Radiotherapy for geriatric head-and-neck cancer patients: what is the value of standard treatment in the elderly?

Tailoring nonsurgical therapy for elderly patients with head and neck squamous cell carcinoma: A deep learning-based approach

To assess deep learning models for personalized chemotherapy selection and quantify the impact of baseline characteristics on treatment efficacy for elderly head and neck squamous cell carcinoma (HNSCC) patients who are not surgery candidates. A comparison was made between patients whose treatments aligned with model recommendations and those whose did not, using overall survival as the primary metric. Bias was addressed through inverse probability treatment weighting (IPTW), and the impact of patient characteristics on treatment choice was analyzed via mixed-effects regression. Four thousand two hundred seventy-six elderly HNSCC patients in total met the inclusion criteria. Self-Normalizing Balanced individual treatment effect for survival data model performed best in treatment recommendation (IPTW-adjusted hazard ratio: 0.74, 95% confidence interval [CI], 0.63-0.87; IPTW-adjusted risk difference: 9.92%, 95% CI, 4.96-14.90; IPTW-adjusted the difference in restricted mean survival time: 16.42 months, 95% CI, 10.83-21.22), which surpassed other models and National Comprehensive Cancer Network guidelines. No survival benefit for chemoradiotherapy was seen for patients not recommended to receive this treatment. Self-Normalizing Balanced individual treatment effect for survival data model effectively identifies elderly HNSCC patients who could benefit from chemoradiotherapy, offering personalized survival predictions and treatment recommendations. The practical application will become a reality with further validation in clinical settings.

Treatment of elderly patients with head and neck cancer in an aging society: Focus on geriatric assessment and surgical treatment

Previous studies of the treatment of elderly head and neck cancer (HNC) patients were very limited and sometimes controversial. Although conclusions differ across various reports, it is often concluded that advanced chronological age does not directly affect prognosis, but that comorbidities and declines in physical and cognitive functions promote the occurrence of adverse events, especially with surgical treatment. Geriatric assessment (GA) and its screening tools are keys to help us understand overall health status and problems, predict life expectancy and treatment tolerance, and to influence treatment choices and interventions to improve treatment compliance. In addition, personal beliefs and values play a large role in determining policies for HNC treatment for elderly patients, and a multidisciplinary approach is important to support this. In this review, past research on HNC in older adults is presented, and the current evidence is explained, focusing on the management of elderly HNC patients, with an emphasis on the existing reports on each treatment stage and modality, especially the surgical procedures.

Outcomes with optimal treatment in geriatric head and neck cancers - Tertiary cancer centre experience

AIM

Older patients with locally advanced head and neck cancers (LA-HNC) are under-represented in clinical trials and denied standard treatment with concurrent chemo-radiation. Most are treated with radiotherapy (RT) alone. However, with the use of Intensity Modulated Radiation Therapy (IMRT) and good supportive care, even this cohort of patients can be considered for chemo-radiation.

METHODS AND MATERIALS

69 patients with age >65 years with LA-HNC treated between April 2015 and December 2019 in our Institute were prospectively evaluated for treatment compliance and outcomes. All patients were planned to receive 70 Gy in 33-35 fractions with IMRT and weekly Cisplatin at a dose of 40 mg/m2 (or Carboplatin-AUC-2). Loco-regional control (LRC), Overall survival (OS), and prognostic factors were evaluated.

RESULTS

Median age at presentation was 67 years (65-81). 54 were male. 64% had Karnofsky Performance Status of >90. 42% had Oropharyngeal Primary. 17% had co-morbidities, 66% had T3 disease, 77% had Node positive disease, and 54% had Stage III disease. All patients completed 70 Gy and 81% patients received at least 5 (>200 mg/m2) chemotherapy cycles. Acute grade-3 toxicity was seen in 20% of patients and 64% had complete response. With a median follow up of 23.6 months (3-71), OS was 53.5%. Estimated 2-year LRC was 60%; estimated 2- and 5-year OS was 53.5% and 34.3%, respectively. On univariate analysis, age <70 years, Cisplatin use, limited nodal disease, Stage III, and complete response to treatment showed good OS (p < 0.05).

CONCLUSION

Definitive chemo-IMRT approach in older patients with LA-HNC is well tolerated with good clinical outcomes. Hence, older age should not be a barrier for standard treatment.

Stereotactic Body Radiotherapy as a Curative Treatment for De Novo Mucosal Carcinoma of the Head and Neck: A Feasible Alternative Option for Fragile Patients with Small Lesion: A Systematic Review

Stereotactic body radiotherapy (SBRT) is characterized by a high dose per fraction, well-defined small targets, superior dose conformity, and a steep off-target dose gradient. A literature search was conducted to examine the experience with SBRT as a curative treatment for newly diagnosed mucosal carcinoma of the head and neck (MCHN). Four retrospective case series and one prospective phase I clinical trial published between 2012 and 2020 described 124 patients. SBRT was mainly performed in older patients with different tumor sites. The median size of the planning target volumes ranged from 5.3 to 41 cm3. Different approaches were used to create margins. In two studies, limited elective nodal irradiation was performed. The equivalent doses used were 60-83.33 Gy delivered in five fractions. Considerable heterogeneity was observed in the radiation dose specification. The incidence of grade ≥3 late toxicity was 0-8.3%, with local and regional control ranging from 73% to 100%. Improved or stable quality of life after SBRT was reported in two studies. Curative-intent SBRT for de novo MCHN appears to be an effective and relatively safe treatment for small tumor targets, preferably without concomitant elective tissue irradiation. Standardization of SBRT practice and well-designed prospective clinical trials are needed to better define the role of SBRT in this setting.

Higher Rates of Inadequate Adjuvant Radiation Dose Among Older Adults with Head and Neck Cancer

OBJECTIVE

To determine the rate of inadequate radiotherapy and identify risk factors associated with inadequate adjuvant radiotherapy for head and neck cancer among older adults.

METHODS

A retrospective review of the National Cancer Database (NCDB) was performed to identify patients diagnosed with squamous cell cancer of the head and neck between 2004 and 2017. Patients with a single malignancy, negative surgical margins, no extranodal extension, and receipt of adjuvant radiation without systemic therapy were included in the study cohort. The main outcome of interest was the adjuvant radiation dose received. Participant data were compared using univariable, multivariable, and correlation analyses to evaluate risk factors for inadequate radiation therapy (RT) dosing.

RESULTS

Among 7608 patients, 1010 patients (13.3%) received an inadequate radiation dose and 6598 (86.7%) received an adequate dose. Patients living in a higher income zip-code, younger age, and those who received intensity-modulated RT (IMRT) were more likely to receive an adequate radiation dose (p < 0.05). Patients older than 70 and 80 years old had a greater likelihood of receiving an inadequate radiation dose (≥70 vs. <70: 16.9% vs. 12.5%; p < 0.05 and ≥80 vs. <80: 20.6% vs. 13.0%%; p < 0.05). Similarly, increasing age was negatively correlated with radiation dose (correlation coefficient: -0.05; p < 0.001).

CONCLUSION

A substantial proportion of older patients receiving adjuvant radiation do not complete the full treatment. Older age, year of diagnosis, non-IMRT, and living in a lower-income zip code were associated with early termination of RT. Future studies should examine strategies to improve tolerance of adjuvant RT so that more patients complete the full treatment.

LEVEL OF EVIDENCE

3; Cohort Study Laryngoscope, 134:2206-2211, 2024.

Treatment with (chemo)-radiation in old patients (≥76 years of age) with newly diagnosed non-metastatic squamous cell cancer of the head and neck region: real-world data from a tertiary referral center

Purpose

Treatment of patients with cancer of the head and neck region is in focus in a multitude of studies. Of these patients, one patient group, those aged 76 and more, is mostly underrepresented despite requiring thorough and well-reasoned treatment decisions to offer curative treatment. This study investigates real-world data on curative treatment of old (≥76 years) patients with newly diagnosed squamous cell carcinoma of the head and neck region (HNSCC).

Patients and methods

Between January 2010 and December 2021, we identified 71 patients older than 76 years with newly diagnosed HNSCC and cM0 at the Department of Radiation Oncology of the University Hospital of Erlangen-Nuremberg. Using electronic medical records, we analyzed treatment patterns and outcomes in terms of overall survival (OS), progression-free survival (PFS), and locoregional control (LRC) rate. Additionally, we performed univariate risk analysis and Cox regression in order to identify predictive factors associated with the abovementioned treatment outcomes.

Results

The median follow-up was 18 months. OS was 83%, 79%, and 72% after 1 year, 2 years, and 3 years, respectively. PFS was 69%, 54%, and 46% after 1 year, 2 years, and 3 years, respectively. A total of 34 (48%) patients were treated with standard therapy according to current guidelines. The reasons for deviation from standard therapy before or during treatment were as follows: unfitness for cisplatin-based chemotherapy (n = 37), reduction of chemotherapy (n = 3), and dose reduction/interruption of radiotherapy (n = 8). Carboplatin-based systemic therapy showed improved PFS compared to cisplatin or cetuximab (60 vs. 28 vs. 15 months, p = 0.037) but without impact on OS (83 vs. 52 vs. 38 months, p = 0.807). Oropharyngeal tumor localization (p = 0.026) and combined treatment (surgery and postoperative treatment) (p = 0.008) were significant predictors for a better OS. In multivariate analysis, oropharyngeal tumor localization (p = 0.011) and combined treatment (p = 0.041) showed significantly increased PFS. After 1 year, 2 years, and 3 years, the cumulative incidence of locoregional recurrences (LRRs) was 13%, 24%, and 27%, respectively, and was significantly decreased in patients with oropharyngeal tumor localization (p = 0.037).

Conclusions

Adherence to treatment protocols for radiotherapy alone in old patients with HNSCC is good, whereas the application of concurrent chemotherapy often deviates from guidelines in terms of de-escalation. An important risk factor for decreased OS, PFS, and a higher rate of LRR appears to be non-oropharyngeal tumor location in old patients.

Multicenter analysis on the value of standard (chemo)radiotherapy in elderly patients with locally advanced adenocarcinoma of the esophagus or gastroesophageal junction

BACKGROUND

To assess the tolerability and oncological results of chemoradiation in elderly patients with locally advanced adenocarcinoma of the esophagus or gastroesophageal junction.

METHODS

This multi-center retrospective analysis included 86 elderly patients (≥ 65 years) with esophageal or gastroesophageal junction adenocarcinoma (median age 73 years; range 65-92 years) treated with definitive or neoadjuvant (chemo)radiotherapy. The treatment was performed at 3 large comprehensive cancer centers in Germany from 2006 to 2020. Locoregional control (LRC), progression-free survival (PFS), distant metastasis-free survival (DMFS), overall survival (OS), and treatment-associated toxicities according to CTCAE criteria v5.0 were analyzed, and parameters potentially relevant to patient outcomes were evaluated.

RESULTS

Thirty-three patients (38%) were treated with neoadjuvant chemoradiation followed by surgery, while the remaining patients received definitive (chemo)radiation. The delivery of radiotherapy without dose reduction was possible in 80 patients (93%). In 66 patients (77%), concomitant chemotherapy was initially prescribed; however, during the course of therapy, 48% of patients (n = 32) required chemotherapy de-escalation due to treatment-related toxicities and comorbidities. Twenty-nine patients (34%) experienced higher-grade acute toxicities and 14 patients (16%) higher-grade late toxicities. The 2-year LRC, DMFS, PFS, and OS amounted to 72%, 49%, 46%, and 52%, respectively. In multivariate analysis, neoadjuvant chemoradiation followed by surgery was shown to be associated with significantly better PFS (p = 0.006), DMFS (p = 0.006), and OS (p = 0.004) compared with all non-surgical treatments (pooled definitive radiotherapy and chemoradiation). No such advantage was seen over definitive chemoradiation. The majority of patients with neoadjuvant therapy received standard chemoradiotherapy without dose reduction (n = 24/33, 73%). In contrast, concurrent chemotherapy was only possible in 62% of patients undergoing definitive radiotherapy (n = 33/53), and most of these patients required dose-reduction or modification of chemotherapy (n = 23/33, 70%).

CONCLUSIONS

In our analysis, omission of chemotherapy or adjustment of chemotherapy dose during definitive radiotherapy was necessary for the overwhelming majority of elderly esophageal cancer patients not eligible for surgery, and hence resulted in reduced PFS and OS. Therefore, optimization of non-surgical approaches and the identification of potential predictive factors for safe administration of concurrent chemotherapy in elderly patients with (gastro)esophageal adenocarcinoma is required.

Is Using the Harmonic Scalpel Better than Conventional Hemostasis in Neck Dissection? A Meta-Analysis

Study Design

Systematic review and meta-analysis.

Objective

The clinical decision to pursue harmonic scalpel (HS) method vs conventional hemostasis to treat head and neck cancers has been arguably predicated on the clinical outcomes observed. This study aims to evaluate the surgical outcomes of neck dissection between both techniques and perform an updated meta-analysis using the available literature.

Methods

We searched PubMed, Scopus, and Cochrane Library through 31st December 2021, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcome metrics included operative time and intraoperative blood loss. Secondary outcomes consisted of length of hospital stay, length of drain stay, total drain output, and postoperative complications. A meta-analysis was conducted using Review Manager Version 5.3 (RevMan) software employing the Random Effects Model.

Results

We identified 114 articles, out of which 10 randomized control trials (RCTs) analyzing a combined total of 558 patients met the inclusion criteria after title and full-text screening. Meta-analysis shows the group treated with HS had a significantly shorter operative time. [MD = -23.21, 95% CI (-34.30, -12.12) P value <.0001 I2 = 92%] but an insignificant lesser intraoperative blood loss [MD = -61.53, 95% CI (-88.61, -34.45) P < .00001 I2 = 79%].

Conclusions

This study confirms that that HS use in neck dissection yields a reduced operative time and intra operative blood loss relative to conventional hemostasis. Furthermore, our paper shows no superiority of HS method over conventional hemostasis where length of hospital stays, length of drain stays, and postoperative complications are concerned. Future RCTs with high-level evidence may further elucidate the relative effectiveness of HS method over conventional hemostasis in treating head and neck cancers.

Nomogram to predict risk of early mortality following definitive or adjuvant radiation and systemic therapy for head and neck cancer

Purpose/Objectives

We sought to create nomograms to predict individual risk of early mortality, which can identify patients who require interventions to prevent early death.

Methods

We included patients in the National Cancer Database with non-metastatic squamous cell carcinoma of the head and neck who received radiation and systemic therapy between 2004 and 2017 in the definitive or adjuvant setting. Early mortality was defined as any death less than 90 days after starting radiation. Multivariable logistic regression was used to assess the relationship between covariates and early mortality. Nomograms to predict the risk of early death were created for both the definitive and adjuvant settings.

Results

Among 84,563 patients in the definitive group and 18,514 patients in the adjuvant group, rates of early mortality were 3.5 % (95 % CI 3.4-3.7 %) and 2.2 %, (95 % CI 1.9-2.4 %), respectively. Patients above the age of 70 had an early mortality rate of 7.8 % (95 % CI 7.3-8.2 %) in the definitive group and 4.4 % (95 % CI 3.6-5.4 %) in the adjuvant group. In the multivariable analysis, age, comorbidity, T and N category, and tumor site were associated with early mortality in both cohorts (p < 0.05 for all). Nomograms including age, comorbidity, T and N category and tumor site performed better than age alone at predicting early mortality (AUC for definitive group: 0.70 vs 0.66; AUC for adjuvant group: 0.71 vs 0.61).

Conclusion

Nomograms including age, comorbidity, T and N category and tumor site were developed to predict the risk of early death following definitive or adjuvant chemoradiation.

App-Controlled Treatment Monitoring and Support for Patients With Head and Neck Cancer Undergoing Radiotherapy: Results From a Prospective Randomized Controlled Trial

BACKGROUND

Head and neck cancers (HNCs) are very common malignancies, and treatment often requires multimodal approaches, including radiotherapy and chemotherapy. Patients with HNC often display a high symptom burden, both due to the disease itself and the adverse effects of the multimodal therapy. Close telemonitoring of symptoms and quality of life during the course of treatment may help to identify those patients requiring early medical support.

OBJECTIVE

The App-Controlled Treatment Monitoring and Support for Patients With Head and Neck Cancer (APCOT) trial aimed to investigate the feasibility of integrating electronic patient-reported outcomes (ePROs) in the treatment surveillance pathway of patients with HNC during the course of their radiotherapy. Additionally, the influence of app-based ePRO monitoring on global and disease-specific quality of life and patient satisfaction with treatment was assessed.

METHODS

Patients undergoing radiotherapy for histologically proven HNCs at the Department of Radiation Oncology, University Medical Center Freiburg, Germany, were enrolled in this trial and monitored by weekly physician appointments. Patients were randomized between additional ePRO monitoring on each treatment day or standard-of-care monitoring. Feasibility of ePRO monitoring was defined as ≥80% of enrolled patients answering ≥80% of their daily app-based questions. Quality of life and patient satisfaction were assessed by the European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire (QLQ-C30), the head and neck cancer module (H&N35), and the validated Patient Satisfaction Questionnaire Short Form (PSQ-18) at the completion of treatment and compared between trial arms.

RESULTS

A total of 100 patients were enrolled in this trial, and 93 patients were evaluable. All patients (100%) in the experimental arm answered ≥80% of the ePRO questions during treatment, reaching the predefined threshold for the feasibility of ePRO monitoring (P<.001 in the binomial test). No clinical or patient-specific factor was found to influence feasibility. Global health and most domains of the general quality of life were comparable between trial arms, but an increased HNC-specific symptom burden was reported by patients undergoing ePRO surveillance. ePRO monitoring resulted in improved patient satisfaction regarding interpersonal manners (P=.01), financial aspects (P=.01), and time spent with a doctor (P=.01).

CONCLUSIONS

This trial demonstrated the feasibility of incorporating daily app-based ePRO surveillance for patients with HNC undergoing radiotherapy. Our data, for the first time, demonstrate that telemonitoring in this setting led to increased reporting of HNC-specific symptom burden and significantly improved several domains of patient satisfaction. Further analyses are needed to assess whether our findings hold true outside the context of a clinical trial.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00020491; https://drks.de/search/en/trial/DRKS00020491.

Primary concurrent chemoradiation therapy with triweekly cisplatin as a standard protocol in patients aged ≥65 years with head and neck squamous cell carcinoma

AIM

To evaluate the results of primary concurrent chemoradiation therapy (CCRT) with triweekly cisplatin in patients with head and neck squamous cell carcinoma (HNSCC) aged ≥65 years by comparing these patients to those aged < 65 years.

METHODS

This prospective, single-center study enrolled patients with HNSCC for whom CCRT was indicated as the primary treatment. The major endpoints were progression-free survival (PFS) and overall survival (OS).

RESULTS

A total of 169 patients were enrolled; 75 (44.4%) and 94 (55.6%) patients were aged ≥65 and < 65 years, respectively. The mean cumulative cisplatin doses were 192.8 mg/m2 and 212.3 mg/m2 in patients ≥65 and < 65, respectively (p < .001). The incidence rates of any grade 3-4 toxicities were 37.3% and 51.1% in the age ≥65 and < 65 groups, respectively (p = .085). The 5-year locoregional control, distant control, PFS, ultimate PFS, and disease-specific survival were comparable between both groups. The 5-year OS was significantly lower in the ≥65 group than the < 65 group (65.5% vs. 86.4%, p = .010) due to a lower salvage rate and higher incidence of non-HNSCC-related death. In a Cox regression analysis, age ≥65 years was not associated with increased risk of treatment failure but was associated with higher overall death rate (hazard ratio, 2.590; 95% confidence interval, 1.219-5.502; p = .013).

CONCLUSION

CCRT with a triweekly cisplatin regimen could act as the standard of ca for HNSCC in elderly patients. However, the relatively lower OS compared to younger patients should be acknowledged, despite a favorable disease control rates.

Geriatric Radiation Oncology: What We Know and What Can We Do Better?

Elderly patients represent a growing subgroup of cancer patients for whom the role of radiation therapy is poorly defined. Older patients are still clearly underrepresented in clinical trials, resulting in very limited high-level evidence. Moreover, elderly patients are less likely to receive radiation therapy in similar clinical scenarios compared to younger patients. However, there is no clear evidence for a generally reduced radiation tolerance with increasing age. Modern radiation techniques have clearly reduced acute and late side effects, thus extending the boundaries of the possible regarding treatment intensity in elderly or frail patients. Hypofractionated regimens have further decreased the socioeconomic burden of radiation treatments by reducing the overall treatment time. The current review aims at summarizing the existing data for the use of radiation therapy or chemoradiation in elderly patients focusing on the main cancer types. It provides an overview of treatment tolerability and outcomes with current standard radiation therapy regimens, including possible predictive factors in the elderly population. Strategies for patient selection for standard or tailored radiation therapy approaches based on age, performance score or comorbidity, including the use of prediction tests or geriatric assessments, are discussed. Current and future possibilities for improvements of routine care and creation of high-level evidence in elderly patients receiving radiation therapy are highlighted.

Clinical and Therapeutic Considerations for Older Adults with Head and Neck Cancer

Approximately 30% of patients with head and neck squamous cell carcinoma (HNSCC) are at least 70 years of age, and this percentage is expected to increase as the population increases and lives longer. Elderly patients are underrepresented in head and neck oncology clinical trials, and there is minimal evidence on the management of HNSCC for this population. Subsequently, despite their best intentions, physicians may unknowingly recommend an ill-suited course of therapy, which may result in suboptimal oncological or functional outcomes or adverse events. Surgical approaches have the potential to carry a higher risk of morbidity and mortality in older adults, especially in patients with multiple comorbidities. Definitive radiation therapy treatment in patients with HNSCC frequently involves 7 weeks of daily radiation, sometimes with concurrent chemotherapy, and this demanding treatment can be difficult for older adult patients, which may lead to treatment interruptions, potential removal of concurrent systemic therapy, compromised outcomes, and diminished quality of life. There are clinical trials currently underway investigating altered fractionation regimens and novel, less toxic systemic treatments in this population. This review provides an overview of how best to approach an older adult with HNSCC, from initial work-up to treatment selection.

Evaluation of Concomitant Systemic Treatment in Older Adults With Head and Neck Squamous Cell Carcinoma Undergoing Definitive Radiotherapy

IMPORTANCE

The number of older adults with head and neck squamous cell carcinoma (HNSCC) is increasing, and these patients are underrepresented in clinical trials. It is unclear whether the addition of chemotherapy or cetuximab to radiotherapy is associated with improved survival in older adults with HNSCC.

OBJECTIVE

To examine whether the addition of chemotherapy or cetuximab to definitive radiotherapy is associated with improved survival in patients with locoregionally advanced (LA) HNSCC.

DESIGN, SETTING, AND PARTICIPANTS

The Special Care Patterns for Elderly HNSCC Patients Undergoing Radiotherapy (SENIOR) study is an international, multicenter cohort study including older adults (≥65 years) with LA-HNSCCs of the oral cavity, oropharynx/hypopharynx, or larynx treated with definitive radiotherapy, either alone or with concomitant systemic treatment, between January 2005 and December 2019 at 12 academic centers in the US and Europe. Data analysis was conducted from June 4 to August 10, 2022.

INTERVENTIONS

All patients underwent definitive radiotherapy alone or with concomitant systemic treatment.

MAIN OUTCOMES AND MEASURES

The primary outcome was overall survival. Secondary outcomes included progression-free survival and locoregional failure rate.

RESULTS

Among the 1044 patients (734 men [70.3%]; median [IQR] age, 73 [69-78] years) included in this study, 234 patients (22.4%) were treated with radiotherapy alone and 810 patients (77.6%) received concomitant systemic treatment with chemotherapy (677 [64.8%]) or cetuximab (133 [12.7%]). Using inverse probability weighting to attribute for selection bias, chemoradiation was associated with longer overall survival than radiotherapy alone (hazard ratio [HR], 0.61; 95% CI, 0.48-0.77; P < .001), whereas cetuximab-based bioradiotherapy was not (HR, 0.94; 95% CI, 0.70-1.27; P = .70). Progression-free survival was also longer after the addition of chemotherapy (HR, 0.65; 95% CI, 0.52-0.81; P < .001), while the locoregional failure rate was not significantly different (subhazard ratio, 0.62; 95% CI, 0.30-1.26; P = .19). The survival benefit of the chemoradiation group was present in patients up to age 80 years (65-69 years: HR, 0.52; 95% CI, 0.33-0.82; 70-79 years: HR, 0.60; 95% CI, 0.43-0.85), but was absent in patients aged 80 years or older (HR, 0.89; 95% CI, 0.56-1.41).

CONCLUSIONS AND RELEVANCE

In this cohort study of older adults with LA- HNSCC, chemoradiation, but not cetuximab-based bioradiotherapy, was associated with longer survival compared with radiotherapy alone.

Chemoradiotherapy in geriatric patients with squamous cell carcinoma of the esophagus: Multi-center analysis on the value of standard treatment in the elderly

Background and purpose

To evaluate the tolerability and outcomes of chemoradiation in elderly patients with locally advanced esophageal squamous cell carcinoma (ESCC).

Materials and methods

This multi-center retrospective analysis included 161 patients with SCC of the esophagus with a median age of 73 years (range 65-89 years) treated with definitive or neoadjuvant (chemo)radiotherapy between 2010 and 2019 at 3 large comprehensive cancer centers in Germany. Locoregional control (LRC), progression-free survival (PFS), distant metastasis-free survival (DMFS), overall survival (OS), and treatment-associated toxicities were analyzed, and parameters determining patient outcomes and treatment tolerance were assessed.

Results

The delivery of radiotherapy without dose reduction was possible in 149 patients (93%). In 134 patients (83%), concomitant chemotherapy was initially prescribed; however, during the course of therapy, 41% of these patients (n = 55) required chemotherapy de-escalation due to treatment-related toxicities. Fifty-two patients (32%) experienced higher-grade acute toxicities, and 22 patients (14%) higher-grade late toxicities. The 2-year LRC, DMFS, PFS, and OS rates amounted to 67.5%, 33.8%, 31.4%, and 40.4%, respectively. Upon multivariate analysis, full-dose concomitant chemotherapy (vs. no or modified chemotherapy) was associated with significantly better DMFS (p=0.005), PFS (p=0.005) and OS (p=0.001). Furthermore, neoadjuvant chemoradiotherapy followed by tumor resection (vs. definitive chemoradiotherapy or definitive radiotherapy alone) significantly improved PFS (p=0.043) and OS (p=0.049). We could not identify any clinico-pathological factor that was significantly associated with LRC. Furthermore, definitive (chemo)radiotherapy, brachytherapy boost and stent implantation were significantly associated with higher-grade acute toxicities (p<0.001, p=0.002 and p=0.04, respectively). The incidence of higher-grade late toxicities was also significantly associated with the choice of therapy, with a higher risk for late toxicities when treatment was switched from neoadjuvant to definitive (chemo)radiotherapy compared to primary definitive (chemo)radiotherapy (p<0.001).

Conclusions

Chemoradiation with full-dose and unmodified concurrent chemotherapy has a favorable prognostic impact in elderly ESCC patients; however, about half of the analyzed patients required omission or adjustment of chemotherapy due to comorbidities or toxicities. Therefore, the identification of potential predictive factors for safe administration of concurrent chemotherapy in elderly ESCC patients requires further exploration to optimize treatment in this vulnerable patient cohort.

Prediction of Radiotherapy Compliance in Elderly Cancer Patients Using an Internally Validated Decision Tree

This study aims to analyze the relationship between the available variables and treatment compliance in elderly cancer patients treated with radiotherapy and to establish a decision tree model to guide caregivers in their decision-making process. For this purpose, 456 patients over 74 years of age who received radiotherapy between 2005 and 2017 were included in this retrospective analysis. The outcome of interest was radiotherapy compliance, determined by whether patients completed their scheduled radiotherapy treatment (compliance means they completed their treatment and noncompliance means they did not). A bootstrap (B = 400) technique was implemented to select the best tuning parameters to establish the decision tree. The developed decision tree uses patient status, the Charlson comorbidity index, the Eastern Cooperative Oncology Group Performance scale, age, sex, cancer type, health insurance status, radiotherapy aim, and fractionation type (conventional fractionation versus hypofractionation) to distinguish between compliant and noncompliant patients. The decision tree's mean area under the curve and 95% confidence interval was 0.71 (0.66-0.77). Although external validation is needed to determine the decision tree's clinical usefulness, its discriminating ability was moderate and it could serve as an aid for caregivers to select the optimal treatment for elderly cancer patients.

Immunotherapy and Modern Radiotherapy Technique for Older Patients with Locally Advanced Head and Neck Cancer: A Proposed Paradigm by the International Geriatric Radiotherapy Group

The standard of care for locally advanced head and neck cancer is concurrent chemoradiation or postoperative irradiation with or without chemotherapy. Surgery may not be an option for older patients (70 years old or above) due to multiple co-morbidities and frailty. Additionally, the standard chemotherapy of cisplatin may not be ideal for those patients due to oto- and nephrotoxicity. Though carboplatin is a reasonable alternative for cisplatin in patients with a pre-existing hearing deficit or renal dysfunction, its efficacy may be inferior to cisplatin for head and neck cancer. In addition, concurrent chemoradiation is frequently associated with grade 3-4 mucositis and hematologic toxicity leading to poor tolerance among older cancer patients. Thus, a new algorithm needs to be developed to provide optimal local control while minimizing toxicity for this vulnerable group of patients. Recently, immunotherapy with check point inhibitors (CPI) has attracted much attention due to the high prevalence of program death-ligand 1 (PD-L1) in head and neck cancer. In patients with recurrent or metastatic head and neck cancer refractory to cisplatin-based chemotherapy, CPI has proven to be superior to conventional chemotherapy for salvage. Those with a high PD-L1 expression defined as 50% or above or a high tumor proportion score (TPS) may have an excellent response to CPI. This selected group of patients may be candidates for CPI combined with modern radiotherapy techniques, such as intensity-modulated image-guided radiotherapy (IM-IGRT), volumetric arc therapy (VMAT) or proton therapy if available, which allow for the sparing of critical structures, such as the salivary glands, oral cavity, cochlea, larynx and pharyngeal muscles, to improve the patients' quality of life. In addition, normal organs that are frequently sensitive to immunotherapy, such as the thyroid and lungs, are spared with modern radiotherapy techniques. In fit or carefully selected frail patients, a hypofractionated schedule may be considered to reduce the need for daily transportation. We propose a protocol combining CPI and modern radiotherapy techniques for older patients with locally advanced head and neck cancer who are not eligible for cisplatin-based chemotherapy and have a high TPS. Prospective studies should be performed to verify this hypothesis.

Temporal trends in oropharyngeal cancer incidence, survival, and cancer-directed surgery among elderly Americans

OBJECTIVE

This study assesses longitudinal epidemiologic trends in the oldest head and neck cancer (HNC) patients, comparing the oropharynx to other mucosal HNC sites.

MATERIALS AND METHODS

Using data from the Surveillance, Epidemiology, and End Results database, trends in incidence, two-year cancer specific mortality, and percent of cases recommended for and which received surgery from 2000 to 2018 in patients ages ≥85 years were assessed using Joinpoint analysis by HNC site. Trends were quantified as annual percentage change (APC) with 95% confidence intervals (CI).

RESULTS

Among older adults, oropharyngeal cancer (OPC) incidence increased (APC = 1.80% [95% CI: 0.94-2.67]), while mortality decreased (APC = -2.01% [95% CI: -3.26--0.74]) from 2000 to 2018. At other mucosal HNC sites, incidence and mortality remained stable. Percentage of patients who received surgery significantly changed for oropharyngeal (APC = -15.34% from 2000 to 2005 [95% CI: -24.37 to -4.79]) and laryngeal (APC = -4.61% from 2000 to 2008 [95% CI -8.28 to -0.80]) cancers. Trends in recommendation for surgery varied by site with significant decreases at the larynx, oral cavity, and oropharynx.

CONCLUSION

OPC incidence is increasing among the oldest HNC patients. An increasing proportion of HPV-associated tumors could account for associated mortality improvement. There has been a shift towards non-surgical therapy possibly due to known favorable response of HPV-associated OPC to radiation therapy and/or poor surgical candidacy in this age group. The evolving treatment approach has not been detrimental to population-level survival outcomes, but optimal treatment has yet to be established. Future studies with pathologically confirmed HPV status are needed to better understand older adult OPC burden.

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

Background

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

Methods

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

Results

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

Conclusion

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

Palliative radiotherapy of bone metastases in octogenarians: How do the oldest olds respond? Results from a tertiary cancer center with 288 treated patients

BACKGROUND

Accompanied by the demographic change, the number of octogenarian cancer patients with bone metastases will increase in the future. Palliative radiotherapy constitutes an effective analgesic treatment; however, as pain perception and bone metabolism change with increasing age, the analgesic efficacy of radiotherapy may be altered in elderly patients. We therefore investigated the treatment outcomes of palliative radiotherapy for bone metastases in octogenarians.

METHODS

Patients between 80 and 89 years undergoing radiotherapy for bone metastases between 2009 and 2019 at a tertiary cancer center were analyzed for patterns-of-care, pain response and overall survival (OS). Logistic regression analyses were carried out to examine parameters associated with pain response, and Cox analyses were conducted to reveal prognostic parameters for OS.

RESULTS

A total of 288 patients with 516 irradiated lesions were included in the analysis. The majority (n = 249, 86%) completed all courses of radiotherapy. Radiotherapy led to pain reduction in 176 patients (61%) at the end of treatment. Complete pain relief at the first follow-up was achieved in 84 patients (29%). Bisphosphonate administration was significantly associated with higher rates of pain response at the first follow-up (p < 0.05). Median OS amounted to 9 months, and 1-year, 2-year and 3-year OS were 43%, 28% and 17%. In the multivariate analysis, ECOG (p < 0.001), Mizumoto score (p < 0.01) and Spinal Instability Neoplastic Score (SINS) (p < 0.001) were independent prognosticators for OS.

CONCLUSION

Palliative radiotherapy for bone metastases constitutes a feasible and effective analgesic treatment in octogenarian patients. ECOG, Mizumoto score and SINS are prognosic variables for survival and may aid treatment decisions regarding radiotherapy fractionation in this patient group. Single-fraction radiotherapy with 8 Gy should be applied for patients with uncomplicated bone metastases and poor prognosis. Prospective trials focusing on quality of life of these very old cancer patients with bone metastases are warranted to reveal the optimal radiotherapeutic management for this vulnerable population.

Characteristics and Assessment of Frailty as Risk Factor of Therapy-Related Acute Toxicities and Delayed Overall Treatment Time in Elderly Patients Treating with External Beam Radiation Therapy at Indonesia Top Referral Hospital

BACKGROUND: Older patients are at a higher risk of being frail. Frailty implies that even a minor stressor can have major negative implications on physical, psychological domains. Geriatric-8 (G-8) screening tool shows good screening properties for identifying vulnerable elderly patients with cancer. AIM: We, therefore, decided to investigate the utility of G-8 associated with acute toxicity and prolonged overall treatment time (OTT) in elderly cancer patients treated with radiotherapy (RT). MATERIALS AND METHODS: A prospective observational cohort study is performed. Eligible subjects are patients aged ≥60 years and were referred for curative or palliative RT. We use the G-8 questionnaire for consecutive patients before starting RT. We recorded acute toxicity and OTT and identified potential predictors. RESULTS: A total of 52 consecutive geriatric patients were included with an average age of 67 years. Of all those subjects, 21% had head-and-neck cancers, 29% gynecology cancers, 23% breast cancers, and 27% other cancers. According to the G-8, 65% of the patients were potentially frail. Toxicity Grade ≥3 was observed among 32% of subjects who were potentially frail according to the G-8 and 0% of the subject who was fit (p = 0.007). Prolonged OTT was observed in 61.8% of potentially frail and 27.8% of the subjects who were fit (p = 0.020). On multivariate analysis, only chemoradiation was strongly associated with acute toxicity Grade ≥3 odds ratio 11.1 (95% confidence interval 1.4–83.6; p = 0.019). CONCLUSION: The utility of G-8 in daily practice seems to be limited. Only concurrent chemoradiation was associated with acute toxicity. Future prospective studies should investigate whether the G-8 is a good predictor for other relevant clinical outcomes and survival in our local settings.

Cost effectiveness and health-related quality of life of chemoradiotherapy versus radiation therapy alone in elderly head and neck cancer patients

Purpose

Radiotherapy (RT) constitutes a mainstay in the treatment of elderly patients with head and neck cancer (HNC), but use of simultaneous chemoradiotherapy (CRT) remains controversial. We have conducted a prospective analysis based on real-world patient data to examine the health-related quality of life (HRQoL) and cost effectiveness (CE) of CRT vs. RT in elderly HNC patients.

Methods

Eligible participants ≥ 65 years treated in a large tertiary cancer center between July 2019 and February 2020 who completed the validated EQ-5D-5L questionnaire (health state index [HI] and visual analog scale [VAS]) before and after RT were included. CE referred to direct medical costs, including diagnosis-related group (DRG)-based billings for inpatients and uniform assessment standard (EBM)-based costs for outpatients. The primary endpoint was cost (euros [€]) per quality-adjusted life year (QALY). The incremental cost-effectiveness ratios (ICERs) were calculated. Costs and QALYs were not discounted for short overall survival (OS).

Results

Baseline HRQoL was 0.878 (±0.11) in the CRT group and 0.857 (±0.17) in the RT group. Upon completion of therapy, HRQoL amounted to 0.849 (±0.14) in the CRT and 0.850 (±0.13) in the RT group. The mean treatment-related cost in the CRT cohort was €22,180.17 (±8325.26) vs. €18,027.87 (±26,022.48) in the RT group. The corresponding QALYs amounted to 2.62 in the CRT and 1.91 in the RT groups. The ICER was €5848.31.

Conclusion

This is the first analysis from the German health care system demonstrating that the addition of chemotherapy to RT for selected elderly HNC patients is cost effective and not associated with a significant HRQoL decline.

Outcomes of curative treatment for head and neck squamous cell carcinoma in very elderly adults ≥80 years old

BACKGROUND

Head and neck cancer treatment can be difficult and advancing age is associated with greater frailty. It is unclear if curative treatment for very elderly patients is beneficial. This study compared outcomes to curative treatment in patients ≥80 aged with HNSCC to patients aged 70-79.

METHODS

Retrospective study of 114 patients diagnosed with HNSCC. Overall survival (OS), Disease-Free Survival (DFS), and local-regional control (LRC) were compared and adjusted for confounders.

RESULTS

Patients aged 70-79 had a higher median OS (35 months [95% CI, 19.58-50.42]) compared with patients aged ≥80 (19 months [11.72-26.28]; p = 0.008) but similar DFS and LRC. KPS < 90 was the stand-alone independent prognostic factor for OS (HR = 2.14 [1.05-4.38]).

CONCLUSION

Very elderly HNSCC patients (aged ≥80) can have favorable outcomes with curative therapy and advanced chronological age alone should not prohibit patients from receiving treatment. Performance status may be a greater predictor of survival outcome than age alone.

LEVEL OF EVIDENCE

Level III.

Management of Older Adults with Locally Advanced Head and Neck Cancer

Simple Summary

Approximately one third of patients with head and neck cancer are older adults. The number of older adults with head and neck cancer continues to rise especially as life expectancy increases. However, this population remains significantly underrepresented in clinical trials. Due to this, there is no clear consensus regarding the optimal treatment for older adults with head and neck cancer. In general, older adults are a complex cohort due to variations in functional and performance status, medical comorbidities, and medication management. Treatment for head and neck cancer involves surgery, radiation therapy, systemic therapy, or a combination. These treatments are highly demanding. Additionally, they are associated with toxicity which can be especially difficult for older adults to tolerate. This may lead to treatment interruptions and compromised outcomes. In order to understand the optimal treatment for older adults with head and neck cancer, novel predictive scores are being developed. Additionally, ongoing clinical trials are investigating less intensive treatments for older adults. This review provides an overview of current clinical data, treatment considerations, and future areas of investigation for older adults with head and neck cancer.

Abstract

Thirty percent of patients with head and neck squamous cell carcinoma (HNSCC) are at least 70 years of age. This number continues to rise as life expectancy continues to increase. Still, older adults with HNSCC remain underrepresented in clinical trials, resulting in ambiguity on optimal management. Older adults are a complex patient population, often requiring increased support due to issues relating to functional and performance status, medical comorbidities, and medication management. Furthermore, in older adults with HNSCC, many of these conditions are independently associated with increased toxicity and worse outcomes. Toxicity in the older adult remains difficult to predict and to understand, and as treatment decisions are based on treatment tolerability, it is essential to understand the toxicities and how to minimize them. Novel predictive scores are being developed specifically for older adults with HNSCC to understand toxicity and to assist in personalized treatment decisions. There are clinical trials presently underway that are investigating shortened radiation courses and novel, less toxic systemic treatments in this population. In the forthcoming sections, we provide a detailed overview of the clinical data, treatment paradigms, and considerations in this population. This review provides a comprehensive overview of existing clinical data and clinical considerations in the older adult head and neck cancer population. Additionally, we provide a detailed overview of pertinent current and ongoing clinical trials, as well as future areas for investigation.

The association of frailty and outcomes of geriatric assessment with acute radiation-induced toxicity in patients with head and neck cancer

BACKGROUND AND PURPOSE

Geriatric impairments and frailty are highly prevalent in patients with head and neck cancer (HNC). This study investigated the association of frailty and outcomes of geriatric assessment (GA) with radiation-induced toxicity (RIT) in patients undergoing (chemo)radiotherapy ((C)RT) for HNC.

MATERIALS AND METHODS

Between October 2014 and April 2016, patients with HNC were prospectively included in OncoLifeS, an institutional data-biobank. Before treatment initiation, patients underwent GA and frailty screening (Groningen Frailty Indicator and Geriatric 8). The main outcome of this study was RIT (weight loss, mucositis, salivary gland inflammation, oral pain, sore throat, hoarseness, dry mouth, dysgeusia, dysphagia and general pain) according to the common terminology criteria of adverse events (CTCAE) version 4.0. Linear mixed models were performed, to analyse factors associated with increasing mean RIT over time during the treatment period.

RESULTS

160 patients were included. 114 (71.3%) were male and the mean age was 66.1 years. Age ≥ 65 (β = 0.03(95 %CI = 0.01;0.05), p = 0.01), regional RT (β = 0.05(95 %CI = 0.02;0.09), p = 0.004), and concurrent chemotherapy (β = 0.04(95 %CI = 0.02;0.07), p = 0.001), were independent factors associated with increasing toxicity during the 7-week treatment period, adjusted for relevant covariates. None of the single items of GA, as well as the frailty screening instruments, were associated with increasing RIT.

CONCLUSION

In this study, frailty and GA were not associated with additional RIT during treatment. These results suggest that (C)RT is equally tolerated in frail and non-frail patients, with respect to acute RIT. RT could be a suitable alternative to surgery in selected frail patients.

Management of elderly patients with head and neck cancer

There are no established guidelines for managing older patients with head and neck cancer. Most clinical trials that define current standard therapy included few elderly patients. On the other hand, there is great variability in patients' comorbidities, physical functions, cognitive function, familial and financial background and values. The key point appears to be appropriate geriatric assessment, clarifying the patients' outcomes and a multidisciplinary team approach, including the treatment decision-making policy. Although these processes should be scientific in nature, the evidence for the treatment of elderly head and neck patients is very limited. This review summarizes the evidence available regarding the management of geriatric assessment, each treatment modality and the multidisciplinary team approach for older patients with head and neck cancers.

Palliative Care and End-of-Life Issues in Elderly Cancer Patients With Head and Neck Cancer

The number of elderly patients with incurable head and neck cancer will increase. They are in need of geriatric palliative care, that takes into account oncology, palliative care and geriatric medicine. In this review of the most recent and relevant literature and includes the expert opinion of the authors, several physical problems (e.g. pain, fatigue, malnutrition, and loco-regional problems) encountered by the elderly head and neck cancer patients are addressed. In addition end-of life issues in this patient population are discussed.

Patterns-of-Care Analysis for Radiotherapy of Elderly Head-and-Neck Cancer Patients: A Trinational Survey in Germany, Austria and Switzerland

OBJECTIVES

The number of elderly head-and-neck squamous cell carcinoma (HNSCC) patients is increasing, and clinical trials defining the standard of care either excluded or underrepresented elderly patients. This leaves physicians with a challenging and highly individual treatment decision largely lacking clinical evidence.

METHODS

A tri-national patterns-of-care survey was sent to all members of the German (DEGRO), Austrian (ÖGRO), and Swiss (SRO/SSRO) national societies of radiation oncology. The online questionnaire consisted of 27 questions on the treatment of elderly HNSCC patients, including 6 case-based questions. Frequency distributions and subgroup comparisons were calculated using SPSS statistics software.

RESULTS

A total of 132 answers were collected, including 46(35%) form universities, 52(39%) from non-university-hospitals and 34(26%) from private practices. 83(63%) treat 1-5 and 42(32%) >5 elderly HNSCC patients per month. Target volumes are defined analog current guidelines by 65(50%) of responders and altered based on age/comorbidities or tumor stage by 36(28%) and 28(22%), respectively. Chemotherapy is routinely administered by 108(84%) if indicated, with weekly 40mg/m² of cisplatin being the favored regimen by 68(53%) in the definitive situation and 60(47%) in the adjuvant setting. Hypofractionation and hyperfractionation/acceleration are used by 26(20%) and 11(9%), respectively. Only 7(5%) clinicians routinely recommend inpatient treatment for elderly HNSCC patients. In a typical definitive patient case, 73(63%) responders recommended chemoradiation with bilateral elective node irradiation analog current guidelines. In an adjuvant example case recommendations regarding elective volume and chemotherapy were heterogeneous. Differences between responders' institutions concern the frequency of PET-CT in staging, preventive port-catheter and PEG implantation, the choice of chemotherapy regimens and the use of alternative fractionations.

CONCLUSION

Treatment of elderly HNSCC-patients in the German-speaking countries mainly follows guidelines established for younger patients. Algorithms for patient stratification and treatment de-escalation for "unfit" elderly patients are needed.

Head and Neck Squamous Cell Carcinoma in Elderly Patients: Role of Radiotherapy and Chemotherapy

Head and neck squamous cell carcinomas (HNSCC) constitute the sixth most common malignancy worldwide, with approximately 25-40% of the diagnosed patients older than 70 years. HNSCC patients are often frail and frequently have multiple comorbidities due to their unhealthy lifestyle, and evidence suggests that older patients may receive less aggressive and suboptimal treatment than younger patients with the same disease status. The aim of this review is to depict and summarize the evidence regarding the different strategies that can be used in the clinical management of elderly HNSCC patients. Key references were derived from a PubMed query. Hand searching and clinicaltrials.gov were also used. This paper contains a narrative report and a critical discussion of clinical approaches in the context of elderly HNSCC.

Adjuvant chemoradiotherapy in elderly patients with head and neck cancer: a monoinstitutional, two-to-one pair-matching analysis

Purpose

About one fifth of patients with head and neck cancer are aged 70 years and older at the time of diagnosis. In these patients, risk factors (R1 status or extracapsular extension of lymph node metastases, ECE) often lead to a need for combined chemoradiotherapy (CRT) in the postoperative setting. However, there is considerable concern about the toxicity of such therapy in this age group.

Methods

Retrospective evaluation of the data of 53 patients ≥ 70 years of age who underwent surgery in our hospital between 1999 and 2015 for tumors of the oral cavity, the oropharynx, the hypopharynx, or the larynx, who subsequently received adjuvant radiation therapy. Two younger patients (< 70 years) were assigned to each of the elderly patients in a matching procedure based on anatomic sublocalization and tumor stage. The total cohort was comprised of 154 patients.

Results

Univariate analyses revealed a statistically significant influence of many factors on overall survival (OS) and progression-free survival (PFS), including Karnofsky performance score (KPS), alcohol consumption, smoking, R status, ECE, chemotherapy, and discontinuation of RT. Younger patients had better OS and PFS compared to the elderly (p = 0.013 and 0.012, respectively). In a multivariate Cox regression, no independent influence of age on OS and PFS was found. Survival was primarily dependent on the addition of chemotherapy to radiotherapy (RT), application of the full course of RT, continued alcohol abuse, KPS, and the presence of ECE. Toxicity analysis showed a higher incidence of chronic renal failure but, generally, side effects for elderly patients were not substantially greater.

Conclusion

Performance status and behavioral risk factors but not chronological age are crucial for the prognosis of patients who require adjuvant chemoradiation.

Supplementary Information

The online version of this article (10.1007/s00066-021-01890-2) contains supplementary material, which is available to authorized users.

Predictors for Adherence to Treatment Strategies in Elderly HNSCC Patients

Simple Summary

The aim of this study was to find predictors for adherence to a therapy recommended by a multidisciplinary tumour board regarding 1125 elderly patients (70–100 years) with head and neck squamous cell carcinoma (HNSCC). The 5-year overall survival was significantly higher in adherent patients (45.1% versus 19.2%). Nonadherent patients were significantly more often smokers, drinkers, and had a worse tumour stage and lower health status (Karnofsky performance status). In contrast to the chronological patient age, the biological age (Charlson Comorbidity Index) was a significant predictor for adherence. The evaluated predictors for nonadherence need to be verified prospectively.

Abstract

Finding a cure may be less important than ensuring the quality of life in elderly patients with head and neck squamous cell carcinoma (HNSCC). The aim of this study was to determine predictors for adherence. Clinical and pathological data from patients ≥70 years with HNSCC (initial diagnoses 2004–2018) were investigated retrospectively. Evaluated clinical predictors included biological age (Charlson Comorbidity Index; CCI), patient health (Karnofsky Performance Status; KPS) and therapy data. A total of 1125 patients were included. The median age was 75 years, 33.1% reached CCI ≥ 6, and 53.7% reached KPS ≤ 70%. In total, 968 patients were adherent, whereas 157 were nonadherent. Nonadherent patients were significantly more often smokers (p = 0.003), frequent drinkers (p = 0.001), had a worse health status (p ≤ 0.001) and a lower biological age (p = 0.003), an advanced T classification and lymph node involvement or UICC stage (each p ≤ 0.001). Approximately 88.0% of the included patients received a curative treatment recommendation. A total of 6.9% discontinued the therapy, and 7.0% refused the therapy. With the increasing complexity of a recommended therapy, adherence decreased. The 5-year overall survival was significantly higher in adherent patients (45.1% versus 19.2%). In contrast to the chronological patient age, biological age is a significant predictor for adherence. The evaluated predictors for nonadherence need to be verified prospectively.

Postoperative Radiochemotherapy Using Modern Radiotherapy Techniques in Elderly Patients with Head and Neck Squamous Cell Carcinoma: The Challenge of Weighing Up Benefits and Harms of Treatment Modalities in Clinical Practice

Simple Summary

Locally advanced head and neck squamous cell carcinomas (HNSCC) are often managed with surgery and postoperative radiochemotherapy (RCT). Until now, a deeper understanding of specific management strategies for elderly patients was lacking. In the present study, we compared patients ≥70 years of age and younger patients treated with postoperative RCT for HNSCC. All patients were treated with modern radiotherapy techniques (IMRT/VMAT). Elderly patients had more comorbidities. In addition, they less frequently received concomitant systemic treatment. The rates of mucositis and dermatitis were lower in patients ≥70 years. Elderly patients had significantly worse overall survival and progression-free survival. Locoregional and distant control were comparable in elderly and younger patients. In conclusion, postoperative radiochemotherapy is a safe and effective treatment option in patients ≥70 years. In light of comorbidities and poor survival rates, potential benefits and harms of radiotherapy and concomitant systemic treatment should be weighed carefully for this age group.

Abstract

Locally advanced head and neck squamous cell carcinomas (HNSCC) are often managed with surgery followed by postoperative radiochemotherapy (RCT). With the general increase in life expectancy, the proportion of elderly patients with HNSCC is expected to grow rapidly. Until now, a deeper understanding of specific management strategies for these patients in clinical routine was lacking. In the present study, we compared elderly patients (≥70 years, n = 52) and younger patients (n = 245) treated with postoperative RCT for HNSCC at our tertiary cancer center. All patients were irradiated with modern radiotherapy techniques (IMRT/VMAT). Patients ≥70 years of age had more comorbidities. Additionally, elderly patients less frequently received concomitant systemic treatment. The rates of mucositis and dermatitis were lower in patients ≥70 years. Elderly patients had significantly worse overall and progression-free survival. Locoregional and distant control were comparable in elderly and younger patients. In conclusion, postoperative RCT is a safe and effective treatment option in patients ≥70 years. In light of comorbidities and poor overall survival rates, benefits and harms of radiotherapy and concomitant systemic treatment should be weighed carefully. When exclusively applying up-to-date radiotherapy techniques with, at the same time, careful use of concomitant systemic therapy, favorable acute toxicity profiles are achieved.

The value of primary and adjuvant radiotherapy for cutaneous squamous cell carcinomas of the head-and-neck region in the elderly

Purpose

To examine treatment patterns, oncological outcomes and toxicity rates in elderly patients receiving radiotherapy for cutaneous squamous cell carcinoma (cSCC) of the head-and-neck region.

Material and methods

In this retrospective single-center analysis, locoregional control (LRC), progression-free survival (PFS) and overall survival (OS) of elderly patients > 65 years with cSCC of the head-and-neck region undergoing radiotherapy between 2010 and 2019 were calculated. The prognostic value of clinicopathological parameters on radiotherapy outcomes was analyzed using the Cox proportional hazards model. In addition, both acute and chronic toxicities were retrospectively quantified according to CTCAE version 5.0.

Results

A total of 69 elderly patients with cSCC of the head-and-neck region with a median age of 85 years were included in this analysis, of whom 21.7% (15 patients) presented with nodal disease. The majority of patients exhibited a good performance status, indicated by a median Karnofsky performance status (KPS) and Charlson Comorbidity Index (CCI) of 80% and 6 points, respectively. Radiotherapy was administered as primary (48%), adjuvant (32%) or palliative therapy (20%). 55 patients (79.7%) completed treatment and received the scheduled radiotherapy dose. Median EQD2 radiation doses were 58.4 Gy, 60 Gy and 51.3 Gy in the definitive, adjuvant and palliative situation, respectively. 2-year LRC, PFS and OS ranged at 54.2%, 33.5 and 40.7%, respectively. Survival differed significantly between age groups with a median OS of 20 vs. 12 months (p < 0.05) for patients aged 65–80 or above 80 years. In the multivariate analysis, positive lymph node status remained the only significant prognostic factor deteriorating OS (HR 3.73, CI 1.54–9.03, p < 0.01). Interestingly, neither KPS nor CCI impaired survival in this elderly patient cohort. Only 3 patients (4.3%) experienced acute CTCAE grade 3 toxicities, and no chronic CTCAE grade 2–5 toxicities were observed in our cohort.

Conclusion

Radiotherapy was feasible and well-tolerated in this distinct population, showing the general feasibility of radiotherapy for cSCC of the head-and-neck region also in the older and oldest olds. The very mild toxicities may allow for moderate dose escalation to improve LRC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13014-021-01832-3.

Nutritional Care in Patients with Head and Neck Cancer during Chemoradiotherapy (CRT) and Bioradiotherapy (BRT) Provides Better Compliance with the Treatment Plan

Simple Summary

The nutritional status of patients with head and neck cancer (HNC) during concurrent chemoradiotherapy (CRT) with platinum derivatives or concurrent radiotherapy with cetuximab (bioradiotherapy, BRT) inevitably deteriorates during treatment. Malnutrition is responsible for increased treatment-related toxicity, an increased incidence of infectious complications, the risk of postponing or discontinuing therapy, reduced drug doses (platinum derivatives or cetuximab), deteriorating quality of life (QoL), worse outcome, and increased treatment costs. A nutritional care programme, which included prophylactic dietary counselling and early enteral nutrition, reduced the incidence of complications and prevented drug dose reduction and the deterioration of patients’ anthropometric and laboratory parameters. The study confirmed that nutritional care before and during CRT and BRT in patients with HNC is a determinant of therapeutic benefit.

Abstract

The treatment of locally advanced head and neck cancer (HNC) is based on extensive resections followed by concurrent chemoradiotherapy (CRT) with platinum derivatives or concurrent radiotherapy with cetuximab (bioradiotherapy; BRT). Malnutrition, which occurs in up to 60% of patients before treatment commencement, severely increases the risk of CRT/BRT drug dose reductions and the incidence of treatment-related adverse events. A prospective observational study was performed regarding the influence of nutritional care on nutritional status, compliance with the treatment’s planned regimen, and the incidence of treatment-related complications in patients with advanced HNC during CRT and BRT. The study population encompassed 153 patients compared with a retrospective control group of 72 patients treated before nutritional care was included in the standard of oncological care. Patients enrolled in the nutritional care programme received significantly higher doses of platinum derivatives or cetuximab than patients in the control group. A significant difference between the compared populations was observed in patients below 70 years of age (92.8% of the study population), after prior surgery, and with initial weight loss lower than 10%. Nutritional care reduced final weight loss and prevented a decline within the laboratory markers of nutritional status. Weight loss was comparable in both modes of treatment—CRT and BRT. The incidence of treatment-related complications was significantly higher in patients without nutritional support in the subgroups of patients under 70 years of age and after primary surgery. Nutritional care before and during CRT and BRT in patients with HNC is a determinant of therapeutic benefit, defined as preventing down-dosing, weight loss, and the incidence of complications. Platinum derivatives and cetuximab had comparable influence on weight loss.

Physician practice variation in head and neck cancer therapy: Results of a national survey

OBJECTIVES

Choice between surgical or medical treatments in head and neck cancer depends of many patient-related and disease-related factors. We investigated how patients' socioeconomic status and practitioners' specialty could affect medical decision-making.

MATERIALS AND METHODS

We conducted a cross-sectional online, nationwide survey, send to surgeons, oncologists and radiotherapists specialized in head and neck oncology. We collected data on medical decision-making for seven clinical scientific scenarios involving head and neck carcinoma and physicians' demographic data. Patients' gender and socioeconomic position were distributed across scientific scenarios using a Latin square design. The scientific scenarios were grouped into several categories according to the prognostic and functional impact of the therapeutic choice.

RESULTS

We obtained 206 assessable answers. Surgeons seemed to propose surgery in 49% of cases, whereas oncologists and radiotherapists opted for it in 34% of cases only. This was particularly relevant when the oncological result of surgery and the medical approach were equivalent, and when the surgery appeared to be superior in terms of curative potential but was burdened by a large functional impact. Patient's socioeconomic position also influence therapeutic decision. Among surgeons, the "single male manager" had significantly more chance of being offered surgery than the "married male blue-collar worker". Among oncologists and radiotherapists, the "single male blue-collar worker" had the lowest probability of being proposed surgery. Regarding gender, surgeons tended to offer surgical management more to women regardless of their clinical profile.

CONCLUSIONS

Patients' sex, marital status, socioeconomic status, practitioners' specialty affect therapeutic management decisions in head and neck oncology.

Surviving Elderly Patients with Head-and-Neck Squamous Cell Carcinoma-What Is the Long-Term Quality of Life after Curative Radiotherapy?

The effects of radiotherapy on the long-term quality of life (QoL) of surviving elderly HNSCC patients are not well understood, therefore, we analyzed QoL in this population. A cross-sectional analysis was performed at a tertiary cancer center to assess long-term QoL in elderly HNSCC patients. Eligible patients were ≥65 years at the time of treatment who had to be alive for ≥1 year after radiotherapy and without current anti-cancer treatment. QoL and patient satisfaction were assessed using the EORTC QLQ-C30, QLQ-H&N35 and ZUF-8 questionnaires, respectively, and treatment-related toxicities were graded according to CTCAE (Common Terminology Criteria of Adverse Effects) v.5.0. Seventy-four patients met the inclusion criteria, of which 50 consented to participate. Median time between radiotherapy and QoL assessment was 32 months (range 12-113). The QLQ-C30 global QoL median amounted to 66.7 points (interquartile range (IQR) 50.0-83.3), which was comparable to the age- and gender-adjusted German population (median 65.3). Median global QoL was similar between patients undergoing definitive (75.0, IQR 50.0-83.3) and adjuvant (chemo)radiotherapy (66.7, IQR 41.7-83.3, p = 0.219). HPV-positive HNSCC patients had superior global QoL after radiotherapy than their HPV-negative counterparts (p < 0.05), and concomitant chemotherapy did not influence the long-term QoL (p = 0.966). Median global QoL did not correspond with physician-assessed highest-graded chronic toxicities (p = 0.640). The ZUF-8 ranged at 29 points in median (IQR 27-31), showing high patient satisfaction. Surviving elderly HNSCC patients treated by radiotherapy exhibit a relatively high long-term global QoL which is a relevant information for clinicians treating elderly HNSCC patients.

Radiotherapy for locally advanced head and neck cancer in elderly patients: results and prognostic factors a single cohort

Background

The objective of this study was to assess the treatment outcomes and prognostic factors of elderly patients with locally advanced head and neck cancer (LAHNC) undergoing radiotherapy (RT).

Materials and methods

A retrospective cohort from a single institution, from 2000 to 2015, including patients older than 65 years old with LAHNC (stage III-IVa) treated by RT combined or not with chemotherapy (CRT). Univariate and multivariate analysis (MVA) were performed to identify prognostic factors associated with overall survival (OS), cancer-specific survival (CS), and locoregional control (LRC). A p-value < 0.05 was considered significant.

Results

220 patients with LAHNC and > 65 years of age were identified. The median follow-up was 3.8 years, the 3/5 years estimated OS, CS, and LRC rate was 40%/30%, 49%/34%, 76%/45%, respectively. In the univariate analysis, clinical stage (III vs. IVa/b, p = 0.01), tumor stage (T1/2 vs. T3/4, p = 0.035), Karnofsky performance status (KPS, 60-70, p = 0.03) and tumor site (other than vs. hypopharynx, p = 0.0001) were associated with lower OS. Patients with clinical stage (III vs. IVa/b, p = 0.01), tumor stage (T1/2 vs. T3/4, p = 0.015), N stage (N0/1 vs. N2/3, p = 0.04), (KPS 60-70, p = 0.04) and tumor site (other than vs. hypopharynx, p = 0.0001) had worst CS. For the LRC, clinical stage (III vs. IVa/b, p = 0.02), tumor stage (T1/2 vs. T3/4, p = 0.02), treatment type (CRT vs. RT, p = 0.02), RT technique (IMRT vs. 2DRT/3DRT, p = 0.0001), and tumor site (other than vs. hypopharynx, p = 0.02) were significant. In the MVA, KPS maintained significant for OS and CS. For LRC, clinical stage (Iva/b, p = 0.007), tumor stage (T3/4, p = 0.047) and radiotherapy technique other than IMRT (p = 0.0001) were significant.

Conclusion

The OS, CS, and LRC were associated with several prognostic factors. The clinical performance was the main marker of OS and CS. Chemoradiation should be offered to selected elderly patients using IMRT to improve LRC.

Prognostic Factors Predict Oncological Outcome in Older Patients With Head and Neck Cancer Undergoing Chemoradiation Treatment

Purpose

Older patients with head and neck cancer (HNC) represent a challenging group, as frailty and comorbidities need to be considered. This study aimed to evaluate the efficacy and side effects of curative and palliative (chemo) radiation ([C]RT) with regard to basic geriatric screening in older patients.

Methods

This study included HNC patients aged ≥70 years who were treated with curative or palliative (C)RT. Clinicopathological data including Charlson Comorbidity Index (CCI), Karnofsky performance status (KPS), and treatment data were analyzed as predictors of overall survival (OS).

Results

A total of 271 patients (median age, 74 years) were enrolled. The majority had UICC stage III/IV (90%) and underwent curative treatment (85.2%). A total of 144 (53.1%) patients received definitive and 87 (32.1%) had adjuvant (C)RT. Overall, 40 patients (14.8%) received palliative (C)RT. Median follow-up duration (curative setting) was 87 months, and the 2- and 5-year OS rates were 57.8 and 35.9%, respectively. Median OS was significantly different for age ≤75 vs. >75 years, CCI <6 vs. ≥6, KPS ≥70 vs. <70%, Tx/T1/T2 vs. T3/T4, and adjuvant vs. definitive (C)RT, respectively. Age 70–75 years (p = 0.004), fewer comorbidities when CCI < 6 (p = 0.014), good KPS ≥ 70% (p = 0.001), and adjuvant (C)RT (p = 0.008) independently predicted longer survival. Palliative RT resulted in a median OS of 4 months.

Conclusion

Older age, lower KPS, higher CCI, and definitive (C)RT are indicators of worse survival in older patients with HNC treated curatively. Without a comprehensive geriatric assessment in patients aged >75 years, the KPS and CCI can be useful tools to account for “fitness, vulnerability or frailty” to help in treatment decision-making.

Treatment outcomes of elderly salivary gland cancer patients undergoing radiotherapy - Results from a large multicenter analysis

BACKGROUND AND PURPOSE

To evaluate oncological outcomes and treatment-related toxicities of elderly salivary gland cancer patients undergoing (chemo)radiotherapy.

MATERIAL AND METHODS

Local/locoregional control (LRC), progression-free survival (PFS) and overall survival (OS) of elderly patients ≥ 65 years with primary salivary gland cancers undergoing (chemo)radiotherapy between 2005 and 2020 at three tertiary cancer centers were calculated. The impact of clinicopathological and treatment parameters on outcomes were analyzed, and acute and chronic toxicities were quantified.

RESULTS

288 elderly salivary gland cancer patients were included in this multicenter analysis, and their median LRC, PFS and OS amounted to 113, 39 and 75 months, respectively. Age, performance status, comorbidities, definitive vs. adjuvant (chemo)radiotherapy as well as locally/locoregionally advanced cancers and distant metastases correlated with reduced outcomes in elderly salivary gland patients. Patients receiving dose-escalated radiotherapy (total doses > 70 Gy_EQD2) with carbon ion boost radiation resulted in improved LRC, but no improvements in PFS or OS. Concomitant chemoradiotherapy did not improve treatment outcomes in elderly salivary gland carcinoma patients. Radiotherapy of elderly salivary gland cancer patients resulted in moderate higher-grade toxicities despite dose escalation with 70 (24.3%) and 48 patients (16.7%) experiencing acute and chronic grade 3 toxicities, respectively. No grade 4/5 toxicities were observed in this patient cohort.

CONCLUSION

Data from the largest multicenter analysis of elderly salivary gland cancer patients undergoing (chemo)radiotherapy demonstrate favorable LRC and tolerable toxicity rates. Decision-making for these vulnerable patients should be based on patient performance rather than chronological patient age.

App-Controlled Treatment Monitoring and Support for Head and Neck Cancer Patients (APCOT): Protocol for a Prospective Randomized Controlled Trial

BACKGROUND

Head and neck cancers (HNCs) are among the most common malignancies, which often require multimodal treatment that includes radiation therapy and chemotherapy. Patients with HNC have a high burden of symptoms due to both the damaging effects of the tumor and the aggressive multimodal treatment. Close symptom monitoring over the course of the disease may help to identify patients in need of medical interventions.

OBJECTIVE

This APCOT (App-Controlled Treatment Monitoring and Support for Head and Neck Cancer Patients) trial is designed to assess the feasibility of monitoring HNC patients during the course of (chemo)radiation therapy daily using a mobile app. Additionally, symptom patterns, patient satisfaction, and quality of life will be measured in app-monitored patients in comparison to a patient cohort receiving standard-of-care physician appointments, and health economy aspects of app monitoring will be analyzed.

METHODS

This prospective randomized single-center trial will evaluate the feasibility of integrating electronic patient-reported outcome measures (ePROMs) into the treatment workflow of HNC patients. Patients undergoing definitive or adjuvant (chemo)radiation therapy as part of their HNC treatment at the Department of Radiation Oncology, University Medical Center Freiburg (Freiburg, Germany) will receive weekly physician appointments and additional appointments as requested to monitor and potentially treat symptoms during the course of treatment. Patients in the experimental arm will additionally be monitored daily using a dedicated app regarding their disease- and treatment-related symptoms, quality of life, and need for personal physician appointments. The feasibility of ePROM monitoring will be tested as the primary endpoint and will be defined if ≥80% of enrolled patients have answered ≥80% of their daily app-based questions. Quality of life will be assessed using the validated European Organisation for Research and Treatment of Cancer questionnaires, and patient satisfaction will be measured by the validated Patient Satisfaction Questionnaire Short Form at the initiation, in the middle, and at completion of radiation therapy, as well as at follow-up examinations. Additionally, the number and duration of physician appointments during the course of radiation therapy will be quantified for both ePROM-monitored and standard-of-care patients.

RESULTS

This trial will enroll 100 patients who will be randomized (1:1) between the experimental arm with ePROM monitoring and the control arm with standard patient care. Recruitment will take 18 months, and trial completion is planned at 24 months after enrollment of the last patient.

CONCLUSIONS

This trial will establish the feasibility of close ePROM monitoring of HNC patients undergoing (chemo)radiation therapy. The results can form the basis for further trials investigating potential clinical benefits of detailed symptom monitoring and patient-centered care in HNC patients regarding oncologic outcomes and quality of life.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00020491; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020491.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/21693.

Development and validation of a novel prognostic score for elderly head-and-neck cancer patients undergoing radiotherapy or chemoradiation

BACKGROUND AND PURPOSE

To establish a clinically feasible prognostic score and nomogram based on easily accessible clinical data that will aid decision-making in elderly head-and-neck squamous cell carcinoma (HNSCC) patients undergoing (chemo)radiotherapy.

MATERIAL AND METHODS

284 elderly HNSCC patients (≥65 years) undergoing curative (chemo)radiotherapy were included for the development of a score predicting overall survival (OS) based on the beta regression coefficients from significant parameters in a multivariate Cox regression analysis with p < 0.1 as inclusion criterion. A second, external cohort of 217 elderly HNSCC patients receiving (chemo)radiotherapy was used for validation. Using the aggregated data (n = 501), a nomogram was developed to predict 2- and 4-year OS.

RESULTS

Karnofsky Performance Status (HR = 2.654; p < 0.001), Charlson Comorbidity Index (HR = 2.598; p < 0.001) and baseline C-reactive protein (CRP) level (HR = 1.634; p = 0.068) were prognostic for OS in the multivariate analysis. An OS score based on beta regression coefficients was created, in which reduced performance status, increased comorbidity burden and increased CRP levels were included, leading to 3 distinct survival groups. The median OS for the 3 groups amounted to 107, 28 and 6 months, respectively (p < 0.001). The developed score was able to significantly differentiate between a favorable (median OS = 130 months), intermediate (29 months) and unfavorable prognosis (9 months) also in the external validation cohort (p = 0.005).

CONCLUSION

We propose a novel, validated prognostic score based on easily accessible clinical data allowing stratification between prognostic groups of elderly HNSCC patients receiving (chemo)radiotherapy. The derived nomogram for the prediction of 2-year and 4-year OS may aid decision-making for this vulnerable population.

Clinical characteristics and prognosis of elderly nasopharyngeal carcinoma patients receiving intensity-modulated radiotherapy

Purpose

To evaluate the clinical characteristics and prognosis of elderly nasopharyngeal carcinoma (NPC) patients receiving intensity-modulated radiotherapy (IMRT).

Methods

From June 2008 to October 2014, 148 newly diagnosed non-metastatic elderly NPC patients (aged ≥ 70 years) receiving IMRT were recruited. Comorbid condition was evaluated using the age-adjusted Charlson Comorbidity Index (ACCI). Kaplan–Meier method was used to estimate survival rates and the differences were compared using log-rank test. Hazard ratio (HR) and the associated 95% confidence interval (CI) were calculated using Cox proportional hazard model by means of multivariate analysis.

Results

The median follow-up time was 66.35 months. Estimated OS rate at 5 years for the entire group was 61.8% (95% confidence interval [CI] 0.542–0.703). The 5-year OS rate of RT alone group was 58.4% (95% [CI] 0.490–0.696) compared with 65.2% (95% [CI] 0.534–0.796) in CRT group (p = 0.45).

In patients receiving IMRT only, ACCI score equal to 3 was correlated with superior 5-year OS rate in comparison with higher ACCI score 62.1% (95% [CI] 0.510–0.766) to 48.5% (95% [CI] 0.341–0.689), respectively; p = 0.024). A 5-year OS rate of 63.1% (95% [CI] 0.537–0.741) was observed in patients younger than 75 years old compared with 57.5% (95% [CI] 0.457–0.723) in patients older (p = 0.026). Patients with early-stage disease (I–II) showed better prognosis than patients with advanced-stage (III–IV) disease (5-year OS, 72.3–55.4%, respectively; p = 0.0073). The Cox proportional hazards model suggested that age independently predicted poorer OS (HR, 1.07; 95%CI 1.00–1.15, p = 0.04).

Conclusion

The survival outcome of patients aged ≥ 70 years receiving IMRT only was similar to chemoradiotherapy with significantly less acute toxicities. Among the population, age is significantly prognostic for survival outcomes.

Characterization of health-related quality of life based on the EQ-5D-5L questionnaire in head-and-neck cancer patients undergoing modern radiotherapy

Background: Patient-reported quality of life in cancer patients is becoming increasingly important, especially for head-and-neck (H&N) cancers, which are at risk of experiencing severe treatment-related toxicities. Therefore, we sought to characterize the peritherapeutic HRQOL of contemporary patients using the well-validated EQ-5D-5 L questionnaire. Methods: All patients receiving radiotherapy for H&N cancers between July 2019 and November 2019 at the University of Freiburg Medical Center who completed the first two follow-ups were included. Results: All 49 patients completed the questionnaires at all time points of data collection, yielding 196 total questionnaires. The mean EQ-5D-5 L index score of the overall population before radiotherapy, after radiotherapy, and three and six months following radiotherapy was 0.837 (standard deviation, SD 0.17), 0.828 (SD 0.16), 0.855 (SD 0.15), and 0.856 (SD 0.14) respectively. The respective mean EQ VAS scores were 63.88 (SD 20.72), 63.67 (SD 21.81), 63.67 (SD 21.81), and 65.20 (SD 22.41) respectively. The respective changes of the HI and EQ VAS score over time for this cohort were not significant (Friedman test p = 0.273, p = 0.618). Conclusion: Despite the known therapy-related toxicities, no significant permanent deterioration of HRQOL in this cohort was observed.

Radiation-induced toxicities and outcomes after radiotherapy are independent of patient age in elderly salivary gland cancer patients: results from a matched-pair analysis of a rare disease

Purpose

This study analyzed survival and toxicity after (chemo)radiotherapy for primary salivary gland cancer patients aged ≥ 65 years and compared these results with younger patients using a matched-pair analysis.

Methods

Twenty-nine elderly patients with primary salivary gland carcinomas treated with (chemo)radiotherapy from 2008 to 2020 at University of Freiburg Medical Center were analyzed for oncological outcomes and therapy-associated toxicities. Local/locoregional control (LRC), progression-free survival (PFS) and overall survival (OS) were calculated using the Kaplan–Meier method, and the influence of clinical parameters on patient outcomes was assessed. A matched-pair analysis was performed after matching with patients < 65 years.

Results

Nine patients (31.0%) received definitive (chemo)radiotherapy, and 20 patients (69.0%) were treated in the adjuvant setting. 2-year LRC, PFS and OS ranged at 82.4%, 53.7% and 71.8%, respectively. Smoking (HR 3.980, p = 0.020), reduced performance status (HR 3.735, p = 0.016) and higher comorbidity burden (HR 4.601, p = 0.005) correlated with inferior OS. Using a matched-pair analysis with younger patients, elderly patients exhibited a trend towards reduced OS (HR 3.015, p = 0.065), but not PFS (HR 1.474, p = 0.371) or LRC (HR 1.324, p = 0.633). Acute and chronic grade 3 toxicities occurred in 31.0% and 12.5% of elderly patients, respectively, and the matched-pair analysis revealed no significant differences between age groups regarding treatment-related toxicities.

Conclusion

Treatment-related toxicities as well as LRC and PFS were comparable for salivary gland cancer patients undergoing radiotherapy. Therefore, concerns for more pronounced toxicities or reduced local/locoregional response rates should not guide treatment decisions in affected elderly patients.

Electronic supplementary material

The online version of this article (10.1007/s00405-020-06393-x) contains supplementary material, which is available to authorized users.

The Value of Laboratory Parameters for Anemia, Renal Function, Systemic Inflammation and Nutritional Status as Predictors for Outcome in Elderly Patients with Head-and-Neck Cancers

The purpose of this study was to evaluate the value of routine blood markers regarding their predictive potential for treatment outcomes of elderly head-and-neck squamous cell carcinoma (HNSCC) patients. In total, 246 elderly HNSCC patients (≥65 years) undergoing (chemo)radiotherapy from 2010 to 2018 were analyzed for treatment outcomes, depending on their hemoglobin, glomerular filtration rate (GFR), C-reactive protein (CRP) and albumin values, representing anemia, kidney function, inflammation and nutrition status, respectively. Local/locoregional control, progression-free and overall survival (OS) were calculated using the Kaplan–Meier method. Cox analyses were performed to examine the influence of blood parameters on oncological outcomes. In the univariate Cox regression analysis, hemoglobin ≤ 12 g/dL (HR = 1.536, p < 0.05), a GFR ≤ 60 mL/min/1.73 m² (HR = 1.537, p < 0.05), a CRP concentration > 5 mg/L (HR = 1.991, p < 0.001) and albumin levels ≤ 4.2 g/dL (HR = 2.916, p < 0.001) were significant risk factors for OS. In the multivariate analysis including clinical risk factors, only performance status (HR = 2.460, p < 0.05) and baseline albumin (HR = 2.305, p < 0.05) remained significant prognosticators. Additionally, baseline anemia correlated with the prevalence of higher-grade chronic toxicities. We could show for the first time that laboratory parameters for anemia (and at least partly, tumor oxygenation), decreased renal function, inflammation and reduced nutrition status are associated with impaired survival in elderly HNSCC patients undergoing (chemo)radiotherapy.

Radiotherapy for nonagenarians: the value of biological versus chronological age

Background

The number of nonagenarian cancer patients (≥ 90 years) is continuously increasing, and radiotherapy is performed in a relevant proportion of patients, as surgery and chemotherapy are often not feasible for these patients. However, the evidence regarding the feasibility and treatment outcomes after radiotherapy for this patient group is very limited.

Methods

All nonagenarian patients receiving (chemo) radiotherapy between 2009 and 2019 at the University of Freiburg - Medical Center were analyzed for patterns of care, overall survival (OS) and therapy-associated toxicities according to the Common Terminology Criteria for Adverse Events. Uni- and multivariate Cox regression analyses were conducted to assess the influence of patient- and treatment-related factors on patient outcomes.

Results

One hundred nineteen patients with a total of 137 irradiated lesions were included in this analysis. After a median follow-up of 27 months, median OS was 10 months with a 3-year OS amounting to 11.1%. Univariate analyses demonstrated that a reduced performance status (HR = 1.56, 95% CI 1.00–2.45, p < 0.05), a higher burden of comorbidities (HR = 2.00, 95% CI 1.00–4.10, p < 0.05) and higher UICC tumor stages (HR = 2.21, 95% CI 1.14–4.26, p < 0.05) were associated with impaired survival rates. Split-course treatments (HR = 2.05, 95% CI 1.07–3.94, p < 0.05), non-completion of radiotherapy (HR = 7.17, 95% CI 3.88–13.26, p < 0.001) and palliative treatments (HR = 2.84, 95% CI 1.68–4.81, p < 0.05) were found to result in significantly reduced OS. In the multivariate analysis, split-course concepts (HR = 2.21, 95% CI 1.10–4.37, p < 0.05) and palliative treatments (HR = 3.19, 95% CI 1.77–5.75, p < 0.001) significantly deteriorated outcomes, while impaired ECOG status (HR = 1.49, 95% CI 0.91–2.43, p = 0.11) did not. The vast majority of patients reported either no (n = 40; 33.6%) or grade 1–2 acute toxicities (n = 66; 55.5%), and only very few higher-grade toxicities were observed in our study.

Conclusion

Radiotherapy for nonagenarian patients is generally feasible and associated with a low toxicity profile. Given the relatively poor OS rates and the importance of the quality of life for this patient group, individualized treatment regimens including hypofractionation concepts should be considered.

The value of moderate dose escalation for re-irradiation of recurrent or second primary head-and-neck cancer

Background

Treatment for local and locoregional recurrence or second head-and-neck (H&N) cancers after previous radiotherapy is challenging, and re-irradiation carries a significantly increased risk for radiotherapy-related normal tissue toxicities and treatment failure due to a radioresistant tumor phenotype. Here, we analyzed re-irradiation management and outcomes in patients with recurrent or second primary H&N carcinoma using state-of-the-art diagnostic procedures and radiotherapy techniques.

Methods

Between 2010 and 2019, 48 patients with recurrent or second primary H&N carcinoma received re-radiotherapy at the University of Freiburg Medical Center and were included in this study. Overall survival (OS) and progression-free survival (PFS) were calculated with the Kaplan-Meier method, and univariate Cox-regression analyses were performed to assess the effects of clinico-pathological factors on treatment outcomes. Acute and chronic treatment-related toxicities were quantified using the Common Terminology Criteria for Adverse Events (CTCAE v4.03).

Results

Thirty-one patients (64.6%) received definitive and 17 (35.4%) adjuvant radiotherapy. Simultaneous chemotherapy was administered in 28 patients (58.3%) with cetuximab as the most commonly used systemic agent (n = 17, 60.7%). After a median time of 17 months (range 4 months to 176 months) between first and second radiotherapy, patients were re-irradiated with a median of 58.4 Gy and a treatment completion rate of 87.5% (n = 42). Median OS was 25 months with a 1-year OS amounting to 62.4%, and median PFS was 9 months with a 1-year PFS of 37.6%. Univariate analyses demonstrated that both a lower rT-status and a radiotherapy boost were associated with improved OS (p < 0.05). There was a trend towards superior OS for patients who received > 50 Gy (p = 0.091) and who completed the prescribed radiotherapy (p = 0.055). Five patients (10.4%) suffered from at least one grade 3 toxicities, while 9 patients (27.3%) experienced chronic higher-grade toxicities (≥ grade 3) with one (3.0%) grade 4 carotid blowout and one (3.0%) grade 4 osteoradionecrosis.

Conclusion

Re-irradiation of recurrent or second primary H&N cancer with modern radiation techniques such as intensity-modulated radiotherapy resulted in promising survival rates with acceptable toxicities compared to historical cohorts. Increased re-irradiation doses, utilization of a radiotherapy boost and completion of the re-irradiation treatment were found to result in improved survival.