The "decay" of brachytherapy use in tumors of the oral cavity: A population-based patterns of care and outcomes analysis from 1973 to 2012

Population-based comparative survival analysis of surgery with or without adjuvant radiotherapy and non-operative primary radiotherapy in patients with early-stage oral tongue squamous cell carcinoma

Purpose

Although recent clinical guidelines do allow primary radiotherapy for selected patients with early-stage oral tongue cancer, there has been little knowledge on the treatment outcomes of non-operative radiotherapy using modern treatment techniques. This study evaluated recent prognostic differences between primary radiotherapy and surgical resection in T1‒2N0 oral tongue squamous cell carcinoma.

Methods

Patients diagnosed with T1‒2N0 oral tongue squamous cell carcinoma were identified from the Surveillance, Epidemiology, and End Results database. After propensity score matching, the disease-specific survival of primary radiotherapy and surgery was compared.

Results

From a total of 8,458 patients initially identified, we defined matched cohorts: cohort A, comparing surgery alone vs. primary radiotherapy (n = 230 vs. 230), and cohort B, comparing surgery plus adjuvant radiotherapy vs. primary radiotherapy (n = 230 vs. 230). The 7-year disease-specific survival rates were 77% vs. 35% (cohort A) and 65% vs. 35% (cohort B) (P < 0.001 for all comparisons). Primary radiotherapy was independently associated with worse disease-specific survival in both cohorts A (hazard ratio 4.06; 95% confidence interval 2.53‒6.52) and B (hazard ratio 2.81; 95% confidence interval 1.96‒4.04). Time-course hazard rate function plots showed a distinct short-term risk increment in disease-specific mortality in the primary radiotherapy group.

Conclusion

In the contemporary treatment era, the use of radiotherapy as a definitive treatment resulted in an inferior prognosis in patients with T1‒2N0 oral tongue squamous cell carcinoma. The present population-based data suggest that primary radiotherapy cannot be used as an alternative to surgical management and it needs to be avoided as much as possible in early-stage tumors.

Brachytherapy and non-cancer mortality in patients with oral cavity and oropharynx SCCs

BACKGROUND

Oral cavity and oropharyngeal squamous cell cancers (OC-OPSCC) display high cancer-specific mortality and increased non-cancer mortality. We examined cause of death in patients treated for OC-OPSCC with brachytherapy, chemotherapy, external beam radiation, surgery, or combination of modalities. We hypothesized that brachytherapy does not increase non-cancer mortality comparably with external beam radiation.

METHODS

A database was constructed from institutional tumor registry and electronic medical record data from all patients with first OC-OPSCC diagnosis at our institution between 2000 and 2010, excluding patients with a second primary cancer at diagnosis. The primary outcome was association between treatment modality and non-cancer mortality.

RESULTS

Of 693 eligible patients, 460 were deceased; 84 from primary malignancy and 96 from a non-primary cancer cause, including 24 with a second primary cancer. 193 patients received brachytherapy. Cox proportional hazards regression was performed on treatment regimen, stratified by AJCC stage, race, and sex. Age, smoking history, and alcohol had HRs for death of 1.05 (p < 0.005), 1.37 (p = 0.106), and 2.24 (p < 0.005), respectively, while brachytherapy had a 0.53 HR (p < 0.005) for death. Non-smoking OPC patients had an 88% 5-year OS, suggesting these were largely HPV-driven cancers. In smoking OPC patients, 5-year OS was 61%. Non-cancer mortality HR of 0.36 for brachytherapy-treated patients.

CONCLUSION

We report non-cancer mortality from a cohort of curatively treated OC-OPSCC and show a significant correlation between brachytherapy and non-cancer survival, independent of remission status. The impact of brachytherapy in OPC was strongest in smokers.

Permanent Interstitial Brachytherapy for Previously Irradiated Head and Neck Cancer

Objective: To evaluate our institutional experience using brachytherapy for the re-irradiation of the head and neck.

Study Design/Methods: We reviewed the records of patients who received brachytherapy for head and neck cancer in a previously irradiated field between 2007 and 2016.

Results: Sixty-nine patients received brachytherapy-based re-irradiation. Forty-nine patients (71%) were treated for recurrent cancers, 15 patients (22%) had second primary cancers, and five patients (7%) were treated for persistent tumors. The median dose was 90 Gy (range 30-180). Median follow-up was 3.0 years for surviving patients and 0.6 years for all patients. Overall survival at one, three, and five years was 58%, 19%, and 12%, respectively. Local control at one, three, and five years was 55%, 38%, and 28%, respectively. A disease-free interval of less than one year was associated with significantly worse local control (p=.04). Patients who received brachytherapy for a neck disease had significantly worse locoregional control than those who received brachytherapy for mucosal disease (heart rate (HR) 2.14, 95% CI 1.00-4.56, p=.05). Patients who had an extranodal extension had significantly worse overall survival than those without an extranodal extension (HR 2.57, 95% CI 1.28-5.37, p=.008). Seventy-four percent of patients who had pain before brachytherapy (with or without surgery) had an improvement of symptoms. Acute and chronic toxicity of at least Common Terminology Criteria for Adverse Events Grade 3 was seen in 27% and 19% of the patients, respectively.

Conclusions: Brachytherapy-based re-irradiation is an effective approach for patients undergoing re-irradiation for head and neck cancer. Brachytherapy may be more effective for mucosal recurrences than neck recurrences.

Brachytherapy in Head and Neck Cancers: "Are We Doing It or Are We Done with It"

We performed an e-Survey and reviewed the literature on the prevalence of use of brachytherapy in head and neck cancers in order to understand the patterns of care and probable application of this modality. A five-point questionnaire was prepared and sent to 300 oncologists through a web-based survey engine. This was done in preparation for my lecture on "Ongoing Research and Potential Research Avenues" in IBSCON held in Chennai in August 2016. SPSS software was used for the statistical analysis. Of a total of 300 emails that were sent out for the survey, 120 replies were received, which is 40%. Among the results of various questions, (i) 65% of the oncologists felt that there were > 300 ongoing studies in brachytherapy and out of them only 10-20 were on head and neck brachytherapy; (ii) 58% of the responders felt that external beam radiotherapy (EBRT) advances followed by lack of training and experience are the reasons for declining role of brachytherapy; (iii) among the responders, numbers of head and neck brachytherapy performed stand third after gynecological and breast brachytherapy. This survey shows that brachytherapy in head and neck cancers is an essential tool, but seldom practiced. If no path-breaking event happens, we may be dealing with it as a dying art.