these patients, 1187 (16%) were classified as elderly (age >70 years). The characteristics of the entire cohort and when divided between elderly and

Discussion

Decisions on adjuvant therapy after definitive surgical resection are often challenging. The physician must incorporate patient, tumor, and surgical information to determine the optimal adjuvant therapy. Although decisions were historically made on the basis of numbers of tumor risk factors, the addition of concurrent CRT has largely been based on the pooled analysis of the RTOG trial of adjuvant therapy published by Cooper et al (2) and the EORTC trial published by Bernier et al (1). The

Conclusion

Among elderly patients with resected squamous cell carcinoma of the head and neck, decision making on the benefit of adjuvant therapy is complex. This study demonstrates that in the elderly population with high-risk disease the use of adjuvant CRT is increasing alongside increased use of IMRT. Among elderly patients with the high-risk features of ECE or positive margins, the use of CRT was associated with an improvement in overall survival on multivariable analysis but did not reach

References (13)

There are more references available in the full text version of this article.

Cited by (24)

  • Influence of Treatment Package Time on outcomes in High-Risk Oral Cavity Carcinoma in patients receiving Adjuvant Radiation and Concurrent Systemic Therapy: A Multi-Institutional Oral Cavity Collaborative study

    2022, Oral Oncology
    Citation Excerpt :

    This was highlighted in a study that analyzed the patterns of utilization of chemotherapy among elderly cases (>70 years). Even though the benefit of CRT was maintained, only 42% of high-risk elderly patients received the indicated concurrent chemotherapy [31]. Upcoming trials incorporating more tolerable targeted agents and/or immunotherapy in the care of high-risk OCSCC need to recruit this elderly population.

  • Gender disparities in head and neck cancer chemotherapy clinical trials participation and treatment

    2019, Oral Oncology
    Citation Excerpt :

    Although women can be 2–3 times less likely than men to have HNSCC [7,8], proportional inclusion in clinical trials is paramount to understanding relevance and generalization of trial results to women. While several studies investigated whether patients with HNSCC receive guideline-recommended therapy, the prevalent focus was on differences by age and race [9–11]. A few cancer studies found gender disparities in the administration of chemotherapy [12–15] including oropharyngeal cancer [16].

View all citing articles on Scopus

Conflict of interest: none.

View full text