Relation between age and head and neck cancer recurrence after surgery: a multivariate analysis

A comparative study of treatment outcome in younger and older patients with locally advanced oral cavity and oropharyngeal cancers treated by chemoradiation

Background:

Evidence suggests that older patients with oral cavity and oropharyngeal cancers may behave differently from their younger peers.

Aim:

The aim of this study is to determine if there is difference in responses, survival, and toxicities between young patients (≤40 years of age) with oral cavity and oropharyngeal cancers and older patients (>40 years of age) treated with concurrent chemoradiation.

Materials and Methods:

Sixty-one patients with unresectable, locally advanced oral cavity and oropharyngeal cancers received concomitant chemoradiation to a dose of 70 Gray in 35 fractions over 7 weeks with concomitant weekly cisplatin (40 mg/m²). These patients were then distributed in two arms. Arm-A patients having age ≤40 years and Arm-B patients having age >40 years, and the two arms were assessed for treatment outcome.

Results:

The overall response rate (complete responders + partial responders) evaluated using response evaluation criteria in solid tumors criteria version 1.1 was equivalent in both groups (80.76% in Arm-A and 74.28% in Arm-B; P = 0.93). Older patients (>40 years) experienced more acute mucositis and xerostomia (P < 0.5); although not statistically significant, more acute skin and pharynx toxicities were also observed in this group. Higher late salivary gland toxicity (P < 0.5) was also seen in older patients; however, disease-free survival and progression-free survival were found to be similar in both groups.

Conclusions:

Older patients with locally advanced oral cavity and oropharyngeal cancers have similar response rates and survival as compared to their younger counterparts but may experience higher treatment-related toxicities.

Site-specific familial risk and survival of familial and sporadic head and neck cancer

The vast majority of head and neck cancers (HNCs) are sporadic squamous cell carcinomas, smoking and heavy drinking being the main risk factors. However, little is known about the possible role of family history and the importance of inherited factors versus shared environment. We used Swedish population-based registries to study the family history of HNC. In order to estimate the risk for family members to get the same cancer, and the risk for cancer-specific death in patients with a family history of HNC compared with patients without a family history, multivariate Cox proportional hazards analyses were performed. A 1.43-fold increased risk for developing HNC in the first-degree relatives (FDRs) of HNC patients [hazard ratio (HR), 1.43; 95% CI, 1.28-1.61] was found, when compared with relatives of healthy controls. In spouses of patients with HNC, the risk for developing any HNC was moderately increased (HR, 1.25; 95% CI, 1.01-1.53), compared with spouses of healthy controls. In addition, a 1.34-fold increased risk for death of HNC was found in HNC patients with a family history of HNC (HR, 1.34; 95% CI, (1.03-1.73) compared with HNC patients without a family history. We found an increased risk for HNC in relatives and spouses of HNC patients, when compared with family members of healthy controls. This suggests that in addition to inherited factors, shared environmental factors have a significant role in the development of the cancer. Family history of HNC was associated with worse survival in a newly diagnosed HNC patient.

Oral cavity and oropharyngeal squamous cell carcinoma in young adults: a review of the literature

BACKGROUND

Head and neck squamous cell carcinoma (HNSCC) is a disease of middle-aged to elderly adults. However, an increased incidence of HNSCC in young people under 45 years of age has been reported recently. In the present review, we focused on the epidemiology and aetiology of HNSCC in adults under 45 years of age.

METHODS

We reviewed literature related to HNSCC in adult patients less than 45 years of age and discussed current treatment options and prognosis.

RESULTS

HNSCC in young adults is associated with a higher incidence rate in nonsmokers, lower female-to-male ratio, a higher percentage of oral cavity and oropharynx tumours, and fewer second primary tumours. However, aside from traditional risk factors of tobacco and alcohol exposure, the causes of these cancers in young adults remain unclear. Agents that might contribute to risk include infection with high-risk human papillomavirus subtypes as well as genetic factors or immunodeficiency status. The expected increase in incidence and mortality of the young with HNSCC may become a major public health concern if current trends persist, particularly lifestyle habits that may contribute to this disease.

CONCLUSIONS

Given the younger age and potential long-term adverse sequelae of traditional HNSCC treatments, young adults should be treated on a case-by-case basis and post-therapy quality of life must be considered in any treatment-decision making process.

The role of genetic factor in etiopathogenesis of squamous cell carcinoma of the head and neck in young adults

Patients with squamous cell carcinoma of the head and neck (HNSCC) aged less than 45 years are categorized as young adults (YA) and in opinion of many authors in comparison to older (typical) patients (OP) are characterized with more serious form of the disease and often lack the classical risk factors associated with the illness. Hence, there is a need of an exact clinical analysis and a search for additional causative factors. The purpose of this study was to estimate the role of genetic factors in the etiology of HNSCC in YA. Studies carried out on 60 patients of the study group (YA) and 72 older control patients were directed to: (1) a degree of spontaneous and induced chromosome breaks estimated by bleomycin test, (2) a degree of spontaneous and induced DNA damage and a potential of DNA repair determined by comet assay and (3) polymorphism of genes of glutathione transferases M1 and T1, responsible for detoxification of metabolites of carcinogens of tobacco smoke, studied by PCR-based genotyping. The level of chromosome breaks (spontaneous and induced), the level of DNA damage (spontaneous and induced), DNA repair potential and the distribution of polymorphic variants of GSTT1 gene are not significantly different in YA and in OP, which suggests that these factors do not appear the causative factors for HNSCC in young age. The significant risk factor of HNSCC in YA may be GSTM1 null genotype, which may cause the defective detoxification of metabolites of polycyclic aromatic hydrocarbons of tobacco smoke.

Second Malignant Neoplasms in Patients Under 40 Years of Age With Laryngeal Cancer

OBJECTIVES/HYPOTHESIS

To determine the incidence of second malignant neoplasms (SMN) in patients under 40 years of age with invasive squamous cell carcinoma (SCC) of the larynx.

STUDY DESIGN

Retrospective.

METHODS

Using a National Cancer Institute tumor registry database encompassing 1973-1996, the incidence of SMN in patients under 40 years of age with laryngeal cancer was determined and compared with that of the registry's older, more traditional laryngeal cancer population. Median follow-up was 136 months.

RESULTS

Among the 364 patients under the age of 40 years with laryngeal cancer, 30 (8.2%) had developed a secondary malignancy to date. In comparison, 4876 (21.4%) of 22,786 patients 40 years or older with laryngeal cancer were affected by an SMN. Kaplan-Meier analysis of the younger cohort projected 3.0%, 6.8%, and 10.7% relative risk of developing a SMN at any site over 5-, 10-, and 15-year periods, respectively, after index tumor diagnosis. Similar results for the older cohort were 14.2%, 28.1%, and 39.4% at 5, 10, and 15 years, respectively. Further Kaplan-Meier analysis demonstrated at least a fourfold increased risk for the development of secondary upper aerodigestive tract malignancies among older compared with younger patients.

CONCLUSION

Patients under 40 years of age with invasive SCC of the larynx are significantly less likely to develop a second malignancy than their older counterparts.

Sensitivity to radiation-induced chromosome damage may be a marker of genetic predisposition in young head and neck cancer patients

We previously showed that levels of chromosome damage induced by ionizing radiation were, on average, higher in G(2)and G(0)lymphocytes of breast cancer patients than of normal healthy controls, but that there was no correlation between the results in the two assays. We proposed that enhanced sensitivity to G(2)or G(0)irradiation was a marker of low-penetrance predisposition to breast cancer, and have recently demonstrated heritability of sensitivity in families of breast cancer cases. We have now applied these assays to patients with head and neck cancers, for whom there is epidemiological evidence of inherited predisposition in addition to environmental causes. The mean frequency of radiation-induced G(2)aberrations was higher in the 42 patients than in 27 normal controls, but not significantly so. However, cases less than 45 years old were significantly more sensitive than normals of the same age range (P = 0.046), whereas there was no difference between patients and normals of less than 45 years. Also, there was an inverse correlation between G(2)sensitivity and age for patients but not for normals. Radiation-induced micronuclei in G(0)cells were more frequent in 49 patients than in 31 normals (P = 0.056) but, as with the G(2)assay, the greatest difference was seen between early-onset patients and young normals. Again there was an inverse correlation with age for patients but not for normals. Six patients with enhanced toxicity to radiotherapy were G(2)tested and four other such patients were G(0)tested; levels of chromosome damage were not significantly greater than in patients with normal reactions. Both assays were used on 64 individuals (39 patients, 25 normals) and there was no significant correlation between the results. We suggest that a proportion of early-onset head and neck cancer patients are genetically predisposed and that each of the two assays detects a different subset of these cases.

Human papillomavirus infection in "young" versus "old" patients with squamous cell carcinoma of the head and neck

BACKGROUND

Human papillomavirus (HPV) represents a potential risk factor for squamous cell cancer of the head and neck (SCCHN). We evaluated the prevalence of HPV DNA in patients with SCCHN diagnosed at the University of Michigan from 1994-1996.

METHODS

Patients were stratified by age at diagnosis as "young" (<50 years; median, 39) or "old" (>50 years; median, 66). Fourteen "young" and 14 "old" were matched for tumor site, and 4 additional "old" patients were included. Specimens were analyzed by polymerase chain reaction for HPV DNA using 2 sets of consensus primers. HPV sequences were confirmed by Southern blot hybridization and typed with type-specific probes.

RESULTS

Overall, 15 of 32 (46.9%) samples contained HPV sequences. HPV 16 was detected in 9 of 15 (60%), HPV-18 in 1 of 15 (6.6%), and 5 of 15 (33.3%) remained untyped by multiple methods. When stratified, 7 of 14 (50%) "young" were HPV-positive compared with 8 of 18 (44.4%) "old" (p =.76). Survival in patients with HPV-positive SCCHN was significantly longer than that for HPV-negative patients.

CONCLUSIONS

The incidence of HPV in "young" versus "old" is not significantly different, suggesting similar roles for both groups. Patients with HPV-positive tumors may have a survival advantage relative to patients with HPV-negative tumors.

Carcinoma of the hypopharynx and cervical esophagus in young adults

Squamous cell carcinoma of the hypopharynx and cervical esophagus usually presents in the late-middle-aged and elderly. When diagnosed in young adults, the disease process is often thought to be more aggressive and have a worse long-term outcome. Four hundred ninety patients presented to the Christie Hospital and Manchester Royal Infirmary between 1981 and 1990 with squamous cell carcinoma of the hypopharynx and cervical esophagus. Of this group, 24 patients (5%) received their diagnosis before the age of 45. A comparison is made with a control group of 156 (32%) patients who presented between the ages of 60 and 69 years. Analysis of tumor and nodal staging at presentation demonstrates no statistically significant difference between the 2 age groups. There is a higher incidence of a combination of smoking and alcohol abuse in the older age group, but it is of no statistical significance. There is no difference in 5-year survival results between the 2 groups. We conclude that patients with squamous cell carcinoma of the hypopharynx and cervical esophagus who receive their diagnosis under the age of 45 show no difference in tumor stage or long-term outcome when compared with a control group encompassing the mean age of presentation.

Cancer of the tongue in patients less than forty

INTRODUCTION

It is the opinion of many surgeons that the biologic potential of cancer that develops in young people is different compared with older patients. Prior reports on small series of patients addressing this issue have inadequate statistical power to resolve the question.

METHODS

By use of the techniques of meta-analysis, patients less than 40 years old who had undergone treatment of squamous cell carcinoma (SCC) of the oral tongue were examined. Twenty-eight patients who were encountered in the Department of Otolaryngology, University of Pittsburgh School of Medicine, and 94 patients were identified in the literature for a total of 122 patients <40 years old. A control group of 150 patients, aged 40 years and older treated for SCC of the oral tongue between 1982 and 1994 was identified.

RESULTS

Three-year disease-free survival in the group of patients aged less than 40 was 53.3% compared with 3-year disease free survivorship of 55.0% in the older cohort of patients.

CONCLUSION

These data strongly suggest that the outcomes of treatment for SCC of the oral tongue in young patients are similar compared with patients older than 40 with similar extent of disease.

Oral cancer in young adults: report of three cases and review of the literature

Oral cancer in young adults is fortunately uncommon in the UK. However, since it is so rare, when cases present they are often misdiagnosed and inappropriately treated leading to delay in definitive treatment. This may, in turn, lead to a poorer prognosis for these patients. It is debatable if oral cancer in younger adults carries an inherently poor prognosis and presents with more aggressive tumours. Three cases of oral cancer in young adults, aged under 30 years are presented and the literature reviewed with respect to oral cancer in this group of patients.

Genetic alterations in oral squamous cell carcinoma of young adults

The underlying molecular abnormalities associated with head and neck squamous cell carcinoma in young adults (< 40 years) are unknown. We analyzed DNA extracted from paired microdissected samples of normal squamous epithelia and invasive oral squamous cell carcinomas from 36 young adults at microsatellite loci commonly found in older patients and correlated the results with clinicopathologic parameters and outcome. Our results showed that 30 of the 36 (83%) tumors manifest loss of heterozygosity (LOH) in at least one marker. Microsatellite instability was manifested in only six tumors (< 17%). The highest incidences of alterations were noted at markers D9S168 (9p23-22), TP53 (17p13), and D17S799 (17p11) on the short arms of chromosomes 9 and 17. In general, the incidences of LOH at 3, 9 and 17p regions in young adults were similar to those found in older patients. No correlation between LOH at chromosomes 3, 9, and 17p and clinicopathologic parameters was found. Our study indicates that chromosomal regions with frequent genetic alterations involved in young adult squamous tumorigenesis are similar to those reported in older patients. Further studies of other chromosomes in this population are underway to define the novel molecular features of these tumors.

A matched control study of treatment outcome in young patients with squamous cell carcinoma of the head and neck

OBJECTIVES/HYPOTHESIS

To determine if there is a difference in overall survival, cause-specific survival, and relapse-free rate between young patients (<40 years of age) with head and neck squamous cell carcinoma (HNSCC) and older patients (>40 years of age).

STUDY DESIGN

A matched control study describing the outcome of 185 previously untreated HNSCC patients less than 40 years of age treated at the Princess Margaret Hospital, Toronto, Ontario, Canada, between 1958 and 1992. The young patient group was compared with a control group of older patients (> 40 years of age) which was selected randomly from an entire cohort of patients (n = 10,072) and matched for site, sex, and date of presentation.

METHODS

The medical records were reviewed and data abstracted for demographic information, tobacco and alcohol use, family history, primary site, clinical stage, primary treatment, histology, the occurrence of residual or recurrent disease, salvage treatment, development of subsequent primaries, survival, and the eventual cause of death. The patient's TNM stage was reclassified according to American Joint Cancer Committee/Union Internationale Contre le Cancer (AJCC/UICC) 1992 criteria on the basis of the initial clinical description and staging investigations. A multivariate regression analysis was performed. To assess the importance of age as a prognostic factor for survival, the Cox proportion hazard model was used. Smoking status was also tested in the stratified Cox proportional hazard model.

RESULTS

Tumor stage and treatment modalities were comparable in both groups. The 5-year, cause-specific survival in both groups was not statistically different (72% vs. 68%, P = .91). The young patient group had a significantly better 5-year overall survival compared with the older patient group (68% vs. 49%, P = .0011). Older patients developed more subsequent primary neoplasms than the younger patient population (18% vs. 8%, P = .005). There were significantly more females, an increased incidence of oral or oropharyngeal cancer, and fewer smokers in the young patient group. Smoking, however, had an important impact on outcome with all but one patient who developed a second primary in the upper aerodigestive tract having smoked. Multivariate analysis showed that only disease stage and cancer site were significant prognostic factors for survival.

CONCLUSIONS

Young patients with HNSCC do not have a worse prognosis than a matched older patient group in this case-controlled study (power > 0.75 for a minimal detectable difference of 10% disease-free survival between the two groups).