International Journal of Radiation Oncology*Biology*Physics
Current PracticeAdjuvant Chemoradiation After Surgical Resection in Elderly Patients With High-Risk Squamous Cell Carcinoma of the Head and Neck: A National Cancer Database Analysis
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
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Conflict of interest: none.