Treatment tolerability and outcomes in elderly patients with head and neck cancer

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.

Adjuvant Reirradiation With Proton Therapy in Head and Neck Squamous Cell Carcinoma

Purpose

For patients with head and neck squamous cell carcinoma (HNSCC), locoregional failure and second primary tumors are common indications for adjuvant reirradiation (re-RT). Given an absence of clear consensus on the role of adjuvant re-RT, we sought to assess histopathologic risk factors of patients with HNSCC and their resulting outcomes after adjuvant re-RT with proton therapy.

Methods and Materials

We conducted a retrospective analysis of patients with HNSCC who underwent salvage surgery at our institution followed by adjuvant re-RT with proton therapy over 1.5 years. All included patients received prior radiation therapy. The Kaplan-Meier method was used to evaluate locoregional recurrence-free survival and overall survival.

Results

The cohort included 22 patients, with disease subsites, including oropharynx, oral cavity, hypopharynx, larynx, and nasopharynx. Depending on adverse pathologic features, adjuvant re-RT to 66 Gy (32% of cohort) or 60 Gy (68%), with (59%) or without (41%) concurrent systemic therapy was administered. The majority (86%) completed re-RT with no reported treatment delay; 3 patients experienced grade ≥3 acute Common Terminology Criteria for Adverse Events toxicity and no patient required enteral feeding tube placement during re-RT. Median follow-up was 21.0 months (IQR, 11.7-25.2 months). Five patients had biopsy-proven disease recurrences a median of 5.9 months (IQR, 3.8-9.7 months) after re-RT. Locoregional recurrence-free survival was 95.2%, 70.2%, 64.8% at 6, 12, and 24 months, respectively. OS was 100%, 79.2%, and 79.2% at 6, 12, and 24 months, respectively. Four patients had osteoradionecrosis on imaging a median of 13.2 months (IQR, 8.7-17.4 months) after re-RT, with 2 requiring surgical intervention.

Conclusions

Adjuvant re-RT for patients with HNSCC was well-tolerated and offered reasonable local control in this high-risk cohort but appears to be associated with a risk of osteoradionecrosis. Additional study and longer follow-up could help define optimal patient management in this patient population.

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.

Nonsurgical Treatment Strategies for Elderly Head and Neck Cancer Patients: An Emerging Subject Worldwide

Consistent with the increasing rate of head and neck cancers among elderly adults, there has been an increase in the rate of those receiving nonsurgical treatments to maintain their function and quality of life. However, various problems, such as poor tolerance to chemoradiotherapy-related toxicity, are of greater concern in elderly adults than in younger individuals. In this review, we describe adverse events that should be particularly noted in elderly patients and provide an overview of countermeasures in nonsurgical treatments. We mainly focus on cisplatin-based chemoradiotherapy-the primary treatment for head and neck squamous cell carcinoma (HNSCC). Furthermore, we review the molecular targeted drugs and immune checkpoint inhibitors for elderly patients with HNSCC. Although the number of older patients is increasing worldwide, clinical trials aimed at determining the standard of care typically enroll younger or well-conditioned elderly patients. There is still very little evidence for treating elderly HNSCC older patients, and the question of optimal treatment needs to be explored.

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.

Optimizing the prescription doses and tolerability of systemic therapy in head and neck cancer patients

PURPOSE OF REVIEW

Squamous cell carcinoma of the head and neck accounts for 330 000 deaths and 650 000 cases worldwide annually. Systemic therapy is an essential pillar of multimodal therapy despite being accompanied with substantial toxicity. This article reviews the latest advances in systemic therapy for the treatment of locoregionally advanced and reccurent/metastatic head and neck cancer from a tolerability perspective.

RECENT FINDINGS

Multiple recent attempts have been made to optimize tolerability (and efficacy) of systemic therapy utilizing new regimens, modified prescription doses, drugs such as immunotherapies or genotyping to tailor the systemic therapy to the individual patient.

SUMMARY

Although treatment benefit has to be weighed against potential toxicity, it is reasonable to anticipate potential side effects of systemic therapies. In a vulnerable elderly or Asian patient population upfront dose modifications of cytotoxic chemotherapies might be reasonable. Special attention should be laid on the patient's nutritional status and early intervention recommended. Dihydropyrimidine dehydrogenase genotyping can predict 5-fluorouracil toxicity and identify patients for whom alternative regimens are more suitable. As for immune checkpoint inhibitor therapy, despite being well tolerated, the identification of biomarkers to predict reduced tolerability or severe toxicity would be highly desirable.

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.

Use of the comprehensive geriatric assessment for the prediction of postoperative complications in elderly patients with head and neck cancer

BACKGROUND

To determine the efficacy of preoperative Comprehensive Geriatric Assessment (CGA) in predicting postoperative complications in elderly patients undergoing head and neck cancer surgery.

METHODS

Medical records of patients aged ≥70 who underwent elective head and neck cancer surgery were reviewed. CGA scores were prospectively collected prior to surgery and analyzed to determine their association with postoperative complications.

RESULTS

Of the 65 patients enrolled in this study, 34 (52.3%) with deficits in two or more preoperative CGA domains were categorized as "frail." Fourteen patients (21.5%) experienced postoperative complications. Age was not a risk factor for the complications (p = 0.504). The multivariate analysis indicated that major postoperative complications were significantly associated with frailty (odds ratio [OR] = 21.9, p = 0.039), operation time (OR = 39, p = 0.048), and estimated blood loss (OR = 19.8, p = 0.043).

CONCLUSIONS

Frailty assessed by preoperative CGA, but not chronological age, was significantly associated with major postoperative complications in elderly patients undergoing head and neck cancer surgery.

Emergent tracheostomy during the pandemic of COVID-19: Slovenian National Recommendations

PURPOSE

Emergent tracheostomy under local anaesthesia is a reliable method of airway management when orotracheal intubation is not possible. COVID-19 is spread through aerosol making the emergent tracheostomy a high-risk procedure for surgeons. The surgical establishment of the air conduit in emergency scenarios must be adjusted for safety reasons.

METHODS

To establish the Slovenian National Guidelines for airway management in cannot intubate-cannot ventilate situations in COVID-19 positive patients.

RESULTS

Good communication and coordination between surgeon and anaesthesiologist is absolutely necessary. Deep general anaesthesia, full muscle relaxation and adequate preoxygenation without intubation are initial steps. The surgical cricothyrotomy is performed quickly, the thin orotracheal tube is inserted, the cuff is inflated and ventilation begins. Following patient stabilisation, the conversion to the tracheostomy is undertaken with the following features: skin infiltration with vasoconstrictor, a vertical incision, avoidance of electrical devices in favour of classical manners of haemostasis, the advancement of the tube towards the carina, performing the tracheal window in complete apnoea following adequate oxygenation, the insertion of non-fenestrated canulla attached to a heat and moisture exchanger, the fixation of canulla with stitches and tapes, and the cricothyrotomy entrance closure. Appropriate safety equipment is equally important.

CONCLUSION

The goal of the guidelines is to make the procedure safer for medical teams, without harming the patients. Further improvements of the guidelines will surely appear as COVID-19 is a new entity and there is not yet much experience in handling it.

Impact of the SARS-CoV-2 pandemic on ophthalmic care in Germany

Background

Survey by the commission for cross-sectoral ophthalmology, as a joint commission of the German Ophthalmological Society (DOG) and the Professional Association of German Ophthalmologists (BVA) on the effects of the SARS-CoV‑2 pandemic on ophthalmological patient care in Germany.

Methods

Online-based survey.

Results

A total of 1190 questionnaires were (partly) answered. With respect to outpatient care and consultations from 15 March to 15 April 2020, a total of 69 (5.8%) participants indicated unlimited, 756 (63.5%) reduced and 330 (27.7%) emergency care only, independent of the type of institution. Outpatient surgery was restricted to emergency surgery in 68% of clinics, 42.0% of inpatient wards, 45.0% of surgical medical care centers and group practices and 33.0% of private practices. Inpatient procedures were limited to emergency care in 75.0% of inpatient wards and in 71.0% of clinics. With the exception of endophthalmitis (+8.2%), the number of urgent indications and emergencies declined: retinal detachment (−34.8%), perforating eyeball injuries (−7.3%), acute glaucoma (−17.8%), central retinal artery occlusion and anterior ischemic optic neuropathy (−31.0%), others (−30.9%), penetrating keratoplasty and amniotic membrane transplantation (−59.1%). Institutional or professional policy requirements (76.0%) and appointment cancellation by patients (84.0%) were the most common reasons for limitations in ophthalmic patient care.

Conclusion

The initial phase of the pandemic was characterized by a massive reduction in non-urgent conservative and surgical treatment that affected all areas of ophthalmology. Due to intensive care capacities required for COVID-19 patients, inpatient treatment was largely restricted to emergencies. Treatment of ophthalmological patients, including ocular emergencies and urgent treatment, was maintained across all sectors with a (considerable) decrease in the number of cases even in these groups.