Head and Neck Cancer and the Elderly Patient

Evaluation of a new two-step frailty assessment of head and neck patients in a prospective cohort

PURPOSE

Assessing frailty, in head and neck cancer (HNC) patients is key when choosing appropriate treatment. Optimal screening is challenging, as it should be feasible and should avoid over-referral for comprehensive geriatric assessment (CGA) This study aims to evaluate the association between geriatric assessment using a new two-step care pathway, referral to geriatrician and adverse outcomes.

METHODS

This institutional retrospective analysis on a prospective cohort analysed the multimodal geriatric assessment (GA) of newly diagnosed HNC patients. Uni- and multivariable logistic regression was performed to study the association between the screening tests, and referral to the geriatrician for complete geriatric screening, and adverse outcomes.

RESULTS

This study included 539 patients, of whom 276 were screened. Patients who underwent the GA, were significantly older and more often had advanced tumour stages compared to non-screened patients. Referral to the geriatrician was done for 30.8% of patients. Of the 130 patients who underwent surgery, 26/130 (20%) experienced clinically relevant postoperative complications. Of the 184 patients who underwent (radio)chemotherapy, 50/184 (27.2%) had clinically relevant treatment-related toxicity. Age, treatment intensity, polypharmacy and cognitive deficits, were independently associated with referral to geriatrician. A medium to high risk of malnutrition was independently associated with acute radiation induced toxicity and adverse outcomes in general.

CONCLUSION

The current study showed a 30.8% referral rate for CGA by a geriatrician. Age, treatment intensity, cognitive deficits and polypharmacy were associated with higher rates of referral. Furthermore, nutritional status was found to be an important negative factor for adverse treatment outcomes, that requires attention.

Identification of a disulfidptosis-related lncRNA signature for the prognostic and immune landscape prediction in head and neck squamous cell carcinoma

PURPOSE

Disulfidptosis, a newly identified form of cell death, is triggered by disulfide stress. Herein, a unique signature was developed based on disulfidptosis-related lncRNAs (DRlncRNAs) for the prognostic and immune landscape prediction of head and neck squamous cell carcinoma (HNSCC).

METHODS

Transcriptome, somatic mutation, and clinical data were acquired at The Cancer Genome Atlas database. Individuals were partitioned into training and test cohorts at a 1:1 ratio to facilitate the development of a DRlncRNA signature using the least absolute shrinkage and selection operation method. Based on the median risk score, all HNSCC individuals were stratified into the high-risk group (HRG) and low-risk group (LRG). Kaplan-Meier survival and time-dependent receiver operating characteristic (ROC) analyses were used to estimate the prognostic value, and a nomogram was generated for survival prediction. To provide a more comprehensive assessment, the tumor microenvironment, functional enrichment, immune cell infiltration, and immunotherapeutic sensitivity were explored between LRG and HRG.

RESULTS

A DRlncRNA signature was established with 10 DRlncRNAs. The corresponding values of areas under the ROC curves for 1-, 3-, and 5-year overall survival were 0.710, 0.692, and 0.640. A more favorable prognosis was noted in the patients with lower risk, along with higher immune scores, increased immune-related functions, and immune cell infiltration, as well as improved response to the immunotherapeutic intervention in comparison with individuals at higher risk.

CONCLUSION

These findings demonstrate that the developed DRlncRNA signature holds promise as a reliable prognostic marker and predictor of immunotherapy response in HNSCC patients.

Foregoing elective neck dissection for elderly patients with oral cavity squamous cell carcinoma

OBJECTIVE

Elective neck dissection (END) improves outcomes among clinically node-negative patients with oral cavity squamous cell carcinoma (OCSCC). However, END is of questionable value, considering the potentially higher comorbidities and operative risks in elderly patients.

METHODS

A retrospective review of all patients older than 65 years of age who were treated for OCSCC at a tertiary care centre between 2005 and 2020 was conducted.

RESULTS

Fifty-three patients underwent primary tumour resection alone, and 71 had simultaneous END. Most primary tumours were located on the mobile tongue. The patients who did not undergo END had a higher mean age (81.2 vs. 75.1 years, P < 0.00001), significantly shorter surgeries, and shorter hospitalizations. Occult cervical metastases were found in 24% of the patients who underwent END. The two groups showed no significant differences in overall survival or recurrence rates. Similar results were shown in a subpopulation analysis of patients older than 75 years.

CONCLUSION

Foregoing END in elderly patients with no clinical evidence of neck metastases did not result in lower survival rates or higher recurrence rates.

Going Off Guidelines: An NCDB Analysis of Missed Adjuvant Therapy Among Surgically Treated Oral Cavity Cancer

OBJECTIVE

Patient factors associated with failure to receive adjuvant therapy after oral cavity cancer resection remain understudied. Here, we identified rates of missed adjuvant therapy, determined factors associated with missed therapy, and assessed associations with survival.

STUDY DESIGN

Retrospective cohort.

SETTING

National Cancer Database.

METHODS

Patients with resected oral cavity squamous cell carcinoma and known adjuvant therapy status were included. T3-4 stage, N2-3 stage, and lymphovascular invasion were considered indications for adjuvant radiation. Extranodal extension or positive margins were considered indications for chemoradiation. Patient factors were examined for associations with missed adjuvant therapy. Overall survival was evaluated by Cox proportional hazard analysis.

RESULTS

A total of 53,503 patients were included. 27.5% missed adjuvant therapy altogether, and 26.7% with a documented indication for chemoradiation missed chemotherapy. Factors associated with missed adjuvant therapy were age, white race, low income, metropolitan population, increasing comorbidities, travel distance, lip primary, and treatment at the academic facility. Factors associated with missed chemotherapy were age, female sex, nontongue subsite, and treatment at a nonacademic center. Among patients with indications for adjuvant radiation, missed radiation was associated with worse overall survival (hazard ratio [HR]: 1.42, 95% confidence interval [CI]: 1.31-1.53). Among patients with indications for adjuvant chemoradiation, missed chemotherapy was associated with worse overall survival (HR: 1.19, 95% CI: 1.09-1.29).

CONCLUSION

Missed adjuvant therapy occurs frequently after oral cavity resection. Patients treated at academic centers may be at risk of missed therapy related to travel distance, though these patients are more likely to receive adjuvant chemotherapy when indicated. Missed adjuvant therapy is associated with worse survival.

The Association between Patient’s Age and Head and Neck Cancer Treatment Decision—A Population-Based Diagnoses-Related Group-Based Nationwide Study in Germany

Investigations on the association between patient’s age and head and neck cancer (HNC) treatment decision are sparse. Nationwide diagnoses-related group-based data of 1,226,357 cases hospitalized with primary HNC in Germany from 2005 to 2018 were included. Negative binomial regression was performed to study the development of the treatment rates over time. For all treatment options, i.e., biopsies, surgery, radiotherapy, and chemotherapy/biologicals, increases in the treatment rates were seen in patients >80 years (surgery: oral cavity: relative risk [RR]: 1.2, CI: 1.13–1.20; oropharynx: RR: 1.2, CI: 1.15–1.34; hypopharynx: RR: 1.1, CI: 1.02–1.17; larynx: RR: 1.1, CI: 1.04–1.12; radiotherapy: oral cavity: RR: 1.1, CI: 1.07–1.23; oropharynx: RR: 1.3, CI: 1.16–1.49; hypopharynx: RR: 1.3, CI: 1.21–1.46; larynx: RR 1.2, CI: 1.03–1.29; chemotherapy: oral cavity: RR: 1.2, CI: 1.06–1.31; salivary glands: RR: 1.3, CI: 1.09–1.50; oropharynx: RR: 1.4, CI: 1.12–1.83; hypopharynx: RR: 1.3, CI: 1.06–1.48; larynx: RR: 1.3, CI: 1.08–1.52, all p < 0.05). Older age cohorts (≥80 years) need more awareness as they are mainly responsible for the increase in the rates of surgery, radiotherapy, and chemotherapy/biologics in HNC patients.

Age Alone Is Not a Barrier to Concurrent Chemoradiotherapy for Advanced Head and Neck Cancer

BACKGROUND

Head and Neck Cancer (HNC) is associated with significant morbidity and mortality, especially when high stage disease is present. There exists a range of options for the management of locoregionally advanced HNC, though doubt remains as to the optimal strategy in the elderly population.

AIMS

To evaluate the benefits imparted by concurrent chemoradiotherapy (CCRT) to the elderly population of HNC patients in Ireland.

METHODS

A retrospective cohort study was conducted using 20 years of cancer registry data provided by the National Cancer Registry of Ireland. Cox multivariate regression analysis was applied to test for the benefits of CCRT in HNC.

RESULTS

Survival analysis showed an overall benefit to the use of CCRT in patients with advanced disease over 70 years, particularly when used for hypopharyngeal, oropharyngeal, and laryngeal malignancy. There was a benefit to cancer-specific but not all-cause mortality in those over 75 years, and no benefit was observed to the addition of chemotherapy in those over 80 years; only 8 patients over 80 received CCRT. There was no statistically significant difference in the benefits derived by those over 70 years relative to those under 70 years.

CONCLUSION

CCRT confers significant survival benefits to appropriately selected elderly HNC patients and should therefore not be withheld solely on the basis of age.

Head and neck cancer surgery in elderly patients: the role of frailty assessment

OBJECTIVES

To study whether any risk model, frailty index, patients' comorbidities, or demographic characteristics correlate with postoperative morbidity in elderly patients who underwent surgery for head and neck cancer (HNC). A secondary objective was to compare between frailty indexes that are used at our medical center.

METHODS

A retrospective analysis of head and neck cancer patients operated between 2007 and 2021 was performed.

RESULTS

One hundred and fifteen patients were included and divided into three age groups: 50-69 years, 70-79 years and ≥ 80 years. Although most elderly patients had a significantly higher rate of comorbidities and lower Norton scores, no statistically significant difference was found between the groups in postoperative morbidity rates, intensive care unit (ICU) or internal medicine department admissions, re-hospitalization in 1-3 months, and in falling risk (MFS-Morse Fall Scale). On multivariate analysis there was a positive correlation between preoperative cerebrovascular accident (CVA), dementia, and cardiac arrhythmias, and the probability for developing postoperative complication. The latter findings were not related to the patients' age.

CONCLUSIONS

In this study, we did not find higher postoperative morbidity rates among elderly population in comparison to younger age groups, and therefore, our current evaluation system could not assist in identifying elderly at risk. However, prediction of operative risk based on physiologic reserve or frailty is an important tool in the evaluation of elderly head and neck cancer patients. Future studies are needed to assess the role of frailty index in the elderly head and neck cancer population.

Impact of adjuvant radiation therapy after definitive surgery in senior adults >80 years old with advanced head and neck squamous cell carcinoma on overall survival

Background

Adjuvant radiotherapy (RT) following surgical resection confers a survival benefit for adult patients with locally advanced head and neck squamous cell carcinoma (HNSCC). We aim to investigate if adjuvant RT provides a similar survival advantage to patients ages 80+ through a national curated database.

Methods

This retrospective cohort study queried the National Cancer Database (NCDB) for all cases of HNSCC between 2004-2016. Patients treated with surgical resection alone were compared to those treated with surgery plus adjuvant RT. Overall survival (OS) was compared within adult (age <80 years) and senior adult (age ≥80 years) cohorts using Kaplan-Meier analysis. Hazard ratios (HR) were assessed using Cox proportional hazards to account for differences in patient characteristics, primary site, and HNSCC stage.

Results

NCDB identified 16,504 locally advanced HNSCC treated with definitive surgery with 9,129 (55.3%) also receiving adjuvant RT. The mean age was 63.8 years (SD = 12.0) with 88.7% of patients ages <80 years and 11.3% ages ≥80 years. In the adult cohort, adjuvant RT was associated with a significant increase in OS compared to surgery alone at 1 year (88.4% vs. 83.8%, p=<0.001), 3 years (64.0% vs. 59.2%, p=<0.001) and 5 years (52.8% vs. 47.2%, p=<0.001). Treatment with surgery alone remained a significant predictor of mortality risk at 1 year (HR 1.48, 95% CI 1.35-1.64, p<0.001), 3 years (HR 1.25, 95% CI 1.18-1.33, p<0.001), and 5 years (HR of 1.23, 95% CI 1.17-1.30, p=<0.001). In the senior adult cohort, there were no significant differences in OS between treatment groups at 1 year (73.4% vs. 74.8%, 0.296), 3 years (45.8% vs. 41.8%, p=0.465), or 5 years (28.2% vs. 27.7% p=0.759). Treatment with surgery alone was not a significant predictor of mortality risk at 1 year (HR 1.11, 95% CI 0.90-1.36, p=0.316), 3 years (HR 0.94, 95% CI 0.81-1.08, p=0.423), or 5 years (HR 0.95, 95% CI 0.83-1.08, p=0.476).

Conclusion

The addition of adjuvant RT in senior patients (age ≥80 years) may not provide a similar OS benefit to that observed in younger patients. Further research is needed to best guide shared-decision making in this population.

Comparison between three age-stratified cohorts reveals poor prognosis of young patients with tongue carcinoma

Objectives

Investigation of the prognosis of young patients with tongue carcinoma has been the focus of several recent studies aimed at improving future precision treatment. Most studies have been two-cohort investigations comparing young and older patients, who have wide discrepancies in prognosis. Older patients, especially those aged >70 years, often have a poor general condition. This affects the prognosis of the older cohort and accounts for the discrepancies observed in two-cohort studies. Accordingly, in this study, older patients (aged ≥71 years) were separated and compared to young and middle-aged patients.

Methods

A total of 257 patients with oral tongue carcinoma referred during 2011–2017 were analyzed. Patients were sorted into young (aged ≤40 years), middle-aged (aged ≥41 and ≤70 years), and older (aged ≥71 years) groups. Overall survival (OS) and disease-free survival (DFS) were compared among the groups. Furthermore, patterns of recurrence rates were compared.

Results

Compared with young patients, there was no difference in OS or DFS for older patients (hazard ratio [HR]: 1.2, 95% confidence interval [CI]: 0.5–2.7 and HR: 0.7, 95% CI: 0.4–1.2, respectively) in a multivariate analysis. There was also no difference in OS (HR: 0.6, 95% CI: 0.3–1.3) for middle-aged patients. However, middle-aged patients had low recurrence rates (HR: 0.5, 95% CI: 0.3–0.8). With respect to the recurrence type, middle-aged patients had a low local recurrence rate (HR: 0.3, 95% CI: 0.1–0.7).

Conclusion

Three-cohort studies should be conducted to evaluate whether the prognosis of young patients with tongue carcinoma is truly poor in terms of future precision treatment.

Effectiveness of Geriatric Assessment-Driven Interventions on Survival and Functional and Nutritional Status in Older Patients with Head and Neck Cancer: A Randomized Controlled Trial (EGeSOR)

Simple Summary

Due to population ageing, there is an increasing number of older patients with head and neck cancers (HNC). Management of HNCs is complex. This population may be frailer than other patients with solid cancer. The Geriatric Assessment (GA) is a multidimensional diagnostic and therapeutic tool focused on frailty to propose a coordinated treatment plan and long-term follow-up. Several trials assessed the efficacy of GA-driven interventions on diverse outcomes but no recent randomized controlled trial demonstrated the impact on mortality, functional, or nutritional status as a primary outcome in this particular population. This trial highlighted several difficulties in implementation of geriatric interventions and suggested that the assessment of other models as co-management with oncologists and/or experienced practice nurses could be useful in clinical routine practice.

Abstract

This study assesses the efficacy of Geriatric Assessment (GA)-driven interventions and follow-up on six-month mortality, functional, and nutritional status in older patients with head and neck cancer (HNC). HNC patients aged 65 years or over were included between November 2013 and September 2018 by 15 Ear, Nose, and Throat (ENT) and maxillofacial surgery departments at 13 centers in France. The study was of an open-label, multicenter, randomized, controlled, and parallel-group design, with independent outcome assessments. The patients were randomized 1:1 to benefit from GA-driven interventions and follow-up versus standard of care. The interventions consisted in a pre-therapeutic GA, a standardized geriatric intervention, and follow-up, tailored to the cancer-treatment plan for 24 months. The primary outcome was a composite criterion including six-month mortality, functional impairment (fall in the Activities of Daily Living (ADL) score ≥2), and weight loss ≥10%. Among the patients included (n = 499), 475 were randomized to the experimental (n = 238) or control arm (n = 237). The median age was 75.3 years [70.4–81.9]; 69.5% were men, and the principal tumor site was oral cavity (43.9%). There were no statistically significant differences regarding the primary endpoint (n = 98 events; 41.0% in the experimental arm versus 90 (38.0%); p = 0.53), or for each criterion (i.e., death (31 (13%) versus 27 (11.4%); p = 0.48), weight loss of ≥10% (69 (29%) versus 65 (27.4%); p = 0.73) and fall in ADL score ≥2 (9 (3.8%) versus 13 (5.5%); p = 0.35)). In older patients with HNC, GA-driven interventions and follow-up failed to improve six-month overall survival, functional, and nutritional status.

Measurement of Sarcopenia in Head and Neck Cancer Patients and Its Association With Frailty

In head and neck cancer (HNC) there is a need for more personalized treatment based on risk assessment for treatment related adverse events (i.e. toxicities and complications), expected survival and quality of life. Sarcopenia, defined as a condition characterized by loss of skeletal muscle mass and function, can predict adverse outcomes in HNC patients. A review of the literature on the measurement of sarcopenia in head and neck cancer patients and its association with frailty was performed. Skeletal muscle mass (SMM) measurement only is often used to determine if sarcopenia is present or not. SMM is most often assessed by measuring skeletal muscle cross-sectional area on CT or MRI at the level of the third lumbar vertebra. As abdominal scans are not always available in HNC patients, measurement of SMM at the third cervical vertebra has been developed and is frequently used. Frailty is often defined as an age-related cumulative decline across multiple physiologic systems, with impaired homeostatic reserve and a reduced capacity of the organism to withstand stress, leading to increased risk of adverse health outcomes. There is no international standard measure of frailty and there are multiple measures of frailty. Both sarcopenia and frailty can predict adverse outcomes and can be used to identify vulnerable patients, select treatment options, adjust treatments, improve patient counselling, improve preoperative nutritional status and anticipate early on complications, length of hospital stay and discharge. Depending on the definitions used for sarcopenia and frailty, there is more or less overlap between both conditions. However, it has yet to be determined if sarcopenia and frailty can be used interchangeably or that they have additional value and should be used in combination to optimize individualized treatment in HNC patients.

Treatment Sequences in Patients with Recurrent or Metastatic Head and Neck Squamous Cell Carcinoma: Cetuximab Followed by Immunotherapy or Vice Versa

BACKGROUND

The prognosis was poor when patients had recurrent or metastatic head and neck squamous cell carcinoma (R/M HNSCC). Herein, we conducted an observational study of cetuximab followed by immunotherapy (Cet-IO) versus immunotherapy followed by cetuximab (IO-Cet) in patients with R/M HNSCC.

METHODS

Patients who were diagnosed with R/M HNSCC and treated with a sequential cetuximab-containing regimen and immunotherapy-containing regimen were enrolled in our study. Kaplan-Meier curves were estimated for progression-free survival (PFS) and overall survival (OS).

RESULTS

A total of 75 patients were enrolled in our study for oncologic outcomes evaluation, with 40 patients in Cet-IO and 35 patients in IO-Cet. The median PFS1 was 5.1 months in Cet-IO and 4.5 months in IO-Cet (p = 0.777) and the median PFS2 was 16.5 months in Cet-IO and 11.4 months in IO-Cet (p = 0.566). The median OS was 23.7 months versus 22.8 months in Cet-IO and IO-Cet, respectively (p = 0.484). The overall response rate (ORR) were 73% in Cet-IO versus 37% in IO-Cet (p = 0.002). Multivariate analysis demonstrated that the treatment sequences, Cet-IO or IO-Cet, were insignificantly different with survival.

CONCLUSION

Both Cet-IO and IO-Cet are effective in R/M HNSCC patients with insignificant survival differences. The higher ORR of Cet-IO might render it to be considered in patients with large tumor burdens and urgent needs for treatment responses. Further prospective studies are merited to validate our conclusions.

Occult lymph node metastasis in the contralateral neck of oropharyngeal squamous cell carcinoma: a meta-analysis and literature review

PURPOSE

The purpose of this study was to determine whether contralateral cervical lymph node dissection is needed in patients with oropharyngeal squamous cell carcinoma (OPSCC) with contralateral cervical cN0.

METHODS

We searched the PubMed, Web of Science, Embase, Chinese Biomedical Literature Database (CBM) and Cochrane Library databases up to August 14, 2021 for studies examining the contralateral neck occult metastasis rate of patients with ipsilateral clinical neck-negative (cN0) OPSCC and the contralateral neck occult metastasis rate of patients with ipsilateral clinical neck-positive (cN1, cN2a, cN2b) OPSCC. This rate is used to determine whether patients with contralateral cN0 OPSCC need contralateral cervical lymph node dissection.

RESULTS

A total of 14 articles, including 532 cases, were included in the analysis. When studying the rate of ipsilateral cervical occult metastasis in patients with ipsilateral cN0, 163 cases were included in 11 studies. The results showed that the rate of contralateral cervical occult lymph node metastasis in patients with ipsilateral cN0 was 0.6816% (95% CI 0.0000-4.4880 (P = 0.3005)). In the study of ipsilateral cN+ (cN1, cN2a, cN2b), a total of 369 cases of 10 articles were included in the analysis. The results showed that the rate of contralateral cervical occult lymph node metastasis in patients with ipsilateral cN+ was 11.4920% [95% CI 7.8944-15.5223 (P = 0.0000)].

CONCLUSION

For cancer treatment, the ultimate goal is to achieve the best control of cancer and the lowest complications. It seems unnecessary to intervene in the contralateral neck of patients with OPSCC with ipsilateral cN0. For OPSCC with ipsilateral cN+ , this index is a factor that cannot be ignored when making clinical decisions.

Quality of Life of the Patient with Head and Neck Cancer Submitted to Radiotherapy and the Overload of Their Caregivers

Introduction  Esthetic and functional changes are frequent in patients with head and neck cancer, and they can be caused by both tumor and treatment. Physical and functional impairment often requires the need of a caregiver, who may feel overwhelmed with the tasks of care.

Objective  This study aims to evaluate the quality of life of patients with head and neck cancer submitted to radiotherapy and the overload of their caregivers.

Method  This is a quantitative cross-sectional study with 42 patients with head and neck cancer and 17 caregivers evaluated during the radiotherapy treatment. Patients responded to the following questionnaires: Functional Assessment of Cancer Therapy for Head and Neck Cancer (FACT-H&N) and Shame and Stigma Scale (SSS), while the caregivers responded to the Zarit Burden Interview Scale (ZBI) and Palliative Performance Scale (PPS).

Results  Head and neck cancer patients showed a decline in the quality of life in all FACT-H&N domains, with the domain of additional concerns having the worst outcome. Among the feelings reported by patients, the most important was penitence. Less than half of the patients needed caregivers. It was observed that the greater the degree of commitment of the patient, the greater the degree of overload of the caregiver.

Conclusion  Therefore, the quality of life of the patient with head and neck cancer is an important aspect to be considered during the therapeutic choice and in the follow-up of the patient, since it has influenced both the patient and his caregiver.

Tegafur-Uracil versus 5-Fluorouracil in Combination with Cisplatin and Cetuximab in Elderly Patients with Recurrent or Metastatic Head and Neck Squamous Cell Carcinoma: A Propensity Score Matching Analysis

Simple Summary

Elderly patients with recurrent or metastatic head and neck squamous cell carcinoma are a unique subset because they are at increased risks of miserable prognosis. Although cisplatin, 5-fluorouracil plus cetuximab (EXTREME) is the most commonly used regimen, chemotherapy de-escalation strategy was suggested in elderly patients due to toxicity. Herein, an oral tegafur–uracil is usually substituted for 5-fluorouracil and combined with cisplatin plus cetuximab (UPEx) as a novel agent for elderly patients with recurrent or metastatic head and neck squamous cell carcinoma. The median progression-free survival was 5.4 months in UPEx and 5.8 months in EXTREME (p = 0.451). The median overall survival was 10.8 months in UPEx and 10.2 months in EXTREME (p = 0.807). Grade 3/4 adverse events were much fewer in UPEx than in EXTREME (p < 0.001). Our study demonstrated that UPEx is effective with improving safety profiles. We suggested UPEx might be a better treatment option for elderly patients with recurrent or metastatic head and neck squamous cell carcinoma.

Abstract

There are increasing incidences of elderly patients with recurrent or metastatic head and neck squamous cell carcinoma (R/M HNSCC). However, the treatment is not yet established. We conducted a propensity score matching analysis to evaluate the efficacy and safety of tegafur–uracil versus 5-fluorouracil in combination with cisplatin plus cetuximab in elderly patients with R/M HNSCC. Elderly patients with R/M HNSCC treated with cetuximab-containing chemotherapy were recruited into this study. In order to reduce the selection bias, propensity score matching was performed. Kaplan–Meier curves were plotted for progression-free survival (PFS) and overall survival (OS). Toxicities were graded according to the National Cancer Institute’s Common Terminology Criteria V3.0. After propensity sore matching, 54 patients with tegafur–uracil, cisplatin plus cetuximab (UPEx), and 54 patients with 5-fluorouracil, cisplatin plus cetuximab (EXTREME) were identified. The median PFS was 5.4 months in UPEx and 5.8 months in EXTREME (p = 0.451). The median OS was 10.8 months in UPEx and 10.2 months in EXTREME (p = 0.807). The overall response rate (ORR) and disease control rate (DCR) were insignificant in both arms, accounting for 61% versus 59% (p = 0.680) and 72% versus 70% (p = 0.732) in the UPEx arm and the EXTREME arm, respectively. A multivariate analysis showed that age and ECOG PS were, independently, predictors. Grade 3/4 adverse events were much fewer in UPEx than in EXTREME (p < 0.001). Both cetuximab-containing chemotherapies are effective in elderly patients with R/M HNSCC. Safety profiles are improved when tegafur–uracil is substituted for 5-fluorouracil. Further prospective studies are warranted to validate our conclusions.

A model to predict postoperative complications for otorhinolaryngology and maxillofacial surgery procedures in elderly patients

PURPOSE

All kinds of ear, nose, and throat and maxillofacial surgery (ENT/MFS) procedures are being increasingly performed in the elderly although old age is a major risk factor for increased postoperative complications. With only scarce evidence on the topic, surgeons are asked to critically evaluate their procedures' indications and outcomes to balance the treatment risks and benefits. Our primary aim was to identify predictive factors for surgical outcomes in this setting and to create a predictive model for a tailored risk assessment.

METHODS

We analyzed a case series of 435 patients from an institutional clinical database at our academic tertiary care center. Multivariate logistic regression was used to identify all possible covariates and nomograms using stepwise backward method were generated. The performance was assessed by calibration curves and c-index.

RESULTS

Overall complication rate was 18.3% within the first 30 days and the need for re-intervention was 5.9%. For those under general anesthesia, we identified specific risk factors and developed three risk-predicting models of overall, early, and late complications. All of the nomograms showed satisfactory accuracy with a c-index of 0.83, 0.75, 0.86, and 0.82, respectively.

CONCLUSION

Using clinical preoperative variables, we constructed a model for predicting major adverse events in ENT/MFS patients. In our experience, patients over 65 showed a non-negligible risk for postoperative complications depending on several factors. Such tools might help in decision-making, by increasing the risk-awareness of clinicians, to better address peri-operative and post-operative care of these patients.

Special considerations for elderly patients with head and neck cancer during the COVID-19 pandemic

Elderly patients with head and neck cancer are at increased risk of adverse outcomes during and after treatment of head and neck cancer. COVID-19 severity and mortality can be expected to be significantly greater in elderly patients with head and neck cancer, given that increased age, comorbidities, and presence of malignancy are known risk factors for disease severity and mortality in patients with COVID-19. Therefore, their management requires multidisciplinary consensus and patient input. A thorough geriatric assessment, which has been shown to be beneficial prior to the COVID-19 pandemic, could be particularly helpful in this patient population with the added dimension of COVID-19 risk. In many cases, prudent treatment plan modification may allow for overall best outcomes. Furthermore, recruitment of social services and, when appropriate, palliative care, may allow for optimal management of these patients.

[Head and neck cancer in the elderly-current aspects]

BACKGROUND

The treatment of head and neck cancer is dominated by surgery and radiochemotherapy, which is in part associated with high morbidity. In elderly patients, however, the otorhinolaryngologist often has to question the rationality of invasive treatment. Although the proportion of geriatric patients with head and neck tumors is increasing, the paucity of data means that there are few consistent standards and recommendations in the literature and guidelines.

OBJECTIVE

The aim of this paper is to provide concrete clinical recommendations for geriatric patients with head and neck tumors based on a systematic literature search.

MATERIALS AND METHODS

A keyword-based literature search was performed to present the current level of evidence and provide a clinical algorithm.

RESULTS

In addition to age, the pretreatment dispositional evaluation of geriatric patients should include psychosocial, functional, and medical (patient history) comorbidities. For pretreatment risk stratification, an algorithm was created on the basis of these data for individual evaluation of the patient's pretreatment risk.

CONCLUSION

Pretreatment risk stratification of geriatric patients with head and neck malignancies is of high relevance for the individual decision for or against invasive treatment, but the currently available evidence is limited. This paper is based on a systematic literature review and provides a clinical algorithm for otorhinolaryngologists and head and neck surgeons.

Synthesis of novel N-vinylpyrrolidone/acrylic acid nanoparticles as drug delivery carriers of cisplatin to cancer cells

This study aimed to synthesize novel polymeric nanoparticles (NPs) bound with cisplatin for the treatment of oral cancer. The NPs were synthesized from N-vinylpyrrolidone (NVP) and acrylic acid (AA) using 2 different methods based on a surfactant-free emulsion polymerization reaction. An azo initiator (V₅₀) and bisacrylamide crosslinker were used in the reaction to create the NPs. The morphology, physicochemical characteristics, drug loading, and in vitro release were evaluated. Moreover, the cytotoxicity, death induction mechanism, and in vitro intracellular accumulation of cisplatin in HN22 cells were also investigated. Relatively spherical NPs with negative charge were obtained from both synthesis methods with the size in the range of 136-183 nm. The NPs were bound to cisplatin via coordination bond which was confirmed by FT-IR. The optimal NPs to cisplatin ratio was found to be 1:10 with %entrapment efficiency and loading capacity of 12-18% and 4 mmol/g, respectively. Approximately 47-83% of cisplatin was released from the NPs in 7 days in the presence of chloride ions depending on the pH of the release medium. The novel NPs from both methods were nontoxic to gingival fibroblast cells while the IC₅₀ values of cisplatin-loaded NPs on HN22 cells were just above 20 μg/mL. In addition, the cisplatin-loaded NPs demonstrated a higher percentage in the early apoptotic death mechanism. Higher cellular deposition of cisplatin at the earlier period was obtained by the cisplatin-loaded NPs suggesting a slower but safer cancer-killing effect. Therefore, these novel NPs may be promising nanocarriers of cisplatin for oral cancer treatment.