Treatment outcomes for human papillomavirus negative oropharyngeal cancer: A meta-analysis

BACKGROUND

Current treatment guidelines for HPV-negative oropharyngeal squamous cell carcinoma (OPSCC), the predominant form of OPSCC in Asia, are largely extrapolated from the evidence available from HPV-associated OPSCC due to a paucity in the literature in terms of the best treatment option for these cancers.

METHODS

Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and clinical trial registries were searched from January 01, 2009 to June 20, 2023 for studies comparing at least two interventions [randomized (RCT)and non-randomized] performed as primary curative treatment in HPV-negative OPSCC. Random effects model was used for the meta-analysis.

RESULTS

Forty-seven studies could be included (randomized controlled trials: 12, 1230 participants; non-randomized cohort studies: 35, 44253 participants). The largest comparison in the non-randomized studies was between upfront surgery and non-surgical intervention [RT/concurrent chemoradiation (CRT)] with 24 studies. The outcomes in the former for overall survival (HR:0.63, 95 %C.I: 0.56, 0.71) and disease-free survival (HR:0.48, 95 %C.I: 0.30, 0.76) were found to be superior (risk of bias: "high" or "serious"). Due to the lack of reporting of treatment-related toxicity and health-related quality of life, meta-analysis could not be performed for these outcomes.

CONCLUSION

and Relevance: Upfront surgery showed superior outcomes in terms of OS and DFS compared with non-surgical modalities in HPV-negative OPSCC, but the observed differences may be due to confounding bias. Toxicity and quality of life reporting was sparse.

P16/HPV-negative oropharyngeal squamous cell carcinoma survival: Comparing primary surgery to primary chemoradiotherapy. A systematic review and meta-analysis

OBJECTIVES

This study investigated differences in survival for p16/HPV-negative OPSCC patients treated with primary surgery versus primary (chemo-)radiation therapy (CRT).

MATERIALS AND METHODS

PubMed, CINAHL and Web of Science databases and the online Cochrane Library were searched for relevant English language studies describing the survival outcomes of p16/HPV-negative OPSCC patients treated with primary surgery or primary CRT. The primary endpoint was the 5-year OS; the secondary endpoints included 5-year DSS and DFS, and 3- and 2-year OS, DSS and DFS. The pooled survival curves were estimated using a distribution-free approach assuming random effects. Cumulative KM curves for OS, DSS and DFS were built for each treatment group.

RESULTS

Twenty-two publications were included in the final analysis. Patients included (n = 1903) were divided according to treatment ("surgery" group, n = 942; "RT/CRT" group, n = 961). For all the endpoints, surgery demonstrated improved short- and long-term survival compared to RT/CRT, although selection bias may have impacted the outcomes. The estimated pooled 5-year OS for the surgery and the RT/CRT group was 54.1 % (95 % CI: 44.4%-65.9 %) and 45.7 % (95 % CI: 41.8%-49.9 %), respectively.

CONCLUSION

Primary surgery and primary CRT for p16/HPV-negative OPSCC both provide acceptable survival outcomes, although in many cases surgery has shown improved survival rates. Further research should focus on when each treatment modality should be used to achieve the goals of treatment completion, survival and functional outcomes.

Loss of LRP1B expression drives acquired chemo and radio-resistance in HPV-positive head and neck cancer

OBJECTIVES

Although human papillomavirus positive (HPV+) oropharyngeal squamous cell carcinoma (OPSCC) patients typically experience excellent survival, 15-20 % of patients recur after treatment with chemotherapy and radiation. Therefore, there is a need for biomarkers of treatment failure to guide treatment intensity.

MATERIALS AND METHODS

Whole genome sequencing was carried out on HPV+OPSCC patients who were primarily treated with concurrent chemotherapy (cisplatin) and radiation. We then explored whether the loss of LRP1Bwas sufficient to drive an aggressive phenotype, and promote a resistance to cisplatin and radiation therapy both in vitro using HPV+ cell lines (93VU147T, UMSCC47, UWO37 and UWO23) and in vivo.

RESULTS

Through integrative genomic analysis of three HPV+OPSCC tumour datasets, we identified that deletion of LRP1B was enriched in samples that recurred following chemo-radiation. Knockdown using siRNA in four HPV+ cell lines (UWO23, UWO37, UMSCC47 and 93VU147T) resulted in increased proliferation of all cases. CRISPR/Cas9 deletion of LRP1B in the same cell line panel demonstrated increased proliferation, clonogenic growth and migration, as well as resistance to both cisplatin and radiation in LRP1B deleted cells compared to their respective non-targeting control cells. Cell line derived xenograft studies indicated that the LRP1B knockout tumours were more resistant to cisplatin and radiation therapy compared to their controls invivo.

CONCLUSION

Taken together, our work implicates LRP1B deletion as a potential biomarker for identifying treatment resistant HPV+ OPSCC cases.

Immune-based classification of HPV-associated oropharyngeal cancer with implications for biomarker-driven treatment de-intensification

BACKGROUND

There is significant interest in treatment de-escalation for human papillomavirus-associated (HPV⁺) oropharyngeal squamous cell carcinoma (OPSCC) patients given the generally favourable prognosis. However, 15-30% of patients recur after primary treatment, reflecting a need for improved risk-stratification tools. We sought to develop a molecular test to risk stratify HPV⁺ OPSCC patients.

METHODS

We created an immune score (UWO3) associated with survival outcomes in six independent cohorts comprising 906 patients, including blinded retrospective and prospective external validations. Two aggressive radiation de-escalation cohorts were used to assess the ability of UWO3 to identify patients who recur. Multivariate Cox models were used to assess the associations between the UWO3 immune class and outcomes.

FINDINGS

A three-gene immune score classified patients into three immune classes (immune rich, mixed, or immune desert) and was strongly associated with disease-free survival in six datasets, including large retrospective and prospective datasets. Pooled analysis demonstrated that the immune rich group had superior disease-free survival compared to the immune desert (HR = 9.0, 95% CI: 3.2-25.5, P = 3.6 × 10^-5) and mixed (HR = 6.4, 95% CI: 2.2-18.7, P = 0.006) groups after adjusting for age, sex, smoking status, and AJCC8 clinical stage. Finally, UWO3 was able to identify patients from two small treatment de-escalation cohorts who remain disease-free after aggressive de-escalation to 30 Gy radiation.

INTERPRETATION

With additional prospective validation, the UWO3 score could enable biomarker-driven clinical decision-making for patients with HPV⁺ OPSCC based on robust outcome prediction across six independent cohorts. Prospective de-escalation and intensification clinical trials are currently being planned.

FUNDING

CIHR, European Union, and the NIH.

Validated algorithms for identifying timing of second event of oropharyngeal squamous cell carcinoma using real-world data

BACKGROUND

Understanding occurrence and timing of second events (recurrence and second primary cancer) is essential for cancer specific survival analysis. However, this information is not readily available in administrative data.

METHODS

Alberta Cancer Registry, physician claims, and other administrative data were used. Timing of second event was estimated based on our developed algorithm. For validation, the difference, in days between the algorithm estimated and the chart-reviewed timing of second event. Further, the result of Cox-regression modeling cancer-free survival was compared to chart review data.

RESULTS

Majority (74.3%) of the patients had a difference between the chart-reviewed and algorithm-estimated timing of second event falling within the 0-60 days window. Kaplan-Meier curves generated from the estimated data and chart review data were comparable with a 5-year second-event-free survival rate of 75.4% versus 72.5%.

CONCLUSION

The algorithm provided an estimated timing of second event similar to that of the chart review.

Human Papillomavirus-Negative Oropharyngeal Cancer Survival Outcomes Based on Primary Treatment: National Cancer Database Analysis

OBJECTIVE

To compare survival outcomes between primary surgery and primary radiation therapy (RT) in patients with human papillomavirus (HPV)-negative oropharyngeal squamous cell carcinoma (OPSCC).

STUDY DESIGN

A retrospective observational cohort study.

SETTING

National Cancer Database.

METHODS

A National Cancer Database review was conducted of 2635 patients with HPV-negative OPSCC who underwent surgery or RT ± chemotherapy between 2010 and 2014. Univariate analysis was performed on all variables and entered into a multivariate model. The main outcome was overall survival (OS).

RESULTS

A total of 2635 patients with HPV-negative OPSCC were organized into 4 groups based on cancer staging. In group 1 (T1-2 N0-1; n = 774), up-front surgery had significantly better 5-year OS (76.2%) than RT (56.8%; adjusted hazard ratio [aHR], 1.76; P = .009; 95% CI, 1.15-2.69) and chemoradiation therapy (CRT; 69.5%; aHR, 1.56; P = .019; 95% CI, 1.08-2.26). In group 2 (T3-4 N0-1; n = 327), no significant difference existed between surgery and CRT (5-year OS, 51.3% vs 52.4%; aHR, 0.96; P = .88; 95% CI, 0.54-1.69). In group 3a (T1-2 N2-3; n = 807), surgery with adjuvant treatment showed significantly better 5-year OS than CRT (78.6% vs 68.8%; aHR, 1.51; P = .027; 95% CI, 1.05-2.18). In group 3b (T3-4 N2-3; n = 737), surgery with adjuvant treatment was not statistically associated with better 5-year OS as compared with CRT (61.0% vs 43.7%; aHR, 1.53; P = .06; 95% CI, 0.98-2.39).

CONCLUSION

Primary surgery may provide improved survival outcomes in many cases of HPV-negative OPSCCs. These data should be used in weighing treatment options and may serve as a basis to better delineate treatment algorithms for HPV-negative disease.

Revisiting the Radiation Therapy Oncology Group 1221 Hypothesis: Treatment for Stage III/IV HPV-Negative Oropharyngeal Cancer

OBJECTIVE

In 2014, the Radiation Therapy Oncology Group 1221 trial was initiated to analyze whether surgery with risk-based radiation therapy or chemoradiation therapy was superior to chemoradiation therapy alone in patients with clinically staged T1-2N1-2bM0 HPV-negative oropharyngeal squamous cell carcinoma. However, the study was prematurely terminated. Given the lack of a randomized controlled trial, we retrospectively approached the same question using large national cancer databases.

STUDY DESIGN

Retrospective cohort study.

SETTING

The National Cancer Database and Surveillance, Epidemiology, and End Results (SEER) program from 2010 to 2016.

METHODS

We identified 3004 patients in the National Cancer Database and 670 patients in the SEER database. Statistical techniques included Kaplan-Meier survival analysis, binary and multinomial logistic regressions, Cox proportional hazard regressions, and inverse propensity score weighting.

RESULTS

On weighted multivariable Cox regression, patients recommended to receive frontline surgery had improved overall survival as compared with those recommended to receive chemoradiation therapy alone (hazard ratio [HR], 0.77; 95% CI, 0.68-0.86). On post hoc multivariable analysis based on therapy actually received, frontline surgery with adjuvant chemoradiation therapy was associated with improved overall survival (HR, 0.59; 95% CI, 0.50-0.71) as compared with chemoradiation therapy without surgery. Analysis of the SEER cohort revealed improved overall survival (HR, 0.69; 95% CI, 0.54-0.87) and head and neck cancer-specific survival (HR, 0.59; 95% CI, 0.41-0.84) in patients recommended to receive frontline surgery over chemoradiation therapy alone.

CONCLUSION

Our findings support the use of surgery with risk-based addition of adjuvant therapy in patients with cT1-2N1-2bM0 HPV-negative oropharyngeal cancer.

Association of p16 as Prognostic Factors for Oropharyngeal Cancer: Evaluation of p16 in 1470 Patients for a 16 Year Study in Northeast China

Human papillomavirus (HPV) is an etiological risk factor for oropharyngeal squamous cell carcinomas (OPSCC). Our study investigates the prevalence, prognostic, and clinicopathologic features of HPV-related oropharyngeal cancer in Northeast China and elucidates the involvement of p16 in the tumorigenesis and progression of OPSCC. Specimens from 1470 OPSCC patients collected from 2000 to 2016 were analyzed using the status of HPV by polymerase chain reaction (PCR) and p16 immunohistochemistry. Overexpression of p16 was observed in 81 (5.51%) of the 1470 cases, and HPV positive was present in 78 cases (5.31%) of the 1470 cases. HPV positive and p16 overexpression have a good concordance. However, we found that the etiological fraction of HPV in cancers of the OPSCCs was obviously lower in Northeast China than other cohorts previously reported. Interestingly, nearly 89% of patients with p16 expression were smokers, and nearly 70% of patients with p16 expression had a history of alcohol. Our study also demonstrates that p16 expression is significantly associated with early stage primary OPSCCs and the patients with p16 expression tend to show better survival following surgery and radiotherapy.