Prolongation of definitive head and neck cancer radiotherapy: Survival impact and predisposing factors

Trends and predictors of unplanned hospitalization among oral and oropharyngeal cancer patients; an 8-year population-based study

PURPOSE

The incidence of oral cancers, particularly HPV-related oropharyngeal cancer, is steadily increasing worldwide, presenting a significant healthcare challenge. This study investigates trends and predictors of unplanned hospitalizations for oral cavity cancer (OCC) and oropharyngeal cancer (OPC) patients in the province of Alberta, Canada.

METHODS

This retrospective, population-based, cohort study used administrative data collected from all hospitals in the province. Using the Alberta Cancer Registry (ACR), a cohort of adult patients diagnosed with a single primary OCC or OPC between January 2010 and December 2017 was identified. Linking this cohort with the Discharge Abstract Database (DAD), trends in hospitalizations, primary diagnoses, and predictors of unplanned hospitalization (UH) and 30-day unplanned readmission were analyzed.

RESULTS

Of 1,721 patients included, 1,244 experienced 2,228 hospitalizations, with 48 % being categorized as UH. The UHs were significantly associated with a higher mortality rate, 18.5 % as compared to 4.6 % for planned, and influenced by sex, age groups, comorbidities, cancer types, stages, and treatment modalities. The rate of UH per patient decreased from 0.69 to 0.54 visits during the study period (P = 0.02). Common diagnoses for UH were palliative care and post-surgical convalescence, while surgery-related complications such as infection and hemorrhage were frequent in 30-day unplanned readmissions. Predictors of UH included cancer stage, material deprivation, and treatment, while cancer type and comorbidity predicted readmissions.

CONCLUSION

The rate of UHs showed a noteworthy decline in this study, which could be a result of enhanced care coordination. Furthermore, identified primary diagnosis and predictors associated with UHs and readmissions, provide valuable insights for enhancing the quality of care for cancer patients.

Chemoradiation with Cisplatin vs. Carboplatin for Squamous Cell Carcinoma of the Head and Neck (SCCHN)

Cisplatin is the standard for the chemoradiation of squamous cell carcinoma of the head and neck (HNSCC). Many patients cannot receive cisplatin due to impaired renal function. This study investigated carboplatin as an alternative option. In total, 131 patients assigned to two courses of cisplatin (20 mg/m²/d1--5 or 25 mg/m²/d1-4) were matched to 45 patients not suitable for cisplatin and receiving carboplatin (AUC 1.0/d1-5 or AUC 1.5/d1-4). The endpoints included loco-regional control (LRC), metastases-free survival (MFS), overall survival (OS), toxicities, and the completion of chemotherapy. The patients in the carboplatin group were significantly older and had more G3 tumors. Otherwise, the baseline characteristics were balanced. The LRC rates at 2 and 3 years were 77% and 76% in the cisplatin group vs. 69% and 65% in the carboplatin group (p = 0.21). The MFS rates were 83% and 78% vs. 78% and 74% (p = 0.34) and the OS rates 83% and 79% vs. 83% and 75% (p = 0.64), respectively. The outcomes were not significantly different in the subgroups receiving definitive or adjuvant chemoradiation. No significant differences were found regarding toxicities. Non-significantly more patients in the carboplatin group completed their chemotherapy (78% vs. 66%, p = 0.15). Carboplatin was associated with similar outcomes and toxicities as cisplatin, although these patients had worse renal function, more aggressive tumors, and were older. Given the limitations of this study, carboplatin appears an option for patients not suitable for cisplatin.

The dental management of patients irradiated for head and neck cancer

Patients undergoing radiotherapy for head and neck cancers are prone to a range of dental complications, including mucositis, trismus, xerostomia, radiation caries and osteoradionecrosis. Specific considerations include the preventive, restorative and rehabilitative management of such patients, and the prevention and treatment of complications. This article aims to highlight the current understanding and management of dental needs for patients who have had or will undergo radiotherapy.

Investigating Predictive Factors of Dysphagia and Treatment Prolongation in Patients with Oral Cavity or Oropharyngeal Cancer Receiving Radiation Therapy Concurrently with Chemotherapy

Radiation therapy (RT) treatment for head and neck cancer has been associated with dysphagia manifestation leading to worse outcomes and decrease in life quality. In this study, we investigated factors leading to dysphagia and treatment prolongation in patients with primaries arising from oral cavity or oropharynx that were submitted to radiation therapy concurrently with chemotherapy. The records of patients with oral cavity or oropharyngeal cancer that received RT treatment to the primary and bilateral neck lymph nodes concurrently with chemotherapy were retrospectively reviewed. Logistic regression models were used to analyze the potential correlation between explanatory variables and the primary (dysphagia ≥ 2) and secondary (prolongation of total treatment duration ≥ 7 days) outcomes of interest. The Toxicity Criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC) were used to evaluate dysphagia. A total of 160 patients were included in the study. Age mean was 63.31 (SD = 8.24). Dysphagia grade ≥ 2 was observed in 76 (47.5%) patients, while 32 (20%) experienced treatment prolongation ≥ 7 days. The logistic regression analysis showed that the volume in the primary site of disease that received dose ≥ 60 Gy (≥118.75 cc, p < 0.001, (OR = 8.43, 95% CI [3.51-20.26]) and mean dose to the pharyngeal constrictor muscles > 40.6 Gy (p < 0.001, OR = 11.58, 95% CI [4.84-27.71]) were significantly associated with dysphagia grade ≥ 2. Treatment prolongation ≥ 7 days was predicted by higher age (p = 0.007, OR = 1.079, 95% CI [1.021-1.140]) and development of grade ≥ 2 dysphagia (p = 0.005, OR = 4.02, 95% CI [1.53-10.53]). In patients with oral cavity or oropharyngeal cancer that receive bilateral neck irradiation concurrently with chemotherapy, constrictors mean dose and the volume in the primary site receiving ≥ 60 Gy should be kept below 40.6 Gy and 118.75 cc, respectively, whenever possible. Elderly patients or those that are considered at high risk for dysphagia manifestation are more likely to experience treatment prolongation ≥ 7 days and they should be closely monitored during treatment course for nutritional support and pain management.

A review of unplanned admissions in head and neck cancer patients undergoing oncological treatment

AIM

Non-surgical treatment for head and neck cancer (HNC) often results in severe toxicities, which are detrimental to a patient's health and quality of life. There is limited published UK data on unplanned hospital admissions and reasons associated with admission. We aim to identify frequencies and reasons for unplanned hospital admissions, highlighting those patient groups who are most vulnerable.

METHODS

A retrospective study of unplanned hospital admissions of HNC patients receiving non-surgical treatment was completed. An inpatient admission was defined as ≥ 1 night spent in the hospital. To test potential demographic and treatment predictors of inpatient admission, a multiple regression model was constructed using the endpoint measure (unplanned admission), as the dependent variable.

RESULTS

A cohort of 216 patients was identified over a 7-month period, and 38 of these patients (17%) required an unplanned admission. Treatment type was the only statistically significant predictor of in-patient admission. The majority of admissions were patients receiving chemoradiotherapy (CRT) (58%) with predominant reasons for admission being nausea and vomiting (25.5%) and decreased oral intake/dehydration (30%). Of the patients admitted, 12 had a prophylactic PEG placed pre-treatment, and 18 of 26 admitted without prophylactic PEG required nasogastric tube feeding during their admission.

DISCUSSION

Almost one-fifth of HNC patients over this time period required hospital admission; the majority of which can be attributed to treatment toxicities when receiving CRT. This is concurrent with other studies which review the impact of radiotherapy versus CRT. Increased support and monitoring, particularly focused on nutrition, are required for patients with HNC who receive CRT.

KEY MESSAGE

This article describes a retrospective review of a patient undergoing non-surgical treatment for head and neck cancer. These patients frequently require unplanned hospital admission. The results indicate that patients undergoing (chemo)radiotherapy are most vulnerable to deterioration and additional support focused on nutrition for these patients is indicated.

Active Immune Phenotype in Head and Neck Cancer: Reevaluating the Iso-Effect Fractionation Based on the Linear Quadratic (LQ) Model-A Narrative Review

Altered fractionation concepts and especially moderate hypo-fractionation are evaluated as alternatives to standard treatment for head and neck squamous cell carcinoma (HNSCC), associated with or not concurrent with or sequential to chemotherapy. The calculation of the iso-equivalent dose regimens has as its starting point the linear quadratic (LQ) formalism traditionally based on the "4Rs" of radiobiology. The higher rates of therapeutic failure after radiotherapy of HNSCC are associated with the heterogeneity of radio-sensibility. The identification of genetic signatures and radio-resistance scores aims to improve the therapeutic ratio of radiotherapy and to conceptualize personalized fractionation schemes. The new data regarding the involvement of the sixth "R" of radiobiology in HNSCC, especially for the HPV-driven subtype, but also for the "immune active" minority of HPV-negative HNSCCs, bring to the fore a multifactorial variation of the α/β ratio. The involvement of the antitumor immune response and the dose/fractionation/volume factors as well as the therapeutic sequence in the case of new multimodal treatments including immune checkpoint inhibitors (ICIs) could be included as an additional term in the quadratic linear formalism especially for hypo-fractionation regimens. This term should take into account the dual immunomodulatory effect (immunosuppressant and stimulator of antitumor immunity) of radiotherapy, which varies from case to case and can bring benefit or a detrimental effect.

Enteral Nutrition during Radiotherapy for Oropharyngeal Cancers: Prevalence and Prognostic Factors Based on HPV Status (A GETTEC Study)

Nutritional support during radiotherapy is crucial to tolerating and completing oropharyngeal squamous cell carcinoma (OPSCC) treatment. The impact of HPV status on nutritional support is debated. The objective was to evaluate the rate of Reactive Feeding Tube (RFT) use and determine its prognostic factors during definitive radiotherapy for OPSCC. All OPSCC patients treated from 2009 to 2014 were included in this multicentric retrospective study. The impact of tumor p16 status on the risk of RFT was assessed through multivariate analyses. Among the 543 patients, 103 patients required an RFT (19.0%). The use of RFT differed between centers (5% to 32.4%). In multivariate analysis, only tongue base involvement and concurrent chemotherapy were significantly associated with RFT (OR = 2.18 and 3.7, respectively). Tongue base involvement and concomitant chemotherapy were prognostic factors for RFT. HPV status was not a prognostic factor for enteral nutrition during radiotherapy for OPSCC.

Quality of Life, Psychological Distress, and Nutritional Status of Polish Patients with Head and Neck Cancer Treated with Radiotherapy

INTRODUCTION

Head and neck cancer (HNC) is a global epidemiological and clinical problem. In 2020, it was the seventh most common type of cancer worldwide. In 2019, HNC was the fourth most common cause of cancer death among men in Poland. Radiotherapy plays an important role in the treatment of patients with HNC at all clinical stages. However, it is associated with a significant rate of early and late adverse effects. As head and neck cancers are located close to vital anatomical structures, both the local progression of the disease and the treatments used can cause serious problems for patients with HNC, reducing their health-related quality of life (HRQoL) as well as increasing the risk of depressive disorders. Despite this, the current literature lacks research on these aspects of the therapeutic process in the Polish population. The aim of this study was to assess the early impact of radiotherapy on HRQoL outcomes, psychological distress, nutritional status, and overall performance of patients with HNC.

METHODS

The study was carried out among 85 patients with HNC treated in the Inpatient Radiotherapy Unit of the Radiotherapy Department of the Lower Silesian Oncology Center in Wrocław. The patients were asked to complete a set of questionnaires, including the EORTC QLQ-H&N35, the BDI, the NRS-2002, and the ECOG scale, at two time points: before the initiation of radiotherapy treatment and after a course of radiotherapy. The period between the assessments was 7 to 8 weeks.

RESULTS

Our findings demonstrated a negative impact of radiotherapy on scores in all the cancer-specific symptom and functioning scales used in the study. As regards functioning scales, the largest differences were observed for senses and swallowing, whereas with symptoms scales, the largest differences were noted for "sticky saliva" and "dry mouth". Over half of the patients included in the study required nutritional support after radiotherapy treatment. We found statistically significant differences in the levels of depressive symptom severity before and after radiotherapy treatment.

CONCLUSION

The present study showed significant changes in the physical and psychological functioning and nutritional status of the patients with HNC studied after radiotherapy treatment, which may have an impact on the effectiveness of cancer treatment.

Distinct Failure Patterns in Hypopharyngeal Cancer Patients Receiving Surgery-Based Versus Radiation-Based Treatment

BACKGROUND

To cure advanced hypopharyngeal squamous cell carcinoma (HPSCC), primary operation followed by adjuvant (chemo-)radiotherapy (OP-CRT) or definitive chemoradiation (CCRT) are the two primary options. This study aimed to compare the failure patterns and long-term survival outcomes of HPSCC patients treated with these two strategies. PATIENTS AND METHODS: From 2007 to 2015, 198 pathologically confirmed HPSCC patients receiving either OP-CRT or CCRT were retrospectively reviewed. Failure patterns and survival outcomes stratified by the 7th American Joint Committee on Cancer staging system and treatment modalities were compared.

RESULTS

One hundred and eighty-nine patients (95.4%) were stage III/IV and 62 patients (31.3%) received OP-CRT. Median follow-up duration was 4.9 years. Compared with CCRT, OP-CRT provided better 3-year local relapse-free survival for T3 (93 vs 48%, p < 0.0001), T4a (88 vs 37%, p = 0.0005) and better 3-year regional relapse-free survival for N2b+2c (93 vs 60%, p < 0.0001). Of note, for stage IVA subjects, OP-CRT provided better 3-year loco-regional relapse-free survival (85 vs 37%, p < 0.0001), marginal poor 3-year distant metastasis-free survival (62 vs 79%, p = 0.06), but comparable 3-year OS (52 vs 44%, p = 0.37) and 5-year OS (44 vs 31%, p = 0.15) compared with CCRT.

CONCLUSIONS

For patients with advanced HPSCC, although OP-CRT and CCRT provided similar overall survival, failure patterns were distinct. OP-CRT provided better loco-regional control but was more likely to encounter distant metastases than CCRT. The detailed analysis of failure patterns will pave the way to improve this devastating disease.

Landscape of mortality during and within thirty days after non-palliative radiotherapy across eleven major cancer types

BACKGROUND AND PURPOSE

Peri-RT mortality (death during or within 30 days of non-palliative radiotherapy) has been historically overlooked, and rates and risk factors are unclear.

MATERIALS AND METHODS

Patients with non-metastatic cancer, treated with non-palliative external beam radiation (RT) 2004-2016, were identified in the National Cancer Database for 11 cancer types: breast, prostate, non-prostate genitourinary, bone/soft tissue, gynecological, head/neck, lymphoma, gastrointestinal (GI), small cell lung, non-small cell lung, and central nervous system (CNS). Multivariable logistic regression was used to identify predictors of peri-RT mortality controlled for 17 covariates, including patient, tumor, and treatment factors.

RESULTS

Approximately 1.53 million patients were identified. Peri-RT mortality was 2.46% overall, spanning two orders of magnitude from 0.14% for breast to 8.52% for CNS. Peri-RT mortality steadily improved from 3.13% in 2004 to 1.78% in 2016 (P < .0001). Major predictors of peri-RT mortality included age, baseline comorbidity, male sex, and stage (P < .0001). Conversely, higher patient volume at the treating facility and use of more conformal RT planning techniques were moderately protective (P < .0001). Racial disparities varied based on disease site, as Black patients had increased peri-RT mortality for breast, lymphoma, and GI cancers, but not for other cancer types. Lack of private insurance was associated with substantially increased peri-RT mortality regardless of cancer type.

CONCLUSION

Peri-RT mortality varied considerably according to multiple factors. Sociodemographic differences highlight areas of health disparities and opportunities for quality improvement. Early recognition of patients at increased risk may facilitate implementation of closer monitoring or other preventive measures.

Recurrent/Metastatic Squamous Cell Carcinoma of the Head and Neck: A Big and Intriguing Challenge Which May Be Resolved by Integrated Treatments Combining Locoregional and Systemic Therapies

Squamous cell carcinoma of the head and neck (SCCHN) is a complex group of malignancies, posing several challenges to treating physicians. Most patients are diagnosed with a locally advanced disease and treated with strategies integrating surgery, chemotherapy, and radiotherapy. About 50% of these patients will experience a recurrence of disease. Recurrent/metastatic SCCHN have poor prognosis with a median survival of about 12 months despite treatments. In the last years, the strategy to manage recurrent/metastatic SCCHN has profoundly evolved. Salvage treatments (surgery or re-irradiation) are commonly employed in patients suffering from locoregional recurrences and their role has gained more and more importance in the last years. Re-irradiation, using some particularly fractionating schedules, has the dual task of reducing the tumor mass and eliciting an immune response against cancer (abscopal effect). In this review, we will analyze the main systemic and/or locoregional strategies aimed at facing the recurrent/metastatic disease, underlining the enormous importance of the multidisciplinary approach in these types of patients.