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Guigay J, Le Caer H, Ferrand FR, Geoffrois L, Saada-Bouzid E, Fayette J, Sire C, Cupissol D, Blot E, Guillet P, Pavillet J, Bozec L, Capitain O, Rolland F, Debourdeau P, Pointreau Y, Falandry C, Lopez S, Coutte A, Chatellier T, Dalloz P, Ortholan C, Michel C, Lacas B, Cheurfa N, Schwob D, Bourhis J, Mertens C, Aupérin A. Adapted EXTREME regimen in the first-line treatment of fit, older patients with recurrent or metastatic head and neck squamous cell carcinoma (ELAN-FIT): a multicentre, single-arm, phase 2 trial. THE LANCET. HEALTHY LONGEVITY 2024; 5:e392-e405. [PMID: 38759667 DOI: 10.1016/s2666-7568(24)00048-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND A standard treatment for fit, older patients with recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) is yet to be established. In the previous EXTREME trial, few older patients were included. We aimed to evaluate the efficacy and tolerance of an adapted EXTREME regimen in fit, older patients with recurrent or metastatic HNSCC. METHODS This single-arm, phase 2 study was done at 22 centres in France. Eligible patients were aged 70 years or older and assessed as not frail (fit) using the ELAN Geriatric Evaluation (EGE) and had recurrent or metastatic HNSCC in the first-line setting that was not eligible for local therapy (surgery or radiotherapy), and an Eastern Cooperative Oncology Group performance status of 0-1. The adapted EXTREME regimen consisted of six cycles of fluorouracil 4000 mg/m2 on days 1-4, carboplatin with an area under the curve of 5 on day 1, and cetuximab on days 1, 8, and 15 (400 mg/m2 on cycle 1-day 1, and 250 mg/m2 subsequently), all intravenously, with cycles starting every 21 days. In patients with disease control after two to six cycles, cetuximab 500 mg/m2 was continued once every 2 weeks as maintenance therapy until disease progression or unacceptable toxicity. Granulocyte colony-stimulating factor was systematically administered and erythropoietin was recommended during chemotherapy. The study was based on the two-stage Bryant and Day design, combining efficacy and toxicity endpoints. The primary efficacy endpoint was objective response rate at week 12 after the start of treatment, assessed by central review (with an unacceptable rate of ≤15%). The primary toxicity endpoint was morbidity, defined as grade 4-5 adverse events, or cutaneous rash (grade ≥3) that required cetuximab to be discontinued, during the chemotherapy phase, or a decrease in functional autonomy (Activities of Daily Living score decrease ≥2 points from baseline) at 1 month after the end of chemotherapy (with an unacceptable morbidity rate of >40%). Analysis of the coprimary endpoints, and of safety in the chemotherapy phase, was based on the per-protocol population, defined as eligible patients who received at least one cycle of the adapted EXTREME regimen. Safety in the maintenance phase was assessed in all patients who received at least one dose of cetuximab as maintenance therapy. The study is registered with ClinicalTrials.gov, NCT01864772, and is completed. FINDINGS Between Sept 27, 2013, and June 20, 2018, 85 patients were enrolled, of whom 78 were in the per-protocol population. 66 (85%) patients were male and 12 (15%) were female, and the median age was 75 years (IQR 72-79). The median number of chemotherapy cycles received was five (IQR 3-6). Objective response at week 12 was observed in 31 patients (40% [95% CI 30-51]) and morbidity events were observed in 24 patients (31% [22-42]). No fatal adverse events occurred. Four patients presented with a decrease in functional autonomy 1 month after the end of chemotherapy versus baseline. During chemotherapy, the most common grade 3-4 adverse events were haematological events (leukopenia [22 patients; 28%], neutropenia [20; 26%], thrombocytopenia [15; 19%], and anaemia [12; 15%]), oral mucositis (14; 18%), fatigue (11; 14%), rash acneiform (ten; 13%), and hypomagnesaemia (nine; 12%). Among 44 patients who received cetuximab during the maintenance phase, the most common grade 3-4 adverse events were hypomagnesaemia (six patients; 14%) and acneiform rash (six; 14%). INTERPRETATION The study met its primary objectives on objective response and morbidity, and showed overall survival to be as good as in younger patients treated with standard regimens, indicating that the adapted EXTREME regimen could be used in older patients with recurrent or metastatic HNSCC who are deemed fit with use of a geriatric evaluation tool adapted to patients with head and neck cancer, such as the EGE. FUNDING French programme PAIR-VADS 2011 (sponsored by the National Cancer Institute, the Fondation ARC, and the Ligue Contre le Cancer), Sandoz, GEFLUC, and GEMLUC. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Joël Guigay
- Partnerships and Clinical Development-Early Assets, GORTEC, Tours, France.
| | - Hervé Le Caer
- Medical Oncology Unit, Hospital Centre of Saint-Brieuc, Saint-Brieuc, France
| | | | - Lionel Geoffrois
- Medical Oncology Unit, Lorraine Cancerology Institute, Nancy, France
| | - Esma Saada-Bouzid
- Medical Oncology Department, Centre Antoine Lacassagne, University Côte d'Azur, Nice, France
| | - Jérôme Fayette
- Medical Oncology Unit, Cancer Research Centre Léon Bérard, Lyon, France
| | - Christian Sire
- Oncology-Radiotherapy Unit, Hospital Group South Bretagne, Lorient, France
| | - Didier Cupissol
- Medical Oncology Unit, Cancer Institute of Montpellier, Montpellier, France
| | - Emmanuel Blot
- Medical Oncology Unit, ELSAN Group, Private Hospital Océane, Vannes, France
| | - Pierre Guillet
- Medical Oncology Unit, Intercommunal Hospital Centre, La Seyne-sur-Mer, France
| | | | - Laurence Bozec
- Medical Oncology Unit, Curie Institute, Saint Cloud, France
| | - Olivier Capitain
- Medical Oncology Unit, West Cancerology Institute, Angers, France
| | - Frédéric Rolland
- Medical Oncology Unit, West Cancerology Institute, Saint Herblain, France
| | | | - Yoann Pointreau
- Radiation Oncology Unit, Inter-regional Cancerology Institute, Jean Bernard Center, Le Mans, France; Victor Hugo Private Clinic, Sarthe Cancer Center, Le Mans, France
| | - Claire Falandry
- Medical Oncology Unit, Hospital Centre of South Lyon, Pierre Bénite, France
| | - Stéphane Lopez
- Medical Oncology Unit, Hospital Centre of Annecy Genevois, Pringy, France
| | - Alexandre Coutte
- Medical Oncology Unit, South Hospital Centre of Amiens, Amiens, France
| | - Thierry Chatellier
- Medical Oncology Unit, Mutualist Clinic of the Estuary, Saint Nazaire, France
| | - Pierre Dalloz
- Medical Oncology Unit, Centre Jean Perrin, Clermont-Ferrand, France
| | - Cécile Ortholan
- Oncology-Radiotherapy Unit, Hospital Centre Princesse-Grace, Monaco
| | - Cécile Michel
- Centre Antoine Lacassagne, FHU OncoAge, University Côte d'Azur, Nice, France
| | - Benjamin Lacas
- Biostatistics and Epidemiology Office, Gustave-Roussy, Inserm U1018 Oncostat, Labelled Ligue Contre le Cancer, University Paris-Saclay, Villejuif, France
| | - Nadir Cheurfa
- Biostatistics and Epidemiology Office, Gustave-Roussy, Inserm U1018 Oncostat, Labelled Ligue Contre le Cancer, University Paris-Saclay, Villejuif, France
| | - Dominique Schwob
- Biostatistics and Epidemiology Office, Gustave-Roussy, Inserm U1018 Oncostat, Labelled Ligue Contre le Cancer, University Paris-Saclay, Villejuif, France
| | - Jean Bourhis
- Radiotherapy Unit, University Hospital Center of Vaudois, Lausanne, Switzerland
| | - Cécile Mertens
- Oncogeriatrics Unit, Bergonié Institute, Bordeaux, France
| | - Anne Aupérin
- Biostatistics and Epidemiology Office, Gustave-Roussy, Inserm U1018 Oncostat, Labelled Ligue Contre le Cancer, University Paris-Saclay, Villejuif, France
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Yasuda K, Uchinami Y, Kano S, Taguchi J, Kawakita D, Kitayama M, Nishioka K, Mori T, Koizumi F, Fujii Y, Shimizu Y, Kobashi K, Yoshimoto S, Nibu KI, Homma A, Aoyama H. Radiotherapy with or without chemotherapy for locally advanced head and neck cancer in elderly patients: analysis of the Head and Neck Cancer Registry of Japan. Int J Clin Oncol 2024; 29:241-247. [PMID: 38155239 DOI: 10.1007/s10147-023-02450-7] [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: 09/15/2023] [Accepted: 12/03/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Whether concurrent chemotherapy with radiotherapy (CRT) is effective for elderly patients with head and neck cancer is a controversial topic. This study aimed to analyze the effectiveness of CRT vs. radiation therapy (RT) among elderly patients in Japan. METHODS Data from the Head and Neck Cancer Registry of Japan were extracted and analyzed. Patients with locally advanced squamous cell carcinoma of the oropharynx, hypopharynx, or larynx who received definitive CRT or RT between 2011 and 2014 were included. RESULTS CRT was administered to 78% of the 1057 patients aged ≥ 70 years and 67% of the 555 patients aged ≥ 75 years. For the patients aged ≥ 75 years, the overall survival (OS) rate was significantly better in the CRT group than in the RT group (P < 0.05), while the progression-free survival (PFS) rate was not significantly different (P > 0.05). The add-on effect of CRT was significantly poor in elderly patients (P < 0.05), and it was not a significant factor in the multivariate analysis for patients aged ≥ 75 years. After propensity score matching, there were no significant differences in the OS and PFS rates between the patients aged ≥ 70 years and those aged ≥ 75 years (all, P > 0.05). CONCLUSION Although aggressive CRT is administered to elderly patients in Japan, its effectiveness is uncertain. Further prospective randomized trials are needed to verify whether CRT is superior to RT alone for elderly patients.
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Affiliation(s)
- Koichi Yasuda
- Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, 060-8638, Japan.
| | - Yusuke Uchinami
- Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, 060-8638, Japan
| | - Satoshi Kano
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Jun Taguchi
- Department of Medical Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Daisuke Kawakita
- Japan Society for Head and Neck Cancer, Tokyo, Japan
- Department of Otorhinolaryngology, Head and Neck Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Megumi Kitayama
- Japan Society for Head and Neck Cancer, Tokyo, Japan
- Clinical Study Support Center, Wakayama Medical University Hospital, Wakayama, Japan
| | - Kentaro Nishioka
- Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, 060-8638, Japan
- Global Center for Biomedical Science and Engineering, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Takashi Mori
- Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, 060-8638, Japan
| | - Fuki Koizumi
- Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, 060-8638, Japan
| | - Yuri Fujii
- Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, 060-8638, Japan
| | - Yasushi Shimizu
- Department of Medical Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Keiji Kobashi
- Global Center for Biomedical Science and Engineering, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Seiichi Yoshimoto
- Japan Society for Head and Neck Cancer, Tokyo, Japan
- Department of Head and Neck Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Ken-Ichi Nibu
- Japan Society for Head and Neck Cancer, Tokyo, Japan
- Department of Otolaryngology-Head and Neck Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Akihiro Homma
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hidefumi Aoyama
- Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, 060-8638, Japan
- Global Center for Biomedical Science and Engineering, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
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Guigay J, Ortholan C, Vansteene D, Cupissol D, Even C, Kaminsky MC, Sire C, Blot E, Debourdeau P, Bozec L, Saada-Bouzid E, Fayette J, Dalloz P, Pointreau Y, Caer HL, Falandry C, Digue L, Braccini A, Lopez S, Guillet P, Michel C, Cheurfa N, Schwob D, Bourhis J, Mertens C, Aupérin A. Cetuximab versus methotrexate in first-line treatment of older, frail patients with inoperable recurrent or metastatic head and neck cancer (ELAN UNFIT): a randomised, open-label, phase 3 trial. THE LANCET. HEALTHY LONGEVITY 2024; 5:e182-e193. [PMID: 38432247 DOI: 10.1016/s2666-7568(23)00284-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND At present, there is no established standard treatment for frail older patients with recurrent or metastatic head and neck squamous cell carcinoma. We aimed to compare the efficacy and safety of cetuximab to those of methotrexate (the reference regimen) in this population. METHODS This randomised, open-label, phase 3 trial was done at 20 hospitals in France. Patients aged 70 years or older, assessed as frail by the ELAN Geriatric Evaluation, with recurrent or metastatic head and neck squamous cell carcinoma in the first-line setting and with an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2 were eligible for inclusion. Patients were randomly assigned (1:1) to receive cetuximab 500 mg/m2 intravenously every 2 weeks or methotrexate 40 mg/m2 intravenously every week, with minimisation by ECOG performance status, type of disease evolution, Charlson Comorbidity Index score, serum albumin concentration, and geriatrician consultation. To avoid deterministic minimisation and assure allocation concealment, patients were allocated with a probability of 0·80 to the treatment that most reduced the imbalance. Treatment was continued until disease progression or unacceptable toxicity, whichever occurred first. The primary endpoint was failure-free survival (defined as the time from randomisation to disease progression, death, discontinuation of treatment, or loss of 2 or more points on the Activities in Daily Living scale, whichever occurred first) and was analysed in the intention-to-treat population. 151 failures expected out of 164 patients were required to detect a hazard ratio (HR) of 0·625 with 0·05 alpha error, with 80% power. A futility interim analysis was planned when approximately 80 failures were observed, based on failure-free survival. Safety analyses included all patients who received at least one dose of the study drug. This study is registered on ClinicalTrials.gov (NCT01884623) and was stopped for futility after the interim analysis. FINDINGS Between Nov 7, 2013, and April 23, 2018, 82 patients were enrolled (41 to the cetuximab group and 41 to the methotrexate group); 60 (73%) were male, 37 (45%) were aged 80 years or older, 35 (43%) had an ECOG performance status of 2, and 36 (44%) had metastatic disease. Enrolment was stopped for futility at the interim analysis. At the final analysis, median follow-up was 43·3 months (IQR 30·8-52·1). At data cutoff, all 82 patients had failure; failure-free survival did not differ significantly between the groups (median 1·4 months [95% CI 1·0-2·1] in the cetuximab group vs 1·9 months [1·1-2·6] in the methotrexate group; adjusted HR 1·03 [95% CI 0·66-1·61], p=0·89). The frequency of patients who had grade 3 or worse adverse events was 63% (26 of 41) in the cetuximab group and 73% (30 of 41) in the methotrexate group. The most common grade 3-4 adverse events in the cetuximab group were fatigue (four [10%] of 41 patients), lung infection (four [10%]), and rash acneiform (four [10%]), and those in the methotrexate group were fatigue (nine [22%] of 41), increased gamma-glutamyltransferase (seven [17%]), natraemia disorder (four [10%]), anaemia (four [10%]), leukopenia (four [10%]), and neutropenia (four [10%]). The frequency of patients who had serious adverse events was 44% (18 of 41) in the cetuximab group and 39% (16 of 41) in the methotrexate group. Four patients presented with a fatal adverse event in the cetuximab group (sepsis, decreased level of consciousness, pulmonary oedema, and death of unknown cause) as did two patients in the methotrexate group (dyspnoea and death of unknown cause). INTERPRETATION The study showed no improvement in failure-free survival with cetuximab versus methotrexate. Patients with an ECOG performance status of 2 did not benefit from these systemic therapies. New treatment options including immunotherapy should be explored in frail older patients with recurrent or metastatic head and neck squamous cell carcinoma, after an initial geriatric evaluation, such as the ELAN Geriatric Evaluation. FUNDING French programme PAIR-VADS 2011 (sponsored by the National Cancer Institute, the Fondation ARC and the Ligue Contre le Cancer), GEMLUC, GEFLUC, and Merck Santé. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Joël Guigay
- Partnerships and Clinical Development - Early Assets, GORTEC, Tours, France.
| | - Cécile Ortholan
- Oncology-Radiotherapy Unit, Hospital Centre Princesse-Grace, Monaco
| | - Damien Vansteene
- Medical Oncology Unit, West Cancerology Institute, Saint Herblain, France
| | - Didier Cupissol
- Medical Oncology Unit, Cancer Institute of Montpellier, Montpellier, France
| | - Caroline Even
- Medical Oncology Unit, Gustave-Roussy Institute, Villejuif, France
| | | | - Christian Sire
- Oncology-Radiotherapy Unit, Hospital Group South Bretagne, Lorient, France
| | - Emmanuel Blot
- Medical Oncology Unit, ELSAN Group, Private Hospital Océane, Vannes, France
| | | | - Laurence Bozec
- Medical Oncology Unit, Curie Institute, Saint Cloud, France
| | - Esma Saada-Bouzid
- Medical Oncology and Research Department, Centre Antoine Lacassagne, University Côte d'Azur, Nice, France
| | - Jérôme Fayette
- Medical Oncology Unit, Cancer Research Centre Léon Bérard, Lyon, France
| | - Pierre Dalloz
- Medical Oncology Unit, Centre Jean Perrin, Clermont-Ferrand, France
| | - Yoann Pointreau
- Radiation Oncology Unit, ILC (Inter-regional Cancerology Institute) - Jean Bernard Center & Victor Hugo Private Clinic, Sarthe Cancer Center, Le Mans, France
| | - Hervé Le Caer
- Medical Oncology Unit, Hospital Centre of Saint-Brieuc, Saint-Brieuc, France
| | - Claire Falandry
- Medical Oncology Unit, Hospital Centre of South Lyon, Pierre Bénite, France
| | - Laurence Digue
- Medical Oncology Unit, Saint André Universitary Hospital of Bordeaux, Bordeaux, France
| | - Antoine Braccini
- Medical Oncology Unit, Centre Azuréen de Cancérologie, Mougins, France
| | - Stéphane Lopez
- Medical Oncology Unit, Hospital Centre of Annecy Genevois, Pringy, France
| | - Pierre Guillet
- Medical Oncology Unit, Intercommunal Hospital Centre, La Seyne sur Mer, France
| | - Cécile Michel
- Medical Oncology and Research Department, Centre Antoine Lacassagne, University Côte d'Azur, Nice, France
| | - Nadir Cheurfa
- Biostatistics and Epidemiology Unit, Gustave Roussy, Inserm U1018 Oncostat, Labelled Ligue Contre le Cancer, University Paris-Saclay, Villejuif, France
| | - Dominique Schwob
- Biostatistics and Epidemiology Unit, Gustave Roussy, Inserm U1018 Oncostat, Labelled Ligue Contre le Cancer, University Paris-Saclay, Villejuif, France
| | - Jean Bourhis
- Radiotherapy Unit, Universitary Hospital Center of Vaudois, Lausanne, Switzerland
| | - Cécile Mertens
- Oncogeriatrics Unit, Bergonié Institute, Bordeaux, France
| | - Anne Aupérin
- Biostatistics and Epidemiology Unit, Gustave Roussy, Inserm U1018 Oncostat, Labelled Ligue Contre le Cancer, University Paris-Saclay, Villejuif, France
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4
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Boyi T, Williams LC, Kafle S, Roche AM, Judson BL. Association of Age and Frailty With 30-Day Outcomes Among Patients Undergoing Oral Cavity Cancer Surgery. Otolaryngol Head Neck Surg 2023; 169:1523-1532. [PMID: 37595108 DOI: 10.1002/ohn.476] [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: 06/06/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 08/20/2023]
Abstract
OBJECTIVE To evaluate the impact of age and frailty on 30-day outcomes following surgery for oral squamous cavity carcinoma (OSCC). STUDY DESIGN Retrospective cross-sectional analysis. SETTING American College of Surgeons' National Quality Improvement Program (NSQIP) database. METHODS Patients who underwent OSCC resection were queried via NSQIP (2015-2020). Cases were stratified by age (18-65, 65-75, and older than 75) as well as by modified frailty index scores (mFI 0, mFI 1, and mFI 2+) for comparative analyses. Univariate and multivariable analyses were conducted to examine demographics, perioperative outcomes, and 30-day postoperative adverse events. RESULTS A total of 3238 patients who underwent OSCC surgery were identified and categorized as nongeriatric ("NGA," age 18-65), younger geriatric ("YGA," age 65-75), and older geriatric ("OGA," age >75) adults. Compared to NGA, geriatric patients had higher the American Society of Anesthesiologists classification, higher modified frailty index scores, and more comorbidities such as hypertension, congestive heart failure, chronic obstructive disease, and diabetes (p < .001). YGAs and OGAs were also less likely to undergo neck dissection (p < .001), composite resection (p = .006), and free flap reconstruction compared to NGAs (p < .001). When controlling for confounders, age was not independently associated with an increased risk of poor outcomes. On the other hand, frailty was found to be independently associated with a higher risk of adverse events (odds ratio: 1.40 [1.15-1.70], p < .001 for mFI 1, odds ratio: 1.45 [1.04-2.02], p = .027 for mFI 2+). CONCLUSION A higher mFI score, not older age, is associated with an increased risk of 30-day complications following OSCC surgery.
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Affiliation(s)
- Trinithas Boyi
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lauren C Williams
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Samipya Kafle
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ansley M Roche
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Benjamin L Judson
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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Dickstein DR, Powers AE, Vujovic D, Roof S, Bakst RL. Clinical and Therapeutic Considerations for Older Adults with Head and Neck Cancer. Clin Interv Aging 2023; 18:409-422. [PMID: 36959837 PMCID: PMC10029371 DOI: 10.2147/cia.s366155] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/04/2023] [Indexed: 03/18/2023] Open
Abstract
Approximately 30% of patients with head and neck squamous cell carcinoma (HNSCC) are at least 70 years of age, and this percentage is expected to increase as the population increases and lives longer. Elderly patients are underrepresented in head and neck oncology clinical trials, and there is minimal evidence on the management of HNSCC for this population. Subsequently, despite their best intentions, physicians may unknowingly recommend an ill-suited course of therapy, which may result in suboptimal oncological or functional outcomes or adverse events. Surgical approaches have the potential to carry a higher risk of morbidity and mortality in older adults, especially in patients with multiple comorbidities. Definitive radiation therapy treatment in patients with HNSCC frequently involves 7 weeks of daily radiation, sometimes with concurrent chemotherapy, and this demanding treatment can be difficult for older adult patients, which may lead to treatment interruptions, potential removal of concurrent systemic therapy, compromised outcomes, and diminished quality of life. There are clinical trials currently underway investigating altered fractionation regimens and novel, less toxic systemic treatments in this population. This review provides an overview of how best to approach an older adult with HNSCC, from initial work-up to treatment selection.
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Affiliation(s)
- Daniel R Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ann E Powers
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dragan Vujovic
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Scott Roof
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Richard L Bakst
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Correspondence: Richard L Bakst, Icahn School of Medicine at Mount Sinai, 1184 5th Avenue 1st Fl, Box 1236, New York, NY, 10029, USA, Tel/Fax +1 212 241 3545, Email
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6
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Sjöström M, Danielsson D, Munck-Wikland E, Nyberg J, Sandström K, Thor A, Johansson H, Ceghafi P, Dybeck Udd S, Emanuelsson J, Forsberg Pettersson L, Halle M, Laurell G. Mandibular resection in patients with head and neck cancer: acute and long-term complications after reconstruction. Acta Otolaryngol 2022; 142:78-83. [PMID: 35023428 DOI: 10.1080/00016489.2021.2021283] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The treatment of head and neck cancer is an intensive multimodal treatment that has a great impact on the individual patient. AIMS/OBJECTIVES This study aimed to evaluate acute and long-term complications associated with mandibular resections and reconstructions. MATERIAL AND METHODS We retrospectively retrieved data on complications and recurrences among patients that underwent mandibular resections and reconstructions for treating oral cavity cancer (n = 190 patients) and osteoradionecrosis (ORN, n = 72). Reconstructions included composite grafts (n = 177), soft tissue flaps (n = 61), or primary closure without any graft (n = 24). RESULTS Forty-two patients that underwent reconstructions with composite grafts displayed serious complications (Clavien-Dindo ≥ IIIa). The complication rates were similar between patients treated for oral cavity cancer and patients treated for ORN. Patients that underwent a primary closure without any graft, had a significantly lower risk of complications compared to patients that underwent the other treatments. After hospitalization, 181 patients (69%) had at least one complication. CONCLUSIONS A majority of patients undergoing resection and reconstruction due to oral cancer/ORN suffered from postoperative complications regardless of indication, comorbidity status or reconstruction technique. The risk of Clavien-Dindo grade IIIa-V events was significantly lower for patients treated with primary closure without grafts. SIGNIFICANCE The results from this study clarifies the importance of in-depth analyse prior to decision of treatment for patients with head and neck cancer.
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Affiliation(s)
- Mats Sjöström
- Department of Odontology, Oral and Maxillofacial Surgery, Umeå University Hospital, Umeå, Sweden
| | - Daniel Danielsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Patient Area, Craniofacial Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Munck-Wikland
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Patient Area Head and Neck-, Lung-, and Skin-Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Nyberg
- Department of Oral and Maxillofacial Surgery, Centre for Head and Neck Oncology, Örebro University Hospital, Örebro, Sweden
| | - Karl Sandström
- Otolaryngology and Head and Neck surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Andreas Thor
- Oral and Maxillofacial Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Hemming Johansson
- Department of Oncology and Pathology, Karolinska Institute and University Hospital, Stockholm, Sweden
| | - Payam Ceghafi
- Department of Oral and Maxillofacial Surgery, Centre for Head and Neck Oncology, Örebro University Hospital, Örebro, Sweden
| | - Sebastian Dybeck Udd
- Patient Area, Craniofacial Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Emanuelsson
- Department of Odontology, Oral and Maxillofacial Surgery, Umeå University Hospital, Umeå, Sweden
| | | | - Martin Halle
- Department of Molecular Medicine and Surgery, Karolinska Institute and Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Göran Laurell
- Otolaryngology and Head and Neck surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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7
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Obeso-Benítez P, Muñoz-Vigueras N, Castillo-Pérez I, Rodríguez-Torres J, Granados-Santiago M, Cabrera-Martos I, Valenza MC. Global functional impairment in head and neck cancer survivors after completing radiotherapy treatment. Disabil Rehabil 2021; 44:6394-6400. [PMID: 34415231 DOI: 10.1080/09638288.2021.1966677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Improvements in diagnosis and treatment of head and neck cancer (HNC) patients have resulted in improved long-term survival rates. However, a variety of symptoms and comorbidities, often secondary to the cancer and its treatments, are experienced by a relevant number of survivors. So, the aim of this study was to determine the global functional impairment in HNC survivors 1 year after radiotherapy treatment. MATERIALS AND METHODS A descriptive case-control study was performed. HNC survivors were recruited from San Cecilio Clinical University Hospital in Granada. The main variables included were functionality and quality of life. RESULTS 30 HNC survivors were included in our study. Significant differences were found in the WHO-DAS 2.0 test, with a worse score in the HNC group in most subscales (p < 0.05), and poorer scores in the COMP test, performance (p < 0.001) and satisfaction (p < 0.001). Significant differences were also found in most QLQ-30 subscales (p < 0.05) and the QLQ-H&N35. In regard to the EQ-5D, significant differences were found between groups, with worse results in the HNC group (p < 0.05). CONCLUSION HNC survivors presented a poorer global function and a worse quality of life and health status 1 year after the radiotherapy treatment. Moreover, a good correlation was found between functionality and quality of life outcomes.IMPLICATIONS FOR REHABILITATIONA worse quality of life and health status are shown in head and neck survivors 1 year after radiotherapy.Global functionality is related to quality of life outcomes in head and neck cancer survivors.There is a need to recognise the need for and to provide longer term rehabilitation.
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Affiliation(s)
- Paula Obeso-Benítez
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Natalia Muñoz-Vigueras
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | | | - Janet Rodríguez-Torres
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - María Granados-Santiago
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Irene Cabrera-Martos
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Marie C Valenza
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Granada, Spain
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Postoperative Radiochemotherapy Using Modern Radiotherapy Techniques in Elderly Patients with Head and Neck Squamous Cell Carcinoma: The Challenge of Weighing Up Benefits and Harms of Treatment Modalities in Clinical Practice. Cancers (Basel) 2021; 13:cancers13143384. [PMID: 34298599 PMCID: PMC8307771 DOI: 10.3390/cancers13143384] [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: 04/23/2021] [Revised: 06/22/2021] [Accepted: 07/02/2021] [Indexed: 11/24/2022] Open
Abstract
Simple Summary Locally advanced head and neck squamous cell carcinomas (HNSCC) are often managed with surgery and postoperative radiochemotherapy (RCT). Until now, a deeper understanding of specific management strategies for elderly patients was lacking. In the present study, we compared patients ≥70 years of age and younger patients treated with postoperative RCT for HNSCC. All patients were treated with modern radiotherapy techniques (IMRT/VMAT). Elderly patients had more comorbidities. In addition, they less frequently received concomitant systemic treatment. The rates of mucositis and dermatitis were lower in patients ≥70 years. Elderly patients had significantly worse overall survival and progression-free survival. Locoregional and distant control were comparable in elderly and younger patients. In conclusion, postoperative radiochemotherapy is a safe and effective treatment option in patients ≥70 years. In light of comorbidities and poor survival rates, potential benefits and harms of radiotherapy and concomitant systemic treatment should be weighed carefully for this age group. Abstract Locally advanced head and neck squamous cell carcinomas (HNSCC) are often managed with surgery followed by postoperative radiochemotherapy (RCT). With the general increase in life expectancy, the proportion of elderly patients with HNSCC is expected to grow rapidly. Until now, a deeper understanding of specific management strategies for these patients in clinical routine was lacking. In the present study, we compared elderly patients (≥70 years, n = 52) and younger patients (n = 245) treated with postoperative RCT for HNSCC at our tertiary cancer center. All patients were irradiated with modern radiotherapy techniques (IMRT/VMAT). Patients ≥70 years of age had more comorbidities. Additionally, elderly patients less frequently received concomitant systemic treatment. The rates of mucositis and dermatitis were lower in patients ≥70 years. Elderly patients had significantly worse overall and progression-free survival. Locoregional and distant control were comparable in elderly and younger patients. In conclusion, postoperative RCT is a safe and effective treatment option in patients ≥70 years. In light of comorbidities and poor overall survival rates, benefits and harms of radiotherapy and concomitant systemic treatment should be weighed carefully. When exclusively applying up-to-date radiotherapy techniques with, at the same time, careful use of concomitant systemic therapy, favorable acute toxicity profiles are achieved.
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9
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O'Donovan A, Leech M. Personalised treatment for older adults with cancer: The role of frailty assessment. Tech Innov Patient Support Radiat Oncol 2020; 16:30-38. [PMID: 33102819 PMCID: PMC7568178 DOI: 10.1016/j.tipsro.2020.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 09/04/2020] [Accepted: 09/04/2020] [Indexed: 12/13/2022] Open
Abstract
It is widely accepted in clinical practice that chronological age is a poor predictor of treatment tolerance and outcomes in older adults with cancer. Intrinsic vulnerability is more a function of underlying frailty, rather than chronological age. Frailty is a state of increased vulnerability to stressors, such as cancer and its treatment, which can lead to adverse health outcomes for patients. Capturing this heterogeneity in reserve capacity is the cornerstone of management in geriatricmedicine, but remains poorly understood or adopted in radiation oncology. A two-step approach, using a shorter screening tool, followed by full assessment for those who need it, is the mostresourceful way of implementing frailty assessment in radiotherapy departments. It is important for radiation oncology professionals to identify frailty and to use this information in multidisciplinary decision making in order to develop a personalised radiotherapy approach for the older person. There are many ways we can effectively use this information, such as considering treatment fractionation schedules that would limit the burden of travel for those with social frailty, or reviewing the range of modalities at our disposal, which might limit toxicity in the older person at high risk of deterioration during treatment. Frailty assessment is not carried out in many radiotherapy departments presently, but there are many international models to use as exemplars as to how it may be implemented in clinical practice. There are many opportunities for further research and role development in this field at the current time.
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10
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Advanced head and neck cancer in older adults: Results of a short course accelerated radiotherapy trial. J Geriatr Oncol 2020; 12:441-445. [PMID: 33097457 DOI: 10.1016/j.jgo.2020.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/01/2020] [Accepted: 10/14/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To assess the feasibility and safety of a repeated SHort course Accelerated RadiatiON therapy (SHARON) regimen in the palliative setting of Head and Neck (H&N) cancer in older adults. MATERIAL AND METHODS Patients with histological confirmed H&N cancers, age ≥ 80 years, expected survival >3 months, and Eastern Cooperative Oncology Group (ECOG) performance status of ≤3 were enrolled. Patients were treated in cohorts of six patients: a total dose of 20 Gy was delivered in 2 consecutive days with a twice-daily fractionation (5 Gy per fraction) and at least 8-h interval. If no Grade 3 toxicity was registered, a second enrollment started with another cohort of six patients to whom were administered two cycles (total dose of 40 Gy). The primary endpoint was to evaluate the feasibility of the two cycles of treatment. Secondary endpoints were evaluation of symptoms control rate, symptoms-free survival (SFS), and Quality of Life (QoL) scores. RESULTS Seventeen consecutive patients (median age: 85 years) were treated. Nine patients were treated with one cycle and 8 patients with two cycles. No G3 toxicity was reported in either cohort. With a median follow-up time of 4 months, 3-month SFS in the first and second cohorts was 83.3%, and 87.5%, respectively. The overall palliative response rate was 88%. Among 13 patients reporting pain, 8 (61.5%) showed an improvement or resolution of their pain. CONCLUSION Repeated short course accelerated radiotherapy in a palliative setting of H&N cancers is safe and well-tolerated in older adults.
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11
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Song L, Zhang S, Yu S, Ma F, Wang B, Zhang C, Sun J, Mao X, Wei L. Cellular heterogeneity landscape in laryngeal squamous cell carcinoma. Int J Cancer 2020; 147:2879-2890. [PMID: 32638385 DOI: 10.1002/ijc.33192] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/24/2020] [Accepted: 06/29/2020] [Indexed: 12/13/2022]
Abstract
Laryngeal squamous cell carcinoma (LSCC) is a highly malignant tumor originated from respiratory system. Although there have been many improvements in therapy until now, reducing the high mortality remains difficult. Understanding the cellular heterogeneity of LSCC could contribute to improve this problem. Single-cell RNA sequencing was applied to dissect the cell composition and molecular characteristics of LSCC tissues. Immunohistochemistry staining of the LSCC tissues was performed to identify the spatial location of tumor cells. Survival analysis of marker genes was executed in The Cancer Genome Atlas to verify the correlation between each cell clusters and patients' prognosis. The LSCC tissue cells were finely grouped into various clusters, including tumor cells, immune cells, epithelial cells, fibroblasts and endothelial cells. Notably, in tumor cells, keratinocyte-like cells were in the core of tumor while malignant proliferating cells were located at the tumor edge. The malignant proliferating cells were correlated with poor prognosis. In summary, this is the first study to delineate a landscape of the LSCC intratumor heterogeneity. Our work might help researchers have a better understanding for tumor progression.
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Affiliation(s)
- Lianhao Song
- Department of Microbiology, Harbin Medical University, Harbin, China.,Wu Lien-Teh Institute, Harbin Medical University, Harbin, China
| | - Siwei Zhang
- Department of Microbiology, Harbin Medical University, Harbin, China.,Wu Lien-Teh Institute, Harbin Medical University, Harbin, China
| | - Siyang Yu
- Department of Microbiology, Harbin Medical University, Harbin, China.,Wu Lien-Teh Institute, Harbin Medical University, Harbin, China
| | - Fen Ma
- Department of Microbiology, Harbin Medical University, Harbin, China.,Wu Lien-Teh Institute, Harbin Medical University, Harbin, China
| | - Bozhi Wang
- Department of Microbiology, Harbin Medical University, Harbin, China.,Wu Lien-Teh Institute, Harbin Medical University, Harbin, China
| | - Congcong Zhang
- Department of Microbiology, Harbin Medical University, Harbin, China.,Wu Lien-Teh Institute, Harbin Medical University, Harbin, China
| | - Ji Sun
- Department of Otolaryngology, Head and Neck Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xionghui Mao
- Department of Otolaryngology, Head and Neck Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Lanlan Wei
- Department of Microbiology, Harbin Medical University, Harbin, China.,Wu Lien-Teh Institute, Harbin Medical University, Harbin, China
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12
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Zhou Z, Tang Q, Chen X, Yu T, Huang W, Liang F. The association between the socioeconomic status and systemic comorbidities in patients with oral cancers: a retrospective study in Guangxi Province. Clin Oral Investig 2020; 25:1085-1097. [PMID: 32572641 DOI: 10.1007/s00784-020-03405-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 06/10/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND It is unclear whether and how the prevalence of systemic comorbidities in oral cancer patients would change with socioeconomic development. MATERIALS AND METHODS A retrospective study of association between socioeconomy and prevalence of systemic comorbidities in oral cancer patients from 2003 to 2017 was performed in Guangxi Province, a southwestern part of China. According to the Union for International Cancer Control (UICC) classification, 2814 patients with squamous cell carcinoma (SCC) of the lip, oral cavity, and oropharynx and 423 patients with ameloblastoma were collected and assigned to the oral cancer group and control group, respectively. Then, comparisons between the socioeconomy and healthcare expenditure in Guangxi Province, the whole China, and the USA were carried out. RESULTS The prevalence of systemic comorbidities in oral cancer patients increased from 0.820% in 2003 to 32.302% in 2017, which was significantly higher than that in non-cancer patients(P < 0.001) and was positively correlated with the increase in gross regional product (GRP) (r = 0.911, P < 0.001) and per capita GRP (r = 0.910, P < 0.001) of Guangxi Province. In addition, the prevalence of cardiovascular diseases has the largest correlation coefficient with GRP(r = 0.957, P < 0.001) and per capita GRP(r = 0.959, P < 0.001). And the prevalence of endocrine diseases increased by 13.402% and exhibited the most significant increase in 15 years. The per capita health care expenditure of Guangxi Province and whole China was nearly equal (P = 0.353). Although the health care expenditure of Guangxi Province had been increasing year by year, its proportion in GRP remains far below that of the USA. CONCLUSIONS With socioeconomic growth, oral cancer patients in Guangxi Province are more common to comorbid with systemic diseases. Cardiovascular and endocrine diseases may be the most susceptible systemic comorbidities in oral cancer patients to the socioeconomic status. In order to control the prevalence of systemic diseases, the government of Guangxi Province may need to expend more budgets in the health care. CLINICAL RELEVANCE Clinicians need to pay more attention to the detection of systemic comorbidities and the concept of multidisciplinary collaboration. Instructing oral cancer patients to treat and control systemic comorbidities is also an indispensable part in the treatment of oral cancer.
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Affiliation(s)
- Zhuoqian Zhou
- Department of Oral and Maxillofacial Surgery, College and Hospital of Stomatology, Guangxi Medical University, 10 Shuangyong Road, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Nanning, 530021, Guangxi, China
- Guangxi Clinical Research Center for Craniofacial Deformity, Nanning, 530021, Guangxi, China
| | - Qinchao Tang
- Department of Oral and Maxillofacial Surgery, College and Hospital of Stomatology, Guangxi Medical University, 10 Shuangyong Road, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Nanning, 530021, Guangxi, China
- Guangxi Clinical Research Center for Craniofacial Deformity, Nanning, 530021, Guangxi, China
| | - Xueru Chen
- Department of Oral and Maxillofacial Surgery, College and Hospital of Stomatology, Guangxi Medical University, 10 Shuangyong Road, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Nanning, 530021, Guangxi, China
- Guangxi Clinical Research Center for Craniofacial Deformity, Nanning, 530021, Guangxi, China
| | - Tao Yu
- Department of Oral and Maxillofacial Surgery, College and Hospital of Stomatology, Guangxi Medical University, 10 Shuangyong Road, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Nanning, 530021, Guangxi, China
- Guangxi Clinical Research Center for Craniofacial Deformity, Nanning, 530021, Guangxi, China
| | - Wanqian Huang
- Department of Oral and Maxillofacial Surgery, College and Hospital of Stomatology, Guangxi Medical University, 10 Shuangyong Road, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Nanning, 530021, Guangxi, China
- Guangxi Clinical Research Center for Craniofacial Deformity, Nanning, 530021, Guangxi, China
| | - Feixin Liang
- Department of Oral and Maxillofacial Surgery, College and Hospital of Stomatology, Guangxi Medical University, 10 Shuangyong Road, Nanning, 530021, Guangxi, China.
- Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Nanning, 530021, Guangxi, China.
- Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Nanning, 530021, Guangxi, China.
- Guangxi Clinical Research Center for Craniofacial Deformity, Nanning, 530021, Guangxi, China.
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13
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Abstract
PURPOSE OF REVIEW Elderly head and neck cancer (HNC) patients are very rarely enrolled in clinical trials, and even more so in dedicated trials in curative or palliative setting. As a result, no standards of treatment exist for this population and thus, adaptation of standard treatments is commonly used. RECENT FINDINGS The choice between a monotherapy and a platinum-cetuximab combination is based on the performance status, which is not suitable and/or sufficient to evaluate the patient ability to receive a systemic treatment combined or not with radiotherapy. The evaluation of functional age using geriatric assessment is recommended. However, access to comprehensive geriatric assessment is limited in many centers, and the choice of the type of treatment is often not based on objective and reproducible criteria. As a result, fragile elderly HNC patients may be overtreated with a risk of increased toxicity and fit patients proposed for suboptimal treatment with a risk of failure of tumor control. SUMMARY It is therefore crucial to develop and evaluate customized treatments by enrolling elderly HNC patients in dedicated therapeutics trials, such as the ELAN (Elderly Head and Neck Cancer) studies or new approaches involving promising immunotherapies. To administer the most suitable therapy, a simple and reproducible geriatric assessment could efficiently guide practitioners.
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14
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Taberna M, Gil Moncayo F, Jané-Salas E, Antonio M, Arribas L, Vilajosana E, Peralvez Torres E, Mesía R. The Multidisciplinary Team (MDT) Approach and Quality of Care. Front Oncol 2020; 10:85. [PMID: 32266126 PMCID: PMC7100151 DOI: 10.3389/fonc.2020.00085] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 01/16/2020] [Indexed: 12/17/2022] Open
Abstract
The core function of a multidisciplinary team (MDT) is to bring together a group of healthcare professionals from different fields in order to determine patients' treatment plan. Most of head and neck cancer (HNC) units are currently led by MDTs that at least include ENT and maxillofacial surgeons, radiation and medical oncologists. HNC often compromise relevant structures of the upper aerodigestive tract involving functions such as speech, swallowing and breathing, among others. The impairment of these functions can significantly impact patients' quality of life and psychosocial status, and highlights the crucial role of specialized nurses, dietitians, psycho-oncologists, social workers, and onco-geriatricians, among others. Hence, these professionals should be integrated in HNC MDTs. In addition, involving translational research teams should also be considered, as it will help reducing the existing gap between basic research and the daily clinical practice. The aim of this comprehensive review is to assess the role of the different supportive disciplines integrated in an MDT and how they help providing a better care to HNC patients during diagnosis, treatment and follow up.
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Affiliation(s)
- Miren Taberna
- Medical Oncology Department, Catalan Institute of Oncology (ICO), ONCOBELL, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Francisco Gil Moncayo
- Psicooncology Department, Catalan Institute of Oncology (ICO), IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Enric Jané-Salas
- Department of Odontostomatology, Faculty of Medicine and Health Sciences (Dentistry), University of Barcelona, Barcelona, Spain.,Oral Health and Masticatory System Group (Bellvitge Biomedical Research Institute) IDIBELL, L'Hospitalet de Llobregat, University of Barcelona, Barcelona, Spain
| | - Maite Antonio
- Oncogeriatrics Unit, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Lorena Arribas
- Clinical Nutrition Unit, Catalan Institute of Oncology (ICO), IDIBELL, L'Hospitalet de Llobregat, University of Barcelona, Barcelona, Spain
| | - Esther Vilajosana
- Head and Neck Nurse, Head and Neck Functional Unit, Catalan Institute of Oncology (ICO), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Elisabet Peralvez Torres
- Expert SLP in Oncologic Patients, Head of SLP's Department, Atos Medical Spain, Barcelona, Spain
| | - Ricard Mesía
- Medical Oncology Department, Catalan Institute of Oncology (ICO), B-ARGO, Barcelona, Spain
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15
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Saba NF, Blumenschein G, Guigay J, Licitra L, Fayette J, Harrington KJ, Kiyota N, Gillison ML, Ferris RL, Jayaprakash V, Li L, Brossart P. 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. Oral Oncol 2019; 96:7-14. [PMID: 31422216 PMCID: PMC7723820 DOI: 10.1016/j.oraloncology.2019.06.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/03/2019] [Accepted: 06/13/2019] [Indexed: 01/17/2023]
Abstract
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.
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Affiliation(s)
- Nabil F Saba
- Winship Cancer Institute of Emory University, 1365-C Clifton Road NE, Atlanta, GA 30322, USA.
| | | | - Joel Guigay
- Centre Antoine Lacassagne, FHU OncoAge, Université Côte d'Azur, 33 Avenue de Valombrose, Nice 06189, France.
| | - Lisa Licitra
- Fondazione IRCCS Istituto Nazionale dei Tumori and University of Milan, via Venezian 1, Milan 20133, Italy.
| | - Jerome Fayette
- Centre Leon Berard, 28 Prom. Léa et Napoléon Bullukian, Lyon 69008, France.
| | - Kevin J Harrington
- Royal Marsden NHS Foundation Trust/The Institute of Cancer Research, Fulham Road, London SW3 6JJ, UK.
| | - Naomi Kiyota
- Kobe University Hospital Cancer Center, 7 Chome-5-2 Kusunokicho, Chuo Ward, Kobe 650-0017, Japan.
| | - Maura L Gillison
- MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA.
| | - Robert L Ferris
- University of Pittsburgh Medical Center Hillman Cancer Center, 5115 Centre Ave., Pittsburgh, PA 15232, USA.
| | | | - Li Li
- Bristol-Myers Squibb, 3401 Princeton Pike, Lawrenceville 08648, NJ, USA.
| | - Peter Brossart
- University Hospital of Bonn, Sigmund-Freud-Straße 25, Bonn 53127, Germany.
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16
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Systemic treatment in elderly head and neck cancer patients: recommendations for clinical practice. Curr Opin Otolaryngol Head Neck Surg 2019; 27:142-150. [DOI: 10.1097/moo.0000000000000526] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Simon SR, Florie M, Pilz W, Winkens B, Winter N, Kremer B, Baijens LWJ. Association Between Pharyngeal Pooling and Aspiration Using Fiberoptic Endoscopic Evaluation of Swallowing in Head and Neck Cancer Patients with Dysphagia. Dysphagia 2019; 35:42-51. [PMID: 30868301 PMCID: PMC6987057 DOI: 10.1007/s00455-019-09992-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 02/23/2019] [Indexed: 11/29/2022]
Abstract
Postswallow pharyngeal pooling may be a risk factor for tracheal aspiration. However, limited literature shows the potential association between pharyngeal pooling and aspiration in head and neck cancer (HNC) patients. This study investigates the relationship between postswallow pharyngeal pooling and aspiration in HNC patients with oropharyngeal dysphagia. Furthermore, the effects of tumor stage, tumor location, and cancer treatment on aspiration were examined. Ninety dysphagic HNC patients underwent a standardized fiberoptic endoscopic evaluation of swallowing (FEES) using thin and thick liquid boluses. For each swallow, three visuoperceptual ordinal variables were scored: postswallow vallecular pooling, postswallow pyriform sinus pooling, and aspiration. Logistic regression analyses with correction for the location of pooling, tumor stage, tumor location, and cancer treatment were performed to explore the association between pooling and aspiration. No significant association was found between postswallow vallecular pooling and aspiration for thin liquid. However, severe versus mild-to-moderate postswallow vallecular pooling of thick liquid was significantly associated to aspiration. Similar results were seen after correction for the presence of pyriform sinus pooling, tumor stage, tumor location, or type of cancer treatment. This study showed a significant association between severe postswallow pyriform sinus pooling of thick liquid and aspiration, independent of the presence of vallecular pooling, tumor stage, tumor location, or cancer treatment. Concluding, location (valleculae versus pyriform sinuses), liquid bolus consistency (thin versus thick liquid), and amount of postswallow pharyngeal pooling (no pooling, mild/moderate pooling, severe pooling) have an influence on the probability of aspiration in dysphagic HNC patients, and they should be carefully considered during FEES, even in the absence of aspiration during the examination.
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Affiliation(s)
- Sorina R Simon
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Michelle Florie
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Walmari Pilz
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.,School for Oncology and Developmental Biology - GROW, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands.,Care and Public Health Research Institute - CAPHRI, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Naomi Winter
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Bernd Kremer
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.,School for Oncology and Developmental Biology - GROW, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Laura W J Baijens
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.,School for Oncology and Developmental Biology - GROW, Maastricht University Medical Center, Maastricht, The Netherlands
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Iqbal MS, Dua D, Kelly C, Bossi P. Managing older patients with head and neck cancer: The non-surgical curative approach. J Geriatr Oncol 2018; 9:411-417. [PMID: 29685382 DOI: 10.1016/j.jgo.2018.03.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 02/27/2018] [Accepted: 03/28/2018] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Muhammad Shahid Iqbal
- Department of Clinical Oncology, Northern Centre for Cancer Care, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom.
| | - Divyanshu Dua
- Department of Medical Oncology, The Canberra Hospital, Garran ACT 2605, Australia
| | - Charles Kelly
- Department of Clinical Oncology, Northern Centre for Cancer Care, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Paolo Bossi
- Department of Medical Oncology, Fondazione IRCCS Instituto Nazionale Tumori, Milan, Italy
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19
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Bonomo P, Desideri I, Loi M, Lo Russo M, Olmetto E, Maragna V, Francolini G, Delli Paoli C, Grassi R, Pezzulla D, Greto D, Meattini I, Livi L. Elderly patients affected by head and neck squamous cell carcinoma unfit for standard curative treatment: Is de-intensified, hypofractionated radiotherapy a feasible strategy? Oral Oncol 2017; 74:142-147. [DOI: 10.1016/j.oraloncology.2017.10.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/01/2017] [Accepted: 10/04/2017] [Indexed: 12/22/2022]
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20
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[A French multicenter research program for a personalized treatment of elderly head and neck cancer patient]. Bull Cancer 2017; 104:816-819. [PMID: 28797481 DOI: 10.1016/j.bulcan.2017.06.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/19/2017] [Accepted: 06/22/2017] [Indexed: 11/21/2022]
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21
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Falk AT, Hébert C, Tran A, Chand ME, Leysalle A, Thariat J, Dassonville O, Poissonnet G, Bozec A, Saada E, Peyrade F, Benezery K. Radiotherapy for elderly patients and cetuximab, a monocentric study. Eur Arch Otorhinolaryngol 2016; 274:1061-1065. [DOI: 10.1007/s00405-016-4336-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 10/04/2016] [Indexed: 12/16/2022]
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22
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Hwang-Bo J, Park JH, Bae MG, Chung IS. Recombinant canstatin inhibits VEGF-A-induced lymphangiogenesis and metastasis in an oral squamous cell carcinoma SCC-VII animal model. Cancer Med 2016; 5:2977-2988. [PMID: 27650585 PMCID: PMC5083751 DOI: 10.1002/cam4.866] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 06/22/2016] [Accepted: 07/24/2016] [Indexed: 01/30/2023] Open
Abstract
We describe the inhibitory effects of recombinant canstatin on tumor growth and lymphangiogenesis induced by an oral squamous cell carcinoma (SCC) using an orthotropic oral SCC animal model. Recombinant canstatin treatment decreased final tumor volumes and weights, as well as densities of blood and lymphatic vessels. Lung metastasis of oral SCC was significantly reduced in recombinant canstatin‐treated animals. Recombinant canstatin reduced vascular endothelial growth factor (VEGF)‐A expression in SCC‐VII cells treated with the hypoxia mimetic agent, CoCl2. VEGF‐A induced in vivo lymphatic vessel formation in a Matrigel plug, but this was remarkably reduced in a recombinant canstatin‐treated Matrigel. Recombinant canstatin suppressed the expression of vascular endothelial growth factor receptors (VEGFR)‐1 and ‐2 stimulated by VEGF‐A. Based on immunohistochemical analysis, recombinant canstatin significantly reduced the expression of VEGF‐A, VEGFR‐1, and ‐2 in SCC‐VII‐induced tumors. Recombinant canstatin did not affect the expression of VEGF‐C or VEGFR‐3. In addition, recombinant canstatin suppressed the VEGF‐A‐induced phosphorylation of VEGFR‐1 and ‐2. Our results indicate that recombinant canstatin exhibits antitumoral and antilymphangiogenic activities against oral SCC cells. Antilymphangiogenic signaling by recombinant canstatin is probably mediated by the suppression of the integrin αvβ3/VEGFR‐1 and/or ‐2 signaling induced by VEGF‐A. Our results also suggest that recombinant canstatin has a high potential to inhibit oral SCC‐induced tumors and lymphatic metastasis.
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Affiliation(s)
- Jeon Hwang-Bo
- Department of Genetic Engineering and Graduate School of Biotechnology, Kyung Hee University, Yongin, 17104, Korea
| | - Jong-Hwa Park
- Department of Genetic Engineering and Graduate School of Biotechnology, Kyung Hee University, Yongin, 17104, Korea
| | - Mun Gyeong Bae
- Department of Genetic Engineering and Graduate School of Biotechnology, Kyung Hee University, Yongin, 17104, Korea
| | - In Sik Chung
- Department of Genetic Engineering and Graduate School of Biotechnology, Kyung Hee University, Yongin, 17104, Korea.
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23
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Szturz P, Vermorken JB. Treatment of Elderly Patients with Squamous Cell Carcinoma of the Head and Neck. Front Oncol 2016; 6:199. [PMID: 27630826 PMCID: PMC5006317 DOI: 10.3389/fonc.2016.00199] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 08/23/2016] [Indexed: 12/27/2022] Open
Abstract
The demographics of squamous cell carcinoma of the head and neck (SCCHN) is marked by a growing number of patients aged 65 and over, which is in line with global projections for other cancer types. In developed countries, more than half of new SCCHN cases are diagnosed in older people, and in 15 years from now, the proportion is expected to rise by more than 10%. Still, a high-level evidence-based consensus to guide the clinical decision process is strikingly lacking. The available data from retrospective studies and subset analyses of prospective trials suffer from a considerable underrepresentation of senior participants. The situation is even more challenging in the recurrent and/or metastatic setting, where usually only palliative measures are employed. Nevertheless, it is becoming clear that, if treated irrespective of chronological age, fit elderly patients in a good general condition and with a low burden of comorbidities may derive a similar survival advantage as their younger counterparts. Despite that, undertreatment represents a widespread phenomenon and, together with competing non-cancer mortality, is suggested to be an important cause of the worse treatment outcomes observed in this population. Due to physiological changes in drug metabolism occurring with advancing age, the major concerns relate to chemotherapy administration. In locally advanced SCCHN, concurrent chemoradiotherapy in patients over 70 years remains a point of controversy owing to its possibly higher toxicity and questionable benefit. However, accumulating evidence suggests that it should, indeed, be considered in selected cases when biological age is taken into account. Results from a randomized trial conducted in lung cancer showed that treatment selection based on a comprehensive geriatric assessment (CGA) significantly reduced toxicity. However, a CGA is time-consuming and not necessary for all patients. To overcome this hurdle, geriatric screening tools have been introduced to decide who needs such a full evaluation. Among the various screening instruments, G8 and Flemish version of the Triage Risk Screening Tool were prospectively verified and found to have prognostic value. We, therefore, conclude that also in SCCHN, the application of elderly specific prospective trials and integration of clinical practice-oriented assessment tools and predictive models should be promoted.
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Affiliation(s)
- Petr Szturz
- Department of Internal Medicine, Hematology, and Oncology, University Hospital Brno, Brno, Czech Republic
- School of Medicine, Masaryk University, Brno, Czech Republic
| | - Jan B. Vermorken
- Department of Medical Oncology, Antwerp University Hospital, Edegem, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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24
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Kim H, Kim SD, Shim YJ, Lee SY, Sung MW, Kim KH, Hah JH. Is There Any Age Cutoff to Treat Elderly Patients with Head and Neck Cancer? Comparing with Septuagenarians and Octogenarians. J Korean Med Sci 2016; 31:1300-6. [PMID: 27478343 PMCID: PMC4951562 DOI: 10.3346/jkms.2016.31.8.1300] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 04/20/2016] [Indexed: 12/20/2022] Open
Abstract
With the increase in life expectancy, age is no longer considered as a limitation for treatment. Nevertheless, the treatment of elderly patients with head and neck cancer (HNC) remains controversial. Here, we aimed to review our experience with the treatment for elderly patients, while particularly focusing on the differences among older old patients (septuagenarians vs. octogenarians). We retrospectively reviewed the records of 260 elderly patients who were assigned to 3 groups according to age: 70 years old ≤ group 1 < 75 years old, 75 years old ≤ group 2 < 80 years old, and group 3 ≥ 80 years old. The patients were assessed for comorbidities using the Adult Comorbidity Evaluation (ACE)-27, and the American Society of Anesthesia (ASA) physical status was also compared. Group 1, 2, and 3, consisted of 97, 102, and 61 patients, respectively. No significant difference in demographic data was noted among the groups. However, group 3 showed more comorbidities than groups 1 and 2. With regard to the initial treatment for HNC, radiation therapy (RT) was more frequently performed in group 3 than in groups 1 and 2. Among 7 patients of non-compliant to treatment in group 3, 6 patients had have performed RT. In group 3, a total of 18 patients underwent surgery, including microvascular free flap reconstruction and no significant difference in complications was observed postoperatively compared with group 1 and 2. Moreover, no significant difference was noted in overall survival between the groups, regardless of the treatment modality chosen. In conclusion, octogenarians with HNC should be more carefully managed than septuagenarians with HNC. Surgical treatment can be considered in octogenarians with HNC, if it can be tolerated.
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Affiliation(s)
- Heejin Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University, Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Seong Dong Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ye Ji Shim
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Yeon Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Myung-Whun Sung
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang Hyun Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - J. Hun Hah
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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25
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Clement PM, Gauler T, Machiels JP, Haddad RI, Fayette J, Licitra LF, Tahara M, Cohen EEW, Cupissol D, Grau JJ, Guigay J, Caponigro F, de Castro G, de Souza Viana L, Keilholz U, Del Campo JM, Cong XJ, Ehrnrooth E, Vermorken JB. Afatinib versus methotrexate in older patients with second-line recurrent and/or metastatic head and neck squamous cell carcinoma: subgroup analysis of the LUX-Head & Neck 1 trial. Ann Oncol 2016; 27:1585-93. [PMID: 27084954 PMCID: PMC4959921 DOI: 10.1093/annonc/mdw151] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 03/15/2016] [Accepted: 03/21/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In the phase III LUX-Head & Neck 1 (LHN1) trial, afatinib significantly improved progression-free survival (PFS) versus methotrexate in recurrent and/or metastatic (R/M) head and neck squamous cell carcinoma (HNSCC) patients progressing on/after platinum-based therapy. This report evaluates afatinib efficacy and safety in prespecified subgroups of patients aged ≥65 and <65 years. PATIENTS AND METHODS Patients were randomized (2:1) to 40 mg/day oral afatinib or 40 mg/m(2)/week intravenous methotrexate. PFS was the primary end point; overall survival (OS) was the key secondary end point. Other end points included: objective response rate (ORR), patient-reported outcomes, tumor shrinkage, and safety. Disease control rate (DCR) was also assessed. RESULTS Of 483 randomized patients, 27% (83 afatinib; 45 methotrexate) were aged ≥65 years (older) and 73% (239 afatinib; 116 methotrexate) <65 years (younger) at study entry. Similar PFS benefit with afatinib versus methotrexate was observed in older {median 2.8 versus 2.3 months, hazard ratio (HR) = 0.68 [95% confidence interval (CI) 0.45-1.03], P = 0.061} and younger patients [2.6 versus 1.6 months, HR = 0.79 (0.62-1.01), P = 0.052]. In older and younger patients, the median OS with afatinib versus methotrexate was 7.3 versus 6.4 months [HR = 0.84 (0.54-1.31)] and 6.7 versus 6.2 months [HR = 0.98 (0.76-1.28)]. ORRs with afatinib versus methotrexate were 10.8% versus 6.7% and 10.0% versus 5.2%; DCRs were 53.0% versus 37.8% and 47.7% versus 38.8% in older and younger patients, respectively. In both subgroups, the most frequent treatment-related adverse events were rash/acne (73%-77%) and diarrhea (70%-80%) with afatinib, and stomatitis (43%) and fatigue (31%-34%) with methotrexate. Fewer treatment-related discontinuations were observed with afatinib (each subgroup 7% versus 16%). A trend toward improved time to deterioration of global health status, pain, and swallowing with afatinib was observed in both subgroups. CONCLUSIONS Advancing age (≥65 years) did not adversely affect clinical outcomes or safety with afatinib versus methotrexate in second-line R/M HNSCC patients. CLINICAL TRIAL REGISTRATION NCT01345682 (ClinicalTrials.gov).
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Affiliation(s)
- P M Clement
- Department of Oncology, KU Leuven, Leuven Department of General Medical Oncology, UZ Leuven, Leuven, Belgium
| | - T Gauler
- Department of Medicine (Cancer Research), West German Cancer Center, University Hospital Essen, Essen, Germany
| | - J P Machiels
- Institut Roi Albert II, Service d'Oncologie Médicale, Cliniques Universitaires Saint-Luc and Institut de Recherche Clinique et Expérimentale (Pole MIRO), Université Catholique de Louvain, Brussels, Belgium
| | - R I Haddad
- Departmant of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, USA
| | - J Fayette
- Departmant of Medical Oncology, Léon Bérard Center, University of Lyon, Lyon, France
| | - L F Licitra
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - M Tahara
- Head and Neck Medical Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - E E W Cohen
- Department of Medicine, University of California San Diego Moores Cancer Center, La Jolla, USA
| | - D Cupissol
- Service d'Oncologie Médicale, Institut du Cancer de Montpellier Val d'Aurelle, Montpellier, France
| | - J J Grau
- Department of Medical Oncology, Hospital Clínic and University of Barcelona, Barcelona, Spain
| | - J Guigay
- Department of Medical Oncology, Gustave Roussy, Villejuif Centre Antoine Lacassagne, Nice, France
| | - F Caponigro
- Department of Melanoma, Soft Tissues, Muscolo Scheletal, Head and Neck, Head and Neck Medical Oncology, National Tumor Institute of Naples, Naples, Italy
| | - G de Castro
- Oncologia Clinica, Instituto do Câncer do Estado de São Paulo, São Paulo
| | - L de Souza Viana
- Department of Medical Oncology, Hospital de Câncer de Barretos, São Paulo, Brazil
| | - U Keilholz
- Charité Comprehensive Cancer Center, Berlin, Germany
| | - J M Del Campo
- Department of Medical Oncology, Hospital Universitario Vall D'Hebron, Barcelona, Spain
| | - X J Cong
- Biometrics and Data Management, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, USA
| | - E Ehrnrooth
- Division of Oncology, Boehringer Ingelheim Danmark A/S, Copenhagen, Denmark
| | - J B Vermorken
- Department of Medical Oncology, Antwerp University Hospital, Edegem, Belgium
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Maruyama T, Nakasone T, Matayoshi A, Arasaki A. Successful tongue cancer surgery under general anesthesia in a 99-year-old patient in Okinawa, Japan: A case report and review of the literature. Oncol Lett 2016; 12:1675-1678. [PMID: 27588116 PMCID: PMC4998137 DOI: 10.3892/ol.2016.4864] [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: 02/13/2015] [Accepted: 04/15/2016] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Tessho Maruyama
- Department of Oral and Maxillofacial Functional Rehabilitation, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa 903-0215, Japan; Department of Clinical Neuroscience, Oral and Maxillofacial Functional Rehabilitation, University of the Ryukyus Hospital, Nishihara, Okinawa 903-0215, Japan
| | - Toshiyuki Nakasone
- Department of Clinical Neuroscience, Oral and Maxillofacial Functional Rehabilitation, University of the Ryukyus Hospital, Nishihara, Okinawa 903-0215, Japan
| | - Akira Matayoshi
- Department of Clinical Neuroscience, Oral and Maxillofacial Functional Rehabilitation, University of the Ryukyus Hospital, Nishihara, Okinawa 903-0215, Japan
| | - Akira Arasaki
- Department of Oral and Maxillofacial Functional Rehabilitation, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa 903-0215, Japan; Department of Clinical Neuroscience, Oral and Maxillofacial Functional Rehabilitation, University of the Ryukyus Hospital, Nishihara, Okinawa 903-0215, Japan
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27
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Concurrent chemoradiotherapy in older adults with squamous cell head & neck cancer: Evidence and management. J Geriatr Oncol 2016; 7:145-53. [PMID: 26924572 DOI: 10.1016/j.jgo.2016.01.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/06/2015] [Accepted: 01/29/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Treatment for head and neck cancers incurs substantial associated morbidities, which can be of potentially greater significance in older patients. Though the geriatric population forms a substantial portion of patients with head and neck cancers, this group remains underrepresented in large clinical trials. Hence, management for this unique subpopulation remains empiric and mostly based on data from younger patients. MATERIALS AND METHODS Review of key publications on geriatric patients treated for head and neck cancers. CONCLUSIONS We discuss data regarding chemoradiation for head and neck cancers, as well as management of associated side effects in this population. We encourage oncologists to treat older patients not as a homogeneous subpopulation, but rather assess several factors associated with potential tolerance to chemoradiotherapy. Aggressive supportive treatments for chemoradiotherapy toxicities are highly encouraged in this population, and with new technical/technological developments, there is potential to continually reduce toxicity in this cohort in the future.
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Guntinas-Lichius O, Wendt TG, Kornetzky N, Buentzel J, Esser D, Böger D, Müller A, Schultze-Mosgau S, Schlattmann P, Schmalenberg H. Trends in epidemiology and treatment and outcome for head and neck cancer: A population-based long-term analysis from 1996 to 2011 of the Thuringian cancer registry. Oral Oncol 2014; 50:1157-64. [DOI: 10.1016/j.oraloncology.2014.09.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 09/18/2014] [Accepted: 09/28/2014] [Indexed: 12/24/2022]
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29
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Yang R, Lubek JE, Dyalram D, Liu X, Ord RA. Head and neck cancer surgery in an elderly patient population: a retrospective review. Int J Oral Maxillofac Surg 2014; 43:1413-7. [PMID: 25223605 DOI: 10.1016/j.ijom.2014.08.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 08/18/2014] [Accepted: 08/22/2014] [Indexed: 12/20/2022]
Abstract
Should advanced age be a contraindication to the surgical management of head and neck cancer patients? A retrospective chart review was performed of patients aged ≥80 years treated surgically for a head and neck malignancy during the period 1996-2011 in a tertiary care cancer centre. The average follow-up was 32 months. Fifty-three patients were identified (mean age 85 years). Cardiovascular disease was the most prevalent co-morbidity (43%). Forty-five patients (85%) had oral cavity/oropharynx squamous cell carcinoma. Surgeries performed included 40 neck dissections and 12 microvascular free flaps. The average length of hospital stay (LOS) was 6.4 days. An increased LOS was significant in patients requiring free flap reconstruction (P<0.01). There were no perioperative deaths or free flap failures. The most common postoperative complications were cardiovascular (n=8), infection (n=10), and delirium (n=6). Thirty-four patients were discharged directly home. Free flap reconstruction did not adversely affect discharge disposition (P>0.05). More than 75% of patients did not report any major limitations to their activities of daily living. Major head and neck surgical procedures can be tolerated by patients of advanced age using careful patient selection. Age alone should not be a primary factor in the management of head and neck cancer patients.
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Affiliation(s)
- R Yang
- Department of Oral and Maxillofacial Surgery, Oncology Program, Greenebaum Cancer Center, University of Maryland, Baltimore, MD, USA
| | - J E Lubek
- Department of Oral and Maxillofacial Surgery, Oncology Program, Greenebaum Cancer Center, University of Maryland, Baltimore, MD, USA.
| | - D Dyalram
- Department of Oral and Maxillofacial Surgery, Oncology Program, Greenebaum Cancer Center, University of Maryland, Baltimore, MD, USA
| | - X Liu
- Department of Epidemiology and Preventative Medicine, University of Maryland, Baltimore, MD, USA
| | - R A Ord
- Department of Oral and Maxillofacial Surgery, Oncology Program, Greenebaum Cancer Center, University of Maryland, Baltimore, MD, USA
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