Competing causes of death and medical comorbidities among patients with human papillomavirus-positive vs human papillomavirus-negative oropharyngeal carcinoma and impact on adherence to radiotherapy

Early return to work is possible after transoral robotic surgery (TORS) in carefully selected patients with oropharyngeal squamous cell carcinoma

INTRODUCTION

The aims of this study were to investigate the rate and time to return to work (RTW) after transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC) and to explore the impact of disease or work-related factors leading to variations in RTW outcomes.

METHODS

Cross-sectional survey of disease, socioeconomic, work-related and health-related quality of life (HR-QOL). Qualitative analysis of responses for facilitators and barriers to RTW.

RESULTS

A total of 47 participants employed at diagnosis were included in the study, with an average age 56 years. Median survey time 3.2 years. 22 participants underwent TORS only with 25 undergoing TORS with adjuvant therapy. 93.6 % had stage 1 disease. 95.7 % of participants RTW after TORS with a mean time of 13.6 weeks. Patients returned earlier after TORS alone compared to those requiring adjuvant treatment (10 weeks vs. 17 weeks; p = 0.13) Overall high HR-QOL metrics for all patients, with those undergoing adjuvant having significantly poorer outcomes for the dry mouth/sticky saliva (9.1 vs 41.3, p=<0.001) items. Qualitative analysis of free text responses showed facilitators and barriers to RTW fell under four main categories: physical, phycological/emotional, financial and workplace.

CONCLUSION

High rate of RTW amongst patients after TORS, which is the highest reported amongst head and neck cancer literature to date. Participants returned earlier after surgery only compared to adjuvant treatment, but both groups reported high HR-QOL metrics. Physical effects of treatment, including fatigue and oral dysfunction were some of the main barriers to RTW; whereas flexible working arrangements and support from employer/colleagues were major facilitators.

The epidemic of human papillomavirus virus-related oropharyngeal cancer: current controversies and future questions

The incidence of human papillomavirus (HPV) associated oropharyngeal cancer has increased to epidemic-like proportions in the United States and other industrialized nations. While significant progress has been made in the understanding of this disease with respect to its underlying biology and clinical behavior, numerous questions persist regarding treatment. It is now firmly established that patients with HPV-positive oropharyngeal cancer have a significantly improved prognosis as a result of their exquisite radiosensitivity compared to their HPV-negative counterparts and thus can be targeted with de-escalated approaches using reduced doses of radiation and/or chemotherapy. The fundamental goal of de-escalation is to maintain the high cure and survival rates associated with traditional approaches while reducing the incidence of both short- and long-term toxicity. Although the exact reason for the improved radiosensitivity of HPV-positive oropharyngeal carcinoma is unclear, prospective studies have now been published demonstrating that de-escalated radiation can successfully maintain the high rates of cure and preserve quality of life for appropriately selected patients with this disease. However, the selection criteria and specific means for de-escalation remain uncertain, and paradigms continue to evolve. Given that HPV-positive oropharyngeal cancer is increasingly recognized as a public health problem, the search for answers to many of these provocative questions has important societal implications and is the subject of this review.

Cause of Death in Patients with Oropharyngeal Carcinoma by Human Papillomavirus Status: Comparative Data Analysis

BACKGROUND

The incidence of oropharyngeal squamous cell carcinomas (OPSCC) has increased in recent decades, and human papillomavirus (HPV) infection is the main cause of OPSCC. The data regarding causes of death (CODs) are vitally important in informing follow-up strategies and revising treatment strategies to deal with any possible preventable treatment-related COD. However, limited studies have assessed the competing COD by HPV status in patients with OPSCC.

OBJECTIVE

We aimed to analyze the distribution of the competing COD according to HPV status in OPSCC.

METHODS

We retrospectively included stage I-IVB patients with OPSCC from the Surveillance, Epidemiology, and End Results database between 2010 and 2015. The association between HPV status and head and neck cancer-specific mortality (HNCSM), second primary cancer mortality (SPCM), and noncancer-caused mortality (NCCM) were analyzed. The chi-square test, Kaplan-Meier analysis, and Fine and Gray model were used for statistical analysis.

RESULTS

We included 5852 patients in this study and 73.2% (n=4283) of them had HPV-related tumors. A total of 1537 (26.3%) patients died, including 789 (51.3%), 333 (21.7%), and 415 (27%) patients who died from head and neck cancer, second cancer, and noncancer causes, respectively. The 5-year HNCSM, SPCM, NCCM, and overall mortality were 14.7%, 6.5%, 7.7%, and 26.4%, respectively. Those with HPV-positive disease had a lower cumulative incidence of HNCSM (subdistribution hazard ratio [sHR] 0.362, 95% CI 0.315-0.417; P<.001), SPCM (sHR 0.400, 95% CI 0.321-0.496; P<.001), and NCCM (sHR 0.460, 95% CI 0.378-0.560; P<.001) than those with HPV-negative disease. The 5-year risk of HNCSM was 26.9% and 10.7% in those with HPV-negative and HPV-positive disease, respectively (P<.001). The 5-year risk of SPCM was 12.4% and 4.6% in those with HPV-negative and HPV-positive disease, respectively (P<.001). The 5-year risk of NCCM of death was 13.7% and 5.8% in those with HPV-negative and HPV-positive disease, respectively (P<.001). Using the Fine and Gray competing-risks model, our results show that those with HPV-negative tumors had a significantly higher risk of HNCSM (P<.001), SPCM (P<.001), and NCCM (P<.001) than those with HPV-negative tumors.

CONCLUSIONS

HPV-positive OPSCC has a lower NCSM, SPCM, and NCCM as compared to those with HPV-negative OPSCC. HPV positivity is a favorable prognostic factor in the context of overcoming cancer as well as in terms of reducing the risk of other CODs in OPSCC. Our finding supports the need to tailor patient follow-up based on the HPV status of patients with OPSCC.

Gross tumor volume margin and local control in p16-positive oropharynx cancer patients treated with intensity modulated proton therapy

BACKGROUND

To determine if the extent of high-dose gross tumor volume (GTV) to clinical target volume (CTV) expansion is associated with local control in patients with p16-positive oropharynx cancer (p16+ OPC) treated with definitive intensity modulated proton therapy (IMPT).

METHODS

We performed a retrospective analysis of patients with p16+ OPC treated with IMPT at a single institution between 2016 and 2021. Patients with a pre-treatment PET-CT and restaging PET-CT within 4 months following completion of IMPT were analyzed.

RESULTS

Sixty patients were included for analysis with a median follow-up of 17 months. The median GTV to CTV expansion was 5 mm (IQR: 2 mm). Thirty-three percent of patients (20 of 60) did not have a GTV to CTV expansion. There was one local failure within the expansion group (3%).

CONCLUSION

Excellent local control was achieved using IMPT for p16+ OPC independent of GTV expansion. IMPT with minimal target expansions represent a potential harm-minimization technique for p16-positive oropharynx cancer.

Long-term Survivorship and Non-cancer Competing Mortality in Head and Neck Cancer: A Nationwide Population-Based Study in South Korea

PURPOSE

As the survival of head and neck cancer (HNC) improves, survivors increasingly confront non-cancer-related deaths. This nationwide population-based study aimed to investigate non-cancer-related deaths in HNC survivors.

MATERIALS AND METHODS

Data from the Korean Central Cancer Registry were obtained to characterize causes of death, mortality patterns, and survival in patients with HNC between 2006 and 2016 (n=40,890). Non-cancer-related mortality relative to the general population was evaluated using standardized mortality ratios (SMRs). The 5- and 10-year cause-specific competing risks probabilities of death (cumulative incidence function, CIF) and subdistribution hazards ratios (sHR) from the Fine-Gray models were estimated.

RESULTS

Comorbidity-related mortality was frequent in older patients, whereas suicide was predominant in younger patients. The risk of suicide was greater in patients with HNC than in the general population (SMR, 3.1; 95% confidence interval [CI], 2.7 to 3.5). The probability of HNC deaths reached a plateau at 5 years (5-year CIF, 33.9%; 10-year CIF, 39.5%), whereas the probability of non-HNC deaths showed a long-term linear increase (5-year, CIF 5.6%; 10-year CIF, 11.9%). Patients who were male (sHR, 1.56; 95% CI, 1.41 to 1.72), diagnosed with early-stage HNC (localized vs. distant: sHR, 1.86; 95% CI, 1.58 to 2.21) and older age (65-74 vs. 0-44: sHR, 6.20; 95% CI, 4.92 to 7.82; ≥ 75 vs. 0-44: sHR, 9.81; 95% CI, 7.76 to 12.39) had an increased risk of non-cancer mortality.

CONCLUSION

Non-HNC-related deaths continue increasing. HNC survivors are at increased risk of suicide in the younger and comorbidity-related death in the older. Better population-specific surveillance awareness and survivorship plans for HNC survivors are warranted.

Management of Older Adults with Locally Advanced Head and Neck Cancer

Simple Summary

Approximately one third of patients with head and neck cancer are older adults. The number of older adults with head and neck cancer continues to rise especially as life expectancy increases. However, this population remains significantly underrepresented in clinical trials. Due to this, there is no clear consensus regarding the optimal treatment for older adults with head and neck cancer. In general, older adults are a complex cohort due to variations in functional and performance status, medical comorbidities, and medication management. Treatment for head and neck cancer involves surgery, radiation therapy, systemic therapy, or a combination. These treatments are highly demanding. Additionally, they are associated with toxicity which can be especially difficult for older adults to tolerate. This may lead to treatment interruptions and compromised outcomes. In order to understand the optimal treatment for older adults with head and neck cancer, novel predictive scores are being developed. Additionally, ongoing clinical trials are investigating less intensive treatments for older adults. This review provides an overview of current clinical data, treatment considerations, and future areas of investigation for older adults with head and neck cancer.

Abstract

Thirty percent of patients with head and neck squamous cell carcinoma (HNSCC) are at least 70 years of age. This number continues to rise as life expectancy continues to increase. Still, older adults with HNSCC remain underrepresented in clinical trials, resulting in ambiguity on optimal management. Older adults are a complex patient population, often requiring increased support due to issues relating to functional and performance status, medical comorbidities, and medication management. Furthermore, in older adults with HNSCC, many of these conditions are independently associated with increased toxicity and worse outcomes. Toxicity in the older adult remains difficult to predict and to understand, and as treatment decisions are based on treatment tolerability, it is essential to understand the toxicities and how to minimize them. Novel predictive scores are being developed specifically for older adults with HNSCC to understand toxicity and to assist in personalized treatment decisions. There are clinical trials presently underway that are investigating shortened radiation courses and novel, less toxic systemic treatments in this population. In the forthcoming sections, we provide a detailed overview of the clinical data, treatment paradigms, and considerations in this population. This review provides a comprehensive overview of existing clinical data and clinical considerations in the older adult head and neck cancer population. Additionally, we provide a detailed overview of pertinent current and ongoing clinical trials, as well as future areas for investigation.

Cannabis related side effects in otolaryngology: a scoping review

BACKGROUND

Cannabis has been rapidly legalized in North America; however, limited evidence exists around its side effects. Health Canada defines side effect as a harmful and unintended response to a health product. Given drug safety concerns, this study's purpose was to review the unintended side effects of cannabis in otolaryngology.

METHODS

The Preferred Reporting Items For Systematic Reviews and Meta-analysis extension for Scoping Reviews (PRISMA-ScR) protocol was used to conduct a scoping review of the MEDLINE, EMBASE, CINAHL, and CENTRAL databases. (PROSPERO: CRD42020153022). English studies in adults were included from inception to the end of 2019. In-vitro, animal, and studies with n < 5 were excluded. Primary outcome was defined as unintended side effects (defined as any Otolaryngology symptom or diagnosis) following cannabis use. Oxford Centre for Evidence-Based Medicine: Levels of Evidence and risk of bias using the Risk of Bias in randomized trials (RoB 2) and Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tools were assessed.. Two authors independently reviewed all studies; the senior author settled any discrepancies.

RESULTS

Five hundred and twenty-one studies were screened; 48 studies were analysed. Subspecialties comprised: Head and Neck (32), Otology (8), Rhinology (5), Airway (5), Laryngology (1). Cannabis use was associated with unintended tinnitus, vertigo, hearing loss, infection, malignancy, sinusitis, allergic rhinitis, thyroid dysfunction, and dyspnea. About half (54.1%) of studies showed increased side effects, or no change in symptoms following cannabis use. Oxford Levels of Evidence was 2-4 with substantial heterogeneity. Risk of bias assessment with RoB2 was low to high and ROBINS-1 was moderate to critical.

CONCLUSION

This was the first comprehensive scoping review of unintended side effects of cannabis in Otolaryngology. The current literature is limited and lacks high-quality research Future randomized studies are needed to focus on therapeutic effects of cannabis in otolaryngology. Substantial work remains to guide clinicians to suggest safe, evidence-based choices for cannabis use.

Transoral Robotic Surgery for Residual and Recurrent Oropharyngeal Cancers

Transoral robotic surgery (TORS) is a well-established treatment option for treatment-naïve oropharyngeal cancer. For residual, recurrent, and new primary oropharyngeal tumors emerging in previously irradiated fields, the global experience of management with TORS is limited. This article discusses current concepts on this topic, offers a deeper insight into the transoral anatomy for these cases, and covers the specific complexities of resections in the various subsites of the oropharynx. It provides practical tips on reconstruction, recovery, and rehabilitation as well as offering a synthesis of the current evidence and exploring future trends.

Gene alterations as predictors of radiation-induced toxicity in head and neck squamous cell carcinoma

Background

Optimizing the therapeutic ratio for radiation therapy (RT) in head and neck squamous cell carcinoma (HNSCC) is uniquely challenging owing to high rates of early and late toxicity involving nearby organs at risk. These toxicities have a profound impact on treatment compliance and quality of life. Emerging evidence suggests that RT dose alone cannot fully account for the variable severity of RT-related adverse events (rtAEs) observed in HNSCC patients. Next-generation sequencing has become an increasingly valuable tool with widespread use in the oncology field and is being robustly explored for predicting rtAEs beyond dosimetric data.

Methods

Patients who had Foundation Medicine sequencing data and received RT for primary or locally recurrent HNSCC were selected for this study. Early and late toxicity data were collected and reported based on Common Terminology Criteria for Adverse Events version 5.0. Dosimetric parameters were collected for pertinent structures.

Results

A total of HNSCC 37 patients were analyzed in this study. Genetic alterations in BRCA2, ERBB3, NOTCH1 and CCND1 were all associated with higher mean grade of toxicity with BRCA2 alteration implicated in all toxicity parameters evaluated including mucositis, early dysphagia, xerostomia and to a lesser extent, late dysphagia. Interestingly, patients who exhibited alterations in both BRCA2 and ERBB3 experienced a twofold or greater increase in early dysphagia, early xerostomia and late dysphagia compared to ERBB3 alteration alone. Furthermore, several gene alterations were associated with improved toxicity outcomes. Within an RT supersensitive patient subset, alterations were found in TNFAIP3, HNF1A, SPTA1 and CASP8. All of these alterations were not found in the RT insensitive patient subset. We found 17 gene alterations in the RT insensitive patient subset that were not found in the RT supersensitive patient subset.

Conclusion

Despite consistent RT dosimetric parameters, patients with HNSCC experience heterogeneous patterns of rtAEs. Identifying factors associated with toxicity outcomes offers a new avenue for personalized precision RT therapy and prophylactic management. Here, next-generation sequencing in a population of HNSCC patients correlates several genetic alterations with severity of rtAEs. Further analysis is urgently needed to identify genetic patterns associated with rtAEs in order to reduce harmful outcomes in this challenging population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-021-02876-5.

Evidence for different molecular parameters in head and neck squamous cell carcinoma of nonsmokers and nondrinkers: Systematic review and meta-analysis on HPV, p16, and TP53

BACKGROUND

The goal of this review was to present an overview of the currently identified molecular parameters in head and neck squamous cell carcinoma (HNSCC) of nonsmokers and nondrinkers (NSND).

METHODS

Following the PRISMA guidelines, a systematic search was performed using the electronic databases PubMed, Embase, and Google Scholar.

RESULTS

Of the 902 analyzed unique studies, 74 were included in a quantitative synthesis and 24 in a meta-analysis. Human papillomavirus (HPV) was reported as a molecular parameter in 38 studies, followed by p16 and TP53 (23 and 14 studies, respectively). The variety of other molecular parameters concerned sporadic findings in small numbers of NSND.

CONCLUSIONS

HNSCC in NSND is more often related to HPV and p16 overexpression compared to tumors of smokers-drinkers. In a third of virus-negative tumors, TP53 mutations were detected with a mutational profile associated with aging and ultraviolet light exposure rather than to tobacco consumption.

A new face of the HPV epidemic: Oropharyngeal cancer in the elderly

OBJECTIVES

As the human papillomavirus (HPV) epidemic continues to grow, the number of elderly patients with oropharyngeal squamous cell carcinoma (OPSCC) is rapidly increasing. Despite this observation, this cohort remains understudied. We aimed to understand HPV prevalence and characteristics within this cohort as well as its impact on disease control in elderly patients.

METHODS AND MATERIALS

We identified patients aged ≥70 with newly diagnosed, non-metastatic, OPSCC treated with curative intent at our institution from 2007 to 2018. Logistic regression and survival analyses were used for outcome-specific endpoints.

RESULTS

In total, 88 patients were identified with a median age of 73 (interquartile range [IQR]: 71-78) and a median Charlson Comorbidity Index of 6 (IQR: 5-7). Eighty-two percent were ECOG 0 or 1 performance. Of note, 70% of the cohort had HPV+ tumors. Fifty-one percent of patients were AJCC 8th edition stage I/II and 49% were stage III/IV. Median follow-up time was 2.5 years (IQR: 0.9-4.7). Eight percent had surgery alone, 27% underwent adjuvant RT, and 64% received definitive RT. Sixty-four percent received concurrent chemotherapy. By both univariate and multivariable analyses, HPV+ status was significantly associated with improved locoregional control (LRC), overall survival (OS), and disease specific survival (DSS).

CONCLUSIONS

In our cohort of elderly patients with OPSCC, the majority was HPV+, which was associated with improved clinical outcomes. There are many challenges when managing elderly patients with OPSCC, but as the population ages and the HPV epidemic evolves, these patients should be considered for elderly specific clinical trials.

Association between human papillomavirus status and health-related quality of life in oropharyngeal and oral cavity cancer survivors

OBJECTIVES

The human papillomavirus (HPV) is a risk factor for a subgroup of head and neck cancers (HNC). HPV-positive and HPV-negative HNC patients encompass heterogeneous groups regarding risk factors, sociodemographic and clinical characteristics, which may influence health-related quality of life (HRQL) differently. Since this has been sparsely studied, our study investigated the association between HPV status and HRQL in HNC survivors in Denmark.

MATERIALS AND METHODS

This cross-sectional study included 179 recurrence-free oropharyngeal and oral cavity squamous cell carcinoma (OSCC) survivors. HRQL was assessed on the EORTC QLQ-C30 and QLQ-H&N35 questionnaires. Linear and logistic regression models were adjusted for sociodemographic, clinical and lifestyle factors.

RESULTS

Most unadjusted results showed better HRQL among HPV-positive (n = 119) compared to HPV-negative (n = 60) OSCC survivors (average 18 months since diagnosis). After adjustments, the HPV-positive survivors reported higher role functioning (mean difference [MD] 9.2, 95% confidence interval [CI] 0.1 to -18.4), and fewer problems with speech (MD -9.0, 95% CI -18.0 to -0.1), sexuality (MD -21.9, 95% CI -38.0 to -5.9) and opening mouth (MD -13.7, 95% CI -26.6 to -0.8) compared to HPV-negative survivors.

CONCLUSION

Our findings support that HPV-positive OSCC survivors experience better HRQL than HPV-negative survivors. However, results indicate that sociodemographic, clinical and lifestyle factors explain most of the association between HPV status and HRQL. Findings suggest increased focus on the HPV-negative OSCC survivors with deteriorated HRQL in rehabilitation programs and future research to investigate the long-term effects of treatment among HPV-positive OSCC survivors who may develop symptoms later in survivorship.

Impact of Diabetes Mellitus on Head and Neck Cancer Patients Undergoing Concurrent Chemoradiotherapy

In this retrospective study, we investigated the impact of diabetes mellitus (DM) on patients with head and neck cancer (HNC) undergoing concurrent chemoradiotherapy (CCRT). We analyzed the demographic and clinical characteristics, treatment tolerance, and toxicities of patients with HNC undergoing primary or adjuvant CCRT with or without DM between 2007 and 2016. Of the 556 patients undergoing CCRT, 84 (15.1%) had DM. Compared with patients without DM, patients with DM were significantly older (56.2 ± 11.2 vs. 51.9 ± 9.5 years, P < 0.001), received lower doses of cisplatin (adjuvant CCRT: 175.30 ± 84.03 vs. 214.88 ± 68.25, P = 0.014; primary CCRT: 142.84 ± 79.49 vs. 187.83 ± 76.19, P < 0.001), and experienced higher rates of infection (adjuvant CCRT: 52% vs. 30.5%, P = 0.042; primary CCRT: 45.8% vs. 22.9%, P < 0.001). Among patients undergoing primary CCRT, compared with those without DM, the patients with DM experienced significantly higher rates of hematologic toxicity (65.7% vs. 39.3%, P = 0.004) and treatment-related deaths (10.2% vs. 3.5%, P = 0.051); and a greater weight loss (−6.17 ± 9.27% vs. −4.49 ± 6.84, P = 0.078). Patients with HNC and DM undergoing CCRT, compared with patients without DM, experienced higher rates of infection and hematotoxicity, loss of body weight, and higher treatment-related mortality.

The Statistical Evaluation of Treatment and Outcomes in Head and Neck Squamous Cell Carcinoma Clinical Trials

The purpose of this article is two-fold: to help statisticians confronted with the design, implementation and analysis of clinical trials and new to the field of head and neck cancer; but also to sensitize research physicians with the role, the tasks and the challenges faced by the medical statisticians. These two purposes altogether will hopefully encourage and enable fluid communication between the research physician and the medical statistician and the understanding of each other's field and concerns. In particular, the methodological challenges resulting from the heterogeneity of the head and neck cancer, the complexity of the treatments and the associated comorbidities are presented with examples borrowed from medical literature and from the practical experience of the authors in this field.

Comorbidity in HPV+ and HPV- oropharyngeal cancer patients: A population-based, case-control study

OBJECTIVES

Comorbid conditions impact outcome for patients treated for oropharyngeal squamous cell carcinoma (OPSCC) and serve as competing risk factors for death. The purpose of this study was to examine differences in comorbidities in patients with OPSCC and known HPV-DNA.

MATERIAL AND METHODS

We included patients diagnosed with OPSCC in Eastern Denmark in 2000-2014. Patients were linked to the Danish National Patient Register to identify comorbidities based on the Charlson Comorbidity Index (CCI) at time of diagnosis and following cancer treatment. Patients were age-and sex-matched in a 1:10 ratio with a reference group and stratified according to HPV-status.

RESULTS

In total 1,499 patients (55.0% HPV+) and 14,990 controls were included. Significantly more HPV+ patients had no comorbidities compared to HPV- patients at time of diagnosis (RR: 1.5 (1.3;1.6), n = HPV+: 522, HPV-: 302) and following treatment (RR 1.5 (1.4;1.6), n = HPV+: 342, HPV-: 142). Most prevalent comorbidity was malignancy not including OPSCCs. HPV+ patients had an increased risk of having AIDS before their OPSCC diagnosis compared to the reference population (OR: 4.8 (1.8;12.9)). HPV- patients had increased risk of multiple comorbidities including cerebrovascular disease (OR: 1.9 (1.4;2.5)), peripheral vascular disease (OR: 1.7 (1.9;3.7)), dementia (OR: 2.9 (1.4;5.8)), ulcer disease (OR: 2.6 (1.9;3.5)), liver disease, mild (OR: 9.5 (7.0;13.0)) and severe (OR: 13.9 (5.8;22.8)).

CONCLUSION

This study showed that HPV- patients had more comorbidities than HPV+ patients at the diagnosis time and following treatment. Irrespective of HPV-status, OPSCC patients had a significant increased risk of (secondary) malignancy compared to the reference population.

Chemoradiotherapy-related carotid artery inflammation in head and neck cancer patients quantified by [18F]FDG PET/CT

OBJECTIVES

Radiotherapy (RT) is associated with an increased risk of cardiovascular disease (CVD), but little is known about the mechanism for vascular injury and methods for early detection.

MATERIALS AND METHODS

We conducted a prospective, pilot study of carotid artery inflammation using ¹⁸F-labeled 2-fluoro-2-deoxy-d-glucose ([¹⁸F]FDG) PET/CT imaging pre- and 3 months post-RT in head-and-neck cancer (HNC) patients. [¹⁸F]FDG uptake by the carotid arteries was measured by the maximum and mean target to background ratio (TBR_MAX, TBR_MEAN) and the mean partial volume corrected standardized uptake value (pvcSUV_MEAN).

RESULTS

Of the 22 patients who completed both pre and post-RT scans, the majority (82%) had stage III or stage IV disease and received concurrent chemotherapy. TBR_MAX, TBR_MEAN, and pvcSUV_MEAN were all significantly higher 3 months after RT versus before RT with mean difference values (95% CI; p-value) of 0.17 (0.1-0.25; 0.0001), 0.19 (0.12-0.25; 0.0001), and 0.31 g/ml (0.12-0.5; 0.002), respectively. Fifteen patients (68%) had HPV-positive tumors, which were associated with lower pre-RT [¹⁸F]FDG signal, but a greater increase in TBR_MAX (19% vs 5%), TBR_MEAN (21% vs 11%) and pvcSUV_MEAN (20% increase vs 3% decrease), compared to HPV negativity.

CONCLUSION

There is a significant increase in carotid artery inflammation in HNC patients due to CRT that amounts to a degree that has previously been associated with higher risk for future CVD events. The subset of patients with HPV-positive tumors experienced the greatest increases in vascular inflammation due to CRT. Carotid [¹⁸F]FDG uptake may be an early biomarker of RT-related vascular injury.

Association between comorbidity and survival in head and neck cancer: Results from Head and Neck 5000

BACKGROUND

People with head and neck cancer have higher comorbidity levels but it remains unclear if pretreatment comorbidity is an independent prognosticator in head and neck cancer.

METHODS

Survival analyses were performed using data from participants in a UK multicentre cohort study with cancers of the oral cavity (n = 668), oropharynx (n = 1074), and larynx (n = 530). Survival analyses were incrementally adjusted for age, sex, marital status, income, education, stage, alcohol, and smoking.

RESULTS

After adjusting for demographic, clinical, and behavioral confounders, higher baseline comorbidity was associated with reduced overall survival (mild comorbidity HR = 1.4, 95% CI = 1.1, 1.7; moderate comorbidity HR = 1.7, 95% CI = 1.3, 2.2; severe comorbidity HR = 2.8, 95% CI = 1.9, 4.; P-trend<.001).

CONCLUSIONS

Our findings suggest that comorbidity is an independent prognosticator for overall survival in head and neck cancer. Comorbid illnesses should be considered in the assessment and treatment planning of people with head and neck cancer.

Competing mortality in oropharyngeal carcinoma according to human papillomavirus status

BACKGROUND

The objective of the present study is to assess differences in the competing causes of death in patients with oropharyngeal carcinoma (OPC) as a function of the human papillomavirus (HPV) status.

METHODS

We studied retrospectively 423 patients with OPC with known HPV status. Among the patients included in the study, 53 (12.5%) were HPV-positive. We analyzed overall survival and competing causes of mortality according to the HPV status of the patients.

RESULTS

Patients with HPV-negative tumors had lower OPC cancer-specific survival (P = .0001), second primary neoplasm survival (P = .0001), and noncancer-related causes survival (P = .13) than patients with HPV-positive tumors. This resulted in significant differences in overall survival depending on HPV status (P = .0001).

CONCLUSION

Conclusion: HPV-positive OPC has a better overall survival than HPV-negative OPC. Patients with HPV-positive tumors presented a significant lower OPC cancer-specific and second primary neoplasm mortality and a marginally nonsignificant lower noncancer mortality as compared to HPV-negative tumors.

Long-term survival and swallowing outcomes in advanced stage oropharyngeal squamous cell carcinomas

BACKGROUND

There is a paucity of studies reporting long-term survival outcomes for HPV/p16 positive oropharyngeal squamous cell carcinoma (OPSCC). This study aims to compare long-term outcomes of advanced stage p16 positive and negative OPSCCs, treated by surgical and non-surgical modalities.

METHODS

OPSCC patients from 1998 to 2012 were identified through a prospectively collected cancer registry. P16 immunohistochemistry was used as a surrogate marker for HPV-OPSCC. Overall survival (OS) and aspiration free survival (AFS) comparisons were made between patients treated with chemoradiation (CRT) versus primary surgery and radiation/chemoradiation (S+RT/CRT) at 5, 10 and 15 years post-treatment.

RESULTS

A total of 319 patients were included. P16 positive patients and non-smokers had significantly higher long-term (5, 10 and 15-year) OS. Smokers and p16 negative patients treated with S+RT/CRT had improved long-term OS compared to patients who received CRT. Smokers and p16 negative patients had lower long-term AFS. Multivariate analysis showed improved OS was associated with p16 positivity (HR 0.42, 0.28-0.61) and surgery (HR 0.47, 0.32-0.69), whereas lower OS was associated with ECOG ≥ 2 (HR 2.46, 1.61-3.77), smoking (HR 2.37, 1.41-3.99) and higher stage (HR 1.68, 1.05-2.68).

CONCLUSIONS

In smokers and p16-negative OPSCC patients, primary surgery may be associated with improved long-term survival and dysphagia-related outcomes.

Human Papillomavirus Testing in Head and Neck Carcinomas: Guideline From the College of American Pathologists

Context Human papillomavirus (HPV) is a major cause of oropharyngeal squamous cell carcinomas, and HPV (and/or surrogate marker p16) status has emerged as a prognostic marker that significantly impacts clinical management. There is no current consensus on when to test oropharyngeal squamous cell carcinomas for HPV/p16 or on which tests to choose. Objective To develop evidence-based recommendations for the testing, application, interpretation, and reporting of HPV and surrogate marker tests in head and neck carcinomas. Design The College of American Pathologists convened a panel of experts in head and neck and molecular pathology, as well as surgical, medical, and radiation oncology, to develop recommendations. A systematic review of the literature was conducted to address 6 key questions. Final recommendations were derived from strength of evidence, open comment period feedback, and expert panel consensus. Results The major recommendations include (1) testing newly diagnosed oropharyngeal squamous cell carcinoma patients for high-risk HPV, either from the primary tumor or from cervical nodal metastases, using p16 immunohistochemistry with a 70% nuclear and cytoplasmic staining cutoff, and (2) not routinely testing nonsquamous oropharyngeal carcinomas or nonoropharyngeal carcinomas for HPV. Pathologists are to report tumors as HPV positive or p16 positive. Guidelines are provided for testing cytologic samples and handling of locoregional and distant recurrence specimens. Conclusions Based on the systematic review and on expert panel consensus, high-risk HPV testing is recommended for all new oropharyngeal squamous cell carcinoma patients, but not routinely recommended for other head and neck carcinomas.

Transoral robotic surgery for residual and recurrent oropharyngeal cancers: Exploratory study of surgical innovation using the IDEAL framework for early-phase surgical studies

BACKGROUND

The purpose of this study was to identify the role of transoral robotic surgery (TORS) in the management of residual and recurrent oropharyngeal cancer.

METHODS

IDEAL (Idea, Development, Exploration, Assessment, Long-term Follow-up) 2a framework.

RESULTS

Of 26 patients assessed for TORS, 21 underwent the procedure, 5 underwent open resection (4 due to unsuitable anatomy/tumor extent and 1 on the basis of patient choice). Three patients underwent intraoperative ultrasound-assisted robotic resection, and 3 received robotic-assisted free flap inset. A technical refinement for TORS of residual and recurrent oropharyngeal cancer of the tongue base is described. Actuarial plots showed estimated overall survival of 48.2%, local control of 76.6%, and disease-specific survival of 77.1% at 42.6 months.

CONCLUSION

TORS is a valid management option for residual and recurrent oropharyngeal cancer. Oncologic outcomes are comparable to open surgery and transoral laser microsurgery, with the added advantages of en bloc resections, facility for intraoperative ultrasound imaging, and inset of free flaps without mandibular split.

Impact of Type 2 Diabetes Mellitus on Survival in Head and Neck Squamous Cell Carcinoma

Objective To identify any association between type 2 diabetes mellitus (T2DM) and survival outcomes for mucosal squamous cell carcinoma of the head and neck. An association has been demonstrated between T2DM and cancer outcomes at numerous sites, but data for the head and neck are limited. Improving our understanding of the impact that diabetes has on head and neck cancer survival is relevant for making treatment decisions and counseling patients regarding prognosis. Study Design Retrospective cohort study. Setting Academic tertiary referral head and neck cancer center. Subjects and Methods By accessing data retrospectively from prospectively collected databases at the Princess Margaret Cancer Centre, patients were studied who were treated for mucosal head and neck squamous cell cancer between January 2005 and December 2011. Collection of clinical, pathologic, and survival data was completed with an emphasis on T2DM. Results Of 2498 patients identified in the study period, 319 (12.8%) had T2DM. Five-year overall survival was not different between the diabetic (64%, 95% CI = 58%-71%) and nondiabetic (67%, 95% CI = 65%-69%; P = .078) groups. Furthermore, cause-specific survival did not demonstrate a statistically significant difference between groups (diabetic: 84%, 95% CI = 79%-88%, vs nondiabetic: 84%, 95% CI = 82%-86%; P = .67). Conclusion Despite contradictory evidence at other cancer sites, the presence of T2DM alone does not appear to adversely affect cancer survival outcomes in head and neck squamous cell cancer. This is encouraging for the diabetic patients with head and neck squamous cell cancer, and it provides guidance for the multidisciplinary team that treats them.

Human papillomavirus tumour status is not associated with a positive depression screen for patients with oropharyngeal cancer

BACKGROUND

Several risk factors for depression in patients with oropharyngeal cancer have been determined. However, it is unknown whether human papillomavirus associated oropharyngeal cancer, which has a distinct clinico-demographic profile, modulates this risk.

METHODS

A retrospective analysis was conducted of patients with oropharyngeal cancer. These patients had completed a 10-item depression screening questionnaire before receiving treatment for their disease from 2011 to 2014. Associations between patient or disease characteristics and depression screening questionnaire results were investigated.

RESULTS

The study comprised 69 patients, 31 (44.9 per cent) of whom screened positive for depression. There were no significant differences in distributions of clinico-demographic or histopathological characteristics, including human papillomavirus tumour status, by depression screen result.

CONCLUSION

This population has a high risk for depression, but no obvious risk factors, including human papillomavirus tumour status, were associated with an elevated risk. This inability to risk-stratify patients by clinico-demographic or disease characteristics emphasises the importance of regular depression screening for all patients in this population.

Prognostic Importance of Comorbidity and the Association Between Comorbidity and p16 in Oropharyngeal Squamous Cell Carcinoma

IMPORTANCE

Comorbidity affects the prognosis of patients with cancer through the direct effects of the comorbid illness and by influencing the patients' ability to tolerate treatment and mount a host response. However, the prognostic importance of comorbidity in oropharyngeal squamous cell carcinoma is not well characterized in the era of human papillomavirus infection.

OBJECTIVE

To determine the prognostic importance of comorbidity in both p16-positive and p16-negative oropharyngeal squamous cell carcinoma and to explore the relationship between comorbidity and p16.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of 305 patients at a single tertiary referral center diagnosed as having oropharyngeal squamous cell carcinoma between June 1996 and June 2010, but without a history of head and neck cancer or distant metastasis at time of diagnosis. The data were analyzed from August 1, 2014, through April 30, 2015.

EXPOSURES

Patients were grouped according to p16 status.

MAIN OUTCOMES AND MEASURES

Overall survival, defined as the time from diagnosis to death from any cause. Disease-free survival, defined as the time from diagnosis to either death from any cause or the first documented local, regional, or distant recurrence.

RESULTS

Of the 305 patients who met eligibility criteria, 230 were p16-positive, 70 were p16-negative, and 5 were not evaluable for p16 status. The final cohort of 300 patients had a mean (SD) age of 56.3 (9.3) years and 262 (87%) were male. In Kaplan-Meier analysis, the 5-year overall survival rates were 71% (95% CI, 65%-76%) for 232 patients with no comorbidity to mild comorbidity and 49% (95% CI, 36%-61%) for 63 patients with moderate to severe comorbidity. In multivariate Cox proportional hazards analysis, moderate to severe comorbidity was associated with an increased risk of death from any cause (adjusted hazards ratio [aHR], 1.52 [95% CI, 0.99-2.32]) and increased risk of death or recurrence (aHR, 1.71 [95% CI, 1.13-2.59]). After stratifying by p16 status and controlling for other variables, moderate to severe comorbidity was significantly associated with increased risk of death from any cause among p16-negative patients (aHR, 1.90 [95% CI, 1.03-3.50]) but not among p16-positive patients (aHR, 1.11 [95% CI, 0.61-2.02]).

CONCLUSIONS AND RELEVANCE

Comorbidity is important to consider when assessing the prognosis of patients with oropharyngeal squamous cell carcinoma and is of greater prognostic value in p16-negative than p16-positive cancer.

Comparison of Patient- and Practitioner-Reported Toxic Effects Associated With Chemoradiotherapy for Head and Neck Cancer

IMPORTANCE

Agreement between patient- and practitioner-reported toxic effects during chemoradiotherapy for head and neck cancer is unknown.

OBJECTIVE

To compare patient-reported symptom severity and practitioner-reported toxic effects among patients receiving chemoradiotherapy for head and neck cancer.

DESIGN, SETTING, AND PARTICIPANTS

Forty-four patients participating in a phase 2 trial of deintensified chemoradiotherapy for oropharyngeal carcinoma were included in the present study (conducted from February 8, 2012, to March 2, 2015). Most treatment (radiotherapy, 60 Gy, with concurrent weekly administration of cisplatin, 30 mg/m2) was administered at academic medical centers. Included patients had no prior head and neck cancers, were 18 years or older, and had a smoking history of 10 pack-years or less or more than 10 pack-years but 30 pack-years or less and abstinent for the past 5 years. Cancer status was untreated human papillomavirus or p16-positive squamous cell carcinoma of the oropharynx or unknown head and neck primary site; and cancer staging was category T0 to T3, category N0 to N2c, M0, and Eastern Cooperative Oncology Group performance status 0 to 1. Baseline, weekly, and posttreatment toxic effects were assessed by physicians or nurse practitioners using National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE), version 4.0. Patient-reported symptom severity was measured using the Patient-Reported Outcomes version of the CTCAE (PRO-CTCAE). Descriptive statistics were used to characterize raw agreement between CTCAE grades and PRO-CTCAE severity ratings.

INTERVENTIONS

Baseline, weekly, and posttreatment toxic effects assessed using CTCAE, version 4.0, and PRO-CTCAE.

MAIN OUTCOMES AND MEASURES

Raw agreement indices between patient-reported toxic effects, including symptom frequency, severity, and interference with daily activities (score range, 0 [none] to 4 [very severe]), and practitioner-measured toxic effects, including swallowing, oral pain, and hoarseness (score range, 1 [mild] to 5 [death]).

RESULTS

Of the 44 patients included in the analysis (39 men, 5 women; mean [SD] age, 61 [8.4] years), there were 327 analyzable pairs of CTCAE and PRO-CTCAE symptom surveys and no treatment delays due to toxic effects. Patient-reported and practitioner-reported symptom severity agreement was high at baseline when most symptoms were absent but declined throughout treatment as toxic effects increased. Most disagreement was due to lower severity of toxic effects reported by practitioners (eg, from 45% agreement at baseline to 27% at the final week of treatment for pain). This was particularly noted for domains that are not easily evaluated by physical examination, such as anxiety and fatigue (eg, severity of fatigue decreased from 43% at baseline to 12% in the final week of treatment).

CONCLUSIONS AND RELEVANCE

Practitioner-reported toxic effects are lower than patient self-reports during head and neck chemoradiotherapy. The inclusion of patient-reported symptomatic toxic effects provides information that can potentially enhance clinical management and improve data quality in clinical trials.

The Role of Adjuvant Chemotherapy in Surgically Managed, p16-Positive Oropharyngeal Squamous Cell Carcinoma

Importance

Human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) has a favorable prognosis, and p16 immunohistochemistry is a surrogate marker of high-risk HPV infection and strong prognosticator. Given this favorable prognosis, treatment de-escalation for p16-positive OPSCC is now being considered with the goal of decreasing treatment-associated morbidity without compromising tumor control. The role of adjuvant chemotherapy in this setting is becoming increasingly unclear.

Objective

To compare survival between surgically managed patients with p16-positive OPSCC who received adjuvant chemoradiotherapy and patients who received adjuvant radiotherapy alone.

Design, Setting, and Participants

This was a cohort study of patients with OPSCC diagnosed from June 1996 to June 2010, with follow-up through December 2014, at a single tertiary referral center. One hundred ninety-five surgically managed, p16-positive patients without a history of head and neck cancer or distant metastasis at time of diagnosis were included.

Exposures

Patients were dichotomized into adjuvant radiotherapy and adjuvant chemoradiotherapy groups.

Main Outcomes and Measures

Overall survival was the primary outcome, and disease-free survival was the secondary outcome. Propensity-weighted multivariate Cox proportional hazards analysis was conducted to quantify the effect of adjuvant chemotherapy on survival.

Results

The study included 195 patients with p16-positive, surgically managed OPSCC. Median duration of follow-up was 87 months (interquartile range, 68-116 months). Ninety patients received adjunct chemoradiotherapy (mean age, 54.3 years), 88 patients received adjuvant radiotherapy (mean age, 56.4 years), and 17 patients received surgery alone. The 5-year overall survival rate for patients who received adjuvant chemoradiotherapy was 82% (95% CI, 73%-90%) and 84% (95% CI, 76%-91%) for patients who received adjuvant radiotherapy alone. The 5-year disease-free survival rate for patients who received adjuvant chemoradiotherapy was 79% (95% CI, 71%-88%) and 79% (95% CI, 70%-88%) for patients who received radiotherapy alone. After weighting cases by the inverse probability of receiving adjuvant chemotherapy and controlling for age, comorbidity, smoking, pathological T stage, and pathological N stage, the receipt of adjuvant chemotherapy was not significantly associated with disease-free survival (adjusted hazard ratio, 0.91; 95% CI, 0.59-1.42) but was associated with a statistically insignificant yet clinically meaningful increase in all-cause mortality (adjusted hazard ratio, 1.46; 95% CI, 0.91-2.33).

Conclusions and Relevance

Among patients with p16-positive OPSCC managed surgically with adjuvant radiotherapy, the addition of adjuvant chemotherapy provided no additional disease-free survival benefit and was associated with worse overall survival. These results should help inform future clinical trials aiming to deescalate treatment for p16-positive patients.

Increased Growth of a Newly Established Mouse Epithelial Cell Line Transformed with HPV-16 E7 in Diabetic Mice

Epidemiological evidence supports that infection with high-risk types of human papillomavirus (HPV) can interact with host and environmental risk factors to contribute to the development of cervical, oropharyngeal, and other anogenital cancers. In this study, we established a mouse epithelial cancer cell line, designated as Chinese University Papillomavirus-1 (CUP-1), from C57BL/KsJ mice through persistent expression of HPV-16 E7 oncogene. After continuous culturing of up to 200 days with over 60 passages, we showed that CUP-1 became an immortalized and transformed epithelial cell line with continuous E7 expression and persistent reduction of retinoblastoma protein (a known target of E7). This model allowed in-vivo study of interaction between HPV and co-factors of tumorigenesis in syngeneic mice. Diabetes has been shown to increase HPV pathogenicity in different pathological context. Herein, with this newly-established cell line, we uncovered that diabetes promoted CUP-1 xenograft growth in syngeneic db/db mice. In sum, we successfully established a HPV-16 E7 transformed mouse epithelial cell line, which allowed subsequent studies of co-factors in multistep HPV carcinogenesis in an immunocompetent host. More importantly, this study is the very first to demonstrate the promoting effect of diabetes on HPV-associated carcinogenesis in vivo, implicating the importance of cancer surveillance in diabetic environment.

Employment and return to work following chemoradiation in patient with HPV-related oropharyngeal cancer

Background

Human papillomavirus (HPV)-positive oropharyngeal cancer primarily affects working-age adults. Chemotherapy and radiation (CTRT) used to treat this disease may adversely impact a survivors' ability to work after treatment.

Methods

We surveyed participants with HPV-positive oropharyngeal cancer who completed CTRT regarding employment. We examined the associations between 1) sociodemographic and clinical factors and employment outcomes, and 2) health-related quality of life and satisfaction with ability to work.

Results

102 participants were employed full-time at diagnosis for pay and surveyed at a median of 23 months post-CTRT (range 12-57 months). The median age at diagnosis was 57 years (range 25-76 years). During CTRT, 8 % stopped working permanently, 89 % took time off or reduced responsibility but later returned, and 3 % reported no change. For those who took time off but returned, median time to return to work was 14.5 weeks. In multivariable analysis, younger age predicted for needing more than the median time off. At time of survey, 85 % participants were working, 7 % had retired, and 8 % were not working for other reasons. Seventeen percent of participants were not satisfied with their current ability to work, which was associated with poorer health-related quality of life and persistent treatment toxicities (p < 0.001).

Conclusions

CTRT interrupts employment in the majority of working patients with HPV-positive oropharyngeal cancer but most return. However, treatment-related toxicities might lead to dissatisfaction with ability to work.

Human Papillomavirus and Head and Neck Cancer: Psychosocial Impact in Patients and Knowledge of the Link - A Systematic Review

Head and neck cancer (HNC) currently affects approximately 11 200 people in the UK, with an increasing proportion known to be caused by the human papillomavirus (HPV). We undertook a systematic review of studies measuring the psychosocial impact of HPV-related HNC and also studies measuring knowledge about the link between HPV and HNC among different populations. Searches were conducted on MEDLINE, Embase, PsycINFO, CINAHL Plus and Web of Science, with reference and forward citation searches also carried out on included studies. Studies were selected if they (i) were original peer-reviewed research (qualitative or quantitative), (ii) mentioned HPV and HNC, (iii) measured an aspect of the psychosocial impact of the diagnosis of HPV-related HNC as the dependent variable and/or (iv) measured knowledge of the association between HPV and HNC. In total, 51 papers met the inclusion criteria; 10 measuring psychosocial aspects and 41 measuring knowledge of the link between HPV and HNC. Quality of life in those with HPV-positive HNC was found to be higher, lower or equivalent to those with HPV-negative HNC. Longitudinal studies found quality of life in patients was at its lowest 2–3 months after diagnosis and some studies found quality of life almost returned to baseline levels after 12 months. Knowledge of the link between HPV and HNC was measured among different populations, with the lowest knowledge in the general population and highest in medical and dental professionals. Due to the limited studies carried out with patients measuring the psychosocial impact of a diagnosis of HPV-positive HNC, future work is needed with the partners of HPV-positive HNC patients and health professionals caring for these patients. The limited knowledge of the association between HPV and HNC among the general population also indicates the need for research to explore the information that these populations are receiving.

The rationale for HPV-related oropharyngeal cancer de-escalation treatment strategies

The treatment paradigms for head and neck squamous cell cancer (HNSCC) are changing due to the emergence of human papillomavirus-associated tumors (HPV-related), possessing distinct molecular profiles and responses to therapy. Retrospective studies have suggested that HPV-related HNSCCs are more frequently cured than those caused by tobacco. Current clinical trials focus on the reduction of treatment-related toxicity and the development of HPV-targeted therapies. New treatment strategies include: 1) dose reduction of radiotherapy, 2) the use of cetuximab instead of cisplatin for chemo-radiation 3) less invasive surgical options, i.e. trans-oral robotic surgery and trans-oral laser microlaryngoscopy, and 4) more specific treatment attempts, including immunotherapeutic strategies, thanks to increasing comprehension of the molecular background of HPV-related HNSCC. Whereas recently published data shed light on immune mechanisms, other studies have focused on specific vaccination against HPV-related HNSCC. A crucial problem is patient selection to the chosen bias. Truly HPV-related cancers (p16-positive and HPV DNA-positive) with biomarkers for good response to therapy could be included in randomized trials aiming for less severe and better tailored therapy.

Phase 1 trial of bevacizumab with concurrent chemoradiation therapy for squamous cell carcinoma of the head and neck with exploratory functional imaging of tumor hypoxia, proliferation, and perfusion

PURPOSE

A phase 1 trial was completed to examine the safety and feasibility of combining bevacizumab with radiation and cisplatin in patients with locoregionally advanced squamous cell carcinoma of the head and neck (HNSCC) treated with curative intent. Additionally, we assessed the capacity of bevacizumab to induce an early tumor response as measured by a series of biological imaging studies.

METHODS AND MATERIALS

All patients received a single induction dose of bevacizumab (15 mg/kg) delivered 3 weeks (±3 days) before the initiation of chemoradiation therapy. After the initial dose of bevacizumab, comprehensive head and neck chemoradiation therapy was delivered with curative intent to 70 Gy in 33 fractions with concurrent weekly cisplatin at 30 mg/m(2) and bevacizumab every 3 weeks (weeks 1, 4, 7) with dose escalation from 5 to 10 to 15 mg/kg. All patients underwent experimental imaging with [(18)F]fluorothymidine positron emission tomography (FLT-PET) (proliferation), [(61)Cu]Cu-diacetyl-bis(N4-methylthiosemicarbazone) PET (Cu-ATSM-PET) (hypoxia), and dynamic contrast-enhanced computed tomography (DCE-CT) (perfusion) at 3 time points: before bevacizumab monotherapy, after bevacizumab monotherapy, and during the combined therapy course.

RESULTS

Ten patients were enrolled. All had stage IV HNSCC, all achieved a complete response to treatment, and 9 of 10 remain alive, with a mean survival time of 61.3 months. All patients experienced grade 3 toxicity, but no dose-limiting toxicities or significant bleeding episodes were observed. Significant reductions were noted in tumor proliferation (FLT-PET), tumor hypoxia (Cu-ATSM-PET), and DCE-CT contrast enhancement after bevacizumab monotherapy, with further decreases in FLT-PET and Cu-ATSM-PET during the combined therapy course.

CONCLUSIONS

The incorporation of bevacizumab into comprehensive chemoradiation therapy regimens for patients with HNSCC appears safe and feasible. Experimental imaging demonstrates measureable changes in tumor proliferation, hypoxia, and perfusion after bevacizumab monotherapy and during chemoradiation therapy. These findings suggest opportunities to preview the clinical outcomes for individual patients and thereby design personalized therapy approaches in future trials.