Concurrent chemoradiotherapy in older adults with squamous cell head & amp; neck cancer: Evidence and management. J Geriatr Oncol. 2016;7:145-153. [PMID: 26924572 DOI: 10.1016/j.jgo.2016.01.010]

Primary concurrent chemoradiation therapy with triweekly cisplatin as a standard protocol in patients aged ≥65 years with head and neck squamous cell carcinoma

AIM

To evaluate the results of primary concurrent chemoradiation therapy (CCRT) with triweekly cisplatin in patients with head and neck squamous cell carcinoma (HNSCC) aged ≥65 years by comparing these patients to those aged < 65 years.

METHODS

This prospective, single-center study enrolled patients with HNSCC for whom CCRT was indicated as the primary treatment. The major endpoints were progression-free survival (PFS) and overall survival (OS).

RESULTS

A total of 169 patients were enrolled; 75 (44.4%) and 94 (55.6%) patients were aged ≥65 and < 65 years, respectively. The mean cumulative cisplatin doses were 192.8 mg/m2 and 212.3 mg/m2 in patients ≥65 and < 65, respectively (p < .001). The incidence rates of any grade 3-4 toxicities were 37.3% and 51.1% in the age ≥65 and < 65 groups, respectively (p = .085). The 5-year locoregional control, distant control, PFS, ultimate PFS, and disease-specific survival were comparable between both groups. The 5-year OS was significantly lower in the ≥65 group than the < 65 group (65.5% vs. 86.4%, p = .010) due to a lower salvage rate and higher incidence of non-HNSCC-related death. In a Cox regression analysis, age ≥65 years was not associated with increased risk of treatment failure but was associated with higher overall death rate (hazard ratio, 2.590; 95% confidence interval, 1.219-5.502; p = .013).

CONCLUSION

CCRT with a triweekly cisplatin regimen could act as the standard of ca for HNSCC in elderly patients. However, the relatively lower OS compared to younger patients should be acknowledged, despite a favorable disease control rates.

Equity in adjuvant radiotherapy utilization in locally advanced head and neck cancer: A SEER-data based study

BACKGROUND

Not all patients with locally advanced head and neck cancer (HNC) who are eligible for adjuvant radiotherapy (RT) following upfront surgery appear to receive it.

METHODS

Data were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Selected patients from 2009 to 2018 had locally advanced HNC, underwent upfront surgery, and were eligible for adjuvant RT. Multivariable logistic regression and chi-squared test were used to analyze available patient and tumor characteristics.

RESULTS

Of 12 549 patients, 84.5% underwent adjuvant RT, 15.5% did not. Characteristics associated with lowest adjuvant RT utilization included cancers of the larynx (p < 0.0001) and gingivae (p < 0.0001), age 80 and above (p < 0.0001), unpartnered status (p < 0.0001), and residence within a nonmetropolitan area (p < 0.0024).

CONCLUSIONS

Tumor subsite, age, partnered status, and rural/urban residence correlate with omission of adjuvant RT in locally advanced HNC.

Postoperative chemoradiotherapy versus radiotherapy alone for elderly cervical cancer patients with positive margins, lymph nodes, or parametrial invasion

Objective

Women with cervical cancer (CC) found to have positive surgical margins, positive lymph nodes, and/or parametrial invasion receive a survival benefit from postoperative chemoradiotherapy (CRT) vs. radiation therapy (RT) alone. However, older women may not benefit to the same extent, as they are at increased risk of death from non-oncologic causes as well as toxicities from oncologic treatments. This study sought to evaluate whether there was a survival benefit of CRT over RT in elderly patients with cervical cancer.

Methods

The National Cancer Database was queried for patients ≥70 years old with newly diagnosed IA2, IB, or IIA CC and positive margins, parametrial invasion, and/or positive nodes on surgical resection. Statistics included logistic regression, Kaplan-Meier overall survival (OS), and Cox proportional hazards modeling analyses.

Results

Altogether, 166 patients met inclusion criteria; 62 (37%) underwent postoperative RT and 104 (63%) underwent postoperative CRT. Younger patients and those living in areas of higher income were less likely to receive CRT, while parametrial invasion and nodal involvement were associated with an increased likelihood (p<0.05 for all). There were no OS differences by treatment type. Subgroup analysis by number of risk factors, as well as each of the 3 risk factors separately, also did not reveal any OS differences between cohorts.

Conclusion

In the largest such study to date, older women with postoperative risk factor(s) receiving RT alone experienced similar survival as those undergoing CRT. Although causation is not implied, careful patient selection is paramount to balance treatment-related toxicity risks with theoretical outcome benefits.

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

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

Practice patterns and outcomes of chemoradiotherapy versus radiotherapy alone for older patients with nasopharyngeal cancer

Older patients are at increased risk of toxicities from aggressive oncologic therapy and of nononcologic death. A meta‐analysis of non‐nasopharyngeal head and neck cancers showed no statistical benefit in adding chemotherapy to radiotherapy (RT) in older patients; another meta‐analysis of RT versus chemoradiotherapy (CRT) in NPC found advantages to CRT, but vastly under‐represented patients ≥70 years old. This is the largest study to date evaluating outcomes of CRT versus RT alone in this population. The National Cancer Data Base (NCDB) was queried for primary nasopharyngeal cancer cases (2004–2013) in patients ≥70 years old receiving RT alone or CRT. Patients with unknown RT/chemotherapy and T1N0 or M1 disease were excluded. Logistic regression analysis ascertained factors associated with CRT delivery. Kaplan–Meier analysis evaluated overall survival (OS) between both cohorts. Cox proportional hazards modeling determined variables associated with OS. In total, 930 patients were analyzed (n = 713 (77%) CRT, n = 217 (23%) RT). Groups were relatively balanced; CRT was less frequently delivered in patients with advancing age, lower nodal burden, and females (P < 0.05 for all). Median OS in the CRT and RT groups were 35.3 versus 20.0 months, respectively (P = 0.002). On multivariate analysis, independent predictors of OS included age, comorbidities, income and insurance status, tumor grade, and stage (P < 0.05 for all). Notably, receipt of chemotherapy independently predicted for improved OS (P = 0.036). CRT, compared to RT alone, was independently associated with improved survival in NPC patients ≥70 years old. CRT appears to be a promising approach in this population, but treatment‐related toxicity risks should continue to be weighed against potential oncologic benefits.

Evaluating Factors for Prophylactic Feeding Tube Placement in Gastroesophageal Cancer Patients Undergoing Chemoradiotherapy

PURPOSE

Though better studied in head/neck cancers, there are currently no studies on timing of feeding tube (FT) placement in patients with gastroesophageal cancer. This study sought to discern characteristics of patients who used versus did not use a prophylactic FT (pFT), and also analyzed factors associated with placement of FTs during chemoradiotherapy (CRT).

METHODS/MATERIALS

From 1998 to 2013, 1,329 patients underwent neoadjuvant CRT, of which 323 received an FT. Patients for whom FTs were placed prior to treatment due to tumor occlusion or substantial weight loss (n = 130), and those with FTs placed following treatment (n = 43) were excluded. One hundred patients had pFTs placed, and 50 underwent placement during CRT. The following was collected for each patient: demographic/patient information, oncologic/treatment characteristics, and CRT tolerance.

RESULTS

No significant differences were found in any parameter between cohorts that used (n = 66) versus did not use a pFT (n = 34); on univariate and multivariate analyses, no pretreatment characteristic associated with using a pFT. When compared with patients who used a pFT (n = 66), those who required an FT during CRT (n = 50) had lower body mass index (p = 0.045), underwent higher-dose radiotherapy (p = 0.003), and received induction chemotherapy (p = 0.031). On multivariate analysis, receipt of induction chemotherapy and greater weight loss and esophagitis during treatment were associated with placement of FTs during CRT (p < 0.05).

CONCLUSION

Of our cohort who received pFTs, there were no clinical factors that predicted for their use. Patients must be closely monitored for weight loss and esophagitis when receiving CRT in order to intervene prior to further worsening of toxicities.

Concurrent Radiotherapy and Triweekly Carboplatin for the Definitive Treatment of Locally Advanced Laryngeal Carcinoma

PURPOSE OF THE STUDY

In 2003, our institution adopted triweekly carboplatin (tCb) area under the curve (AUC) 5 as an alternative to high-dose cisplatin (100 mg/m) for select patients receiving definitive concurrent chemoradiation for locally advanced laryngeal carcinoma (LALC). Here, we present our experience and outcomes with this definitive concurrent chemoradiation regimen.

METHODS

From January 2003 through December 2013, 53 patients with stage III (60%) or IVA (40%) LALC were treated with tCb AUC 5 and concurrent radiotherapy to 70 Gy without neoadjuvant chemotherapy. Reasons for using carboplatin instead of cisplatin in these patients were: age 70 and older (21%), poor renal function (6%), presence of 1 or more major comorbid condition(s) (36%), and per discretion of the treating medical oncologist (38%). Primary disease site was glottis in 22 (42%) patients and supraglottis in 31 (58%) patients.

RESULTS

Median follow-up time was 63 months for surviving patients. Out of the 53 patients, 43 (81%) received all 3 cycles of carboplatin and all patients received their intended dose of radiotherapy. Although 17 (32%) patients required a feeding tube during treatment, only 2 (4%) required it long term. There were no acute treatment-related grade 4 or 5 hematologic toxicities. On last follow-up, 14 (26%) patients had died of intercurrent disease. For the subgroup of "RTOG 9111 eligible" patients in our cohort (n=46), 5-year estimates of overall survival, disease-free survival, laryngectomy-free survival, larynx preservation, and locoregional control were: 49%, 42%, 39%, 80%, and 63%, respectively.

CONCLUSIONS

In patients with LALC who are suboptimal candidates for high-dose cisplatin, our experience suggests that tCb AUC 5 with concurrent radiotherapy provides acceptable outcomes with tolerable toxicity.

Relationship and interactions of curcumin with radiation therapy

Curcumin is widely reported to have remarkable medicinal - and antineoplastic - properties. This review details curcumin’s relationship with radiotherapy (RT), principally as a radiosensitizer for various malignancies and a radioprotector for normal tissues. First, examples of radiosensitization are provided for various cancers: Pediatric, lymphoma, sarcoma, prostate, gynecologic, pancreas, liver, colorectal, breast, lung, head/neck, and glioma. It is not the purpose of this article to comprehensively review all radiosensitization data; however, high-quality studies are discussed in relationship to currently-controversial RT questions for many cancers, and thus the importance of developing a natural radiosensitizer. Attention is then shifted to radioprotection, for which supporting research is discussed for the following RT toxicities: Dermatitis, pneumonitis, cataractogenesis, neurocognition, myelosuppression, secondary malignancies, and mucositis/enteritis. Though there is fewer data for radioprotection, the overall quality of clinical evidence is higher, and small clinical trials implicating the efficacy of curcumin for RT toxicities (vs placebo/current therapies) are also detailed. Though the overall level of evidence for curcumin as a radiosensitizer and radioprotector is low, it must be recognized that risks of adverse effects are exceedingly low, and clinicians may need to judge the yet-unproven rewards with low toxicity risks.