Head and neck cancer in the elderly: An overview on the treatment modalities

Treatment of elderly patients with head and neck cancer in an aging society: Focus on geriatric assessment and surgical treatment

Previous studies of the treatment of elderly head and neck cancer (HNC) patients were very limited and sometimes controversial. Although conclusions differ across various reports, it is often concluded that advanced chronological age does not directly affect prognosis, but that comorbidities and declines in physical and cognitive functions promote the occurrence of adverse events, especially with surgical treatment. Geriatric assessment (GA) and its screening tools are keys to help us understand overall health status and problems, predict life expectancy and treatment tolerance, and to influence treatment choices and interventions to improve treatment compliance. In addition, personal beliefs and values play a large role in determining policies for HNC treatment for elderly patients, and a multidisciplinary approach is important to support this. In this review, past research on HNC in older adults is presented, and the current evidence is explained, focusing on the management of elderly HNC patients, with an emphasis on the existing reports on each treatment stage and modality, especially the surgical procedures.

Outcome of radiotherapy for the treatment of laryngeal squamous cell carcinoma in the very elderly population

BACKGROUND

Treatment selection for squamous cell carcinoma patients aged over 84 years is controversial. This retrospective chart review examined and compared characteristics of laryngeal squamous cell carcinoma in very elderly (over 84 years) and younger patients (approximately 65 years). The secondary objective was to further evaluate the outcome of radiotherapy as a treatment modality in this patient population.

METHODS

Of all 23 very elderly patients with laryngeal squamous cell carcinoma treated with radiotherapy, with or without surgery, in the Davidoff Cancer Center, from 1992 to 2012, 19 had sufficient data for analysis, and comprised the study group.

RESULTS

Median age at diagnosis was 86 years. Disease stage at diagnosis was I, II, III and IVA in 53 per cent, 21 per cent, 21 per cent and 5 per cent, respectively. Median radiotherapy dose was 60 Gy given in 25 fractions. Three patients had recurrence. No patient discontinued treatment because of toxicity. Median overall survival was 3.6 years (range, 0-10 years).

CONCLUSION

Very elderly laryngeal squamous cell carcinoma patients may derive a similar survival advantage as younger counterparts. Modern radiotherapy is effective and safe for treating laryngeal squamous cell carcinoma in this study population. Further, large-scale studies are needed.

Incidence of Postoperative Delirium in Cancer Patients After Head and Neck Surgery: A Proportional Meta-analysis

OBJECTIVE

To summarize the incidence of postoperative delirium among cancer patients undergoing head and neck surgery and determine the differential incidence rates among patients undergoing different types of head and neck surgeries.

DATA SOURCES

The databases of PubMed, Cochrane Library, Web of Science, EMBASE, and CINAHL were searched from inception till February 2023. Keywords based on the condition (delirium), context (postoperative), and population (head and neck cancer) were used as search terms.

REVIEW METHODS

The PRISMA and MOOSE reporting guidelines were followed. The Joanna Briggs Institute critical appraisal checklists for cohort studies, case-control studies, and randomized controlled trials were used to evaluate the methodological quality. Data were pooled using a random-effects model, and the incidence with 95% confidence intervals was evaluated using the exact binomial method and Freeman-Tukey double arcsine transformation of proportions. I2 was used to indicate heterogeneity. Predefined subgroup analysis and Meta-regression, was performed to identify the factors affecting heterogeneity.

RESULTS

The summary incidence of postoperative delirium was 18.95% [95% confidence interval, 14.36%-24.00%] with between-study heterogeneity (I2  = 95.46%). The incidence of postoperative delirium in patients who underwent free flap reconstruction was 22.13%, which was higher than those of other types of surgeries. Meta-regression revealed that conducted in sample size (P = .007) of the included studies was the factors affecting heterogeneity.

CONCLUSIONS

The evidence on postoperative delirium incidence provided by the current Meta-analysis enables effective treatment planning.

Laryngectomy in Elderly Patients: A Case Series and Review of the Literature

Background and objective Patients over the age of 75 years make up 20% of the head and neck cancer population, which is a relatively under-represented patient cohort in clinical literature. To our knowledge, there are no studies evaluating the outcomes of laryngectomy in patients aged over 75 years, which prompted us to present this unique series. Methods We reviewed departmental records at the University College Hospital, London over a 10-year period, and identified a total of 18 patients over the age of 75 years who underwent total laryngectomy for squamous cell carcinoma. We evaluated the demographic, clinical, and histopathologic features and outcomes for each patient. Results The age of the cohort ranged from 75 to 90 years, with a mean age of 79.8 years. All patients had a Charlson Comorbidity Index (CCI) score of 3 or more (due to age), with a mean of 4.7, and a maximum score of 8 for two patients. Length of inpatient stay varied significantly, ranging from 20 to 149 days, with a mean of 46 days. We identified 14 patients who underwent laryngectomy prior to September 2017, in whom the five-year survival was 21.4%. The three-year survival rate for all patients was 22.2%. In bivariate analysis, advanced age at surgery positively correlated with increased length of hospital admission and increased incidence of complications, although these results were not statistically significant (p<0.05). Conclusions Our study highlights the significance of the impact of age and comorbidities on postoperative outcomes and sheds light on the unique challenges faced by an ageing population. Careful consideration must be made in terms of appropriate patient selection, and clinicians must offer a robust and tailored approach to elderly care.

Heterocyclic Molecular Targeted Drugs and Nanomedicines for Cancer: Recent Advances and Challenges

Cancer is a top global public health concern. At present, molecular targeted therapy has emerged as one of the main therapies for cancer, with high efficacy and safety. The medical world continues to struggle with the development of efficient, extremely selective, and low-toxicity anticancer medications. Heterocyclic scaffolds based on the molecular structure of tumor therapeutic targets are widely used in anticancer drug design. In addition, a revolution in medicine has been brought on by the quick advancement of nanotechnology. Many nanomedicines have taken targeted cancer therapy to a new level. In this review, we highlight heterocyclic molecular-targeted drugs as well as heterocyclic-associated nanomedicines in cancer.

Predictors of Health Care Utilization Following Major Head and Neck Oncologic Surgery in Older Patients

OBJECTIVE

To identify patient factors in older patients associated with making posttreatment visits in the first year after major head and neck oncologic surgery.

STUDY DESIGN

Retrospective cohort study.

SETTING

Academic institution.

METHODS

Patients aged ≥60 years who underwent a neck dissection with or without a free flap reconstruction were retrospectively analyzed. Data collected included patient demographics, comorbidities, social variables, perioperative course, and clinical visits.

RESULTS

Within a 1-year postoperative period, the 181 patients in our cohort had a mean ± SD 6.37 ± 3.6 postoperative clinic visits; 70% attended at least 4 visits. Multivariable regression analysis showed a significant association with distance closer to the hospital (P = .013): for every 10-mile increase in distance, the number of visits decreased by 0.15 (SE = 0.06). Additionally, receiving adjuvant radiation therapy (P = .0096) demonstrated significant associations: when compared with no adjuvant therapy, radiation therapy had on average 1.5 (SE = 0.56) more visits, and chemoradiation had 0.04 (SE = 0.73) more visits.

CONCLUSION

Older patients who undergo major head and neck oncology surgery are more likely to attend posttreatment visits in the 1 year following surgery if they are discharged home rather than to a skilled nursing facility, live closer to the hospital, and undergo adjuvant radiation therapy.

Emerging roles of PIWI-interacting RNAs (piRNAs) and PIWI proteins in head and neck cancer and their potential clinical implications

Head and neck squamous cell carcinoma (HNSCC) are among the well-known neoplasms originating in the oral cavity, pharynx, and larynx. Despite advancements in chemotherapy, radiotherapy, and surgery, the survival rates of the patients are low, which has posed a major therapeutic challenge. A growing number of non-coding RNAs (ncRNAs), for instance, microRNAs, have been identified whose abnormal expression patterns have been implicated in HNSCC. However, more recently, several seminal research has shown that piwi-interacting RNAs (piRNAs), a promising and young class of small ncRNA, are linked to the emergence and progression of cancer. They can regulate transposable elements (TE) and gene expression through multiple mechanisms, making them potentially more powerful regulators than miRNAs. Hence, they can be more promising ncRNAs candidates for cancer therapeutic intervention. Here, we surveyed the roles and clinical implications of piRNAs and their PIWI proteins partners in tumorigenesis and associated molecular processes of cancer, with a particular focus on HNSCC, to offer a new avenue for diagnosis, prognosis, and therapeutic interventions for the malignancy, improving patient's outcomes.

Comparison of Survival Outcomes of Different Treatment Options for cT1-2, N0 Glottic Carcinoma: A Propensity Score–Weighted Analysis

Background

Treatments for cT1-2, N0 glottic squamous cell carcinoma (GLSCC) include endoscopic resection, open surgery, and radiotherapy. The purpose of this study was to compare the outcomes of three treatment modalities and provide reference data for treatment selection.

Methods

In all, 4274 patients with cT1-2, N0 GLSCC underwent these three treatment modalities from 2004 to 2015 were identified from the Surveillance, Epidemiology, and End Results-18 database. Overall survival (OS) and disease-specific survival (DSS) of patients treated with the three modalities were compared.

Results

In the entire cohort, there were no significant differences in 5-year OS and 5-year DSS among the three treatment groups. In subgroup analyses based on stage and age, endoscopic resection provided significantly better 5-year survival than radiotherapy for cT1, N0 patients aged &lt;65 years, with an OS rate of 89.0% vs. 82.3% (p = 0.009) and a DSS rate of 95.6% vs. 88.2% (p = 0.021). For 5-year DSS, open surgery also had better outcomes than patients who received radiotherapy (5-year DSS: 98.5% vs. 88.2%, respectively; p = 0.046).

Conclusions

To summarize, for cT1, N0 GLSCC patients younger than 65 years, surgical treatment (either endoscopic or open) appears to be superior to the radiotherapy, and endoscopic resection should probably be the first consideration.

Advance directives in patients with head and neck cancer - status quo and factors influencing their creation

Background

Advance Care Planning including living wills and durable powers of attorney for healthcare is a highly relevant topic aiming to increase patient autonomy and reduce medical overtreatment. Data from patients with head and neck cancer (HNC) are not currently available. The main objective of this study was to survey the frequency of advance directives (AD) in patients with head and neck cancer.

Methods

In this single center cross-sectional study, we evaluated patients during their regular follow-up consultations at Germany’s largest tertiary referral center for head and neck cancer, regarding the frequency, characteristics, and influencing factors for the creation of advance directives using a questionnaire tailored to our cohort. The advance directives included living wills, durable powers of attorney for healthcare, and combined directives.

Results

Four hundred and forty-six patients were surveyed from 07/01/2019 to 12/31/2019 (response rate = 68.9%). The mean age was 62.4 years (SD 11.9), 26.9% were women (n = 120). 46.4% of patients (n = 207) reported having authored at least one advance directive. These documents included 16 durable powers of attorney for healthcare (3.6%), 75 living wills (16.8%), and 116 combined directives (26.0%). In multivariate regression analysis, older age (OR ≤ 0.396, 95% CI 0.181–0.868; p = 0.021), regular medication (OR = 1.896, 95% CI 1.029–3.494; p = 0.040), and the marital status (“married”: OR = 2.574, 95% CI 1.142–5.802; p = 0.023; and “permanent partnership”: OR = 6.900, 95% CI 1.312–36.295; p = 0.023) emerged as significant factors increasing the likelihood of having an advance directive. In contrast, the stage of disease, the therapeutic regimen, the ECOG status, and the time from initial diagnosis did not correlate with the presence of any type of advance directive. Ninety-one patients (44%) with advance directives created their documents before the initial diagnoses of head and neck cancer. Most patients who decide to draw up an advance directive make the decision themselves or are motivated to do so by their immediate environment. Only 7% of patients (n = 16) actively made a conscious decision not create an advance directive.

Conclusion

Less than half of head and neck cancer patients had created an advance directive, and very few patients have made a conscious decision not to do so. Older and comorbid patients who were married or in a permanent partnership had a higher likelihood of having an appropriate document. Advance directives are an essential component in enhancing patient autonomy and allow patients to be treated according to their wishes even when they are unable to consent. Therefore, maximum efforts are advocated to increase the prevalence of advance directives, especially in head and neck cancer patients, whose disease often takes a crisis-like course.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00932-5.

Management of elderly patients with head and neck cancer

There are no established guidelines for managing older patients with head and neck cancer. Most clinical trials that define current standard therapy included few elderly patients. On the other hand, there is great variability in patients' comorbidities, physical functions, cognitive function, familial and financial background and values. The key point appears to be appropriate geriatric assessment, clarifying the patients' outcomes and a multidisciplinary team approach, including the treatment decision-making policy. Although these processes should be scientific in nature, the evidence for the treatment of elderly head and neck patients is very limited. This review summarizes the evidence available regarding the management of geriatric assessment, each treatment modality and the multidisciplinary team approach for older patients with head and neck cancers.

Predictors for Adherence to Treatment Strategies in Elderly HNSCC Patients

Simple Summary

The aim of this study was to find predictors for adherence to a therapy recommended by a multidisciplinary tumour board regarding 1125 elderly patients (70–100 years) with head and neck squamous cell carcinoma (HNSCC). The 5-year overall survival was significantly higher in adherent patients (45.1% versus 19.2%). Nonadherent patients were significantly more often smokers, drinkers, and had a worse tumour stage and lower health status (Karnofsky performance status). In contrast to the chronological patient age, the biological age (Charlson Comorbidity Index) was a significant predictor for adherence. The evaluated predictors for nonadherence need to be verified prospectively.

Abstract

Finding a cure may be less important than ensuring the quality of life in elderly patients with head and neck squamous cell carcinoma (HNSCC). The aim of this study was to determine predictors for adherence. Clinical and pathological data from patients ≥70 years with HNSCC (initial diagnoses 2004–2018) were investigated retrospectively. Evaluated clinical predictors included biological age (Charlson Comorbidity Index; CCI), patient health (Karnofsky Performance Status; KPS) and therapy data. A total of 1125 patients were included. The median age was 75 years, 33.1% reached CCI ≥ 6, and 53.7% reached KPS ≤ 70%. In total, 968 patients were adherent, whereas 157 were nonadherent. Nonadherent patients were significantly more often smokers (p = 0.003), frequent drinkers (p = 0.001), had a worse health status (p ≤ 0.001) and a lower biological age (p = 0.003), an advanced T classification and lymph node involvement or UICC stage (each p ≤ 0.001). Approximately 88.0% of the included patients received a curative treatment recommendation. A total of 6.9% discontinued the therapy, and 7.0% refused the therapy. With the increasing complexity of a recommended therapy, adherence decreased. The 5-year overall survival was significantly higher in adherent patients (45.1% versus 19.2%). In contrast to the chronological patient age, biological age is a significant predictor for adherence. The evaluated predictors for nonadherence need to be verified prospectively.

Postoperative Radiation Therapy in Oral Cavity Verrucous Carcinoma

OBJECTIVES/HYPOTHESIS

We investigate the clinicopathologic and treatment factors associated with the use of postoperative radiation therapy (PORT) and its effect on overall survival (OS) for patients with oral cavity verrucous carcinoma (VC).

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective cohort study of the National Cancer Database (NCDB) from 2006 to 2015 was performed. Multivariable logistic regression was used to identify independent predictive factors associated with the use of PORT. Cox Regression survival and propensity score analyses were used to evaluate the effect of PORT on mortality.

RESULTS

A total of 356 adult patients with primary oral cavity VC who underwent definitive surgical resection were identified. A total of 10.7% of patients underwent definitive surgical resection followed by PORT. Variables associated with PORT included distance to the hospital per 10 miles (adjusted odds ratio [aOR], 0.81 [95% confidence interval (CI), 0.70-0.95]) and stage III-IV disease (aOR, 12.13 and 23.92, respectively). Multivariable Cox regression survival analysis indicated no evidence of survival benefit in patients undergoing PORT compared to surgery alone (adjusted hazard ratio 1.50 [0.74-3.05], P = .23). Propensity score analysis also showed no OS benefit with the use of PORT (P = .41).

CONCLUSIONS

Variables associated with the use of PORT on multivariable analysis included closer distance to hospital and stage III-IV disease. No clear survival benefit with PORT was identified on either multivariable survival analysis or propensity score analysis. These results suggest that surgery alone with negative margins may be the optimal treatment for patients with oral cavity VC.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Three weekly versus weekly concurrent cisplatin: safety propensity score analysis on 166 head and neck cancer patients

Background

Radio-chemotherapy with CDDP is the standard for H&N squamous cell cancer. CDDP 100 mg/m²/q3 is the standard; alternative schedules are used to reduce toxicity, mostly 40 mg/m²/q1.

Methods

Patients were treated from 1/2010 to 1/2017 in two Radiation Oncology Centres. Propensity score analysis (PS) was retrospectively used to compare these two schedules.

Results

Patients analyzed were 166. Most (114/166) had 1w-CDDP while 52 had 3w-CDDP. In the 3w-CDDP group, patients were younger, with better performance status, smaller disease extent and a more common nodal involvement than in the 1w-CDDP. Acute toxicity was similar in the groups. Treatment compliance was lower in the w-CCDP. Overall survival before PS was better for female, for oropharyngeal disease and for 3w-CDDP group. After PS, survival was not related to the CDDP schedule.

Conclusions

3w-CDDP remains the standard for fit patients, weekly schedule could be safely used in selected patients.

Treatment Outcomes of Head and Neck Cancer Patients in the Elderly Receiving Different Chemoradiation Combinations: A Single-Center Experience

OBJECTIVES

This study aimed to assess the effect of definitive or adjuvant concurrent chemoradiation (CRT) among elderly patients with locally advanced head and neck squamous cell carcinoma (LA HNSCC).

MATERIALS AND METHODS

We retrospectively analyzed 150 elderly LA HNSCC patients (age ≥70) at a single institution. Demographics, disease control outcomes, and toxicities with different chemotherapy regimens were reviewed. The Kaplan-Meier method was used to estimate progression-free survival (PFS) and overall survival (OS) estimates.

RESULTS

Median age at diagnosis was 74 years (range 70-88). Of the cohort, 98 (65.3%) patients received definitive and 52 (34.7%) received adjuvant CRT; 44 (29.3%) patients received weekly carboplatin and paclitaxel, 43 (28.7%) weekly cetuximab, 33 (22%) weekly carboplatin, and 30 (20%) weekly cisplatin. The OS at 2 years was 70% (95% confidence interval [CI]: 63-79%), and PFS at 2 years was 61% (95% CI: 53-70%). There was no significant difference in OS or PFS between definitive and adjuvant CRT (p = 0.867 and p = 0.475, respectively). Type of chemotherapy regimen (single-agent carboplatin vs. others) (95% CI: 1.1-3.9; p = 0.009) was a key prognostic factor in predicting OS in multivariable analysis. Concurrent use of cetuximab was associated with increased risk of PEG tube dependence at 6 months (p < 0.001).

CONCLUSIONS

Management of LA HNSCC in the elderly is a challenging scenario. Our study shows that CRT is a feasible treatment modality for elderly patients with LA HNSCC. We recommend CRT with weekly cisplatin or weekly carboplatin and paclitaxel. A chemotherapy regimen should be carefully selected in this difficult to treat population.

Ibero-American Expert Consensus on Squamous Cell Carcinoma of the Head and Neck Treatment in Patients Unable to Receive Cisplatin: Recommendations for Clinical Practice

Cisplatin is the standard of treatment for squamous cell carcinoma of the head and neck (SCCHN) that has demonstrated efficacy, either in locally advanced disease when combined with radiotherapy at high doses, or in metastatic/recurrent disease when combined with other agents. However, the usual toxicities related to cisplatin, such as neurotoxicity, nephrotoxicity, ototoxicity, and hematologic toxicities, especially when high doses have been administered, have important implications in the patients' quality of life. The decision to administer cisplatin depends on several patient factors, such as age, performance status, weight loss, comorbidities, previous toxicities, chronic viral infection, or even the current SARS-CoV-2 pandemic. In order to establish recommendations for the management of patients with SCCHN, a group of experts in medical and radiation oncology from Spain and Latin-American discussed how to identify patients who are not candidates for cisplatin to offer them the most suitable therapeutic alternative.

The impact of age on outcome in phase III NRG Oncology/RTOG trials of radiotherapy (XRT) +/- systemic therapy in locally advanced head and neck cancer

PURPOSE

To examine the role age plays in the treatment and prognosis of locally advanced head and neck cancer (LAHNC) treated definitively with radiation alone or combined modality therapy.

METHODS

A retrospective analysis was performed of three NRG/RTOG trials examining either radiation alone or combined radiation and systemic therapy for LAHNC. The effect of age (≥70 yrs.) on cause-specific survival (CSS), overall survival (OS), and toxicity was evaluated.

RESULTS

A total of 2688 patients were analyzed, of whom 309 patients (11.5%) were ≥ 70. For all studies combined, the hazard ratio (HR) for CSS for patients age ≥ 70 vs. those <70 was 1.33 (95%CI: 1.14-1.55, p < 0.001). For OS, the HR for patients age ≥ 70 vs. those <70 for all studies combined was 1.55 (95% CI 1.35-1.77, p < 0.001). After adjustment for all covariates, age ≥ 70 was associated with worse OS regardless of adjustment for smoking and p16 status. The survival difference was more pronounced in those receiving combined radiation and systemic therapy. Hematologic and renal toxicities were increased in combined modality trials in patients ≥70 years old.

CONCLUSIONS

Patients age ≥ 70 with LAHNC were underrepresented in these clinical trials. Their CSS and OS proved inferior to patients <70 years old.

Bone marrow mesenchymal stem cells interact with head and neck squamous cell carcinoma cells to promote cancer progression and drug resistance

Head and neck cancers are often diagnosed at later stages with poor outcomes. Mesenchymal stem cells (MSC) are recruited to primary tumor sites where they can have pro- and antitumorigenic influence. In trying to better understand the dynamics between MSC and cancer cells, we found that head and neck cancer-MSC exposure resulted in mesenchymal features, elevated proliferation rate, and were more motile, like the same cells that fused with MSC. We orthotopically grafted the parental head and neck cancer cells, those fused with MSC, or those exposed to MSC into the tongues of mice. The cancer cells originally incubated with MSC developed larger more aggressive tumors compared to the parental cell line. RNA sequencing analysis revealed the expression of genes associated with drug resistance in the cancer cells exposed to MSC compared to parental cancer cells. Strikingly, MSC exposed cancer cell lines developed paclitaxel resistance that could be maintained up to 30 d after the initial co-incubation period. The secretory profile of the MSC suggested IL-6 to be a potential mediator of epigenetic imprinting on the head and neck cancer cells. When the MSC-imprinted cancer cells were exposed to the demethylation agent, 5-aza-2'deoxycytidine, it restored the expression of the drug resistance genes to that of parental cells. This study demonstrated that the recognized recruitment of MSC to tumors could impart multiple protumorigenic properties including chemotherapy resistance like that observed in the relatively rare event of cancer/MSC cell fusion.

Comparison of the efficacy and safety of the EXTREME regimen for treating recurrent or metastatic head and neck squamous cell carcinoma in older and younger adult patients

Background

Head and neck squamous cell carcinoma (HNSCC) is a geriatric cancer. However, older adult patients are frequently underrepresented in large clinical trials.

Aims

The aim of this study is to assess the efficacy and safety of the EXTREME regimen (platinum + fluorouracil + cetuximab) in older and younger adult patients with HNSCC.

Methods and results

Patients with recurrent or metastatic HNSCC treated with the EXTREME regimen were retrospectively analyzed. We compare the efficacy and safety in older (aged ≥70 years) younger (aged <70 years) adult patients. Of the 86 patients examined in this study, 21 (24.4%) were older adults. There was no difference in overall response rate (46.9% vs 38.5%, P = .76), median progression‐free survival [5.7 months vs 5.8 months, hazard ratio (HR) 0.88, 95% confidence interval (CI) = 0.52‐1.51, P = .66] and overall survival (OS) (14.6 months vs 15.2 months, HR 0.79, 95% CI 0.43‐1.43, P = .44) in younger vs older patients. There was also no difference in the incidence of grade 3/4 adverse events between groups. The exploratory analysis for geriatric nutritional risk index (GNRI) showed the association with lower GNRI (≤98) and poor OS in older adult patients (37.7 months vs 7.0 months, HR 0.53, 95% CI 0.31‐0.89, P = .002).

Conclusions

The EXTREME regimen with optimal dose modification is safe and effective for both older and younger adult patients with HNSCC. The GNRI can be an indicator to select the older adult patients who can get benefit from the EXTREME regimen.

Road traffic whiplash injury in the elderly: Clinical and video-nystagmographic features

PURPOSE

Whiplash is a type of trauma typically caused by a rear end collision in a road accident. About one in two patients who experience whiplash report dizziness and balance problems, which can severely affect their activities in daily life. In industrialized countries, the number of elderly people with a driving license has increased in recent years. The aims of the present study were to describe the video-nystagmographic features in a consecutive series of elderly patients experiencing whiplash injury in a road accident, comparing them with similar injuries in a group of young adults.

METHODS

Twenty-seven patients aged 65 years or more and a control group of 32 young adults between 18 and 21 years old were retrospectively selected. All patients underwent oto-vestibular assessment and video-nystagmography.

RESULTS

After whiplash trauma, vertigo was more common in elderly patients with decreased peak velocity during the saccadic ocular motricity test (p = 0.017) and with evidence of bilateral vestibular hypofunction after caloric stimulation (p = 0.033). Comparing the two age groups, neck pain after the trauma was reported significantly more by young adults (p = 0.003), who also showed more frequently bilateral vestibular hypofunction (p = 0.025).

CONCLUSION

Clinical and instrumental findings seem to support the hypothesis of a functional lesion to the brainstem regions after a whiplash injury. There is an undeniable need, however, for tools capable of objectively assessing the functional or anatomical damage resulting from whiplash-associated disorders, for both clinical and medico-legal reasons.

Long-Term Patient-Reported Quality of Life After Stereotactic Body Radiation Therapy for Recurrent, Previously-Irradiated Head and Neck Cancer

Objectives: Long-term quality-of-life data following stereotactic body radiation therapy (SBRT) for recurrent head and neck cancer (rHNC) is underreported. We report patient-reported quality-of-life (PR-QOL) after at least 1 year post-treatment. Methods and Materials: A retrospective review was performed on 64 patients receiving SBRT for previously-irradiated rHNC. PR-QOL was prospectively evaluated using the University of Washington Quality of Life Questionnaire. The mixed effects proportional odds model was used to assess post-treatment overall PR-QOL changes, as well as the effects of late toxicities, tumor volume > 25 cc, local failure, nodal recurrence, distant failure, prior neck dissection, performance status other than ECOG 0 or Karnofsky 100, sex, age >65, squamous vs. non-squamous primary histology, and specific organ recurrence. Results: SBRT had no significant effect on overall PR-QOL at days 1-90 post-treatment (SBRT effect 0.035, p = 0.93) and days 91-365 (SBRT effect -0.30, p = 0.45). Beyond day 365, overall PR-QOL was significantly worse than baseline (SBRT effect -0.77, p =.03). Grade ≥3 late toxicities (p = 0.0072) and tumor volume > 25 cc (p = 0.032) predicted significantly worse overall PR-QOL. Oral cavity recurrence predicted significant decrements in chewing (p = 0.0006), swallowing (p = 0.0301), and taste PR-QOL (p = 0.02). Nasal recurrence predicted significant decrements in taste PR-QOL (p = 0.030). Grade ≥3 late dysphagia predicted significant decline in chewing (p = 0.039) and swallowing (p = 0.0004). Grade ≥3 late osteonecrosis predicted significant differences in pain PR-QOL (p = 0.0026). Conclusion: PR-QOL across several domains declines immediately after SBRT for previously-irradiated rHNC before returning to baseline levels at 1 year. Long-term PR-QOL declines thereafter. Patients with grade ≥3 late toxicities or tumor volume >25 cc report reduced long-term overall PR-QOL, likely representing late disease progression. Specific organ recurrence and grade ≥3 late toxicities predict decrements in specific PR-QOL domains.

The synthesis of rare earth metal-doped upconversion nanoparticles coated with d-glucose or 2-deoxy-d-glucose and their evaluation for diagnosis and therapy in cancer

Silica coated NaY_0.8Yb_0.16Tm_0.04F₄ NPs functionalized with d-glucose or 2-deoxy-d-glucose were prepared. Cytotoxicity and uptake studies on MCF-7 cells revealed the potential of formulation in bioimaging, therapy.

Nivolumab versus investigator's choice in patients with recurrent or metastatic squamous cell carcinoma of the head and neck: Efficacy and safety in CheckMate 141 by age

OBJECTIVES

Many patients with squamous cell carcinoma of the head and neck (SCCHN) are ≥65 years old; comorbidities and other age-related factors may affect their ability to tolerate traditional chemotherapy. Nivolumab is the only immunotherapy to significantly improve overall survival (OS) versus investigator's choice (IC) of single-agent chemotherapy at primary analysis in a phase 3 trial (CheckMate 141) in patients with recurrent/metastatic SCCHN post-platinum therapy. In this post hoc analysis, we report efficacy and safety by age.

PATIENTS AND METHODS

Eligible patients were randomized 2:1 to nivolumab 3 mg/kg every 2 weeks (n = 240) or IC (methotrexate, docetaxel, or cetuximab n = 121). The primary endpoint of the trial was OS. For this analysis, outcomes were analyzed by age < 65 and ≥65 years. The data cut-off date was September 2017 (minimum follow-up 24.2 months).

RESULTS

At baseline, 68 patients (28.3%) receiving nivolumab and 45 patients (37.2%) receiving IC were ≥65 years. Baseline characteristics were generally similar across age groups. OS and tumor response benefits with nivolumab versus IC were maintained regardless of age. The 30-month OS rates of 11.2% (<65 years) and 13.0% (≥65 years) with nivolumab were more than tripled versus corresponding IC rates of 1.4% and 3.3%, respectively. The nivolumab arm had a lower rate of treatment-related adverse events versus IC regardless of age, consistent with the overall patient population.

CONCLUSION

In CheckMate 141, nivolumab resulted in a higher survival versus IC in patients <65 and ≥65 years, with a manageable safety profile in both age groups. ClinicalTrials.gov: NCT02105636.

Individualized survival prediction for patients with oropharyngeal cancer in the human papillomavirus era

BACKGROUND

Accurate, individualized prognostication in patients with oropharyngeal squamous cell carcinoma (OPSCC) is vital for patient counseling and treatment decision making. With the emergence of human papillomavirus (HPV) as an important biomarker in OPSCC, calculators incorporating this variable have been developed. However, it is critical to characterize their accuracy prior to implementation.

METHODS

Four OPSCC calculators were identified that integrate HPV into their estimation of 5-year overall survival. Treatment outcomes for 856 patients with OPSCC who were evaluated at a single institution from 2003 through 2016 were analyzed. Predicted survival probabilities were generated for each patient using each calculator. Calculator performance was assessed and compared using Kaplan-Meier plots, receiver operating characteristic curves, concordance statistics, and calibration plots.

RESULTS

Correlation between pairs of calculators varied, with coefficients ranging from 0.63 to 0.90. Only 3 of 6 pairs of calculators yielded predictions within 10% of each other for at least 50% of patients. Kaplan-Meier curves of calculator-defined risk groups demonstrated reasonable stratification. Areas under the receiver operating characteristic curve ranged from 0.74 to 0.80, and concordance statistics ranged from 0.71 to 0.78. Each calculator demonstrated superior discriminatory ability compared with clinical staging according to the seventh and eighth editions of the American Joint Committee on Cancer staging manual. Among models, the Denmark calculator was found to be best calibrated to observed outcomes.

CONCLUSIONS

Existing calculators exhibited reasonable estimation of survival in patients with OPSCC, but there was considerable variability in predictions for individual patients, which limits the clinical usefulness of these calculators. Given the increasing role of personalized treatment in patients with OPSCC, further work is needed to improve accuracy and precision, possibly through the identification and incorporation of additional biomarkers.

Free flap head and neck reconstruction: Feasibility in older patients

OBJECTIVES

The main purpose of this study was to evaluate the perioperative morbidity of free flap head and neck reconstructive surgery in patients aged 70 years and over (Group A) by comparison with a cohort of younger patients (Group B). Secondary objectives included assessment of survival rates and functional outcomes in these older patients, likewise by comparison with a cohort of younger patients.

METHODS

A retrospective study was conducted on all patients aged 70 years and over who underwent free flap reconstruction between 2012 and 2017. They were compared to a control group of younger patients to investigate hospital length of stay, postoperative complications and survival rates, and functional outcomes.

RESULTS

No significant difference was observed between the two groups in terms of variables such as hospital length of stay and medical/surgical complications. In multivariate analysis, comorbidity was the only predictive factor for postoperative medical complications, and pharyngolaryngeal location the only significant predictive factor for surgical complications. Factors significantly associated with hospital length of stay were older age, active smoking, pharyngolaryngeal location and the Charlson Comorbidity Index (CCI). Overall survival was the only factor that was substantially lower in the over 70 group, while disease-specific and relapse-free survival were comparable in both groups.

CONCLUSION

Old age per se should not be considered a contraindication to major surgery combined with free flap reconstruction in older patients.

Criteria for eligibility to cisplatin in the curative treatment of head and neck cancer: Consensus opinion from a panel of experts

Squamous-cell carcinoma of the head and neck (SCCHN) is an important problem in Brazil, where epidemiological and socioeconomic features often create barriers to the implementation of combined modalities with curative potential. Cisplatin improves the efficacy of radiotherapy in the adjuvant treatment of localized SCCHN and in the definitive therapy of locally advanced disease. However, the addition of high-dose cisplatin to radiotherapy increases treatment toxicity and is not always warranted. A panel of experts convened in Sao Paulo, Brazil, for discussions and recommendations regarding the use of high-dose cisplatin in combination with radiotherapy in SCCHN. In addition to discussing their professional experience, panel members used the current literature to provide evidence-based, practical recommendations regarding sociodemographic or medical criteria that may preclude safe administration of cisplatin. It is hoped that the application of these recommendations in clinical practice may improve therapeutic results in Brazil and other countries with similar health-care environments.

Managing older patients with head and neck cancer: The non-surgical curative approach

Managing older patients with head and neck cancers poses a challenge due to the often reduced levels of physiological reserve, the frequent comorbidities and treatment related toxicity. These factors have implications on speech, breathing and swallowing functions. Treatment management plans in these patients may result in de-intensification strategies and as a result of this, use of non-standard treatments is increasing. There have been published reports that indicate the addition of concurrent systemic therapy to radiation in selected older patients is feasible, and produces outcomes comparable with younger patients. However, some other studies including meta-analyses suggest a lack of real survival benefit with the addition of chemotherapy. So, the key point appears to be the optimal patient selection. Appropriate geriatric and frailty assessments are required to help determine the optimal treatment for older patients with head and neck cancer. Treatment for this population still needs to be well defined and optimized in both modality and intensity. Qualitative studies are also required to address short and long-term post-treatment quality-of-life and survivorship issues in this specific patient population. This review summarizes the evidence available regarding the non-surgical management of older patients with head and neck cancers.

Increasing prevalence of human papillomavirus-positive oropharyngeal cancers among older adults

BACKGROUND

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is increasing among older adults. It is unknown whether these trends can be explained by human papillomavirus (HPV) and whether HPV-related tumors remain associated with an improved prognosis among older patients.

METHODS

In a retrospective study of OPSCCs diagnosed from 1995 to 2013 at 2 National Comprehensive Cancer Network-designated cancer centers, p16 immunohistochemistry and in situ hybridization (ISH) for HPV-16, high-risk DNA, and/or E6/E7 RNA were performed. The median age at diagnosis was compared by p16 and ISH tumor status. Trends in age were analyzed with nonparametric trends. Survival was analyzed with the Kaplan-Meier method and Cox proportional hazards models.

RESULTS

Among 239 patients, 144 (60%) were p16-positive. During 1998-2013, the median age increased among p16-positive patients (P_trend = .01) but not among p16-negative patients (P_trend = .71). The median age of p16-positive patients increased from 53 years (interquartile range [IQR] in 1995-2000, 45-65 years) to 58 years (IQR for 2001-2013, 53-64 years). Among patients ≥ 65 years old, the proportion of OPSCCs that were p16-positive increased from 41% during 1995-2000 to 75% during 2007-2013 (P_trend = .04). Among all age groups, including older patients, a p16-positive tumor status conferred improved overall survival in comparison with a p16-negative status.

CONCLUSIONS

The median age at diagnosis for HPV-related OPSCC is increasing as the proportion of OPSCCs caused by HPV rises among older adults. The favorable survival conferred by an HPV-positive tumor status persists in older adults. Cancer 2018;124:2993-9. © 2018 American Cancer Society.

Outcomes of Craniofacial Open Surgery in Octogenarians

Introduction  The steady increase in average life expectancy has led to a rise in the number of referrals of elderly patients for major operations. It is not clear whether age itself is a risk factor for morbidity and mortality after skull base operations. We investigated a possible link among a cohort of patients older than 80 years of age who underwent those surgeries in our department. Methods  We conducted a retrospective analysis of all patients who underwent skull base surgery at the TASMC (Tel Aviv Sourasky Medical Center) between 2000 and 2016. Results  A total of 369 patients underwent open skull base surgeries in our institution, and 13 were patients older than 80 years. The median age of the octogenarians was 83.4 (range 80-89), and the male-to-female ratio was 7:6. Twelve patients had major systemic comorbidities. Four patients had major complications associated with surgery: three had early wound complications, and one each had early central nervous system complications, early and late systemic complications, and late orbital complications. This complication rate is comparable to that of our younger group of 356 patients. The overall survival rate was measured for 30 days, 1 year, and 3 years, and it was not significantly different between the octogenarians and that of the younger patients. Further comparison of the elderly group with 13 matched younger patients revealed no difference of morbidity and mortality between the two groups. Conclusions  Despite their systemic comorbidities, the morbidity and mortality rates associated with skull base surgery in octogenarians appear to be comparable to that of younger patients undergoing the same procedures.

Prognostic factors in head and neck cancer: a 10-year retrospective analysis in a single-institution in Italy

This study was undertaken to evaluate the association between demographics, lifestyle habits, and clinical data and overall survival (OS), recurrence and second primary cancer (SPC) in patients with first primary head and neck cancer (HNC). We retrospectively reviewed data from 482 patients treated at the "Agostino Gemelli" Teaching Hospital, Rome, between 2002-2012 for primary HNC. Individual parameters were evaluated for association with specific outcomes such as OS, cancer recurrence and second primary cancer (SPC) appearance using hazard ratios (HR) and 95% confidence intervals (CIs). Five-year OS was 60.6% for all HNC cases, 49.0% for oral cavity, 54.8% for oropharynx, 50.0% for hypopharynx and 63.4% for larynx. Predictors of OS were older age (HR = 1.04; 95% CI: 1.02-1.05) and advanced tumour stage (HR = 2.00; 95% CI: 1.41-2.84). The risk of recurrence was associated with drinking 8-14 drinks per week (HR = 1.73; 95% CI: 1.00-2.97). The risk of developing SPC increased with advanced tumour stage (HR = 2.75; 95% CI: 1.39-5.44) and with smoking for more than 40 years (HR = 3.68; 95% CI: 1.10-12.30). OS differed among HNC sites. Increasing age was an unfavourable predictor of HNC OS. Tumour stage was a prognostic factor both for OS and for risk of developing SPC. Alcohol and tobacco consumption were prognostic factors for recurrence and SPC, respectively.

Third Repeat Microvascular Reconstruction in Head and Neck Cancer Patients Aged 65 Years and Older: A Longitudinal and Sequential Analysis

Performing a sequential third free flap for reconstruction of a head and neck defect after cancer resection can be challenging, and the problem is further compounded in elderly patients. The outcomes in this clinical scenario are currently unknown and this study aims to compare the results in elderly patients with younger patients in a high-volume microsurgical unit. A retrospective review of 126 consecutive patients who had undergone three sequential free flap reconstructions after head and neck cancer was performed. The patients were divided into two groups – older or younger than 65 years old (n = 105 and n = 21, respectively). Patient demographics, intraoperative and postoperative outcomes were noted and analyzed. The overall flap success in this patient cohort was 94.4% (7 flap losses in 126 patients). Cardiovascular complications were significantly more common in the older group (19% vs. 1.9%, p = 0.001). Delirium occurred more frequently in the older group compared with the younger group (23.8% vs. 6.7%, p = 0.023). There were no significant differences regarding surgical complications. With adequate planning, a sequential third free flap can be performed safely and successfully in patients who are more than 65 years of age. Particular attention to the perioperative morbidity in elderly patients is crucial for successful outcomes.

A population-based comparison of European and North American sinonasal cancer survival

OBJECTIVE

Sinonasal cancers (SNC) are rare, thus limiting previous prognostic studies on a multinational level. The aim of this study is to utilize two population-based datasets to compare prognoses for SNC between the United States (US) and Europe.

METHODS

The European Cancer Registry (EUROCARE) database and the United States National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database were searched to identify survival of patients diagnosed with SNC between 1990 and 2007. Relative survival (RS) data were stratified by age group, gender, geographic location, and diagnostic time period.

RESULTS

12,541 SNC cases were identified in EUROCARE, while SEER identified 4,312. Males comprised the majority in Europe (62.3%) and the US (58.3%). Most patients were over 55 years in Europe (77.0%) and the US (69.5%). Age over 75 was a statistically significant poor prognostic indicator for 5-year RS in the US (48.2%; 95% CI=[43.9, 52.4]) and Europe (38.5%; [34.7, 42.7]). Female gender imparted a favorable 5-year RS in all regions except in Central Europe. By region, the US had the highest 5-year RS (58.8%; [56.4, 61.1]) and Eastern Europe had the lowest 5-year RS (37.1%; [34.0, 40.6]). The aggregate European 5-year RS was 48.1% [46.4, 49.8].

CONCLUSION

SNC in Europe and the US most commonly affects males and individuals over the age of 55 years. Male gender and age over 75 are poor prognostic factors at 5 years. Five-year RS in the US is higher than the 5-year European aggregate RS.

Age-specific incidence and treatment patterns of head and neck cancer in the Netherlands-A cohort study

OBJECTIVES

To explore the incidence and treatment pattern of head and neck cancer in different age groups.

DESIGN

Cohort study.

SETTING

Netherlands Cancer Registry.

PARTICIPANTS

All new primary head and neck cancer cases diagnosed between 2010 and 2014 were included and categorised into different age groups.

MAIN OUTCOME MEASURES

Tumour site, stage, treatment modality, location of diagnosis and treatment.

RESULTS

The study population was composed of 11 558 tumours. Oral cancer was the most common primary site (31%), followed by laryngeal (25%) and oropharyngeal cancer (22%). Ninety-six per cent of the entire study population was diagnosed and/or treated in a certified head and neck oncology centre which was lower in the 80+ population (92%). Multimodality treatment was less frequently applied with increasing age (eg oral cavity: 17% in 80+ vs 34% in 60-; P < .001). The percentage of patients not receiving tumour-directed treatment increased with age (eg oropharyngeal cancer: 25% in 80+ vs 6% in 80-; P < .001).

CONCLUSIONS

This study confirms that less multimodal and tumour-directed treatment is applied with the increasing age of head and neck cancer patients.

Calcified carotid artery atheromas on panoramic radiographs of head and neck cancer patients before and after radiotherapy

Background

The aims of this study were to verify if head and neck radiotherapy (RT) is able to induce calcified carotid artery atheroma (CCAA) in a large head and neck cancer (HNC) population and also to compare the socio-demographic and clinical findings of patients with and without CCAA detected on panoramic radiographs.

Material and Methods

Panoramic radiographs taken before and after head and neck radiotherapy (RT) of 180 HNC patients were selected and analyzed in order to identify the presence of CCAA. In addition, CCAA presence or absence on panoramic radiographs were compared and correlated with clinicopathological findings.

Results

A high overall prevalence of CCAA was found on panoramic radiographs (63 out of 180 = 35%) of HNC patients. No significant difference of CCAA before and after RT was observed. There were also no differences between groups (with and without CCAA) regarding age, gender, tobacco and alcohol use, arterial hypertension, diabetes mellitus, acute myocardial infarction, hypercholesterolemia, tumor location, clinical stage of disease and RT dose. However, there was a greater prevalence of strokes in patients with CCAA (p<0.05).

Conclusions

Although CCAA were frequently found in panoramic radiographs of patients with HNC, RT seems not to alter the prevalence of these calcifications.

Key words:Head and neck cancer, radiotherapy, carotid artery diseases, panoramic radiography.

Patterns of Care in Adjuvant Therapy for Resected Oral Cavity Squamous Cell Cancer in Elderly Patients

PURPOSE

To characterize the patterns of care and potential barriers to access to care for elderly patients with oral cavity cancer in the adjuvant setting.

METHODS AND MATERIALS

We performed a retrospective cohort study using the National Cancer Data Base and identified patients with resected oral cavity squamous cell carcinoma diagnosed between 2004 and 2012, who survived for ≥3 months after surgery. We used logistic regression models to assess the association between age (<70, 70-79, and ≥80 years) and the receipt of adjuvant therapy within 3 months of surgery. We additionally assessed the association between patient and tumor characteristics and the receipt of adjuvant therapy among those aged ≥70 years.

RESULTS

A total of 25,829 patients were included in the study. Compared with those aged <70 years, older patients were more likely to have no neck dissection or have fewer lymph nodes dissected and were less likely to receive adjuvant therapy than younger patients. Among our cohort, 11,361 patients (44%) had pathologic T3-T4 disease or N2-N3 disease, and 4185 patients (16%) had extracapsular nodal extension or positive surgical margins. In multivariate analyses controlling for comorbidity and demographic characteristics, older age was independently associated with lower odds of receiving adjuvant radiation therapy in the subgroup with T3 or T4 disease or N2 or N3 disease and adjuvant chemoradiation therapy in the positive extracapsular nodal extension or positive surgical margin subgroup. Among elderly patients, both greater patient distance from reporting facility and older age were associated with lower odds of receiving both adjuvant radiation therapy (odds ratio 0.66; 95% confidence interval, 0.55-0.81) and chemoradiation therapy (odds ratio 0.56; 95% confidence interval, 0.40-0.79).

CONCLUSIONS

In a national hospital-based cohort of patients with oral cavity cancer, elderly patients were less likely to receive adjuvant radiation or chemoradiation therapy. Greater patient distance from reporting facility, in addition to older age, was associated with lower odds of receiving both adjuvant radiation therapy and adjuvant chemoradiation therapy.

Successful tongue cancer surgery under general anesthesia in a 99-year-old patient in Okinawa, Japan: A case report and review of the literature

As advances in the medical field have resulted in increased life expectancy, performing surgery under general anesthesia in elderly patients has become an important issue. A 99-year-old Okinawan female was admitted to the hospital presenting with pain in the tongue. Following physical examination, a clinical diagnosis of early stage tongue cancer (T2N0Mx) was confirmed. Early stage tongue cancer is particularly easy to access for surgical resection. By contrast, later stages of tongue cancer are associated with pain, dysphagia and throat obstruction. The patient and their family agreed to surgery due to the worsening pain associated with the tumor and gave informed consent for surgery. Following consultation with a cardiologist and an anesthesiologist, the tongue tumor was surgically resected under general anesthesia. Subsequent to surgery, the patient experienced pain relief and was discharged from the hospital on day 14 post-surgery. The patient was able to maintain the same quality of life, and lived for 5 years and 2 months longer without evidence of disease, surviving to the age of 104 years old. The present case demonstrates that surgery under general anesthesia may be appropriate in patients of an advanced age, with a treatment plan that should ideally be based on careful assessment of the wishes of the patient and their family, medical risks, and benefits and economic costs of alternative treatments, in addition to consideration of the patient's culture.

Incidence and risk factors for morbidity and mortality in elderly head and neck cancer patients undergoing major oncological surgery

PURPOSE

Cancer incidence in the elderly population has been continuously rising, and their treatment is an increasing concern among oncologists. This study aimed to evaluate the incidence and risk factors for morbidity and mortality after major oncological surgery in elderly patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

The 196 HNSCC patients aged 55 and older who underwent major curative surgery. Patients were categorized into three groups: far-old (≥75 years; n = 41); old (65-74 years; n = 72); or middle-aged (55-64 years; n = 83). The rates of early and late postoperative complications, hospital stays, and mortality were compared among groups. Univariate and multivariate analyses were performed to identify the factors associated with early postoperative complications.

RESULTS

No study patients had mortality during surgery or within 3-month postoperation. Karnofsky performance status, frail functional status, comorbidity, and index cancer and noncancer mortality were the poorest in the far-old group. The far-old group demonstrated significantly higher rates of early overall complications, readmission within 1 month, and recurrence rates (P < 0.05 each). Multivariate analysis showed that age, postoperative hemoglobin, and C-reactive protein are independent predictors of early postoperative complications (P < 0.05 each).

CONCLUSIONS

In elderly patients, chronological age affects the increased risk of early postoperative morbidity and later mortality following major HNSCC surgery. In combination with these risk factors, older patients who are diagnosed with HNSCC should be carefully monitored in order to determine the potential occurrence of postsurgical complications.

Asian expert recommendation on management of skin and mucosal effects of radiation, with or without the addition of cetuximab or chemotherapy, in treatment of head and neck squamous cell carcinoma

With increasing numbers of patients with unresectable locoregionally advanced (LA) head and neck squamous cell carcinoma (HNSCC) receiving cetuximab/radiotherapy (RT), several guidelines on the early detection and management of skin-related toxicities have been developed. Considering the existing management guidelines for these treatment-induced conditions, clinical applicability and standardization of grading methods has remained a cause of concern globally, particularly in Asian countries. In this study, we attempted to collate the literature and clinical experience across Asian countries to compile a practical and implementable set of recommendations for Asian oncologists to manage skin- and mucosa-related toxicities arising from different types of radiation, with or without the addition of cetuximab or chemotherapy. In December 2013, an international panel of experts in the field of head and neck cancer management assembled for an Asia-Pacific head and neck cancer expert panel meeting in China. The compilation of discussion outcomes of this meeting and literature data ultimately led to the development of a set of recommendations for physicians with regards to the approach and management of dermatological conditions arising from RT, chemotherapy/RT and cetuximab/RT, and similarly for the approach and management of mucositis resulting from RT, with or without the addition of chemotherapy or cetuximab. These recommendations helped to adapt guidelines published in the literature or text books into bedside practice, and may also serve as a starting point for developing individual institutional side-effect management protocols with adequate training and education.

Warfarin treatment and antifungal agent caspofungin for severe fungal infection in a patient previously treated with radiotherapy for oropharyngeal cancer

Drug–Drug interactions is important when caring for warfarin‐treated patients. We examined the impact on INR with coadministration of warfarin and caspofungin and showed no affect on the INR. Coadministrations of fluconazole lead to a marked increase in INR. We concluded that administration of caspofungin and warfarin was safe.

Stereotactic body radiotherapy for head and neck cancer: an addition to the armamentarium against head and neck cancer

In the recent years, stereotactic body radiation therapy (SBRT) has emerged as a potential therapy for head and neck malignancies. Although early results appear to be promising, serious acute and late effects have been observed, mainly in patients who have had prior external beam radiotherapy. This review will discuss the radiobiology of SBRT, clinical rationale and outcomes for SBRT in head and neck cancers and focus on the benefits and potential limitations in both de novo and re-irradiation settings.

Elderly patients with squamous cell carcinoma of the head and neck and the benefit of multimodality therapy

BACKGROUND

Limited data are available regarding outcomes in elderly head and neck cancer patients. This retrospective study was designed to characterize head and neck cancer in geriatric patients.

PATIENTS AND METHODS

This study included all patients in a large university-based tumor registry who were diagnosed with head and neck cancer from January 1, 1990, to December 31, 2005. Patients aged ≥70 years at the time of diagnosis were defined as older. Overall survival and progression-free survival were censored at 60 months. Survival differences were compared using the log-rank test. Hazard ratios were estimated using a Cox proportional hazards model, adjusting for potential confounders.

RESULTS

Of 1,598 patients identified, 1,166 patients were aged <70 years (i.e., younger) and 281 patients were aged ≥70 years (older). When controlling for possible confounders, older patients were nearly twice as likely to die within 5 years as their younger counterparts (hazard ratio: 1.92). The median life expectancy for older patients was nearly 5 years for stage I-II disease and <2 years for stage III-IV disease. Older patients with stage III-IV disease who received multimodality therapy had 5-year survival similar to that younger patients with stage III-IV disease who were treated similarly (33.2% vs. 44.0%). Older patients with stage III-IV disease who received single-modality therapy had extremely poor survival compared with all other patients (hazard ratio for progression-free survival: 1.5).

CONCLUSION

This study highlights the need for better understanding of the factors affecting head and neck cancer outcomes in elderly patients. Information about life expectancy in elderly head and neck cancer patients may help guide treatment decisions.