Impact of age on survival of locoregional nasopharyngeal carcinoma: An analysis of the Surveillance, Epidemiology, and End Results program database, 2004-2013

Effect of waiting time for radiotherapy after last induction chemotherapy on prognosis of locally advanced nasopharyngeal carcinoma

BACKGROUND

The effect of radiotherapy waiting time after last induction chemotherapy (IC-RT) on prognosis of patients with locally advanced nasopharyngeal carcinoma (LANPC) needs further discussion.

METHODS

Three hundred and six patients with LANPC diagnosed pathologically by induction chemotherapy (IC) and radiotherapy (RT) from 2013 to 2018 were selected for this study.

RESULTS

The IC-RT was a risk factor for the post-treatment progression of LANPC (OR = 1.017 95%CI: 1.003-1.031), For patients with LANPC, the IC-RT > 40 days significantly reduced 5-year PFS (70% vs. 55%; p = 0.0012), 5-year OS (84% vs. 73%; p = 0.028), 5-year DMFS (80% vs. 66%; p = 0.003), 5-year LRFS (77% vs. 67%; p = 0.012). Indicating that patients with stage IVa who IC-RT > 40 days were found to be a significant predictor of aggravated PFS (HR = 2.69; 95%CI: 1.57-4.6), OS (HR = 2.55; 95%CI: 1.29-5.03), DMFS (HR = 3.07; 95%CI: 1.64-5.76) and LRFS (HR = 2.26; 95%CI: 1.21-4.21).

CONCLUSION

The prognosis of patients will be adversely affected if the IC-RT exceeds 40 days, especially for stage IVa patients.

Nasopharyngeal Carcinoma in Children, Current Treatment Approach

Nasopharyngeal carcinoma (NPC) is a rare and locally aggressive form of childhood cancer. Treatment of pediatric NPC includes chemotherapy and radiotherapy. Most studies on the treatment of pediatric NPC are single-arm studies. With current treatment protocols survival rates for patients with nonmetastatic disease exceed 80%, although most children will have long-term treatment-related late effects. Efforts to reduce early and late toxicities include reduced radiotherapy doses in children with good responses to induction chemotherapy. Further studies are needed to evaluate the role of immunotherapy in both the primary setting and in children with progressive or relapsed disease. This review summarizes current clinical approaches to the treatment of pediatric NPC.

Two web-based dynamically interactive nomograms and risk stratification systems for predicting survival outcomes and guiding treatment in non-metastatic nasopharyngeal carcinoma

BACKGROUND

A nomogram is a valuable and easily accessible tool for individualizing cancer prognosis. This study aims to establish and validate two prognostic nomograms for long-term overall survival (OS) and cancer-specific survival (CSS) in non-metastatic nasopharyngeal carcinoma (NPC) patients and to investigate the treatment options for the nomogram-based risk stratification subgroups.

METHODS

A total of 3959 patients with non-metastatic NPC between 2004 and 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The patients were randomly allocated to the training and validation cohorts in a 7:3 ratio. Prognostic nomograms were constructed to estimate OS and CSS by integrating significant variables from multivariate Cox regression employing a backward stepwise method. We examined the correlation indices (C-index) and areas under the curves (AUC) of time-dependent receiver operating characteristic curves to assess the discriminative ability of our survival models. The comprehensive enhancements of predictive performance were evaluated with net reclassification operating improvement (NRI) and integrated discrimination improvement (IDI). Reliability was validated using calibration plots. Decision curve analysis (DCA) was used to estimate clinical efficacy and capability. Finally, the nomogram-based risk stratification system used Kaplan-Meier survival analysis and log-rank tests to examine differences between subgroups.

RESULTS

The following independent parameters were significant predictors for OS: sex, age, race, marital status, histological type, median household income, AJCC stage tumor size, and lymph node size. Except for the race variables mentioned above, the rest were independent prognostic factors for CSS. The C-index, AUC, NRI, and IDI indicated satisfactory discriminating properties. The calibration curves exhibited high concordance with the exact outcomes. Moreover, the DCA demonstrated performed well for net benefits. The prognosis significantly differed between low- and high-risk patients (p < 0.001). In a treatment-based stratified survival analysis in risk-stratified subgroups, chemotherapy benefited patients in the high-risk group compared to radiotherapy alone. Radiotherapy only was recommended in the low-risk group.

CONCLUSIONS

Our nomograms have satisfactory performance and have been validated. It can assist clinicians in prognosis assessment and individualized treatment of non-metastatic NPC patients.

Conditional survival nomogram for monitoring real-time survival of young non-metastatic nasopharyngeal cancer survivors

BACKGROUND

The aim of this study was to clarify the improvement of the overall survival (OS) over time in young non-metastatic nasopharyngeal carcinoma (NPC) survivors by conditional survival (CS) analysis and to construct a CS-nomogram for updating individualized real-time prognosis.

METHODS

The study included 3409 young non-metastatic NPC patients from the Surveillance, Epidemiology, and End Results (SEER) database (2004-2019). OS was estimated using the Kaplan-Meier method. CS was calculated based on CS(y|x) = OS(y + x)/OS(x), defined as the probability that a patient would survive for another y years after surviving for x years since diagnosis. We identified predictors using the least absolute shrinkage and selection operator (LASSO) regression and developed the CS-nomogram using multivariate Cox regression and the CS formula.

RESULTS

CS analysis showed a continuous increase in 10-year OS for young non-metastatic NPC from the initial 60.4% to 65.0%, 70.2%, 74.2%, 78.2%, 82.6%, 86.9%, 91.1%, 96.2% and 97.0% (surviving 1-9 years after diagnosis, respectively). After screening by LASSO regression, age, race, marital status, histological type, T- and N-status were used as predictors to construct the CS-nomogram. The model accurately estimated the real-time prognosis of survivors during follow-up with a stable time-dependent area under the curve (AUC).

CONCLUSIONS

CS analysis based on SEER database calibrated the real-time prognosis of young non-metastatic NPC survivors, revealing a dynamic improvement during follow-up time. We developed a novel CS-nomogram to update survival data for real-time optimization of monitoring strategies, medical resource allocation, and patient counseling. However, it was important to note that the model still needed external data validation and continuous improvement.

An overall survival predictive nomogram to identify high-risk patients among locoregionally advanced nasopharyngeal carcinoma: Developed based on the SEER database and validated institutionally

Objective

Locoregionally advanced nasopharyngeal carcinoma (LA-NPC) patients, even at the same stage, have different prognoses. We aim to construct a prognostic nomogram for predicting the overall survival (OS) to identify the high-risk LA-NPC patients.

Materials and methods

Histologically diagnosed WHO type II and type III LA-NPC patients in the Surveillance, Epidemiology, and End Results (SEER) database were enrolled as the training cohort (n= 421), and LA-NPC patients from Shantou University Medical College Cancer Hospital (SUMCCH) served as the external validation cohort (n= 763). Variables were determined in the training cohort through Cox regression to form a prognostic OS nomogram, which was verified in the validation cohort, and compared with traditional clinical staging using the concordance index (C-index), Kaplan–Meier curves, calibration curves and decision curve analysis (DCA). Patients with scores higher than the specific cut-off value determined by the nomogram were defined as high-risk patients. Subgroup analyses and high-risk group determinants were explored.

Results

Our nomogram had a higher C-index than the traditional clinical staging method (0.67 vs. 0.60, p&lt;0.001). Good agreement between the nomogram-predicted and actual survival were shown in the calibration curves and DCA, indicating a clinical benefit of the nomogram. High-risk patients identified by our nomogram had worse prognosis than the other groups, with a 5-year overall survival (OS) of 60.4%. Elderly patients at advanced stage and without chemotherapy had a tendency for high risk than the other patients.

Conclusions

Our OS predictive nomogram for LA-NPC patients is reliable to identify high-risk patients.

Development and validation of a risk prediction model for overall survival in patients with nasopharyngeal carcinoma: a prospective cohort study in China

Objective

Nasopharyngeal carcinoma (NPC) is prevailing in Southern China, characterized by distinct geographical distribution. Aimed to predict the overall survival (OS) of patients with nasopharyngeal carcinoma, this study developed and validated nomograms considering demographic variables, hematological biomarkers, and oncogenic pathogens in China.

Methods

The clinicopathological and follow-up data of the nasopharyngeal carcinoma patients obtained from a prospective longitudinal cohort study in the Chongqing University Cancer Hospital between Jan 1, 2017 and Dec 31, 2019 (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\mathrm{n}=1635$$\end{document}n=1635). Cox regression model was used to tested the significance of all available variables as prognostic factors of OS. And independent prognostic factors were identified based on multivariable analysis to model nomogram. Concordance index (C-index), area under the receiver operating characteristic (AUC), calibration curve, and decision curve analysis (DCA) were measured to assess the model performance of nomogram.

Results

Data was randomly divided into a training cohort (1227 observers, about 70% of data) and a validation group (408 observers, about 30% of data). At multivariable analysis, the following were independent predictors of OS in NPC patients and entered into the nomogram: age (hazard ratio [HR]: 1.03), stage (stage IV vs. stage I–II, HR: 4.54), radiotherapy (Yes vs. No, HR: 0.43), EBV (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge 1000$$\end{document}≥1000 vs.\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$<1000$$\end{document}<1000, HR: 1.92), LAR (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$>6.15$$\end{document}>6.15 vs.\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\le 6.15$$\end{document}≤6.15, HR: 2.05), NLR (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$>4.84$$\end{document}>4.84 vs. \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\le 4.84$$\end{document}≤4.84 HR: 1.54), and PLR (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$>206.33$$\end{document}>206.33 vs.\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\le 206.33$$\end{document}≤206.33, HR: 1.79). The C-indexes for training cohort at 1-, 3- and 5-year were 0.73, 0.83, 0.80, respectively, in the validation cohort, the C-indexes were 0.74 (95% CI 0.63–0.86), 0.80 (95% CI 0.73–0.87), and 0.77 (95% CI 0.67–0.86), respectively. The calibration curve demonstrated that favorable agreement between the predictions of the nomograms and the actual observations in the training and validation cohorts. In addition, the decision curve analysis proved that the nomogram model had the highest overall net benefit.

Conclusion

A new prognostic model to predict OS of patients with NPC was developed. This can offer clinicians treatment making and patient counseling. Furthermore, the nomogram was deployed into a website server for use.

The influence of marital status on survival in patients with nasopharyngeal carcinoma: A surveillance, epidemiology, and end results database analysis

BACKGROUND

To assess the influence of marital status on the survival of patients with nasopharyngeal carcinoma (NPC), we used the Surveillance, Epidemiology, and End Results (SEER) database to analyze 5477 patients who were diagnosed with NPC from 2004 to 2016.

METHODS

Kaplan-Meier survival analysis and Cox proportional hazard regression were used to analyze the influence of marital status on cause-specific survival (CSS) and overall survival (OS). Subgroup analyses was used to assess the influence of marital status on CSS based on different factors.

RESULTS

For the 5477 patients, 61.5%, 22.4%, and 16.1% were married, single/unmarried, and separated/widowed/divorced, respectively. The separated/widowed/divorced group was more likely to be female (P < .001), had the highest proportion of elderly subjects (P < .001), were mostly Caucasian (P < .001), had pathological grade I/II (P < .001), were likely to undergo surgery (P = .032), and were registered in the northeast, north-central, and south (P < .001) regions. The 5-year CSS rates were 92.6%, 92.4%, and 85.1% in the married, single/unmarried, and separated/widowed/divorced groups, respectively (P < .001), and the 5-year OS rates were 60.7%, 54.6%, and 40.1%, respectively (P < .001).

CONCLUSION

Marital status is an independent prognostic factor of NPC. Separated/widowed/divorced patients had a significantly increased risk of NPC-related death (hazard ratio [HR] = 2.180, 95% confidence interval [CI] 1.721-2.757, P < .001) compared to married patients. The single/unmarried (P = .355) group had a CSS similar to that of the unmarried group. Marital status is an independent prognostic factor of survival in NPC patients. Separated/widowed/divorced status increases the risk of NPC mortality.

Ferroptosis regulators related scoring system by Gaussian finite mixture model to predict prognosis and immunotherapy efficacy in nasopharyngeal carcinoma

The role of ferroptosis in tumor progression and metastasis has been demonstrated. Nonetheless, potential biological function of ferroptosis regulatory pattern in nasopharyngeal carcinoma (NPC) remains unknown. Ferroptosis regulatory patterns of nasopharyngeal carcinoma samples were evaluated based on 113 ferroptosis regulators and three distinct ferroptosis subtypes were determined by unsupervised clustering. The ferroptosis score (FEP score) was identified to quantify ferroptosis patterns within individual tumors by Gaussian finite mixture model and systematically correlated with representative tumor characteristics. Subtype 1 and subtype 3 were consistent with immune activated phenotype, while subtype 2 was consistent with immune suppressed phenotype. High ferroptosis score, characterized by immune activation and suppression of mRNA based stemness index (mRNAsi) and Epstein-Barr virus (EBV) genes, indicated an immune activated tumor microenvironment (TME) phenotype, with better progression free survival (PFS) and lower risk of recurrence and metastasis. Low ferroptosis score, characterized by activation of Wnt and NF-κB signaling pathways and lack of effective immune infiltration, indicated an immune suppressed tumor microenvironment phenotype and poorer survival. High ferroptosis score was also correlated to enhanced response to immunotherapy, and was confirmed to correlate with therapeutic advantages and clinical benefits in an anti-programmed cell death 1 ligand 1 (PD-L1) immunotherapy cohort. As ferroptosis played a crucial role in the tumor microenvironment’s diversity, assessing the ferroptosis pattern within individual tumor with ferroptosis score could enhance our understanding of tumor microenvironment infiltration characterization and help develop more effective immunotherapy.

Health Insurance Coverage and Survival Outcomes among Nasopharyngeal Carcinoma Patients: A SEER Retrospective Analysis

Objectives Insurance coverage plays a critical role in head and neck cancer care. This retrospective study examines how insurance coverage affects nasopharyngeal carcinoma (NPC) survival in the United States using the Surveillance, Epidemiology, and End Results (SEER) program database.

Design, Setting, and Participants A total of 2,278 patients aged 20 to 64 years according to the International Classification of Diseases for Oncology (ICD-O) codes C11.0–C11.9 and ICD-O histology codes 8070–8078 and 8080–8083 between 2007 and 2016 were included and grouped into privately insured, Medicaid, and uninsured groups. Log-rank test and multivariable Cox's proportional hazard model were performed.

Main Outcome Measures Tumor stage, age, sex, race, marital status, disease stage, year of diagnosis, median household county income, and disease-specific survival outcomes including cause of death were analyzed.

Results Across all tumor stages, privately insured patients had a 59.0% lower mortality risk than uninsured patients (hazard ratio [HR]: 0.410, 95% confidence interval [CI]: [0.320, 0.526], p < 0.01). Medicaid patients were also estimated to have 19.0% lower mortality than uninsured patients (HR: 0.810, 95% CI: [0.626, 1.048], p = 0.108). Privately insured patients with regional and distant NPC had significantly better survival outcomes compared with uninsured individuals. Localized tumors did not show any association between survival and type of insurance coverage.

Conclusion Privately insured individuals had significantly better survival outcomes than uninsured or Medicaid patients, a trend that was preserved after accounting for tumor grade, demographic and clinicopathologic factors. These results underscore the difference in survival outcomes when comparing privately insured to Medicaid/uninsured populations and warrant further investigation in efforts for health care reform.

Nomogram for distant metastasis-free survival in patients with locoregionally advanced nasopharyngeal carcinoma

OBJECTIVE

To develop and validate a nomogram to predict distant metastasis-free survival of patients with locoregionally advanced nasopharyngeal carcinoma.

METHODS

We collected the total clinical data of 820 nasopharyngeal carcinoma (NPC) patients, of whom 482 formed the training cohort from one hospital and 328 made up the validation cohort from another hospital. By analyzing the prognosis of all patients after intensity-modulated radiotherapy by univariate and multivariate Cox regression models, a nomogram related to DMFS was created in the training cohort. The discriminatory and calibration power of the nomogram was successively assessed in the training and validation cohorts by the C‑index and calibration curve. The predictive ability for 3‑year DMFS was compared between the nomogram and TNM stage using ROC curves. Patients were divided into different risk groups based on scores calculated from the nomogram.

RESULTS

Age, lymph node gross tumor volume (GTVnd), and gross tumor volume of the nasopharynx (GTVnx) were the factors included in the nomogram. The C‑index of the nomogram was 0.721 in the training cohort and 0.750 in the validation cohort. The calibration curves were satisfactory. Patients in the high-risk group were more likely to develop metastases.

CONCLUSION

A nomogram incorporating age, GTVnd, and GTVnx showed good performance for predicting DMFS in patients with locoregionally advanced NPC.

Role of Pretreatment Hemoglobin-to-Platelet Ratio in Predicting Survival Outcome of Locally Advanced Nasopharyngeal Carcinoma Patients

Background

The three-year survival rate of locally advanced nasopharyngeal carcinoma (NPC) patients in Indonesia is lower than in other Asian countries. Calculation of hemoglobin-to-platelet ratio (HPR) may become a more practical predictor than the ratios using leukocyte cell components. Yet, no study has been conducted to investigate the potential of HPR in predicting survival outcomes in locally advanced nasopharyngeal cancer patients.

Objective

To determine the role of pretreatment hemoglobin-to-platelet ratio in predicting the three-year overall survival (OS) of locally advanced NPC.

Method

A retrospective cohort study followed up on 289 locally advanced NPC patients who had undergone therapy at the Dr. Cipto Mangunkusumo National General Hospital between January 2012 and October 2016. HPR cut-off was determined using ROC. Subjects were classified into two groups according to the HPR value. Kaplan-Meier curve was utilized to illustrate patients' three-year survival, and Cox regression test analyzed confounding variables to yield an adjusted hazard ratio (HR).

Results

The optimal cut-off for HPR was 0.362 (AUC 0.6228, 95% CI: 0.56-0.69, sensitivity 61.27%, specificity 60.34%). Of the subjects, 48.44% had HPR ≤ 0.362, and they had a higher three-year mortality rate than those with HPR > 0.362 (50% vs. 31.54%). In bivariate analysis, HPR ≤ 0.362 and age ≥ 60 significantly showed a worse three-year OS (p value = 0.003 and 0.075, respectively). In multivariate analysis, we concluded that a pretreatment HPR ≤ 0.362 was an independent negative predictor of three-year OS in locally advanced NPC patients (adjusted HR 1.82; 95% CI: 1.25–2.65).

Conclusion

Pretreatment HPR ≤ 0.362 was a negative predictor of three-year OS in locally advanced nasopharyngeal cancer patients.

Prognostic Value of Inflammatory Markers in Nasopharyngeal Carcinoma Patients in the Intensity-Modulated Radiotherapy Era

Purpose

Inflammatory markers have been widely used in various cancers, but rarely in nasopharyngeal carcinoma (NPC). Here, we evaluated the prognostic value of pretreatment neutrophil-to-lymphocyte ratio (NLR), platelet-lymphocyte-ratio (PLR), systemic immune index (SII), and systemic inflammation response index (SIRI) on NPC in the intensity-modulated radiotherapy (IMRT) era.

Methods

We retrospectively analyzed data from NPC patients from the Renmin Hospital of Wuhan University, between January 2012 and July 2020. We used Chi-square test or Fisher’s exact test to compare the baseline characteristics, then applied Kaplan–Meier (K-M) survival analysis to compare the overall survival (OS) and progression-free survival (PFS) rates. Multivariate Cox proportional risk models were applied to identify independent prognostic factors.

Results

We enrolled a total of 342 NPC patients and found optimal cut-off values of 2.65, 184.91, 804.08, and 1.34 for NLR, PLR, SII, and SIRI, respectively. K-M survival analysis revealed that high NLR, PLR, SII, and SIRI were significantly associated with worse OS and PFS relative to those in the low groups. Results from univariate Cox analysis showed that clinical, T, and M stages, as well as NLR, PLR, SII, and SIRI were associated with OS, whereas age, alongside the aforementioned parameters, was associated with PFS. Moreover, multivariate Cox analysis showed that age ≥49 years (HR=2.48, 95% CI=1.21–5.05, P=0.013) and M1 stage (HR=3.84, 95% CI=1.52–9.73, P=0.013) were independent prognostic factors for OS, whereas SIRI ≥1.34 (HR=1.91, 95% CI=1.05–3.47, P=0.034) and M1 stage (HR=2.91, 95% CI=1.44–5.86, P=0.003) were independent prognostic factors for PFS.

Conclusion

Overall, our findings indicated that high NLR, PLR, SII, and SIRI were significantly associated with poor OS and PFS in NPC patients. High SIRI may be an independent risk factor for PFS of NPC patients in the IMRT era.

A Clinical Update on the Prognostic Effect of microRNA Biomarkers for Survival Outcome in Nasopharyngeal Carcinoma: A Systematic Review and Meta-Analysis

Simple Summary

Current estimates by GLOBOCAN now incorporate NPC as a malignancy discrete from other head and neck malignancies among the 36 disease locales assessed. Based on the latest report, the global cancer burden is estimated to have risen to 19.3 million new cases, and 9.6 million malignancies were recorded in 2020 throughout the world. The study has clinical implications and could improve treatment decision-making and post-treatment care. The study could also motivate future clinical research and development in the arena of NPC prognostic biomarkers.ve men and one in every six women develops cancer during their lifetime, and one out of eight men and one in every 11 women progresses to chronic stage. The study has clinical implications and could improve treatment decision-making and post-treatment care. The study could also motivate future clinical research and development in the arena of NPC prognostic biomarkers.

Abstract

Background: Nasopharyngeal carcinoma (NPC), a relatively uncommon malignancy in the Western world, is highly prevalent in Southeast Asia where the treatment outcomes are poor. Despite recent improvements in diagnosis and treatment locoregional control, distant metastasis and chemoresistance continue to be a significant cause of mortality. Identification of a reliable and comprehensive prognostic biomarker is highly desirable. The potential relevance of microRNAs (miRNAs) as prognostic markers in NPC is assessed in this systematic review and meta-analysis. Methods: A systematic review was performed using the PubMed and Science Direct databases. The search was limited to search results between 2018 and 2020 with the keywords and search strings developed as per the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. The recovered articles were carefully screened based on the selection criteria. In the meta-analysis study, high and low expression levels of miRNAs were measured using the hazard ratio (HR) and 95 percent confidence interval (CI) for patients’ survival outcomes. Egger’s bias indicator test and funnel plot symmetry were used to assess the risk of bias. Results: Amongst the 25 studies, 13 fulfilled the conditions of inclusion in this meta-analysis. The researchers further delved into the 21 miRNA expression levels from 3015 NPC patients to ascertain a link between miRNA’s predictive role and survival outcomes. The majority of the articles retrieved during this study were from China, with two studies from Canada and Malaysia. The overall pooled effect size estimation (HR) for dysregulated miRNAs was 1.590 (95% CI: 1.253–2.017), displaying that miRNA marker expression increased the risk of mortality in NPC patients by 59%. Conclusions: This meta-analysis is novel and looks at the prognostic significance of miRNAs as biomarkers in NPC patients using a continuous version pooled meta-analysis. Although our findings are ambiguous, they do show that greater miRNA expression in NPC may be associated with a lower overall survival rate. To acquire clear conclusions, more prospective studies with large cohorts are required to determine the clinical utility of miRNAs as prognostic biomarkers.

The influence of facility volume on patient treatments and survival outcomes in nasopharyngeal carcinoma

BACKGROUND

This study evaluates the influence of facility case-volume on nasopharyngeal carcinoma (NPC) treatments and overall survival (OS).

METHODS

The 2004-2015 National Cancer Database was queried for patients with NPC receiving definitive treatment.

RESULTS

A total of 8260 patients (5-year OS: 63.4%) were included. The 1114 unique facilities were categorized into 854 low-volume (treating 1-8 patients), 200 intermediate-volume (treating 9-23 patients), and 60 high-volume (treating 24-187 patients) facilities. Kaplan-Meier log-rank analysis demonstrated significantly improved OS with high-volume facilities (p < 0.001). On cox proportional-hazard multivariate regression after adjusting for age, sex, income, insurance, comorbidity index, histology, AJCC clinical stage, and treatment type, high-volume facilities were associated with lower mortality risk than low-volume (HR = 0.865, p = 0.019) and intermediate-volume facilities (HR = 0.916, p = 0.004). Propensity score matching analysis confirmed this association (p < 0.001).

CONCLUSION

Higher facility volume was an independent predictor of improved OS in NPC, suggesting a possible survival benefit of referrals to high-volume medical centers.

Treatment and outcomes of nasopharyngeal carcinoma in a unique non-endemic population

OBJECTIVE

Nasopharyngeal carcinoma (NPC) is common in Southeast Asia. Due to the influx of immigrants from this region, the incidence in British Columbia is increasing. Current literature from non-endemic populations encompasses heterogeneous cohorts. This study examines NPC in a North American population, with a high incidence, to understand the population's characteristics, treatment outcomes and recurrence patterns.

METHODS AND MATERIALS

A retrospective analysis of patients treated for primary and recurrent NPC over 15-years. Regression analyses were used to identify predictors of disease recurrence and death. A subgroup analysis of the locoregional recurrence cohort was conducted. Five-year survival outcomes were determined.

RESULTS

601 patients were included. Asian ethnicity comprised 77% and the majority had non-keratinizing carcinoma (81%). In total, 19.3% of patients experienced recurrence: 58% local, 22% regional and 20% distant. Five-year overall survival was 70%. Smoking, advancing T-stage, poorer performance status and advanced overall stage were all associated with worse overall survival (p < 0.05). Asian ethnicity improved overall survival but not recurrence free survival. Similar features in addition to non-keratinizing histology were associated with increased locoregional recurrence (p < 0.05). Competing risk analysis indicated radiotherapy alone had a higher recurrence relative to chemoradiotherapy (HR 1.91, CI 1.17-3.09, p = 0.01).

CONCLUSIONS

We report the largest study evaluating treatment and outcomes of NPC in a non-endemic population. This unique population falls between described endemic and non-endemic populations. Non-keratinizing pathology and primary radiotherapy did not affect survival; however, both had a propensity for recurrence. Finally, patients experienced more locoregional and less distant recurrence, supporting that this cohort may be amenable to curative salvage therapy.

Development and validation of a web-based calculator to predict individualized conditional risk of site-specific recurrence in nasopharyngeal carcinoma: Analysis of 10,058 endemic cases

Background

Conditional survival (CS) provides dynamic prognostic estimates by considering the patients existing survival time. Since CS for endemic nasopharyngeal carcinoma (NPC) is lacking, we aimed to assess the CS of endemic NPC and establish a web‐based calculator to predict individualized, conditional site‐specific recurrence risk.

Methods

Using an NPC‐specific database with a big‐data intelligence platform, 10,058 endemic patients with non‐metastatic stage I–IVA NPC receiving intensity‐modulated radiotherapy with or without chemotherapy between April 2009 and December 2015 were investigated. Crude CS estimates of conditional overall survival (COS), conditional disease‐free survival (CDFS), conditional locoregional relapse‐free survival (CLRRFS), conditional distant metastasis‐free survival (CDMFS), and conditional NPC‐specific survival (CNPC‐SS) were calculated. Covariate‐adjusted CS estimates were generated using inverse probability weighting. A prediction model was established using competing risk models and was externally validated with an independent, non‐metastatic stage I–IVA NPC cohort undergoing intensity‐modulated radiotherapy with or without chemotherapy (n = 601) at another institution.

Results

The median follow‐up of the primary cohort was 67.2 months. The 5‐year COS, CDFS, CLRRFS, CDMFS, and CNPC‐SS increased from 86.2%, 78.1%, 89.8%, 87.3%, and 87.6% at diagnosis to 87.3%, 87.7%, 94.4%, 96.0%, and 90.1%, respectively, for an existing survival time of 3 years since diagnosis. Differences in CS estimates between prognostic factor subgroups of each endpoint were noticeable at diagnosis but diminished with time, whereas an ever‐increasing disparity in CS between different age subgroups was observed over time. Notably, the prognoses of patients that were poor at diagnosis improved greatly as patients survived longer. For individualized CS predictions, we developed a web‐based model to estimate the conditional risk of local (C‐index, 0.656), regional (0.667), bone (0.742), lung (0.681), and liver (0.711) recurrence, which significantly outperformed the current staging system (P < 0.001). The performance of this web‐based model was further validated using an external validation cohort (median follow‐up, 61.3 months), with C‐indices of 0.672, 0.736, 0.754, 0.663, and 0.721, respectively.

Conclusions

We characterized the CS of endemic NPC in the largest cohort to date. Moreover, we established a web‐based calculator to predict the CS of site‐specific recurrence, which may help to tailor individualized, risk‐based, time‐adapted follow‐up strategies.

A Comprehensive Analysis of Treatment Management and Survival Outcomes in Nasopharyngeal Carcinoma

OBJECTIVES

To comprehensively investigate nasopharyngeal carcinoma (NPC) treatment, overall survival (OS), and the influence of clinical/sociodemographic factors on outcome.

STUDY DESIGN

Retrospective database study.

SETTING

National Cancer Database.

METHODS

The 2004-2015 National Cancer Database was queried for all patients with NPC receiving definitive treatment. Log-rank tests and Cox proportional hazards models were used for statistical analyses.

RESULTS

A total of 8260 patients with NPC were included (71.4% male; 42.5% with keratinizing histology; mean ± SD age, 52.1 ± 15.1 years), with a 5-year OS of 63.4%. Multivariate predictors of mortality included age ≥65 years (hazard ratio [HR], 1.81; P < .001), Charlson/Deyo score ≥1 (HR, 1.27; P = .001), American Joint Committee on Cancer clinical stage III to IV (HR, 1.85; P < .001), and government insurance or no insurance (HR, 1.53; P < .001). Predictors of survival included female sex (HR, 0.82; P = .002), Asian/Pacific Islander race (HR, 0.74; P < .001), nonkeratinizing/undifferentiated histology (HR, 0.79; P = .004), and receiving treatment at academic centers (HR, 0.87; P = .02). Chemoradiotherapy (CRT) demonstrated improved OS as compared with radiotherapy (RT) only for stage II (P = .006) and stage III (P = .005) and with RT or chemotherapy only in stage IVA NPC (P < .001). When compared with CRT alone, surgery plus CRT provided OS benefits in keratinizing (P = .013) or stage IVA (P = .030) NPC. When compared with RT, CRT provided OS benefits in keratinizing (P = .005) but not nonkeratinizing (P = .240) or undifferentiated (P = .390) NPC. Substandard radiation dosing of <60 Gy and <30 fractions were associated with inferior OS (both P < .001).

CONCLUSIONS

NPC survival is dependent on a variety of clinical/sociodemographic factors. Stage-specific treatments with optimal OS include CRT or RT for stages I to II and CRT for stage III to IV. The large representation of nonendemic histology is valuable, as these cases are not well characterized.

Bone Metastases Pattern in Newly Diagnosed Metastatic Nasopharyngeal Carcinoma: A Real-World Analysis in the SEER Database

Objective

To evaluate the prevalence rate and survival situation of bone metastases in initial nasopharyngeal carcinoma (NPC) patients and the hazard and forecast elements of bone metastases NPC patients. Patients and Methods. The data collected from Surveillance, Epidemiology, and End Results (SEER) program between 2010 and 2016 were evaluated. Univariate and multivariable logistic analysis and the Cox regression were carried out to estimate predictors and elements of the being of bone metastases at diagnosis, respectively. The overall survival of different subgroups were appraised by log-rank tests and the Kaplan–Meier analysis.

Results

Factors including male sex, higher N stage, presence of liver, and brain or lung metastases were largely related to the occurrence of bone metastases. The median survival time for bone metastasis NPC patients was 14.0 months. A factor of more than one primary sequence number predicted worse survival.

Conclusion

The data offer corresponding risks and prognostic indicators of bone metastases for NPC patients.

Prognosis viewing for nasopharyngeal carcinoma treated with intensity-modulated radiation therapy: application of nomogram and decision curve analysis

OBJECTIVE

To view and evaluate the prognosis factors in patients with nasopharyngeal carcinoma (NPC) treated with intensity modulated radiation therapy using nomogram and decision curve analysis (DCA).

METHODS

Based on a primary cohort comprising consecutive patients with newly confirmed NPC (n = 1140) treated between January 2014 and December 2015, we identified independent prognostic factors of overall survival (OS) to establish a nomogram. The model was assessed by bootstrap internal validation and external validation in an independent validation cohort of 460 patients treated between January 2013 and December 2013. The predictive accuracy and discriminative ability were measured by calibration curve, concordance index (C-index) and risk-group stratification. The clinical usefulness was assessed by DCA.

RESULTS

The nomogram incorporated T-stage, N-stage, age, concurrent chemotherapy and primary tumour volume (PTV). The calibration curve presented good agreement for between the nomogram-predicted OS and the actual measured survival probability in both the primary and validation cohorts. The model showed good discrimination with a C-index of 0.741 in the primary cohort and 0.762 in the validation cohort. The survival curves of different risk-groups were separated clearly. Decision curve analysis demonstrated that the nomogram provided a higher net benefit (NB) across a wider reasonable range of threshold probabilities for predicting OS.

CONCLUSION

This study presents a predictive nomogram model with accurate prediction and independent discrimination ability compared with combination of T-stage and N-stage. The results of DCA supported the point that PTV can help improve the prognostic ability of T-stage and should be added to the TNM staging system.

Disulfiram/Copper Induces Antitumor Activity against Both Nasopharyngeal Cancer Cells and Cancer-Associated Fibroblasts through ROS/MAPK and Ferroptosis Pathways

Disulfiram/copper (DSF/Cu) is a promising antitumor reagent for clinical application due to its excellent anticancer activity and safety. However, the anticancer mechanism of DSF/Cu has not been fully elucidated. Our study showed that DSF/Cu strongly induced cytotoxic effects on both nasopharyngeal carcinoma (NPC) cells and α-smooth muscle actin (α-SMA)-positive fibroblasts. Fluorescence activated cell sorting (FACS) analysis further showed that DSF/Cu induced a higher late apoptosis rate in α-SMA-positive fibroblasts than in tumor cells, and DSF/Cu promoted apoptosis and necrosis by an aldehyde dehydrogenase (ALDH)-independent method. Furthermore, we found that the antitumor activity of DSF/Cu against NPC cells occurred through ROS/MAPK and p53-mediated ferroptosis pathways, and that the ROS scavenger N-acetyl-l-cysteine (NAC) could reverse the cellular and lipid ROS levels. In 5-8F xenografts, both TUNEL and immunohistochemical (IHC) analyses indicated that DSF/Cu could induce apoptosis and inactivate cancer-associated fibroblasts (CAFs) by inhibiting the expression of α-SMA. In addition, combined with cisplatin (CDDP), DSF/Cu was well tolerated in vivo and could significantly suppress the growth of NPC tissues. Our study demonstrated that DSF/Cu induced antitumor activity against both tumor cells, as well as CAFs and suggested that the use of DSF/Cu as an adjunctive therapy for NPC is worthy of consideration.

Development and validation of a nomogram for predicting long-term overall survival in nasopharyngeal carcinoma: A population-based study

We aimed to develop a nomogram based on a population-based cohort to estimate the individualized overall survival (OS) for patients with nasopharyngeal carcinoma (NPC) and compare its predictive value with that of the traditional staging system.Data for 3693 patients with NPC were extracted from the Surveillance, Epidemiology, and End Results dataset and randomly divided into two sets: training (n = 2585) and validation (n = 1108). On the basis of multivariate Cox regression analysis, a nomogram was constructed to predict the 3-, 5-, and 10-year survival probability for a patient. The performance of the nomogram was quantified with respect to discrimination, calibration, and clinical utility.In the training set, age, sex, race, marital status, histological type, T stage, N stage, M stage, radiotherapy, and chemotherapy were selected to develop a nomogram for predicting the OS probability based on the multivariate Cox regression model. The nomogram was generally more discriminative compared with the American Joint Committee on Cancer 7th staging system. Calibration plots exhibited an excellent consistency between the observed probability and the nomogram's prediction. Categorical net classification improvement and integrated discrimination improvement suggested that the predictive accuracy of the nomogram exceeded that of the classic staging system. With respect to decision curve analyses, the nomogram exhibited preferable net benefit gains than the staging system across a wide range of threshold probabilities.This proposed nomogram exhibits an excellent performance with regard to its predictive accuracy, discrimination capability, and clinical utility, and thus can be used as a convenient and reliable tool for prognosis prediction in patients with NPC.

Role of postoperative radiotherapy in pT3N0 rectal cancer: A risk-stratification system based on population analyses

The impact of adjuvant radiotherapy in pT3N0 rectal cancer is controversial. We aimed to determine the risk factors for cancer-specific survival (CSS) among these patients and to develop a risk-stratification system to identify which of these patients would benefit from adjuvant radiotherapy. In this review of the Surveillance, Epidemiology, and End Results database (2010-2014), we analyzed the data of pT3N0 rectal cancer patients who had not undergone neoadjuvant radiotherapy. Prognostic factors were identified using the Cox proportional hazards model, and risk scores were derived according to the β regression coefficient. A total of 1021 patients were identified from the database search. The overall 5-year CSS was 86.31%. Multivariate analysis showed that age (P < 0.001), tumor differentiation (P = 0.044), number of nodes resected (P = 0.032), marital status (P = 0.005), and radiotherapy (P = 0.006) were independent prognostic factors for CSS. A risk-stratification system composed of age, tumor differentiation, and number of nodes resected was generated. Low-risk patients had better CSS than high-risk patients (92.13% vs 72.55%, P < 0.001). The addition of radiotherapy to surgery doubled the CSS among the high-risk patients (42.06% vs 91.26%, P = 0.001) but produced no survival benefit among the low-risk patients (93.36% vs 96.38%, P = 0.182). Our risk-stratification model based on age, tumor differentiation, and number of nodes resected predicted the outcomes of pT3N0 rectal cancer patients. This model could help identify patients who may benefit from adjuvant radiotherapy.

Clinical outcome and prognostic analysis of young adults nasopharyngeal carcinoma patients of a nonendemic area in intensity-modulated radiotherapy era

AIM

To investigate the clinical outcome and prognostic factors of young adults nasopharyngeal carcinoma (NPC) patients in the era of intensity-modulated radiotherapy.

METHODS

We retrospectively analyzed the clinical outcome and the prognostic factors of young adults NPC patients who were admitted to our hospital from January 2010 to December 2013. COX regression model was used to identify factors associated with survival. The acute and late toxicities were also evaluated.

RESULTS

A total of 165 patients were included; the median follow-up time for all the patients was 65 months (4-96 months). The 5-year overall survival (OS), distant metastasis-free survival, progression-free survival and local-regional recurrence-free survival were 85.9, 82.4, 76.4 and 92.4%, respectively. N stage was an independent prognostic factor for OS (p = 0.009) and distant metastasis-free survival (p = 0.008). Cumulative cisplatin >200 mg/m² was an independent prognostic factor for OS (p = 0.032).

CONCLUSION

Young adults with NPC can achieve a reasonable local-regional control and OS in the era of intensity-modulated radiotherapy with tolerable toxicities.