Head and neck cancer in the elderly: a cohort study in 40 patients

Outcome of radiotherapy for the treatment of laryngeal squamous cell carcinoma in the very elderly population

BACKGROUND

Treatment selection for squamous cell carcinoma patients aged over 84 years is controversial. This retrospective chart review examined and compared characteristics of laryngeal squamous cell carcinoma in very elderly (over 84 years) and younger patients (approximately 65 years). The secondary objective was to further evaluate the outcome of radiotherapy as a treatment modality in this patient population.

METHODS

Of all 23 very elderly patients with laryngeal squamous cell carcinoma treated with radiotherapy, with or without surgery, in the Davidoff Cancer Center, from 1992 to 2012, 19 had sufficient data for analysis, and comprised the study group.

RESULTS

Median age at diagnosis was 86 years. Disease stage at diagnosis was I, II, III and IVA in 53 per cent, 21 per cent, 21 per cent and 5 per cent, respectively. Median radiotherapy dose was 60 Gy given in 25 fractions. Three patients had recurrence. No patient discontinued treatment because of toxicity. Median overall survival was 3.6 years (range, 0-10 years).

CONCLUSION

Very elderly laryngeal squamous cell carcinoma patients may derive a similar survival advantage as younger counterparts. Modern radiotherapy is effective and safe for treating laryngeal squamous cell carcinoma in this study population. Further, large-scale studies are needed.

Treatment Outcomes of Head and Neck Cancer Patients in the Elderly Receiving Different Chemoradiation Combinations: A Single-Center Experience

OBJECTIVES

This study aimed to assess the effect of definitive or adjuvant concurrent chemoradiation (CRT) among elderly patients with locally advanced head and neck squamous cell carcinoma (LA HNSCC).

MATERIALS AND METHODS

We retrospectively analyzed 150 elderly LA HNSCC patients (age ≥70) at a single institution. Demographics, disease control outcomes, and toxicities with different chemotherapy regimens were reviewed. The Kaplan-Meier method was used to estimate progression-free survival (PFS) and overall survival (OS) estimates.

RESULTS

Median age at diagnosis was 74 years (range 70-88). Of the cohort, 98 (65.3%) patients received definitive and 52 (34.7%) received adjuvant CRT; 44 (29.3%) patients received weekly carboplatin and paclitaxel, 43 (28.7%) weekly cetuximab, 33 (22%) weekly carboplatin, and 30 (20%) weekly cisplatin. The OS at 2 years was 70% (95% confidence interval [CI]: 63-79%), and PFS at 2 years was 61% (95% CI: 53-70%). There was no significant difference in OS or PFS between definitive and adjuvant CRT (p = 0.867 and p = 0.475, respectively). Type of chemotherapy regimen (single-agent carboplatin vs. others) (95% CI: 1.1-3.9; p = 0.009) was a key prognostic factor in predicting OS in multivariable analysis. Concurrent use of cetuximab was associated with increased risk of PEG tube dependence at 6 months (p < 0.001).

CONCLUSIONS

Management of LA HNSCC in the elderly is a challenging scenario. Our study shows that CRT is a feasible treatment modality for elderly patients with LA HNSCC. We recommend CRT with weekly cisplatin or weekly carboplatin and paclitaxel. A chemotherapy regimen should be carefully selected in this difficult to treat population.

Management of head and neck cancer in older patients

OBJECTIVE

A progressive increase in the number of older patients with head and neck cancer has been observed in the last few years. The aim of this study was to assess our experience in the management of older patients with head and neck cancer (HNC) in comparison with younger patients.

STUDY DESIGN

A retrospective review was conducted for all patients admitted and treated for newly diagnosed HNC between January 2008 and December 2012. The clinical characteristics, management approaches, and outcome data were recorded.

RESULTS

In total, 316 patients with HNC (232 males, 84 females) were enrolled: 203 (64%) were in the young group, whereas 113 patients (36%) were in the older group. Comorbidities (P < .000005) and stage IV tumors (P < .0005) were more frequently observed in the older group. Treatment options were uniformly distributed within the 2 groups; only radiotherapy alone was more frequently administered in older patients (P < .0005).

CONCLUSIONS

Chronologic age should not be a reason to deny appropriate treatments that could prevent death in older patients. A careful pretreatment assessment should always be performed.

Predicting postoperative complications of head and neck squamous cell carcinoma in elderly patients using random forest algorithm model

BACKGROUND

Head and Neck Squamous Cell Carcinoma (HNSCC) has a high incidence in elderly patients. The postoperative complications present great challenges within treatment and they're hard for early warning.

METHODS

Data from 525 patients diagnosed with HNSCC including a training set (n = 513) and an external testing set (n = 12) in our institution between 2006 and 2011 was collected. Variables involved are general demographic characteristics, complications, disease and treatment given. Five data mining algorithms were firstly exploited to construct predictive models in the training set. Subsequently, cross-validation was used to compare the different performance of these models and the best data mining algorithm model was then selected to perform the prediction in an external testing set.

RESULTS

Data from 513 patients (age > 60 y) with HNSCC in a training set was included while 44 variables were selected (P < 0.05). Five predictive models were constructed; the model with 44 variables based on the Random Forest algorithm demonstrated the best accuracy (89.084%) and the best AUC value (0.949). In an external testing set, the accuracy (83.333%) and the AUC value (0.781) were obtained by using the random forest algorithm model.

CONCLUSIONS

Data mining should be a promising approach used for elderly patients with HNSCC to predict the probability of postoperative complications. Our results highlighted the potential of computational prediction of postoperative complications in elderly patients with HNSCC by using the random forest algorithm model.

Optimal management of the elderly patient with head and neck cancer: Issues regarding surgery, irradiation and chemotherapy

Head and neck cancer (HNC) represents the sixth most common malignancy and accounts for approximately 6% of new cancer cases annually worldwide. As life expectancy constantly increases, the onset of HNC in patients older than 65 years of age at diagnosis is not rare and up to one fourth of cases occurs in patients older that 70 years at age. Because elderly cancer patients are severely under-represented in clinical trials, there is a clear need to address the particular aspects of this specific patient group, especially in the context of novel multidisciplinary therapeutic approaches. The frailty of elderly patients with HNC is attributed to the high incidence of smoking and alcohol abuse in this malignancy and the presence of substantial cardiovascular, respiratory or metabolic comorbidities. In the current work, I provide an overview of current and emerging treatment approaches, in elderly patients with HNC. In particular, I discuss modern surgical approaches that improve radical excision rates while preserving functionality, the incorporation of modern radiotherapeutic techniques and the introduction of novel chemotherapeutic combinations and molecular targeted agents in an effort to reduce toxicity without compromising efficacy. Finally, there is an urgent need to increase accrual and active participation of elderly patients with HNC in clinical trials, including biomarker evaluation in biopsy specimens towards an individualized therapeutic approach.

Elderly patients with squamous cell carcinoma of the head and neck and the benefit of multimodality therapy

BACKGROUND

Limited data are available regarding outcomes in elderly head and neck cancer patients. This retrospective study was designed to characterize head and neck cancer in geriatric patients.

PATIENTS AND METHODS

This study included all patients in a large university-based tumor registry who were diagnosed with head and neck cancer from January 1, 1990, to December 31, 2005. Patients aged ≥70 years at the time of diagnosis were defined as older. Overall survival and progression-free survival were censored at 60 months. Survival differences were compared using the log-rank test. Hazard ratios were estimated using a Cox proportional hazards model, adjusting for potential confounders.

RESULTS

Of 1,598 patients identified, 1,166 patients were aged <70 years (i.e., younger) and 281 patients were aged ≥70 years (older). When controlling for possible confounders, older patients were nearly twice as likely to die within 5 years as their younger counterparts (hazard ratio: 1.92). The median life expectancy for older patients was nearly 5 years for stage I-II disease and <2 years for stage III-IV disease. Older patients with stage III-IV disease who received multimodality therapy had 5-year survival similar to that younger patients with stage III-IV disease who were treated similarly (33.2% vs. 44.0%). Older patients with stage III-IV disease who received single-modality therapy had extremely poor survival compared with all other patients (hazard ratio for progression-free survival: 1.5).

CONCLUSION

This study highlights the need for better understanding of the factors affecting head and neck cancer outcomes in elderly patients. Information about life expectancy in elderly head and neck cancer patients may help guide treatment decisions.

Free flap reconstruction for head and neck cancer can be safely performed in both young and elderly patients after careful patient selection

Surgical treatment of head and neck cancer often results in complex defects requiring reconstruction with microvascular free tissue transfer. However, in elderly patients, curative treatment with radical surgery and free flap reconstruction is often withheld. The objective of this study is to assess the outcomes of free flap surgery in elderly patients, using a standard surgical complication classification system. A retrospective review was conducted of patients who underwent primary free flap reconstruction following major surgery for head and neck cancer between 1995 and 2010. Complications were assessed using the Clavien Dindo classification system, and grades III-V were classified as major complications. Comorbidity was classified according to the adult comorbidity evaluation index 27. A comparison was done between patients <70 and ≥70 years. Two hundred-two patients were included in this study. Multivariate analysis showed that only disease stage was a significant predictor of recipient site complications, and comorbidity was the only significant predictor of medical complications. Age was not a predictor of complications. There were no significant differences in disease specific or overall survival between young and elderly patients. Optimal patient selection for free flap surgery is essential. This requires thorough pre-operative assessment, including analysis of comorbidity in both young and elderly patients. Patients' biological age, and not chronological age, should be individually determined to assess feasibility of major surgery. Patients should not be denied surgery based on age alone.

Relation between age, comorbidity, and complications in patients undergoing major surgery for head and neck cancer

BACKGROUND

Multiple factors have been identified as predictors of complication after head and neck surgery. However, little is known about the exact role of different comorbid conditions in the development of postoperative complications. This question is especially interesting in the elderly population. The aim of this study was to investigate the association between comorbidity and types of postoperative complications with special attention to age differences.

METHODS

A retrospective analysis was performed of 1,201 major surgical interventions for head and neck malignancies in a tertiary referral center between 1995 and 2010. The Adult Comorbidity Evaluation 27 (ACE-27) index was used to analyze severity (mild, moderate, and severe comorbidity) and type (12 different organ systems) of comorbidity. The Clavien-Dindo index was used to evaluate grade and type of complications after treatment.

RESULTS

In univariate analysis gender, comorbidity, stage, mandibulectomy, total laryngectomy, neck dissection, and length of surgery significantly predicted grade of complication. In a multivariate analysis, complication was predicted by age, stage, length of surgery, and various comorbidities. After specification of the complications, age was only a predictor of medical complications; tumor stage was a significant factor in surgical complications. Length of surgery was the only significant variable in all types of complications.

CONCLUSIONS

Specific comorbidities are associated with specific complications; however, age itself seems not to be a contraindication for major head and neck surgery. With careful preoperative assessment and risk analysis, physicians can better individualize treatment recommendations.

A specific approach for elderly patients with head and neck cancer

Approximately 10% of head and neck (HN) tumors occur in patients aged more than or equal to 80 years. In this population, the main challenge for physicians is to deal with the benefit/risk ratio of treatments and tumor-related symptoms. As elderly patients are generally excluded from clinical trials, there is a lack of evidence-based data with regard to the most appropriate multidisciplinary management. The prevalence of frailty and the pattern of comorbidities in this specific population are still unknown. The management of these tumors in a geriatric context is complex due to the high risk of toxicity of locoregional treatments. Thus, physicians often have to adapt to the treatment schedule to decrease potential adverse effects even with a risk of undertreatment. A retrospective series reported that the treatment delivered to elderly patients presenting with HN tumor complies with an institution's policy in less than 50% of cases, emphasizing the need to assess the outcome of personalized/adapted treatment in geriatric patients. The major issue is to determine which adaptation could be carried out, and then, what could be the respective individual benefit/risk ratio of each adaptation. In this review, we will focus on the locoregional management of elderly patients, and develop the issue of adapted local treatment. We will discuss the feasibility of adapted surgery and radiotherapy and provide current evidence-based data that may allow physicians involved in locoregional treatment of elderly patients with HN cancers to be acquainted with practical guidelines. Then, we will highlight the importance of nutritional support in this population in which the prevalence of malnutrition is high.

Conditional relative survival in head and neck squamous cell carcinoma: Permanent excess mortality risk for long-term survivors

BACKGROUND

Dynamic predictions on head and neck cancer survival could offer, besides improved patient counseling, insight into long-term effects of tumor- and patient-based characteristics on survival. Theoretically, there could be a certain time period after diagnosis after which the patient returns to a population risk on survival.

METHODS

In all, 7255 patients with a primary head and neck squamous cell carcinoma (HNSCC) aged 25 to 90 years, diagnosed between January 1980 and January 2004 in The Netherlands, were included. Conditional 5-year relative survival for every additional year survived was computed.

RESULTS

The overall conditional relative prognosis reached a plateau after approximately 4 years; a permanent 20% to 25% excess mortality for long-term HNSCC survivors remained.

CONCLUSIONS

Conditional 5-year relative survival for patients with HNSCC remains poorer compared to age- and sex-matched counterparts in the general population, even when alive at 15 years after diagnosis. We assume that this is caused by an excess comorbidity in these patients, mainly due to smoking and alcohol abuse.

Geriatric oncology: comparing health related quality of life in head and neck cancer patients

BACKGROUND

Population ageing is increasing the number of people annually diagnosed with cancer worldwide, once most types of tumours are age-dependent. High-quality healthcare in geriatric oncology requires a multimodal approach and should take into account stratified patient outcomes based on factors other than chronological age in order to develop interventions able to optimize oncology care.This study aims to evaluate the Health Related Quality of Life in head and neck cancer patients and compare the scores in geriatric and younger patients.

METHODS

Two hundred and eighty nine head and neck cancer patients from the Oncology Portuguese Institute participated in the Health Related Quality of Life assessment. Two patient groups were considered: the geriatric (≥ 65 years old, n = 115) and the younger (45-60 years old, n= 174). The EORTC QLQ-C30 and EORTC QLQ-H&N35 questionnaires were used.

RESULTS

Head and neck cancer patients were mostly males, 77.4% within geriatric group and 91.4% among younger patients group.The most frequent tumour locations were similar in both groups: larynx, oral cavity and oropharynx - base of the tongue.At the time of diagnosis, most of younger male patients were at disease stage III/IV (55.9%) whereas the majority of younger female patients were at disease stage I/II (83.4%). The geriatric patient distribution was found to be similar in any of the four disease stages and no gender differences were observed.We found that age (geriatrics scored generally worse), gender (females scored generally worse), and tumour site (larynx tumours denounce more significant problems between age groups) clearly influences Health Related Quality of Life perceptions.

CONCLUSIONS

Geriatric oncology assessments signalize age-independent indicators that might guide oncologic geriatric care optimization. Decision-making in geriatric oncology must be based on tumour characteristics and chronological age but also on performance status evaluation, co-morbidity, and patient reported outcomes assessment.

Management of head and neck cancer in elderly patients

Head and neck cancer (HNC) represents a heterogeneous group of tumours requiring multimodality approaches. It is debatable whether HNC treatment in geriatric patients should be different to that delivered for younger patients. Furthermore, the risk of death seems to be higher in HNC patients with higher co-morbidity status. Despite the fact that there is no significant difference in outcome in younger versus older patients, older HNC patients are more likely to receive nonstandard, less aggressive therapies than younger patients. Age alone should not be the basis for selecting treatment options in older HNC patients. A thorough pretreatment evaluation of co-morbidities should always be performed, and radical surgical options should not be excluded in older HNC patients treated with curative intent, as postoperative complications occur no more frequently in older patients than in younger patients. Locoregional control and disease-free survival in older patients treated with radiation therapy (either with curative intent or in the palliative setting) are comparable to the results seen in younger HNC patients, with the same acute toxicity profile. In patients receiving systemic therapies, special attention must be given to modification of chemotherapy dosages according to renal and hepatic function. Molecular-targeted therapies appear to be very useful in such patients because of their favourable tolerability. In conclusion, once all physiological and biological risk factors have been addressed, a large proportion of geriatric patients can and should be offered the same HNC treatment as is offered to younger patients.

Oral cavity squamous cell carcinoma in 260 patients aged 80years or more

PURPOSE

We report the experience of two French cancer centers in the treatment of oral cavity squamous cell carcinoma (SCC) in patients aged 80 years.

MATERIALS AND METHODS

Two hundred and sixty patients aged 80 years with a primary oral cavity SCC were included in this retrospective analysis.

RESULTS

Sex ratio was near to 1. Tobacco or alcohol intoxication was the main risk factor for 66% of men and 16% of women and leukoplakia, lichen planus, or oral traumatism for 55% of women and 11% of men (p<0.0001). Two hundred patients received a loco-regional (LR) treatment with a curative intent (surgery and/or radiotherapy), 29 with a palliative intent and 31 did not receive a LR treatment. Curative treatments were initially planned to be adapted to age in 118 patients (59%). The median disease-specific survival (DSS) was 29 months. In multivariate analysis, the independent prognostic factors for DSS were stage (HR=0.42 [0.24-0.72]), age (HR=0.43 [0.24-0.75]) and performance status (HR=0.50 [0.27-0.95]). The median overall survival (OS) was 14 months. In multivariate analysis, the independent prognostic factors for OS were age (HR=0.52 [0.35-0.79]), stage (HR=0.56 [0.38-0.84]), tumor differentiation (HR=0.60 [0.33-0.93]) and performance status (HR=0.6 [0.37-0.97]). In patients treated with a curative intent, treatment adapted to age was not associated with a decreased overall survival or disease-specific survival as compared with the standard treatment. However, prophylactic lymph node treatment in stages I-II tumors decreased the rate of nodal recurrence from 38% to 6% (p=0.01).

CONCLUSION

This study emphasizes the need for prospective evaluation of standard and adapted schedules in elderly patients with oral cavity cancer.

Tobacco abuse relates to significantly reduced survival of patients with oropharyngeal carcinomas

This study represents an in-depth evaluation of the impact of smoking and alcohol consumption on patients' outcome in 809 cases of oropharyngeal carcinoma. Prognostic parameters and additional information such as smoking and drinking habits were evaluated referring to the patients' case notes at the time point of first diagnosis. The overall 10-year survival rate was 45.5%, whereas 33.4% of the patients remained relapse-free. The great majority (92%) of patients had a history of smoking or were current smokers, whereas only 8% of the collective never smoked in their lifetime. Interestingly, we found a significant reduction of 10-year survival rates for smokers (28.8%) in comparison with nonsmokers (43.1%) and ex-smokers (P=0.0007). This study presents data from a large cohort of patients with oropharyngeal carcinoma providing evidence for a relationship between alcohol and tobacco consumption, and significantly worse prognosis.

Predictive factors for complications in elderly patients who underwent head and neck oncologic surgery

BACKGROUND

Postoperative complications are relevant outcomes in patients with head and neck tumor who have undergone surgery. Few trials have assessed predictive factors in older patients. We assessed the predictive effect of preoperative clinical factors on postoperative complications.

METHODS

We conducted a cohort study with 242 patients older than 70 years with head and neck cancer who underwent surgery. Logistic regression identified predictive factors for postoperative complications. Significant variables were used to build a predictive index.

RESULTS

Comorbidities were present in 87.6% of patients, and 56.6% had some type of complication (44.6% local and 28.5% systemic). Male sex, bilateral neck dissection, presence of 2 or more comorbidities, reconstruction, and clinical stage IV were associated with postoperative complications. The predictive index showed a receiver operating characteristics curve (ROC) area of 0.69.

CONCLUSION

It is possible to predict postoperative complications in older patients with head and neck tumors who underwent oncologic surgery using clinical preoperative variables.

Comorbidity Is a Prognostic Factor in Elderly Patients with Head and Neck Cancer

BACKGROUND

The number of aged patients with head and neck cancer is increasing. Comorbidities are common in this population. It is necessary to evaluate the effect of comorbidities as measured with the ACE-27 index on recurrence and survival of elderly patients with head and neck cancer, adjusting by other prognostic factors as age, clinical stage and functional status index.

PATIENTS

Three hundred and ten patients greater than 70 years of age with head and neck cancer in a referral cancer center were studied. Comorbidity measured with the ACE-27 index was the main independent variable. The outcomes were recurrence and survival.

RESULTS

Comorbidities were present in 75% of patients. Five-year disease-free survival, overall survival and cancer-specific survival were 63.1, 42.8 and 55.8%, respectively. Advanced clinical stage and Karnofsky index < or =70 were associated with recurrence. Age >80 years, male gender, Karnofsky index < or =80, advanced clinical stage, and ACE value > or =2 were independently associated with overall survival. The ACE-27 value was not associated with cancer-specific survival. The Karnofsky performance index was associated with overall survival and mortality and acted as a confounding factor on multivariable analysis on overall and cancer-specific survival.

CONCLUSIONS

Comorbidity measured with ACE-27 was a prognostic factor for overall survival in patients older than 70 years with head and neck cancer. The Karnofsky performance index could be included in multivariable analysis of survival for older patients with head and neck cancer.

Complications after CO(2) laser surgery of laryngeal cancer in the elderly

CONCLUSION

Cancer of the larynx in elderly patients should be treated with curative intention, if the extension of the primary tumour allows safe resection. Transoral CO(2) laser microsurgery is associated with a low rate of major complications and can be regarded as suitable even for elderly patients. Age itself should never be the sole factor in deciding which therapy should be undertaken.

OBJECTIVES

In the industrialized nations the age group beyond 75 years will grow steadily, requiring special attention by medical professionals in the future. Nowadays laryngeal cancer is often treated by transoral CO(2) laser microsurgery. Because of a variety of comorbidities, the incidence of perioperative complications in the group of elderly patients is of increasing interest. To date, no references in the literature have discussed complications after transoral CO(2) laser microsurgery in this age group. Patients and methods. Twenty-four patients over the age of 75 suffering from squamous cell carcinoma of the larynx and treated by transoral CO(2) laser microsurgery since 1998 were analysed for intraoperative and postoperative complications.

RESULTS

There was no evidence of surgery-related complications at all. Postoperatively, 6 of 24 patients complained about dysphagia. Due to intraoperative placement of nasogastric feeding tubes in these six cases further complications such as pneumonia resulting from aspiration could have been avoided.

Prognosis as a determinant of free flap utilization for reconstruction of the lateral mandibular defect

BACKGROUND

The purpose of this study was to determine whether patients with a poor prognosis for survival were more likely to undergo reconstruction with a pectoralis flap versus a free flap and whether the use of a pectoralis flap offered any perioperative advantage, such as a reduction in medical complications.

METHODS

Fifty-five consecutive patients who underwent immediate reconstruction after a lateral mandibulectomy were retrospectively reviewed.

RESULTS

Age >or=70 years (p = .03), moderate or severe comorbidity (p = .02), and involvement of the base of tongue by tumor (p = .04) were significantly associated with decreased utilization of a free flap (n = 36). Comorbidity was the main determinant of medical complications (p = .001) and length of hospital stay (p = .03).

CONCLUSIONS

Expectations of prognosis bias the surgeon's decision regarding flap selection. Reconstruction with a pectoralis flap does not necessarily contribute toward the desired outcome of reduced medical complications. Any functional comparison between reconstructive groups needs to account for those differences in health status and prognosis that might explain any observed postoperative differences.