Impact of the treating institution on the survival of patients with head and neck cancer treated with concomitant alternating chemotherapy and radiation

Identifying Opportunities to Deliver High-Quality Cancer Care Across a Health System: A Clinical Responsibility

OBJECTIVE

We examined process-related quality metrics for oral squamous cell carcinoma (OSCC) depending on treating facility type across a health system and region.

STUDY DESIGN

Retrospective in accordance with Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

SETTING

Single health system and region.

METHODS

Patients with OSCC diagnosed between 2012 and 2018 were identified from tumor registries of 6 hospitals (1 academic and 5 community) within a single health system. Patients were categorized into 3 care groups: (1) solely at the academic center, (2) solely at community facilities, and (3) combined care at academic and community facilities. Primary outcome measures were process-related quality metrics: positive surgical margin rate, lymph node yield (LNY), adjuvant treatment initiation ≤6 weeks, National Comprehensive Cancer Network (NCCN)-guideline adherence.

RESULTS

A total of 499 patients were included: 307 (61.5%) patients in the academic-only group, 101 (20.2%) in the community-only group, and 91 (18.2%) in the combined group. Surgery at community hospitals was associated with increased odds of positive surgical margins (11.9% vs 2.5%, odds ratio [OR]: 47.73, 95% confidence interval [CI]: 11.2-275.86, P < .001) and lower odds of LNY ≥ 18 (52.8% vs 85.9%, OR: 0.15, 95% CI: 0.07-0.33, P < .001) relative to the academic center. Compared with the academic-only group, odds of adjuvant treatment initiation ≤6 weeks were lower for the combined group (OR: 0.30, 95% CI: 0.13-0.64, P = .002) and odds of NCCN guideline-adherent treatment were lower in the community only group (OR: 0.35, 95% CI: 0.18-0.70, P = .003).

CONCLUSION

Quality of oral cancer care across the health system and region is comparable to or better-than national standards, indicating good baseline quality of care. Differences by facility type and fragmentation of care present an opportunity for bringing best in-class cancer care across an entire region.

Elucidating survival and functional outcomes in patients with primary head and neck malignancies treated in academic versus community settings

BACKGROUND

Differences in treatment outcomes between community or academic centers are incompletely understood.

METHODS

Retrospective review of head and neck cancer patients between 2010 and 2020 in a rural health region. Kaplan-Meier curves and log-rank tests were used to evaluate survival outcomes, along with bivariate and multivariable Cox proportional hazards models. Linear regression was used for functional outcomes of tracheotomy and gastrostomy tube dependence.

RESULTS

Two hundred and forty-eight patients treated at an academic center were compared with 94 patients treated in community centers. In multivariable analysis, the risk of death (HR = 0.60, p = 0.019), and risk of recurrence were lower (HR = 0.29, p < 0.001) for patients treated in academic centers. Patients treated in community centers had longer gastrostomy tube dependence (p = 0.002).

CONCLUSION

Our findings suggest that treatment at an academic center was associated with a lower risk of recurrence and shorter gastrostomy tube dependence compared to treatment in the community.

The Feasibility of Quality Assurance in the TOPGEAR International Phase 3 Clinical Trial of Neoadjuvant Chemoradiation Therapy for Gastric Cancer (an Intergroup Trial of the AGITG/TROG/NHMRC CTC/EORTC/CCTG)

PURPOSE

The TOPGEAR phase 3 trial hypothesized that adding preoperative chemoradiation therapy (CRT) to perioperative chemotherapy will improve survival in patients with gastric cancer. Owing to the complexity of gastric irradiation, a comprehensive radiation therapy quality assurance (RTQA) program was implemented. Our objective is to describe the RTQA methods and outcomes.

METHODS AND MATERIALS

RTQA was undertaken in real time before treatment for the first 5 patients randomized to CRT from each center. Once acceptable quality was achieved, RTQA was completed for one-third of subsequent cases. RTQA consisted of evaluating (1) clinical target volume and organ-at-risk contouring and (2) radiation therapy planning parameters. Protocol violations between high- (20+ patients enrolled) and low-volume centers were compared using the Fisher exact test.

RESULTS

TOPGEAR enrolled 574 patients, of whom 286 were randomized to receive preoperative CRT and 203 (71%) were included for RTQA. Of these, 67 (33%) and 136 (67%) patients were from high- and low-volume centers, respectively. The initial RTQA pass rate was 72%. In total, 28% of cases required resubmission. In total, 200 of 203 cases (99%) passed RTQA before treatment. Cases from low-volume centers required resubmission more often (44/136 [33%] vs 13/67 [18%]; P = .078). There was no change in the proportion of cases requiring resubmission over time. Most cases requiring resubmission had multiple protocol violations. At least 1 aspect of the clinical target volume had to be adjusted in all cases. Inadequate coverage of the duodenum was most common (53% major violation, 25% minor violation). For the remaining cases, the resubmission process was triggered secondary to poor contour/plan quality.

CONCLUSIONS

In a large multicenter trial, RTQA is feasible and effective in achieving high-quality treatment plans. Ongoing education should be performed to ensure consistent quality during the entire study period.

An Analysis and Comparison of Survival and Functional Outcomes in Oropharyngeal Squamous Cell Carcinoma Patients Treated with Concurrent Chemoradiation Therapy within City of Hope Cancer Center Sites

Oropharyngeal squamous cell carcinoma (OPSCC) is a subset of head and neck cancers that can arise due to human papillomavirus (HPV) infection. We designed a retrospective analysis to determine differences in outcomes of OPSCC patients treated at City of Hope (COH) Cancer Center’s main campus versus selected satellite sites with COH-associated faculty and facilities. Patients diagnosed with OPSCC and treated with concurrent chemoradiation therapy (n = 94) were identified and included in the study. Patients underwent treatment at the COH main campus site (n = 50) or satellite sites (n = 44). The majority of patients were Caucasian, male, and diagnosed with p16 positive stage IV locally advanced OPSCC by AJCC 7th edition. Most patients completed their prescribed cumulative radiation therapy dose and had a complete response to treatment. No significant difference in overall survival and progression-free survival was observed between the main campus and the satellite sites. Our study demonstrates successful treatment completion rates as well as comparable recurrence rates between the main campus and COH-associated satellite sites. A trend toward significant difference in feeding tube dependency at 6-months was observed. Differences in feeding tube placement and dependency rates could be addressed by the establishment of on-site supportive services in satellite sites.

Difficulties in conducting pure academic research, obstacles in data collection and quality of informations: The example of the INTERCEPTOR study

PURPOSE/OBJECTIVE

On September 2009: We started a randomized multicenter phase III study comparing chemoradiation (CRT) (Aldestein RTOG regimen) versus induction chemotherapy followed by Cetuximab radiation (IBRT). The main study's aim was comparison of overall survival but no formal analyses have been made between the two arms because of low accrual and high amount of missing data. The goal of this paper is to identify the reasons of difference in accrual and quality of data among participating centers.

MATERIAL/METHODS

Statistic: We correlated data collection quality with relevance of the centers, accrual and number of scientific papers (both specific on HNC and other topics) of each PI. We created an HNC publishing score dividing the number of HNC specific papers for the overall number of published papers.

RESULTS

We observed a strong difference in the accrual of pts as well as in the quality of data among the participating centers. The accrual was independent from the quality of data since some centers with low accrual produced high quality data with an excellent follow up. We found a correlation among both number of published papers of each PI and HNC publishing score with the quality of data.

CONCLUSION

The study demonstrated that expertise in HNC is important not only to ensure a better outcomes but also to provide high quality data in phase III trials.

Impact of treatment expertise on the outcome of patients with head and neck cancer treated within 6 randomized trials

BACKGROUND

We evaluated the impact of center expertise, in terms of number of patients treated, on the overall survival (OS) and progression-free survival (PFS) of patients with head and neck squamous cell carcinoma (SCC).

METHODS

We performed a pooled analysis including data from 6 randomized trials in head and neck SCC conducted in Italy. We evaluated the association between OS or PFS and the number of patients recruited by the center.

RESULTS

The outcome of 903 patients who had received radiotherapy (RT) was analyzed (median follow-up 76 months). The hazard ratio (HR) comparing the third and the first quartiles of the distribution of number of patients per center showed an advantage in PFS (HR 0.59, range 0.53-0.65, P < .0001) and in OS (HR 0.70, 0.60-0.81, P < .0001) for centers with a higher number of patients recruited. A similar benefit was observed in PFS (HR 0.63, 0.60-0.66) and OS (HR 0.74, 0.69-0.79) considering the mean number of patients per year.

CONCLUSIONS

The PFS and OS were longer for patients treated in high-case-volume centers.

The impact of institutional clinical trial recruitment versus hospital volume on survival outcomes of patients with head and neck cancer: An analysis of the PET-NECK trial outcomes, UKCRN portfolio, and Hospital Episode Statistics (HES) in England

OBJECTIVES

High institutional clinical trial recruitment and high hospital volume are reported to be independent indicators of better patient outcomes following cancer treatment. However, their relationship in head and neck cancers (HNC) remains less clear.

METHODS

We aimed to assess the relationship between institutional clinical trial recruitment, hospital throughput of HNC cases, and survival of patients with advanced HNC treated with primary chemoradiotherapy at hospitals which recruited to the PET-NECK trial (2008-2012). The impact on outcome was assessed using Cox's proportional hazards regression analysis and multivariate analysis.

RESULTS

HNC RCT recruitment positively correlated with hospital throughput (r = 0.57, p < 0.0001). Low-recruiters (1-5 patients) had a 107% increased risk of death when compared to high-recruiters (>5 patients) (HR = 2.07, p = 0.05). There was no significant impact of hospital throughput on overall or disease-specific HNC survival. Multivariate analysis identified p16 status, N-stage, smoking, and RCT recruitment volume as the only significant predictors of survival. There was a significant difference in chemotherapy regimen between low and high-recruiters (p = 0.003) where a higher proportion of patients (50%, n = 13) in low-recruiting compared to high-recruiting hospitals (29%, n = 92) received neoadjuvant chemotherapy. A higher proportion of these patients died at low-recruiting hospitals (46% versus 23%).

DISCUSSION

A significant association exists between high recruitment and better OS for patients with HNC. However, no significance was found between hospital throughput and outcomes. The significance of individual centre differences in chemotherapy regimen needs further investigation. Future studies need a greater number of patient outcome events to support the trends found in this study.

Patient choice for high-volume center radiation impacts head and neck cancer outcome

Background

Studies suggest treatment outcomes may vary between high (HVC)‐ and low‐volume centers (LVC). Radiation therapy (RT) for head and neck cancer (HNC) requires weeks of treatment, the inconvenience of which may influence a patient's choice for treatment location. We hypothesized that receipt of RT for HNC at a HVC would influence outcomes compared to patients evaluated at a HVC, but who chose to receive RT at a LVC.

Methods

From 1998 to 2011, 1930 HNC patients were evaluated at a HVC and then treated with RT at either a HVC or LVC. Time‐to‐event outcomes and treatment factors were compared.

Results

Median follow‐up was 34 months. RT was delivered at a HVC for 1368 (71%) patients and at a LVC in 562 (29%). Patients were more likely to choose HVC‐RT if they resided in the HVC's county or required definitive RT (all P < 0.001). HVC‐RT was associated with a significant improvement in 3‐year LRC (84% vs 68%), DFS (68% vs 48%), and OS (72% vs 57%) (all P < 0.001). On multivariate analysis (MVA), HVC‐RT independently predicted for improved LRC, DFS, and OS (all P < 0.05).

Conclusions

In patients evaluated at a HVC, the choice of RT location was primarily influenced by their residing distance from the HVC. HVC‐RT was associated with improvements in LRC, DFS, and OS in HNC. As treatment planning and delivery are technically demanding in HNC, the choice to undergo treatment at a HVC may result in more optimal delivered dose, RT duration, and outcome.

Long-Term Results of Conventional Radiotherapy versus Accelerated Hyperfractionated Radiotherapy versus Concomitant Radiotherapy and Chemotherapy in Locoregionally Advanced Carcinoma of the Oropharynx

AIMS AND BACKGROUND

To compare conventional fractionation (CF) radiation therapy (RT), arm A, versus a split-course accelerated hyperfractionated schedule (S-AHF), arm B, versus CFRT plus concomitant chemotherapy (CT), arm C, in terms of five-year survival and toxicity for squamous cell tumors of the oropharynx.

METHODS AND STUDY DESIGN

Between January 1993 and June 1998, 192 previously untreated patients with stage III and IV oropharyngeal carcinoma (excluding T1N1 and T2N1) were enrolled in a multicenter randomized phase III trial (ORO 93-01). In arms A and C, 66 to 70 Gy in 33 to 35 fractions was administered five days a week for six and a half to seven weeks. In arm B, the dose delivered was 64 to 67.2 Gy in two fractions of 1.6 Gy every day, five days a week, with a planned two-week split at 38.4 Gy. In arm C the CT regimen consisted of three cycles of carboplatin and 5-fluorouracil (CBDCA 75 mg/m2 on days 1 to 4 and 5-FU 1000 mg/m2 i.v. on days 1 to 4 every 28 days).

RESULTS

No statistically significant difference was found in five-year overall survival (P = 0.39): 21% for arm A, 21% for arm B, and 40% for arm C. Similarly, there was no statistically significant difference in terms of five-year relapse-free survival: 15% for arm A, 17% for arm B, and 36% for arm C. There was a slight trend towards better five-year locoregional control (P = 0.07) for the combined arm: patients without locoregional relapse were 48% in arm C, 21% in arm A and 18% in arm B. Locoregional control was significantly better when arm C was compared with arms A and B combined (P = 0.02; arm A+B 20%; arm C 48%). Distant metastases were fairly balanced in the three arms (A: 14; B: 9; C: 11), with a tendency towards more frequent isolated distant metastasis development in arm C (8 of 11 [72%] versus 7 of 23 [30%] in arms A+B). Five-year second-tumor-free survival was 85%. The 13 second tumors were equally distributed and were mainly correlated with tobacco and alcohol consumption (five lung, two esophagus, two oral cavity, one larynx, one pancreas, one hepatocarcinoma, one myeloma). Arm C showed slightly more G3+ late side effects involving subcutaneous tissues and mucosa, although significant late sequelae were relatively uncommon and the mucosal side effects were mostly transient. The occurrence of persistent G3 xerostomia was comparable in the three treatment arms.

CONCLUSIONS

The results obtained with the combination of CT and RT compared with RT alone did not reach statistical significance, but combined treatment almost doubled the five-year overall survival, relapse-free survival and locoregional control rate. Patients with advanced squamous cell carcinomas of the oropharynx who are medically suitable for the combined approach should be treated with a combination of radiotherapy and chemotherapy. The occurrence of second tumors is relatively common in these patients and may contribute substantially to the causes of death.

Compliance with National Guidelines on the Treatment of Stage II–IVB Nasopharyngeal Carcinoma in a Regional Cancer Center of Southern China

Objective: It is unknown whether the treatment provided to patients with stage II-IVB NPC in southern China adheres to the 2015 NCCN guidelines. Consequently, a retrospective analysis was conducted, in order to evaluate the compliance with NCCN guidelines and identify the areas for improvement. Methods: The present study was a retrospective study that included patients with stage II-IVB NPC in southern China during the period 2013 and 2014. The treatment regimens were compared with the 2015 NCCN guidelines in order to identify potential noncompliance regarding the treatment for stage II–IVB NPC. The statistical analyses included descriptive statistics, univariate and/or multivariate analysis using SPSS version 16.0.0. Results: A total of 215 patients, including 166 men (77.21%) and 49 women (22.79%), were involved in the analysis. Although the overall rate of noncompliance with the NCCN recommendations was 23.26%, the noncompliance rate of concurrent chemoradiation (CCRT), induction of chemotherapy (IC) followed by CCRT and CCRT followed by adjuvant chemotherapy (AC) was 7.02%, 39.76% and 50.00%, respectively. Univariate analysis indicated that NCCN noncompliance regarding the treatment for stage II-IVB NPC did not exhibit a significant correlation with the parameters age, gender, insurance status, education profile, first clinic department, careers, comorbidities and overall clinical stage, but it indicated a significant association with the therapeutic schedule (P<0.05). The multivariate analysis indicated that the NCCN noncompliance regarding the treatment for stage II–IVB NPC exhibited a statistically significant difference between CCRT and CCRT followed by AC (OR=0.10, 95% CI 0.04-0.27, P<0.05 ), although the difference noted between CCRT and IC followed by CCRT was not significantly different (OR=1.71, 95% CI 0.50-5.87,P=0.40). Conclusions: The use of specific therapeutic schedules may affect the noncompliance with NCCN guidelines regarding the treatment for stage II–IVB NPC in southern China, notably with regard to the treatment schedule of CCRT followed by AC.

Future chemotherapy and radiotherapy options in head and neck cancer

Chemoradiation is a standard approach to advanced unresectable head and neck cancer, although the optimum combination regimen remains controversial. However, in the past few years, chemoradiation has been successfully extended from the treatment of unresectable disease to the postsurgical therapy of high-risk patients and its value as an organ preservation procedure is under evaluation. More recently, molecular-targeted therapies have emerged, which interfere with mechanisms of chemo- and radioresistance, and preliminary data are promising. Their use in the combined treatment of head and neck cancer will hopefully further improve the value of chemoradiation in the clinical setting.

Causes of death of patients with laryngeal cancer

Despite remarkable advances in the care of patients with laryngeal cancer over the past several decades, including a growing awareness of therapeutic complications and attention to quality of life, little is known about the causes of mortality in this population. In addition to the laryngeal malignancy itself, acute and late or chronic treatment-associated causes, second primary cancers, intercurrent disease and psychosocial factors are all responsible for patient morbidity and mortality. We examine the current literature related to the causes of death in patients with laryngeal cancer, in the hope of guiding future interventions to improve the longevity and quality of life of individuals with this cancer.

The effect of treating institution on outcomes in head and neck cancer

OBJECTIVE

Factors leading patients with head and neck cancer (HNCA) to seek radiation or chemoradiation in an academic center versus the community are incompletely understood, as are the effects of site of treatment on treatment completion and survival.

STUDY DESIGN

Historical cohort study.

SETTING

Tertiary academic center, community practices.

METHODS

A historical cohort study was completed of patients with mucosal HNCA identified by International Classification of Disease, Ninth Revision (ICD-9) codes receiving consultation at the authors' institution from 2003 to 2008. Patients who received primary and adjuvant radiation at an academic center or in the community were included. The authors compared treatment completion rates and performed univariate and multivariate analyses of treatment outcomes.

RESULTS

Of 388 patients, 210 completed treatment at an academic center and 145 at a community center (33 excluded, location unknown). Patients with HNCA undergoing radiation at an academic site had more advanced disease (P = .024) and were more likely to receive concurrent chemotherapy. Academic hospitals had a higher percentage of noncurrent smokers, higher median income, and higher percentage of oropharyngeal tumors. There was no significant difference in the rate of planned treatment completion between community and academic centers (93.7% vs 94.7%, P > .81) or rate of treatment breaks (22.4% vs 28.4%, P > .28). On Kaplan-Meier analysis, the 5-year survival rate was 53.2% (95% confidence interval [CI], 45.3%-61.1%) for academic centers and 32.8% (95% CI, 22.0%-43.6%) for community hospitals (P < .001).

CONCLUSION

In this cohort, although treatment completion and treatment breaks were similar between academic and community centers, survival rates were higher in patients treated in an academic setting.

Optimal use of recombinant granulocyte colony-stimulating factor with chemotherapy for solid tumors

Neutropenia is a frequent complication of anticancer chemotherapy (CT) often associated with life-threatening infections, hospitalization, dose reduction and/or delay in the administration of CT. Administration of recombinant granulocyte colony-stimulating factor (rG-CSF) reduces the duration and the degree of CT-neutropenia. rG-CSF that stimulates both neutropoiesis and neutrophil function, has become an integral part of supportive care during cytotoxic CT, to prevent febrile neutropenia (FN), particularly in patients with a risk of FN ≥ 20%. International guidelines have standardized conditions for rG-CSF administration, however, some 'gray zones' still exist around optimal timing and tailoring of this therapy. We report here the results of a research project aimed to extend the consensus on the optimal use of rG-CSF in association with CT in patient with solid tumours. We also propose a recently developed pharmacodynamic model, based on the biological effects of CT and rG -CSF on bone marrow compartments that clearly indicates within the prophylactic rather than therapeutic setting the better way of rG-CSF administration.

Postoperative therapy in head and neck cancer: state of the art, risk subset, prognosis and unsolved questions

Head and neck cancer may be easily controlled at early stages, but resectable locally advanced disease often relapses at T and N sites. Therefore, adequate adjuvant treatment is of crucial importance for improving local control and/or survival. Unfortunately, little data are available on the adjuvant setting. Adjuvant radiotherapy is regarded as a standard approach for patients with locally advanced radically resected head and neck cancer, while postoperative chemotherapy alone cannot be considered outside of clinical trials. However, chemoradiotherapy is widely considered superior to radiotherapy in patients at a high risk of relapse and may be considered the standard treatment in this population. In this respect, in the last few decades, there has been a growing interest due to the emerging data on both tumor biology and clinical trials. Several pathological and molecular factors, affecting behavior and head and neck cancer prognosis, could allow for a better selection of postoperative treatment. More recently, new prognostic and predictive factors were identified, including biomolecular aspects, human papillomavirus infection and lifestyle. The integration of these new factors deserves dedicated clinical studies, but the available knowledge already allows some deductive hypotheses. We performed a review of the literature to analyze the role of therapy in the postoperative setting and to discuss both the possibility of a different approach to each class of risk and the unsolved question for which randomized trials are warranted.

Prereferral head and neck cancer treatment: compliance with national comprehensive cancer network treatment guidelines

OBJECTIVE

to evaluate the prereferral treatment of patients referred to our tertiary care center with recurrent or persistent head and neck cancer for compliance with National Comprehensive Cancer Network (NCCN) guidelines.

DESIGN

a prospective recruitment and retrospective chart review.

PATIENTS

the study included new patients identified at multidisciplinary treatment planning conference from October 1, 2008, to February 1, 2009, who had received prior treatment at an outside institution and presented to our department with recurrent or persistent disease.

MAIN OUTCOME MEASURES

all facets of prior care were examined, including the time from initial symptoms to diagnosis and whether their prereferral treatment was compliant with or deviated from NCCN guidelines for head and neck cancer.

RESULTS

a total of 566 consecutive new patients were identified, of whom 107 (18.9%) had persistent or recurrent disease. The average time from first presentation with initial symptoms to diagnosis among patients who presented with persistent disease was 23.8 weeks. Nearly half of the patients who presented with persistent or recurrent disease had either endocrine (21.5%) or cutaneous (24.2%) primary cancers, with the rest of the cases being distributed among 10 other sites. Of the patients who presented with recurrent or persistent disease, 43.0% had prereferral care that was noncompliant with NCCN guidelines. Of these patients, 58.7% had inadequate surgical management, 15.2% were treated for the wrong diagnosis, 10.9% received inadequate adjuvant therapy, 4.4% received inadequate radiotherapy, and 10.9% refused indicated recommended treatment.

CONCLUSIONS

significant deviation from NCCN guidelines for head and neck cancer treatment was observed in the cohort of study patients. The failure to administer adjuvant therapy when indicated by NCCN guidelines is particularly concerning. Economic and noneconomic costs, including lost wages, cost of "do-over" therapy, and potentially diminished survival, are substantial. Measures to ensure that patients receive therapy according to guidelines should be a national priority.

Induction chemotherapy response and recurrence rates in correlation with N0 or N+ stage in oral squamous cell cancer (OSCC)

The authors compared N0 with N+ cases in neoadjuvant chemotherapy regression and recurrence. During a 12-year period, 180 consecutive oral squamous cell cancer patients were observed. Of these patients, 78 were N0 and 102 N+ stages. The drugs used were as follows: bleomycin, vincristine, methotrexate, and mitolactol. After three courses of chemotherapy, the regression (complete response (CR), partial response (PR), and no response (NR)) and side effect rate were determined. All patients were operated on and observed for the number and localization of recurrences during 3 year follow-up time. The N0 cases came from T2-3, while N+ was from T2-4a (AJCC 2002). The regression in the N0 group was CR 46%, PR 53%, and NR 1%; but in the N+ group, it was CR 12%, PR 72%, and NR 16%. The regression rate was significantly higher (p = 0.00025) for N0 group than N+ group. The regression rate for T3 N0 was significantly higher (p = 0.055) than for T3 N+ cases. In the N0 stage, the regression rate was significantly higher (p = 0.0174) for T2 than T3. In N+ stage, there was no significant difference (p = 0.183) for T2-4a. The side effects were slight. The recurrence rate for the N0 group was significantly lower (15%, p = 0.000069), while for N+ group, it was 59%. The dependence in the T3 cases was also significant (p = 0.009) in the 3-year tumor-free survival. The N stage seems a more important prognostic factor for chemotherapy response and recurrence rate than the T stage. Stage III can be divided into subgroups without metastasis (III.a) and with metastasis (III.b.), based on significant difference in regression and recurrence rate.

Importance of treatment institution in head and neck cancer radiotherapy

OBJECTIVE

The treatment for head and neck cancer (HNC) often involves radiotherapy. Many HNC patients are treated at the academic center (AC) where the initial surgery or diagnosis was made. Because of the lengthy time course for radiotherapy, some patients are treated at community radiation facilities (non-AC) rather than the AC despite potential AC advantages in terms of experience and technology. Our goal is to determine if these potential AC advantages correspond to a difference in treatment outcome.

STUDY DESIGN

Historical cohort study.

SETTING

University of Kansas Medical Center, Kansas City, Kansas.

SUBJECTS AND METHODS

Review of records of patients with HNC cancers evaluated at the otolaryngology (ENT) department of an AC. Each patient's information and treatment characteristics were recorded, including radiotherapy treatment venue and treatment outcome.

RESULTS

Three hundred seventy-four patients were analyzed, 263 were treated at an AC and 101 at a non-AC. Patients treated at a non-AC were more likely to present with earlier stage tumors, be treated with radiation alone rather than chemoradiotherapy, and be treated with adjuvant rather than primary radiotherapy. There was no difference in overall survival or recurrence rates between AC and non-AC.

CONCLUSION

Patients treated at an AC are more likely to have advanced stage tumors and receive chemoradiotherapy as their primary treatment. In analyses of matching patient subsets, there was no significant difference in patient outcomes. Patients can be treated at a non-AC without affecting outcome compared with treatment at an AC.

Laryngeal Cancer in the United States: Changes in Demographics, Patterns of Care, and Survival

BACKGROUND

Survival has decreased among patients with laryngeal cancer during the past 2 decades in the United States. During this same period, there has been an increase in the nonsurgical treatment of laryngeal cancer.

OBJECTIVE

The objectives of this study were to identify trends in the demographics, management, and outcome of laryngeal cancer in the United States and to analyze factors contributing to the decreased survival.

STUDY DESIGN

The authors conducted a retrospective, longitudinal study of laryngeal cancer cases.

METHODS

Review of the National Cancer Data Base (NCDB) revealed 158,426 cases of laryngeal squamous cell carcinoma (excluding verrucous carcinoma) diagnosed between the years 1985 and 2001. Analysis of these case records addressed demographics, management, and survival for cases grouped according to stage, site, and specific TNM classifications.

RESULTS

This review of data from the NCDB analysis confirms the previously identified trend toward decreasing survival among patients with laryngeal cancer from the mid-1980s to mid-1990s. Patterns of initial management across this same period indicated an increase in the use of chemoradiation with a decrease in the use of surgery despite an increase in the use of endoscopic resection. The most notable decline in the 5-year relative survival between the 1985 to 1990 period and the 1994 to 1996 period occurred among advanced-stage glottic cancer, early-stage supraglottic cancers, and supraglottic cancers classified as T3N0M0. Initial treatment of T3N0M0 laryngeal cancer (all sites) in the 1994 to 1996 period resulted in poor 5-year relative survival for those receiving either chemoradiation (59.2%) or irradiation alone (42.7%) when compared with that of patients after surgery with irradiation (65.2%) and surgery alone (63.3%). In contrast, identical 5-year relative survival (65.6%) rates were observed during this same period for the subset of T3N0M0 glottic cancers initially treated with either chemoradiation or surgery with irradiation.

CONCLUSIONS

The decreased survival recorded for patients with laryngeal cancer in the mid-1990s may be related to changes in patterns of management. Future studies are warranted to further evaluate these associations.

Alternating gemcitabine and cisplatin with gemcitabine and radiation in stage IV squamous cell carcinoma of the head and neck

BACKGROUND

In order to improve our cisplatin-5-fluorouracil (5-FU)-based alternating chemo-radiotherapy regimen, in 1996 we started an investigational program to explore a modified alternating regimen including gemcitabine given both with radiosensitizing and cytotoxic intent.

MATERIALS AND METHODS

Based on our previous feasibility trial, we conducted a second study testing the feasibility and activity of the following schedule: gemcitabine 800 mg/m(2) on day 1 and cisplatin 20 mg/m(2) on days 2-5 (weeks 1, 4, 7 and 10) alternated with three courses of radiotherapy (RT) (weeks 2-3, 5-6 and 8-9) with conventional fractionation up to 60 Gy. Gemcitabine 300 mg/m(2) was also administered on the Monday of each week of RT.

RESULTS

Forty-seven patients with stage IV (41 patients) unresectable squamous cell carcinoma of the head and neck (SCC-HN) or who had relapsed after surgery (6 patients) were enrolled. None had previously received chemotherapy or radiotherapy. Eight patients (18%) did not complete the treatment. Main grade 3-4 toxicities were as follows: neutropenia (44%); neutropenia with fever (12%); thrombocytopenia (37%); anemia (30% grade 3). One patient died in therapy due to sepsis. Most patients needed hospitalization and tube-feeding or parenteral nutrition. However, 44% of patients had a weight loss >10%. Thirty-four patients had a complete response (72%). Three partial responders were rendered disease-free by surgery (final complete response rate, 79%). At a median follow-up of 38 months actuarial 3-year overall survival, progression-free survival and loco-regional control are 43%, 39% and 64%, respectively. Data of locoregional control favorably compare with those from our database of patients treated with alternating cisplatin-fluorouracil and radiation within controlled clinical trials (64% versus 40%).

CONCLUSIONS

The inclusion of gemcitabine into an alternating regimen seems to improve the results achievable with the original alternating program in stage IV patients. However, due to the high acute toxicity correlated, this intensive regimen should be managed by institutions well trained in multidisciplinary treatments.