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Morse RT, Mell LK. Hypoxic Cell Radiosensitization in Head and Neck Squamous Cell Carcinoma: Running Out of Air. Int J Radiat Oncol Biol Phys 2024; 119:783-785. [PMID: 38851276 DOI: 10.1016/j.ijrobp.2024.02.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 02/24/2024] [Indexed: 06/10/2024]
Affiliation(s)
- Ryan T Morse
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California.
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2
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Zukauskaite R, Kristensen MH, Eriksen JG, Johansen J, Samsøe E, Johnsen L, Lønkvist CK, Grau C, Hansen CR. Comparison of 3-year local control using DAHANCA radiotherapy guidelines before and after implementation of five millimetres geometrical GTV to high-dose CTV margin. Radiother Oncol 2024; 196:110284. [PMID: 38636711 DOI: 10.1016/j.radonc.2024.110284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/26/2024] [Accepted: 04/11/2024] [Indexed: 04/20/2024]
Abstract
INTRODUCTION Treatment planning using a five-millimetre geometrical margin from GTV to high-dose CTV (CTV1) has been used in DAHANCA treatment centres since 2013. We aimed to evaluate changes in CTV1 volumes, local control (LC), and recurrence pattern after the implementation of five-millimetre geometrical margins nationally. MATERIALS AND METHODS 1,948 patients with pharyngeal, and laryngeal squamous cell carcinomas completed definitive IMRT-based treatment in 2010-2012 and 2013-2015 in three centres. The patient-specific margin was calculated as median surface distance from primary tumour GTV (GTV-T) to CTV1. Radiologically verified local recurrences were analysed using a centre of mass (COM) of the delineated recurrence volume, measuring the shortest distance between COM to GTV-T and CTV1 boundaries. RESULTS Median GTV-CTV1 was 0.9 (0.0-0.97) and 0.47 cm (0.4-0.5) for 2010-2012 and 2013-2015, respectively. Median CTV1 changed in three centres from 76, 28, 42 cm3 to 61, 53, 62 cm3 for 2010-2012 and 2013-2015, respectively. Local failures occurred at 247 patients during first three years after radiotherapy. The 3-year LC rate for 2010-2012 and 2013-2015 was 0.84 and 0.87 (p = 0.06). Out of 146 radiology-verified analysable local recurrences, 102 (69.9%) were inside the CTV1. In 74.6% and 91% of cases, the LRs were covered by 95% isodose in 2010-2012 and 2013-2015, respectively. CONCLUSION DAHANCA radiotherapy guidelines based on a geometrically generated isotropic CTV1 margin led to less variation in treatment volumes and between centres than previous guidelines. The transition towards consensus GTV-CTV1 margins did not influence local tumour control. The majority of local recurrences were inside CTV1 and covered by the prescription dose.
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Affiliation(s)
- Ruta Zukauskaite
- Department of Oncology, Odense University Hospital, Odense, Denmark.
| | | | - Jesper Grau Eriksen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jørgen Johansen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Eva Samsøe
- Department of Oncology, Zealand University Hospital, Næstved, Denmark
| | - Lars Johnsen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - Camilla Kjær Lønkvist
- Department of Oncology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark
| | - Cai Grau
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Rønn Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark; Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Mell LK, Pugh SL, Jones CU, Nelson TJ, Zakeri K, Rose BS, Zeitzer KL, Gore EM, Bahary JP, Souhami L, Michalski JM, Hartford AC, Mishra MV, Roach M, Parliament MB, Choi KN, Pisansky TM, Husain SM, Malone SC, Horwitz EM, Feng F. Effects of Androgen Deprivation Therapy on Prostate Cancer Outcomes According to Competing Event Risk: Secondary Analysis of a Phase 3 Randomised Trial. Eur Urol 2024; 85:373-381. [PMID: 36710205 PMCID: PMC10372191 DOI: 10.1016/j.eururo.2023.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 12/22/2022] [Accepted: 01/17/2023] [Indexed: 01/29/2023]
Abstract
BACKGROUND Previous studies indicate that the benefit of short-term androgen deprivation therapy (ADT) with radiotherapy (RT) for prostate cancer depends on competing risks. OBJECTIVE To determine whether a quantitative method to stratify patients by risk for competing events (omega score) could identify subgroups that selectively benefit from ADT. DESIGN, SETTING, AND PARTICIPANTS An ancillary analysis of NRG/RTOG 9408 phase 3 trial (NCT00002597) involving 1945 prostate cancer patients was conducted. INTERVENTION Short-term ADT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We applied generalised competing event regression models incorporating age, performance status, comorbidity, T category, Gleason score (GS), and prostate-specific antigen (PSA), to stratify patients according to relative hazards for primary cancer-related events (distant metastasis or prostate cancer death) versus competing noncancer mortality. We tested interactions between ADT and subgroups defined by standard risk criteria versus relative risk (RR) using the omega score. RESULTS AND LIMITATIONS T2b, higher GS, and higher PSA were associated with an increased RR for cancer-related versus competing mortality events (a higher omega score); increased age and comorbidity were associated with a decreased omega score. Of 996 patients with low-risk/favourable intermediate-risk (FIR) disease, 286 (28.7%) had a high omega score (≥0.314). Of 768 patients with unfavourable intermediate-risk disease, 175 (22.8%) had a low omega score. The overall discordance in risk classification was 26.1%. Both standard criteria and omega score identified significant interactions for the effect of ADT on cancer-related events and late mortality in low- versus high-risk subgroups. Within the low-risk/FIR subgroup, a higher omega score identified patients in whom ADT significantly reduced cancer events and improved event-free survival. Limitations are the need for external/prospective validation and lower RT doses than contemporary standards. CONCLUSIONS Stratification based on competing event risk is useful for identifying prostate cancer patients who selectively benefit from ADT. PATIENT SUMMARY We analysed the effectiveness of androgen deprivation therapy (ADT) for localised prostate cancer among patients, defined by the relative risk (RR) for cancer versus noncancer events. Among patients with traditional low-risk/favourable intermediate-risk disease, those with a higher RR benefitted from short-term ADT.
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Affiliation(s)
- Loren K Mell
- University of California San Diego, Moores Cancer Center, San Diego, CA, USA.
| | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, USA
| | | | - Tyler J Nelson
- University of California San Diego, Moores Cancer Center, San Diego, CA, USA
| | - Kaveh Zakeri
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brent S Rose
- University of California San Diego, Moores Cancer Center, San Diego, CA, USA
| | | | - Elizabeth M Gore
- Froedtert and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jean-Paul Bahary
- CHUM - Centre Hospitalier de l'Universite de Montreal, Montreal, QC, Canada
| | - Luis Souhami
- The Research Institute of the McGill University Health Centre (MUHC), Montreal, QC, Canada
| | | | - Alan C Hartford
- Dartmouth-Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Mark V Mishra
- University of Maryland/Greenebaum Cancer Center, Baltimore, MD, USA
| | - Mack Roach
- UCSF Medical Center-Mount Zion, San Francisco, CA, USA
| | | | - Kwang N Choi
- State University of New York Downstate Medical Center, Brooklyn, NY, USA
| | | | | | | | | | - Felix Feng
- UCSF Medical Center-Mount Zion, San Francisco, CA, USA
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Raab G, Yu Y, Sherman E, Wong R, Mell LK, Lee NY, Zakeri K. Nomogram to predict risk of early mortality following definitive or adjuvant radiation and systemic therapy for head and neck cancer. Clin Transl Radiat Oncol 2024; 45:100725. [PMID: 38304239 PMCID: PMC10832379 DOI: 10.1016/j.ctro.2024.100725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/07/2024] [Indexed: 02/03/2024] Open
Abstract
Purpose/Objectives We sought to create nomograms to predict individual risk of early mortality, which can identify patients who require interventions to prevent early death. Methods We included patients in the National Cancer Database with non-metastatic squamous cell carcinoma of the head and neck who received radiation and systemic therapy between 2004 and 2017 in the definitive or adjuvant setting. Early mortality was defined as any death less than 90 days after starting radiation. Multivariable logistic regression was used to assess the relationship between covariates and early mortality. Nomograms to predict the risk of early death were created for both the definitive and adjuvant settings. Results Among 84,563 patients in the definitive group and 18,514 patients in the adjuvant group, rates of early mortality were 3.5 % (95 % CI 3.4-3.7 %) and 2.2 %, (95 % CI 1.9-2.4 %), respectively. Patients above the age of 70 had an early mortality rate of 7.8 % (95 % CI 7.3-8.2 %) in the definitive group and 4.4 % (95 % CI 3.6-5.4 %) in the adjuvant group. In the multivariable analysis, age, comorbidity, T and N category, and tumor site were associated with early mortality in both cohorts (p < 0.05 for all). Nomograms including age, comorbidity, T and N category and tumor site performed better than age alone at predicting early mortality (AUC for definitive group: 0.70 vs 0.66; AUC for adjuvant group: 0.71 vs 0.61). Conclusion Nomograms including age, comorbidity, T and N category and tumor site were developed to predict the risk of early death following definitive or adjuvant chemoradiation.
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Affiliation(s)
- Gabriel Raab
- Weill Cornell Medical College, New York, NY, USA
| | - Yao Yu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eric Sherman
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard Wong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Loren K. Mell
- Department of Radiation Medicine and Applied Sciences, UC San Diego, La Jolla, CA, USA
| | - Nancy Y. Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kaveh Zakeri
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Han J, Zakeri K, Raab G, Hesse J, Shamseddine A, Chen L, Yu Y, Kang JJ, McBride SM, Riaz N, Jillian Tsai C, Gelblum D, Sherman EJ, Wong RJ, Michel L, Lee NY. Concurrent carboplatin and paclitaxel definitive radiation therapy for locally advanced head and neck cancer. Head Neck 2023; 45:2207-2216. [PMID: 37439286 PMCID: PMC10981461 DOI: 10.1002/hed.27456] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/27/2023] [Accepted: 06/29/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND We report the outcomes of cisplatin-ineligible HNSCC patients treated with definitive chemoradiation and concurrent carboplatin and paclitaxel. MATERIALS AND METHODS We included consecutive HNSCC patients treated from 2013 to 2021 that received definitive chemoradiation with carboplatin and paclitaxel. Locoregional recurrences (LRR) and distant metastases (DM) were estimated using cumulative incidence functions. Progression free survival (PFS) and overall survival (OS) were estimated using Kaplan-Meier methods. RESULTS Sixty-five patients were identified with median age of 71 years (range 44-85). Median radiation dose was 70 Gy and the median doses of carboplatin and paclitaxel were AUC 1 and 40 mg/m2 , respectively. At a median follow-up of 29 (range 5-91) months, the 2-year rates of LRR, DM, PFS, and OS were 8.8%, 9.4%, 72.2%, and 88.7%, respectively. In total, there were 5 LRR, 7 DM, and 12 deaths. CONCLUSIONS Chemoradiation with carboplatin and paclitaxel is an excellent option for cisplatin-ineligible HNSCC patients.
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Affiliation(s)
- James Han
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kaveh Zakeri
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gabriel Raab
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jennifer Hesse
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Achraf Shamseddine
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Linda Chen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yao Yu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jung Julie Kang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sean M. McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - C. Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daphna Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eric J. Sherman
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Richard J. Wong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Loren Michel
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nancy Y. Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Mahdavi H. Induction chemotherapy in locally advanced head and neck cancers, is there a best choice? Crit Rev Oncol Hematol 2023; 186:103986. [PMID: 37059273 DOI: 10.1016/j.critrevonc.2023.103986] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 03/25/2023] [Accepted: 04/11/2023] [Indexed: 04/16/2023] Open
Abstract
Locally advanced stages of squamous cancers of the head and neck (LAHNCs) acquire high propensity for local and systemic relapse. Addition of systemic therapy as an induction (IC) to the standard concurrent chemoradiotherapy (CCRT) has become an approach of many practitioners. This strategy has shown to reduce metastases but did not affect survival in unselected populations. Meanwhile, the induction regimen including docetaxel, cisplatin, 5-FU (TPF) has shown superiority over other combinations, however, a survival advantage was not detected when compared to CCRT alone. This may be attributed to its high toxicity profile, inducing treatment delay, resistance, or variations in tumor sites and responses. Currently, newer systemic therapy combinations are being tested and indicators of benefit are being identified. The focus of this review is on the development of the choice of combination regimen for induction. Subsequently, proposed alternatives and strategies for patient selection will be introduced.
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Affiliation(s)
- Hoda Mahdavi
- Department of Radiation Oncology, School of Medicine, Iran University of Medical Sciences,Tehran, Iran; Department of Radiation Oncology, Firoozgar General Hospital, Beh-Afarin St., Karimkhan-e-Zand Ave., Vali-e-Asr Sq., Tehran, Iran.
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Dickstein DR, Powers AE, Vujovic D, Roof S, Bakst RL. Clinical and Therapeutic Considerations for Older Adults with Head and Neck Cancer. Clin Interv Aging 2023; 18:409-422. [PMID: 36959837 PMCID: PMC10029371 DOI: 10.2147/cia.s366155] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/04/2023] [Indexed: 03/18/2023] Open
Abstract
Approximately 30% of patients with head and neck squamous cell carcinoma (HNSCC) are at least 70 years of age, and this percentage is expected to increase as the population increases and lives longer. Elderly patients are underrepresented in head and neck oncology clinical trials, and there is minimal evidence on the management of HNSCC for this population. Subsequently, despite their best intentions, physicians may unknowingly recommend an ill-suited course of therapy, which may result in suboptimal oncological or functional outcomes or adverse events. Surgical approaches have the potential to carry a higher risk of morbidity and mortality in older adults, especially in patients with multiple comorbidities. Definitive radiation therapy treatment in patients with HNSCC frequently involves 7 weeks of daily radiation, sometimes with concurrent chemotherapy, and this demanding treatment can be difficult for older adult patients, which may lead to treatment interruptions, potential removal of concurrent systemic therapy, compromised outcomes, and diminished quality of life. There are clinical trials currently underway investigating altered fractionation regimens and novel, less toxic systemic treatments in this population. This review provides an overview of how best to approach an older adult with HNSCC, from initial work-up to treatment selection.
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Affiliation(s)
- Daniel R Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ann E Powers
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dragan Vujovic
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Scott Roof
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Richard L Bakst
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Kim SS, Liu HC, Mell LK. Treatment Considerations for Patients with Locoregionally Advanced Head and Neck Cancer with a Contraindication to Cisplatin. Curr Treat Options Oncol 2023; 24:147-161. [PMID: 36696081 PMCID: PMC9992074 DOI: 10.1007/s11864-023-01051-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2022] [Indexed: 01/26/2023]
Abstract
OPINION STATEMENT Significant advancements have been made in the treatment of locally advanced head and neck cancer, predominantly driven by the integration of concurrent chemotherapy with radiation therapy as a standard of care for many patients. The most heavily investigated chemotherapeutic is cisplatin, yet many patients are ineligible for cisplatin due to the presence of pre-existing medical comorbidities. Moreover, given the toxicity profile of cisplatin, identifying which patients stand to benefit from cisplatin is challenging, which is particularly evident in older patients. Efforts to better risk-stratify patients based on age, performance status, and the degree of pre-existing comorbidities are ongoing and have been increasingly utilized in national clinical trials. In parallel, exploration into alternative systemic agents, including novel targeted therapies and immunotherapies, in cisplatin-ineligible patients are rapidly expanding. Cumulatively, identifying appropriate treatment paradigms in patients who harbor contraindications to cisplatin can not only improve clinical outcomes but also critically mitigate detrimental adverse effects.
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Affiliation(s)
- Sangwoo S Kim
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, 3855 Health Sciences Drive, MC0843, La Jolla, CA, 92093, USA
| | - Hannah C Liu
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, 3855 Health Sciences Drive, MC0843, La Jolla, CA, 92093, USA
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, 3855 Health Sciences Drive, MC0843, La Jolla, CA, 92093, USA.
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Mell LK, Wong SJ. Good Radiosensitizer Hunting. J Clin Oncol 2023; 41:2313-2318. [PMID: 36724418 DOI: 10.1200/jco.22.02350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Stuart J Wong
- Division of Hematology Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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10
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Dickstein DR, Lehrer EJ, Hsieh K, Hotca A, Jones BM, Powers A, Sharma S, Liu J, Gupta V, Mell L, Husain Z, Kirke D, Misiukiewicz K, Posner M, Genden E, Bakst RL. Management of Older Adults with Locally Advanced Head and Neck Cancer. Cancers (Basel) 2022; 14:cancers14112809. [PMID: 35681789 PMCID: PMC9179912 DOI: 10.3390/cancers14112809] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/29/2022] [Accepted: 06/01/2022] [Indexed: 02/01/2023] Open
Abstract
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.
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Affiliation(s)
- Daniel R. Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Kristin Hsieh
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Alexandra Hotca
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Brianna M. Jones
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Ann Powers
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.P.); (D.K.); (E.G.)
| | - Sonam Sharma
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Jerry Liu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Vishal Gupta
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Loren Mell
- Department of Radiation Oncology, University of San Diego, La Jolla, CA 92110, USA;
| | - Zain Husain
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5S 1A1, Canada;
| | - Diana Kirke
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.P.); (D.K.); (E.G.)
| | - Krzysztof Misiukiewicz
- Department of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.M.); (M.P.)
| | - Marshall Posner
- Department of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.M.); (M.P.)
| | - Eric Genden
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.P.); (D.K.); (E.G.)
| | - Richard L. Bakst
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
- Correspondence:
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Nelson TJ, Thompson CA, Zou J, Kumar A, Sangchan P, Williamson CW, Vitzthum LK, Sharabi AB, Murphy JD, Fakhry CA, Mell LK. Validation of NRG Oncology's prognostic nomograms for oropharyngeal cancer in the Veterans Affairs database. Cancer 2022; 128:1948-1957. [PMID: 35194791 DOI: 10.1002/cncr.34141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 12/25/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND To test whether nomograms developed by NRG Oncology for oropharyngeal squamous cell carcinoma (OPSCC) patients could be validated in an independent population-based sample. METHODS The authors tested nomograms for estimating progression-free survival (PFS) and overall survival (OS) in patients from the Veterans Health Administration with previously untreated locoregionally advanced OPSCC, diagnosed between 2008 and 2017, managed with definitive radiotherapy with or without adjuvant systemic therapy. Covariates were age, performance status, p16 status, T/N category, smoking history, education history, weight loss, marital status, and anemia. We used multiple imputation to handle missing data and performed sensitivity analyses on complete cases. Validation was assessed via Cox proportional hazards models, log-rank tests, and c-indexes. RESULTS A total of 4007 patients met inclusion criteria (658 patients had complete data). Median follow-up time was 3.20 years, with 967 progression events and 471 noncancer deaths. Each risk score was associated with poorer outcomes per unit increase (PFS score, hazard ratio [HR], 1.42 [1.37-1.47]; OS score, HR, 1.40 [1.34-1.45]). By risk score quartile, 2-year PFS estimates were 89.2%, 78.5%, 65.8%, and 48.3%; OS estimates were 92.6%, 83.6%, 73.9%, and 51.3%, respectively (P < .01 for all comparisons). C-indices for models of PFS and OS were 0.65 and 0.67, for all patients, respectively (0.69 and 0.73 for complete cases). The nomograms slightly overestimated PFS and OS in the overall cohort but exhibited high agreement in complete cases. CONCLUSIONS NRG nomograms were effective for predicting PFS and OS for patients with OPSCC, supporting their broader applicability in the OPSCC population undergoing definitive radiotherapy.
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Affiliation(s)
- Tyler J Nelson
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, La Jolla, California.,La Jolla Center for Precision Radiation Medicine, La Jolla, California.,Veterans Health Administration, San Diego Health Care System, La Jolla, California
| | - Caroline A Thompson
- Division of Epidemiology and Biostatistics, San Diego State University School of Public Health, San Diego, California
| | - Jingjing Zou
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, California
| | - Abhishek Kumar
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, La Jolla, California.,Veterans Health Administration, San Diego Health Care System, La Jolla, California
| | - Prangrawee Sangchan
- Division of Radiation Oncology, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Casey W Williamson
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, La Jolla, California.,Veterans Health Administration, San Diego Health Care System, La Jolla, California
| | - Lucas K Vitzthum
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Andrew B Sharabi
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, La Jolla, California.,La Jolla Center for Precision Radiation Medicine, La Jolla, California
| | - James D Murphy
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, La Jolla, California.,Veterans Health Administration, San Diego Health Care System, La Jolla, California
| | - Carole A Fakhry
- Department of Otolaryngology Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Loren K Mell
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, La Jolla, California.,La Jolla Center for Precision Radiation Medicine, La Jolla, California
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12
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Lacas B, Carmel A, Landais C, Wong SJ, Licitra L, Tobias JS, Burtness B, Ghi MG, Cohen EEW, Grau C, Wolf G, Hitt R, Corvò R, Budach V, Kumar S, Laskar SG, Mazeron JJ, Zhong LP, Dobrowsky W, Ghadjar P, Fallai C, Zakotnik B, Sharma A, Bensadoun RJ, Ruo Redda MG, Racadot S, Fountzilas G, Brizel D, Rovea P, Argiris A, Nagy ZT, Lee JW, Fortpied C, Harris J, Bourhis J, Aupérin A, Blanchard P, Pignon JP. Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): An update on 107 randomized trials and 19,805 patients, on behalf of MACH-NC Group. Radiother Oncol 2021; 156:281-293. [PMID: 33515668 DOI: 10.1016/j.radonc.2021.01.013] [Citation(s) in RCA: 148] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/22/2020] [Accepted: 01/08/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE The Meta-Analysis of Chemotherapy in squamous cell Head and Neck Cancer (MACH-NC) demonstrated that concomitant chemotherapy (CT) improved overall survival (OS) in patients without distant metastasis. We report the updated results. MATERIALS AND METHODS Published or unpublished randomized trials including patients with non-metastatic carcinoma randomized between 1965 and 2016 and comparing curative loco-regional treatment (LRT) to LRT + CT or adding another timing of CT to LRT + CT (main question), or comparing induction CT + radiotherapy to radiotherapy + concomitant (or alternating) CT (secondary question) were eligible. Individual patient data were collected and combined using a fixed-effect model. OS was the main endpoint. RESULTS For the main question, 101 trials (18951 patients, median follow-up of 6.5 years) were analyzed. For both questions, there were 16 new (2767 patients) and 11 updated trials. Around 90% of the patients had stage III or IV disease. Interaction between treatment effect on OS and the timing of CT was significant (p < 0.0001), the benefit being limited to concomitant CT (HR: 0.83, 95%CI [0.79; 0.86]; 5(10)-year absolute benefit of 6.5% (3.6%)). Efficacy decreased as patients age increased (p_trend = 0.03). OS was not increased by the addition of induction (HR = 0.96 [0.90; 1.01]) or adjuvant CT (1.02 [0.92; 1.13]). Efficacy of induction CT decreased with poorer performance status (p_trend = 0.03). For the secondary question, eight trials (1214 patients) confirmed the superiority of concomitant CT on OS (HR = 0.84 [0.74; 0.95], p = 0.005). CONCLUSION The update of MACH-NC confirms the benefit and superiority of the addition of concomitant CT for non-metastatic head and neck cancer.
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Affiliation(s)
- Benjamin Lacas
- Cleveland Clinic Foundation, OH, USA; Institut Saint Catherine, France
| | | | | | | | | | | | | | | | | | - Cai Grau
- H. Lee Moffitt Cancer Center & Research Institute, USA
| | | | | | - Renzo Corvò
- Tata Memorial Centre Advanced Centre for Treatment, Research and Education in Cancer, India
| | - Volker Budach
- State University of New York Downstate Medical Center, USA
| | | | | | | | | | | | - Pirus Ghadjar
- Johns Hopkins Univ/Sidney Kimmel Cancer Center, MD, USA
| | - Carlo Fallai
- Centre Hospitalier Universitaire de Tours, France
| | | | - Atul Sharma
- Cancer Research UK & UCL Cancer Trials Centre, UK
| | | | | | - Séverine Racadot
- Princess Margaret Cancer Centre/University of Toronto, Ontario, Canada
| | | | | | - Paolo Rovea
- Kragulevac University Hospital, Yugoslavia, Serbia
| | | | | | | | | | | | - Jean Bourhis
- Institut Saint Catherine, France; Stanford University School of Medicine, CA, USA
| | - Anne Aupérin
- Cleveland Clinic Foundation, OH, USA; Institut Saint Catherine, France
| | - Pierre Blanchard
- Cleveland Clinic Foundation, OH, USA; Institut Saint Catherine, France; University of Texas-MD Anderson Cancer Center, USA.
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