1
|
Armstrong AT, Velez-Velez LM, Simpson MC, Massa ST. Trends and Implications of Adjuvant Systemic Therapy for Head and Neck Cancer Without High-Risk Features. Otolaryngol Head Neck Surg 2023; 169:556-569. [PMID: 36939584 DOI: 10.1002/ohn.252] [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: 09/20/2022] [Revised: 12/03/2022] [Accepted: 12/19/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Determine trends and survival implications of adjuvant systemic therapy use for lower risk head and neck cancer. STUDY DESIGN Retrospective cohort study. SETTING US National Cancer Database, 2010 to 2019. METHODS Patients with mucosal head and neck squamous cell carcinoma treated with surgery and postoperative radiation therapy were identified. Adjuvant systemic therapy trends in those with and without extranodal extension or positive margins were assessed as annual percent change by JoinPoint analysis. Factors associated with adjuvant systemic therapy and overall survival were assessed with multivariable models and cox proportional hazard models, respectively. RESULTS From 2010 to 2019, approximately one-third of head and neck cancer patients without extranodal extension or positive margins received adjuvant systemic therapy. This rate decreased throughout the study period, with the highest annual percent change from 2016 to 2019 (12.21%; 95% confidence interval: 3.73%-19.95%). Younger age, male sex, Hispanic ethnicity, community program setting, advanced stage, and lymphovascular invasion increased the odds a patient would receive adjuvant systemic therapy. Adjuvant systemic therapy was associated with inferior overall survival when used in those without extranodal extension or positive margins after controlling for covariates. CONCLUSION Though decreasing, adjuvant systemic therapy use is still common in the absence of extranodal extension and positive margins, and a variety of patient, provider, and oncologic factors may influence its use. The inferior overall survival after adjuvant systemic therapy in the absence of high-risk features suggests any oncologic benefit may not outweigh the costs and morbidity of the therapy.
Collapse
Affiliation(s)
- Austin T Armstrong
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| | - Lisa M Velez-Velez
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| | - Matt C Simpson
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| | - Sean T Massa
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| |
Collapse
|
2
|
Adding Concomitant Chemotherapy to Postoperative Radiotherapy in Oral Cavity Carcinoma with Minor Risk Factors: Systematic Review of the Literature and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14153704. [PMID: 35954368 PMCID: PMC9367295 DOI: 10.3390/cancers14153704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 11/17/2022] Open
Abstract
When presenting with major pathological risk factors, adjuvant radio-chemotherapy for oral cavity cancers (OCC) is recommended, but the addition of chemotherapy to radiotherapy (POCRT) when only minor pathological risk factors are present is controversial. A systematic review following the PICO-PRISMA methodology (PROSPERO registration ID: CRD42021267498) was conducted using the PubMed, Embase, and Cochrane libraries. Studies assessing outcomes of POCRT in patients with solely minor risk factors (perineural invasion or lymph vascular invasion; pN1 single; DOI ≥ 5 mm; close margin < 2−5 mm; node-positive level IV or V; pT3 or pT4; multiple lymph nodes without ENE) were evaluated. A meta-analysis technique with a single-arm study was performed. Radiotherapy was combined with chemotherapy in all studies. One study only included patients treated with POCRT. In the other 12 studies, patients were treated with only PORT (12,883 patients) and with POCRT (10,663 patients). Among the patients treated with POCRT, the pooled 3 year OS rate was 72.9% (95%CI: 65.5−79.2%); the pooled 3 year DFS was 70.9% (95%CI: 48.8−86.2%); and the pooled LRFS was 69.8% (95%CI: 46.1−86.1%). Results are in favor of POCRT in terms of OS but not significant for DFS and LRFS, probably due to the heterogeneity of the included studies and a combination of different prognostic factors.
Collapse
|
3
|
Tasoulas J, Lenze NR, Farquhar D, P Schrank T, Shen C, Shazib MA, Singer B, Patel S, Grilley Olson JE, Hayes DN, Gulley ML, Chera BS, Hackman T, Olshan AF, Weiss J, Sheth S. The addition of chemotherapy to adjuvant radiation is associated with inferior survival outcomes in intermediate-risk HPV-negative HNSCC. Cancer Med 2021; 10:3231-3239. [PMID: 33934525 PMCID: PMC8124130 DOI: 10.1002/cam4.3883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/13/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Only high-risk tumors with extranodal extension (ENE) and/or positive surgical margins (PSM) benefit from adjuvant therapy (AT) with concurrent chemoradiation (CRT) compared to radiation therapy (RT) in locally advanced head and neck squamous cell carcinoma (HNSCC). Optimal treatment for intermediate-risk tumors remains controversial. We categorized patients based on their surgical pathologic risk factors and described AT treatment patterns and associated survival outcomes. METHODS Patients were identified from CHANCE, a population-based study, and risk was classified based on surgical pathology review. High-risk patients (n = 204) required ENE and/or PSM. Intermediate-risk (n = 186) patients had pathological T3/T4 disease, perineural invasion (PNI), lymphovascular invasion (LVI), or positive lymph nodes without ENE. Low-risk patients (n = 226) had none of these features. RESULTS We identified 616 HPV-negative HNSCC patients who received primary surgical resection with neck dissection. High-risk patients receiving AT had favorable OS (HR 0.50, p = 0.013) which was significantly improved with the addition of chemotherapy compared to RT alone (HR 0.47, p = 0.021). When stratified by node status, the survival benefit of AT in high-risk patients persisted only among those who were node-positive (HR: 0.17, p < 0.0005). On the contrary, intermediate-risk patients did not benefit from AT (HR: 1.26, p = 0.380) and the addition of chemotherapy was associated with significantly worse OS compared to RT (HR: 1.76, p = 0.046). CONCLUSION In high-risk patients, adjuvant chemoradiotherapy improved OS compared to RT alone. The greatest benefit was in node-positive cases. In intermediate-risk patients, the addition of chemotherapy to RT increased mortality risk and therefore should only be used cautiously in these patients.
Collapse
Affiliation(s)
- Jason Tasoulas
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nicholas R Lenze
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Douglas Farquhar
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Travis P Schrank
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Colette Shen
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - M Ali Shazib
- Division of Diagnostic Sciences, Adams School of Dentistry, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bart Singer
- Department of Pathology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Shetal Patel
- Division of Medical Oncology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Juneko E Grilley Olson
- Division of Medical Oncology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - David N Hayes
- Division of Hematology-Oncology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Margaret L Gulley
- Department of Pathology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bhishamjit S Chera
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Trevor Hackman
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrew F Olshan
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jared Weiss
- Division of Medical Oncology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Siddharth Sheth
- Division of Medical Oncology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
4
|
Goshtasbi K, Yasaka TM, Zandi-Toghani M, Djalilian HR, Armstrong WB, Tjoa T, Haidar YM, Abouzari M. Machine learning models to predict length of stay and discharge destination in complex head and neck surgery. Head Neck 2020; 43:788-797. [PMID: 33142001 DOI: 10.1002/hed.26528] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 10/13/2020] [Accepted: 10/23/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND This study develops machine learning (ML) algorithms that use preoperative-only features to predict discharge-to-nonhome-facility (DNHF) and length-of-stay (LOS) following complex head and neck surgeries. METHODS Patients undergoing laryngectomy or composite tissue excision followed by free tissue transfer were extracted from the 2005 to 2017 NSQIP database. RESULTS Among the 2786 included patients, DNHF and mean LOS were 421 (15.1%) and 11.7 ± 8.8 days. Four classification models for predicting DNHF with high specificities (range, 0.80-0.84) were developed. The generalized linear and gradient boosting machine models performed best with receiver operating characteristic (ROC), accuracy, and negative predictive value (NPV) of 0.72-0.73, 0.75-0.76, and 0.88-0.89. Four regression models for predicting LOS in days were developed, where all performed similarly with mean absolute error and root mean-squared errors of 3.95-3.98 and 5.14-5.16. Both models were developed into an encrypted web-based interface: https://uci-ent.shinyapps.io/head-neck/. CONCLUSION Novel and proof-of-concept ML models to predict DNHF and LOS were developed and published as web-based interfaces.
Collapse
Affiliation(s)
- Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Tyler M Yasaka
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Mehdi Zandi-Toghani
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Hamid R Djalilian
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA.,Department of Biomedical Engineering, University of California, Irvine, California, USA
| | - William B Armstrong
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Tjoson Tjoa
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Yarah M Haidar
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Mehdi Abouzari
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| |
Collapse
|
5
|
Howard FM, Kochanny S, Koshy M, Spiotto M, Pearson AT. Machine Learning-Guided Adjuvant Treatment of Head and Neck Cancer. JAMA Netw Open 2020; 3:e2025881. [PMID: 33211108 PMCID: PMC7677764 DOI: 10.1001/jamanetworkopen.2020.25881] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/20/2020] [Indexed: 12/19/2022] Open
Abstract
Importance Postoperative chemoradiation is the standard of care for cancers with positive margins or extracapsular extension, but the benefit of chemotherapy is unclear for patients with other intermediate risk features. Objective To evaluate whether machine learning models could identify patients with intermediate-risk head and neck squamous cell carcinoma who would benefit from chemoradiation. Design, Setting, and Participants This cohort study included patients diagnosed with squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx from January 1, 2004, through December 31, 2016. Patients had resected disease and underwent adjuvant radiotherapy. Analysis was performed from October 1, 2019, through September 1, 2020. Patients were selected from the National Cancer Database, a hospital-based registry that captures data from more than 70% of newly diagnosed cancers in the United States. Three machine learning survival models were trained using 80% of the cohort, with the remaining 20% used to assess model performance. Exposures Receipt of adjuvant chemoradiation or radiation alone. Main Outcomes and Measures Patients who received treatment recommended by machine learning models were compared with those who did not. Overall survival for treatment according to model recommendations was the primary outcome. Secondary outcomes included frequency of recommendation for chemotherapy and chemotherapy benefit in patients recommended for chemoradiation vs radiation alone. Results A total of 33 527 patients (24 189 [72%] men; 28 036 [84%] aged ≤70 years) met the inclusion criteria. Median follow-up in the validation data set was 43.2 (interquartile range, 19.8-65.5) months. DeepSurv, neural multitask logistic regression, and survival forest models recommended chemoradiation for 17 589 (52%), 15 917 (47%), and 14 912 patients (44%), respectively. Treatment according to model recommendations was associated with a survival benefit, with a hazard ratio of 0.79 (95% CI, 0.72-0.85; P < .001) for DeepSurv, 0.83 (95% CI, 0.77-0.90; P < .001) for neural multitask logistic regression, and 0.90 (95% CI, 0.83-0.98; P = .01) for random survival forest models. No survival benefit for chemotherapy was seen for patients recommended to receive radiotherapy alone. Conclusions and Relevance These findings suggest that machine learning models may identify patients with intermediate risk who could benefit from chemoradiation. These models predicted that approximately half of such patients have no added benefit from chemotherapy.
Collapse
Affiliation(s)
- Frederick Matthew Howard
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Sara Kochanny
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Matthew Koshy
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, Illinois
- Department of Radiation Oncology, University of Illinois at Chicago
| | - Michael Spiotto
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, Illinois
- Department of Radiation Oncology, University of Illinois at Chicago
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Alexander T. Pearson
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, Illinois
| |
Collapse
|
6
|
Goel AN, Sangar S, Mukdad L, Heaton CM, Ryan WR, Wang MB, Long JL, St John MA. Patterns of care and survival impact of adjuvant chemoradiotherapy for oropharyngeal cancer with intermediate-risk features. Head Neck 2019; 41:3177-3186. [PMID: 31107584 DOI: 10.1002/hed.25808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 05/08/2019] [Accepted: 05/09/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Survival outcomes for adjuvant chemoradiotherapy (aCRT) and adjuvant radiotherapy (aRT) were compared in patients with oropharyngeal squamous cell carcinoma (OPSCC) with intermediate-risk features. METHODS We identified 2164 patients with OPSCC in the National Cancer Database without positive margins or extracapsular extension and with at least one intermediate-risk feature: pT3-T4 disease, ≥two positive lymph nodes, level IV/V nodal disease, and/or lymphovascular invasion. We assessed predictors of aCRT use and covariables impacting overall survival. RESULTS aCRT was commonly used for both human papillomavirus (HPV)-positive (62.0%) and HPV-negative (64.3%) patients with OPSCC. Higher N stage, level IV/V neck disease, and younger age strongly predicted aCRT utilization. There was no significant survival benefit associated with aCRT vs aRT in HPV-positive (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.62-1.38; P = .71) or HPV-negative (HR, 0.75; 95% CI, 0.51-1.10; P = .15) disease. CONCLUSIONS Despite high rates of utilization, aCRT is not associated with better survival vs aRT for OPSCC with intermediate-risk features, including HPV-negative tumors.
Collapse
Affiliation(s)
- Alexander N Goel
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sophia Sangar
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Laith Mukdad
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Chase M Heaton
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California
| | - William R Ryan
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California
| | - Marilene B Wang
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California.,Jonsson Comprehensive Cancer Center, UCLA Medical Center, Los Angeles, California.,UCLA Head and Neck Cancer Program, UCLA Medical Center, Los Angeles, California
| | - Jennifer L Long
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California.,Research Service, Department of Veterans Affairs, Los Angeles, California
| | - Maie A St John
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California.,Jonsson Comprehensive Cancer Center, UCLA Medical Center, Los Angeles, California.,UCLA Head and Neck Cancer Program, UCLA Medical Center, Los Angeles, California
| |
Collapse
|
7
|
Benchetrit L, Torabi SJ, Tate JP, Mehra S, Osborn HA, Young MR, Burtness B, Judson BL. Gender disparities in head and neck cancer chemotherapy clinical trials participation and treatment. Oral Oncol 2019; 94:32-40. [PMID: 31178210 DOI: 10.1016/j.oraloncology.2019.05.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/30/2019] [Accepted: 05/09/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To characterize the representation of women in clinical trials directing the National Comprehensive Cancer Network (NCCN) guidelines for chemotherapy use in head and neck squamous cell carcinoma (HNSCC), as well as the relationship between gender and chemotherapy administration in the definitive treatment of HNSCC in the United States. METHODS A review of all HNSCC chemotherapy clinical trials cited by the 2018 NCCN guidelines was performed. Sex-based proportions were compared with the corresponding proportions in the general U.S. population of patients with HNSCC between 1985 and 2015, derived from the Surveillance, Epidemiology, and End Results (SEER) program. A second analysis using the National Cancer Database (NCDB), identified 63,544 adult patients diagnosed with stages III-IVB HNSCC between 2004 and 2014 and treated with definitive radiotherapy or chemoradiotherapy. Univariable and multivariable logistic regression analyses were used to identify predictors of chemotherapy administration. RESULTS While women comprised 26.2% of U.S. patients with HNSCC between 1985 and 2015, they comprised only 17.0% of patients analyzed in U.S. NCCN-cited chemotherapy clinical trials between 1985 and 2017. On multivariable analysis, women had decreased odds of receiving chemotherapy (Odds Ratio [OR]: 0.875; 95% Confidence Interval [CI]: 0.821-0.931; p < 0.001). CONCLUSION Women are underrepresented in HNSCC chemotherapy clinical trials cited by the national guidelines. Additionally, women are less likely than men to receive definitive chemoradiotherapy as oppose to definitive radiotherapy. Reasons for these disparities warrant further investigation as well as re-evaluation of eligibility criteria and enrollment strategies, in order to improve relevance of clinical trials to women with HNSCC.
Collapse
Affiliation(s)
- Liliya Benchetrit
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, United States
| | - Sina J Torabi
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, United States
| | - Janet P Tate
- Department of Internal Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States
| | - Saral Mehra
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, United States; Yale Cancer Center, New Haven, CT, United States
| | - Heather A Osborn
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, United States; Yale Cancer Center, New Haven, CT, United States
| | - Melissa R Young
- Yale Cancer Center, New Haven, CT, United States; Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, United States
| | - Barbara Burtness
- Yale Cancer Center, New Haven, CT, United States; Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Benjamin L Judson
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, United States; Yale Cancer Center, New Haven, CT, United States.
| |
Collapse
|