Nomogram to Predict Risk of Early Mortality Following Definitive or Adjuvant Radiation and Systemic Therapy for Head and Neck Cancer

PURPOSE/OBJECTIVE(S)

Tools to predict individual patient risk for early mortality in head and neck cancer patients receiving chemoradiation are lacking. We sought to create a nomogram to predict individual risk of early mortality, which may help identify patients who require interventions to prevent early death.

MATERIALS/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 either the definitive or adjuvant setting. Covariates analyzed in the cohort include race, gender, income, age, T and N category, tumor site, insurance type, facility type, urban or rural environment, radiation modality, and comorbidity. Early mortality was defined as any death less than 90 days after the beginning of radiation. Chi-squared analysis was used for all categorical covariates and t-tests were used for continuous variables to test for associations with early mortality. 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

The final cohorts included 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%) in the definitive and adjuvant cohorts, 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); while in the definitive group, radiation type, year of diagnosis, and insurance status were also statistically significant (p<0.05). In both cohorts, nomograms were created to predict the risk of early mortality that included age, comorbidity, T and N category and tumor site. The nomogram 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.

Effectiveness of Cisplatin in P16+ Oropharyngeal Cancer According to Relative Risk for Cancer Events: Ancillary Analysis of RTOG 1016

PURPOSE/OBJECTIVE(S)

To test the hypothesis that the effectiveness of cisplatin in p16+ oropharyngeal squamous cell carcinoma (OPSCC) increases with patients' relative risk for cancer events.

MATERIALS/METHODS

Ancillary analysis of 805 patients enrolled on RTOG 1016 accessed via Project DataSphere. Eligible patients had p16+ OPSCC, AJCC 7th T1-T2 N2a-N3 or T3-T4 N0-N3 M0, ECOG PS 0-1. Patients were randomized to RT with concurrent cisplatin vs. cetuximab. Relative risk for competing events was quantified using the Head and Neck Cancer Intergroup predictive classifier (omega score). Higher scores indicate higher relative risk for cancer events (LRF or distant metastasis) vs. competing mortality. We compared this to favorable, unfavorable/low, and unfavorable/intermediate risk groups using standard criteria: NRG HN005 eligible/low RTOG risk (Ang et al.), HN005 ineligible/low RTOG risk, and intermediate RTOG risk. Omega score cutoffs were selected to match numbers in standard risk strata. HRs for the effect of cisplatin vs. cetuximab on PFS and OS were compared for standard vs. relative risk strata. 1-tailed interaction tests were used to test whether cisplatin effectiveness increased within risk strata.

RESULTS

There were 354, 219, and 232 patients in standard favorable, unfavorable/low, and unfavorable/intermediate risk groups. Omega score cutoffs were 0.80 and 0.84 to define low, intermediate, and high relative risk groups. Discordant standard vs. relative risk classifications occurred in 559 patients (69.4%). Increasing omega score was associated with significantly higher relative HR (rHR) for cancer events (3.40, 95% CI: 1.66-6.96) and increasing effectiveness of cisplatin vs. cetuximab (Table), but standard risk grouping was not (rHR 0.80, 95% CI: 0.49-1.32). The effect of cisplatin on PFS significantly increased with higher omega score (interaction -0.30, p = .046), but decreased with increasing standard risk strata (interaction +0.27, p = NS).

CONCLUSION

The effectiveness of cisplatin in p16+ OPSCC increased with higher omega score but not with standard risk group. Relative risk for cancer events should be taken into account when designing deintensification strategies.

Comparison of Standard vs. Relative Risk Models to Define Candidates for Deintensification in Locoregionally Advanced P16+ Oropharyngeal Cancer

PURPOSE/OBJECTIVE(S)

Various methods to identify candidates for treatment deintensification with p16+ oropharyngeal squamous cell carcinoma (OPSCC) have been used, but the optimal approach is unknown.

MATERIALS/METHODS

Multi-institutional cohort study of 385 patients with previously untreated p16+ OPSCC undergoing definitive radiotherapy (RT) with or without systemic therapy between 2009-2020. Chemotherapy intensity was categorized as high (bolus cisplatin and/or induction chemotherapy), medium (weekly cisplatin), or low (non-cisplatin or RT alone). Standard favorable vs. unfavorable risk was defined using NRG HN005 eligibility criteria. High vs. low relative risk (RR) group was defined using the HNCIG omega score (≥ 0.80 vs. < 0.80), which quantifies the proportion of a patient's overall event risk due to cancer. We used multivariable ordinal logistic regression to estimate effects of age (yrs), sex, performance status (PS), Charlson comorbidity index (CCI), T/N (AJCC 8th), current smoking, and pack-years (> 10 vs. ≤ 10) on treatment allocation. Effects on relative event hazards were estimated using generalized competing event regression.

RESULTS

Median follow-up time was 44.2 months. Chemotherapy intensity was high in 206 (54%), medium in 108 (28%), and low in 71 (18%). 280 patients (73%) were unfavorable risk and 197 (51%) were high RR. 178 patients (46%) had discordant risk classification. On univariable analysis, significant predictors of higher intensity chemotherapy (normalized odds ratio (OR)) were CCI 0-1 (OR 1.49, 95% CI: 1.23-1.79), high omega score (OR 1.46; 1.20-1.77), decreased age (OR 1.43; 1.18-1.74), and PS 0 (OR 1.22; 1.01-1.48). Controlling for CCI, higher omega score was associated with significantly higher odds of intensive chemotherapy (OR 1.35; 1.10-1.65, but unfavorable risk (HN005 ineligibility) was not (OR 1.19; 0.98-1.44). Higher omega score was also associated with significantly higher RR for cancer recurrence (Rec) vs. competing mortality (CM) events (relative HR (rHR) 1.76; 1.12-2.75), but unfavorable risk was not (rHR 1.05; 0.63-1.75). Among patients receiving cisplatin, 50 favorable risk patients (58%) had high RR; all of their event risk was due to cancer recurrence (Table). The 110 unfavorable risk patients (48%) with low omega score had significantly lower RR for cancer events compared to the high omega score group (rHR 0.49; 0.29-0.84).

CONCLUSION

Many patients with favorable risk p16+ OPSCC have high relative risk for cancer events, which correlates with a benefit of intensive treatment. The HNCIG omega score is a strong predictor of allocation to intensive chemotherapy and may help identify candidates for deintensification.

Characterization of Antibody Repertoires in Patients with HPV-Related HNSCC Undergoing Definitive Radiation with Immunotherapy

PURPOSE/OBJECTIVE(S)

Integrating immune checkpoint inhibitor (ICI) immunotherapy agents into the definitive treatment of head and neck squamous cell carcinoma (HNSCC) has been challenging. It is apparent that understanding how these therapies affect specific components of the immune response is critical to improve outcomes. The role of B cells has been increasingly recognized, especially in HPV+ HNSCC. As antibodies are one of the chief downstream products of B cells, we sought to evaluate the antibody repertoires of patients with HPV+ HNSCC undergoing definitive radiation therapy (RT) and ICI (RT-ICI).

MATERIALS/METHODS

Serum samples from patients with p16+ HNSCC undergoing RT-ICI were collected for the KEYCHAIN clinical trial (NCT03383094). We analyzed 8 samples from 4 patients collected pre-treatment and 3 months following treatment using the HuProt Human Proteome Microarray, which samples >20,000 human proteins. Genes encoding surface proteins (GESPs) were obtained from The Cancer Surfaceome Atlas. Mutational data were obtained from AACR Project GENIE. For murine studies, C3H mice were injected with 5x105 cells of AT-84-E7-OVA syngeneic SCC into the right flank. Anti-PD-L1 ICI (aPD-L1) was given via intraperitoneal injection every 3 days for 3 doses. RT was 12 Gy in 1 fraction. Cell surface markers in lymph nodes (LNs) were analyzed by flow cytometry.

RESULTS

In total, we detected antibodies against 10959 unique antigens in the pre-treatment serum, of which 14% and 11% were shared by 3 and 4 patients, respectively. Following completion of RT-ICI, we detected antibodies against 11019 unique antigens, of which 20% and 18% were shared by 3 and 4 patients, respectively. Of these, 5824 (53%) antigens were not detected in the pre-treatment serum, and therefore represent antibodies against "newly detected" antigens. We found 777 antigens that were newly detected and shared by at least 2 patients. Analysis of these antigens revealed enrichment in pathways such as, "response to oxygen levels." We next found that 114 (14.7%) of these represented GESPs. We integrated mutational analysis of the most frequently mutated genes in >1,800 HNSCC samples and found 2/114 GESPs were shared. Using a murine model of HPV+ HNSCC, we found that treatment with RT and aPD-L1 led to the greatest frequency of germinal center (GC) B cells in tumor-draining and non-tumor-draining LNs.

CONCLUSION

In patients with p16-positive HNSCC, proteomic analysis of antibody repertoires revealed many antigens against which antibodies were formed during RT-ICI that are shared between patients. Intriguingly, GC formation, which is the nidus for B cell responses, in locoregional LNs was greatest with RT-ICI. These findings support the further investigation of B-cell mediated responses in HPV+ HNSCC.

Advances in External Beam Radiation Therapy and Brachytherapy for Cervical Cancer

The standard of care for the definitive treatment of locoregionally advanced cervical cancer is external beam radiation therapy (EBRT) with concurrent chemotherapy followed by a brachytherapy boost. Historically, EBRT was delivered via a two-dimensional technique based primarily on bony landmarks. This gave way to three-dimensional conformal radiation therapy, which allows for dose calculation and adjustment based on individual tumour and patient anatomy. Further technological advances have established intensity-modulated radiation therapy (IMRT) as a standard treatment modality, given the ability to maintain tumoricidal doses to target volumes while reducing unwanted radiation dose to nearby critical structures, thereby reducing toxicity. Routine image guidance allows for increased confidence in patient alignment prior to treatment, and the ability to visualise the daily position of the targets and organs at risk has been instrumental in allowing safe reductions in treated volumes. Additional EBRT technologies, including proton therapy and stereotactic body radiation therapy, may further improve the therapeutic index. In the realm of brachytherapy, a shift from point-based dose planning to image-guided brachytherapy has been associated with improved local control and reduced toxicity, with additional refinement ongoing. Here we will discuss these advances, the supporting data and future directions.

Variation in clinician recommendations for multiple injections during adoption of inactivated polio vaccine

OBJECTIVES

To describe variation in clinician recommendations for multiple injections during the adoption of inactivated poliovirus vaccine (IPV) in 2 large health maintenance organizations (HMOs), and to test the hypothesis that variation in recommendations would be associated with variation in immunization coverage rates.

DESIGN

Cross-sectional study based on a survey of clinician practices 1 year after IPV was recommended and computerized immunization data from these clinicians' patients. STUDY SETTINGS: Two large West Coast HMOs: Kaiser Permanente in Northern California and Group Health Cooperative of Puget Sound.

OUTCOME MEASURES

Immunization status of 8-month-olds and 24-month-olds cared for by the clinicians during the study.

RESULTS

More clinicians at Group Health (82%), where a central guideline was issued, had adopted the IPV/oral poliovirus vaccine (OPV) sequential schedule than at Kaiser (65%), where no central guideline was issued. Clinicians at both HMOs said that if multiple injections fell due at a visit and they elected to defer some vaccines, they would be most likely to defer the hepatitis B vaccine (HBV) for infants (40%). At Kaiser, IPV users were more likely than OPV users to recommend the first HBV at birth (64% vs 28%) or if they did not, to defer the third HBV to 8 months or later (62% vs 39%). In multivariate analyses, patients whose clinicians used IPV were as likely to be fully immunized at 8 months old as those whose clinicians used all OPV. At Kaiser, where there was variability in the maximum number of injections clinicians recommended at infant visits, providers who routinely recommended 3 or 4 injections at a visit had similar immunization coverage rates as those who recommended 1 or 2. At both HMOs, clinicians who strongly recommended all possible injections at a visit had higher immunization coverage rates at 8 months than those who offered parents the choice of deferring some vaccines to a subsequent visit (at Kaiser, odds ratio [OR]: 1.2; 95% confidence interval [CI]: 1.0-1.5; at Group Health, OR: 1.8; 95% CI: 1.1-2.8).

CONCLUSIONS

Neither IPV adoption nor the use of multiple injections at infant visits were associated with reductions in immunization coverage. However, at the HMO without centralized immunization guidelines, IPV adoption was associated with changes in the timing of the first and third HBV. Clinical policymakers should continue to monitor practice variation as future vaccines are added to the infant immunization schedule.

Impact of the change in polio vaccination schedule on immunization coverage rates: a study in two large health maintenance organizations

OBJECTIVE

In January 1997, one of the most significant changes to United States vaccine policy occurred when polio immunization guidelines changed to recommend a schedule containing inactivated polio vaccine (IPV). There were concerns that parent or physician reluctance to accept IPV into the routine childhood immunization schedule would lead to lowered coverage. We determined whether adoption of an IPV schedule had a negative impact on immunization coverage.

DESIGN

A cohort study of 2 large health maintenance organizations (HMOs), Group Health Cooperative and Kaiser Permanente Northern California, was conducted. For analysis at 12 months of age, children who were born between October 1, 1996, and December 31, 1997, and were commercially insured and covered by Medicaid were continuously enrolled; for analysis at 24 months of age, children who were born between October 1, 1996, and June 30, 1997, and were commercially insured and covered by Medicaid were continuously enrolled. The 3 measures of immunization status at 12 and 24 months of age were up-to-date status, cumulative time spent up-to-date, and the number of missed opportunity visits.

RESULTS

At both HMOs, children who received IPV were as likely to be up to date at 12 months as were children who received oral poliovirus vaccine (OPV), whereas at Group Health, children who received IPV were slightly more likely to be up to date at 24 months (relative risk: 1.12; 95% confidence interval [CI]: 1.05, 1.19). These findings were consistent for children who were covered by Medicaid. At Kaiser Permanente, children who received IPV spent ~3 fewer days up to date in the first year of life, but this difference did not persist at 2 years of age. At Group Health, children who received IPV were no different from those who received OPV in terms of days spent up to date by 1 or 2 years of age. At Group Health, children who received IPV were less likely to have a missed opportunity by 12 months old (odds ratio [OR] 0.46; 95% CI: 0.31, 0.70), but this finding did not persist at 24 months of age. At Kaiser Permanente, children who received IPV were more likely to have a missed opportunity by 12 months (OR 2.06; 95% CI: 1.84, 2.30), and 24 months of age (OR 1.50; 95% CI: 1.36, 1.67).

CONCLUSIONS

The changeover from an all-OPV schedule to one containing IPV had little if any negative impact on vaccine coverage. Use of IPV was associated with a small increase in the likelihood of being up to date at 2 years of age at one of the HMOs and conversely was associated with a small increase in the likelihood of having a missed-opportunity visit in the other HMO.polio, poliomyelitis, vaccination, immunization coverage.