Influence of the delay of adjuvant postoperative radiation therapy on relapse and survival in oropharyngeal and hypopharyngeal cancers

Impact of esthesioneuroblastoma treatment delays on overall patient survival

OBJECTIVES

To characterize clinical factors associated with esthesioneuroblastoma treatment delays and determine the impact of these delays on overall survival.

STUDY DESIGN

Retrospective database analysis.

METHODS

The 2004-2016 National Cancer Database was queried for patients with esthesioneuroblastoma managed by primary surgery and adjuvant radiation. Durations of diagnosis-to-treatment initiation (DTI), diagnosis-to-treatment end (DTE), surgery-to-RT initiation (SRT), radiotherapy treatment (RTD), and total treatment package (TTP) were analyzed. The cohort was split into two groups for each delay interval using the median time as the threshold.

RESULTS

A total of 814 patients (39.6% female, 88.5% white) with mean ± SD age of 52.6 ± 15.1 years who underwent both esthesioneuroblastoma surgery and adjuvant radiotherapy were queried. Median DTI, DTE, SRT, RTD, and TTP were 34, 140, 55, 45, and 101 days, respectively. A significant association was identified between increased regional radiation dose above 66 Gy and decreased DTI (OR = 0.54, 95% CI 0.35-0.83, p = 0.01) and increased RTD (OR = 3.94, 95% CI 2.36-6.58, p < 0.001) durations. Chemotherapy administration was linked with decreased SRT (OR = 0.64, 95% CI 0.47-0.89, p = 0.01) and TTP (OR = 0.59, 95% CI 0.43-0.82, p = 0.001) durations. Cox proportional-hazards analysis revealed that increased RTD was associated with decreased survival (HR = 1.80, 95% CI 1.26-2.57, p < 0.005), independent of age, sex, race, regional radiation dose, facility volume, facility type, insurance status, modified Kadish stage, chemotherapy status, Charlson-Deyo comorbidity index, and surgical margins.

CONCLUSIONS

Delays during, and prolongation of radiotherapy for esthesioneuroblastoma appears to be associated with decreased survival.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:764-772, 2023.

Impact of Nonadherence to NCCN Adjuvant Radiotherapy Initiation Guidelines in Head and Neck Squamous Cell Carcinoma in an Underserved Urban Population

BACKGROUND

Nonadherence to NCCN Guidelines during time from surgery to postoperative radiotherapy (S-PORT) can alter survival outcomes in head and neck squamous cell carcinomna (HNSCC). There is a need to validate this impact in an underserved urban population and to understand risk factors and reasons for delay. We sought to investigate the impact of delayed PORT with outcomes of overall survival (OS) in HNSCC, to analyze predictive factors of delayed PORT, and to identify reasons for delay.

METHODS

We conducted a retrospective cohort study in an urban, community-based academic center. A total of 184 patients with primary HNSCC were identified through the Montefiore Medical Center cancer registry who had been treated between March 1, 2005, and March 8, 2017, and met the inclusion and exclusion criteria. The primary exposure was S-PORT. OS, recurrence, and risk factors and reasons for treatment delay were the main outcomes and measures.

RESULTS

Among 184 patients with HNSCC treated with PORT, the median S-PORT was 48.5 days (interquartile range, 41-67 days). The S-PORT threshold that optimally differentiated worse OS outcomes was >50 days (46.7% of our cohort; n=86). Independent of other relevant factors, patients with HNSCC and S-PORT >50 days had worse OS (hazard ratio, 2.30; 95% CI, 1.34-3.95) and greater recurrence (odds ratio, 3.51; 95% CI, 1.31-9.39). Predictors of delayed S-PORT included being underweight or obese, prolonged postoperative length of stay, and age >70 years. The most frequent reasons for PORT delay were complications related to surgery (22.09%), unrelated medical comorbidities (18.60%), and nonadherence/missed appointments (6.98%).

CONCLUSIONS

Delayed PORT beyond 50 days after surgery was associated with decreased OS and greater recurrence. Identification of predictive factors and reasons for treatment delay helps to target at-risk patients and facilitates interventions in underserved populations.

Relationship between oral cancer stage and elapsed time from the onset of signs and symptoms to diagnosis and treatment

BACKGROUND

Oral cancer includes a variety of diagnoses of malignancies that manifest in the oral tissues. Prognosis and treatment depend on the site of involvement, the time of diagnosis, and the stage of the tumor. Early diagnosis of oral mucosal lesions facilitates the early detection of cancer, which is a key step for treatment. The purpose of this study was to investigate the relationship between delayed referral of patients with oral cancer and disease progression at the time of diagnosis.

MATERIALS AND METHODS

In this cross-sectional study, data were collected from 108 patients with a definitive diagnosis of oral cancer by a standardized questionnaire. Data were analyzed by descriptive statistics, including mean, standard deviation, frequency, frequency percentage, and inferential statistics, including logistic regression analysis. P<0.05 was considered to be statistically significant.

RESULTS

The mean time of referral to a therapist was 17.73 ± 22.80 weeks, with 53 (49.1%) patients having a delay of more than 10 weeks. Age, education level, smoking, disease stage, N class, M class, and type of cancer were not significantly associated with the incidence of delay (P>0.05). Patients whose first signs were significant bleeding and/or unrecovered ulceration showed a significant reduction in the delay time (OR = 0.024 and P = 0.038).

CONCLUSION

There was no significant relationship between the disease progression in oral cancer and the time elapsed from the onset of symptoms to diagnosis and treatment. Hence, it seems necessary to take appropriate measures to enhance public awareness of oral cancer and its symptoms.

The Efficacy of Low Postoperative Radiation Dose in Patients with Advanced Hypopharyngeal Cancer without High-Risk Factors

Objective

To evaluate the feasibility and efficacy of low postoperative radiotherapy (PORT) dose in patients with advanced hypopharyngeal squamous cell carcinoma (HPSCC) and identify prognostic factors in this group.

Patients and Methods

Between January 2013 and September 2015, 110 consecutive patients with HPSCC with no high-risk factors were treated postoperatively to 50 Gy (n=89), 56 Gy (n=12), and 60 Gy (n=9) in 2 Gy/fraction. Overall survival (OS), 3-year progression-free survival (PFS), 3-year loco-regional recurrence-free survival (LRFS), and treatment-related toxicities were analyzed.

Results

Median follow-up time was 40 months (range=6–75 months). The 3-year local-regional control (LRC) and 3-year neck control rate were 86.3% and 91.8%, respectively. The 3-year OS, PFS, and LRFS were 69.9%, 65.5%, and 80.5%, respectively. In a univariate analysis, T stage showed a significant correlation with improved OS, PFS, and LRFS (P=0.008, P=0.039, P=0.034). On multivariate analysis, T stage showed a significant correlation with improved OS and PFS. N stage showed a significant correlation with improved PFS. However, interval surgery-radiotherapy, reconstructive methods, and RT dose cannot serve as a significant prognostic factor for survival outcome.

Conclusion

This study suggests that treating no high-risk factors for locally advanced HPSCC with a dose of 50 Gy to the whole operative bed and elective lymph node levels cannot compromise disease control and survival.

The Effect of Time to Postoperative Radiation Therapy on Survival in Resected Merkel Cell Carcinoma

OBJECTIVES

Delays from surgery to adjuvant radiation therapy (aRT) are associated with poorer prognosis in multiple neoplasms. Presently, no data exist for Merkel cell carcinoma (MCC). The authors sought to assess the time interval from surgery to aRT and effect on outcomes in MCC.

MATERIALS AND METHODS

The National Cancer Database was queried for histologically confirmed nonmetastatic MCC status post resection and aRT diagnosed between 2004 and 2015 who received aRT within 24 weeks of surgery. Kaplan-Meier analysis assessed univariate overall survival (OS); multivariable Cox proportional hazards modeling assessed multivariate OS; χ and logistic regression assessed differences in baseline characteristics and predictors of delayed aRT.

RESULTS

Of 5952 patients meeting criteria, 13% commenced aRT within 4 weeks, 48% between 4 and 7 weeks, 23% between 8 and 11 weeks, 11% between 12 and 15 weeks, and 6% between 16 and 24 weeks. There were no differences in OS on the basis of the surgery-aRT interval (P=0.99). Predictors of worse OS on the multivariate analysis included advanced age, greater comorbidities, male sex, lower regional income, earlier year of diagnosis, more advanced tumor and nodal staging, positive margins, head and neck location, and treatment at community facilities (P<0.05 for all). Factors predictive of delayed aRT were identified. Subset analyses on these factors, such as receipt of chemotherapy or positive lymph nodes, did not demonstrate that the timing of aRT affected survival (P≥0.37).

CONCLUSION

This study of a contemporary national database revealed that delays from resection to aRT were not associated with survival in MCC, somewhat discordant from other malignancies such as squamous cell carcinoma.

Association of Survival With Shorter Time to Radiation Therapy After Surgery for US Patients With Head and Neck Cancer

Importance

Shortening the time from surgery to the start of radiation (TS-RT) is a consideration for physicians and patients. Although the National Comprehensive Cancer Network recommends radiation to start within 6 weeks, a survival benefit with this metric remains controversial.

Objective

To determine the association of delayed TS-RT with overall survival (OS) using a large cancer registry.

Design, Setting, and Participants

In this observational cohort study, 25 216 patients with nonmetastatic stages III to IV head and neck cancer were identified from the National Cancer Database (NCDB).

Exposures

Patients received definitive surgery followed by adjuvant radiation therapy, with an interval duration defined as TS-RT.

Main Outcomes and Measures

Overall survival as a function of TS-RT and the effect of clinicopathologic risk factors and accelerated fractionation.

Results

We identified 25 216 patients with nonmetastatic squamous cell carcinoma of the head and neck. There were 18 968 (75%) men and 6248 (25%) women and the mean (SD) age of the cohort was 59 (10.9) years. Of the 25 216 patients, 9765 (39%) had a 42-days or less TS-RT and 4735 (19%) had a 43- to 49-day TS-RT. Median OS was 10.5 years (95% CI, 10.0-11.1 years) for patients with a 42-days or less TS-RT, 8.2 years (95% CI, 7.4-8.6 years; absolute difference, -2.4 years, 95% CI, -1.5 to -3.2 years) for patients with a 43- to 49-day TS-RT, and 6.5 years (95% CI, 6.1-6.8 years; absolute difference, -4.1 years, 95% CI, -3.4 to -4.7 years) for those with a 50-days or more TS-RT. Multivariable analysis found that compared with a 42-days or less TS-RT, there was not a significant increase in mortality with a 43- to 49-day TS-RT (HR, 0.98; 95% CI, 0.93-1.04), although there was for a TS-RT of 50 days or more (HR, 1.07; 95% CI, 1.02-1.12). A significant interaction was identified between TS-RT and disease site. Subgroup effect modeling found that a delayed TS-RT of 7 days resulted in significantly worse OS for patients with tonsil tumors (HR, 1.22; 95% CI, 1.05-1.43) though not other tumor subtypes. Accelerated fractionation of 5.2 fractions or more per week was associated with improved survival (HR, 0.93; 95% CI, 0.87-0.99) compared with standard fractionation.

Conclusions and Relevance

Delayed TS-RT of 50 days or more was associated with worse overall survival. The multidisciplinary care team should focus on shortening TS-RT to improve survival. Unavoidable delays may be an indication for accelerated fractionation or other dose intensification strategies.

Timing of Postoperative Radiotherapy in Surgically Treated HPV-Positive Oropharyngeal Squamous Cell Carcinoma

OBJECTIVE

Optimal timing of postoperative radiotherapy (PORT) remains understudied in human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma. Objectives are to determine if delays between surgery and radiotherapy, breaks during radiotherapy, disease, or patient factors are associated with recurrence or survival decrements in HPV-related disease.

DESIGN

Retrospective review.

SETTING

Academic medical center.

SUBJECTS

A total of 240 cases of HPV-positive oropharyngeal squamous cell carcinoma from 2000 to 2016.

METHODS

Patient and tumor characteristics (American Joint Committee on Cancer, eighth edition), delays to radiation initiation, and breaks during radiation were recorded. Overall survival (OS) and recurrence-free survival (RFS) were analyzed.

RESULTS

RFS and OS were not significantly affected by delays to PORT >6 weeks or by treatment intervals >100 days (surgery to PORT completion). Breaks during PORT significantly imparted an OS detriment (hazard ratio [HR], 2.4; 95% CI, 1.2-4.8). Advanced-stage disease was significantly associated with reduced RFS and OS. Subgroup analysis of stage I versus stage II/III disease found that >6 weeks to PORT initiation and treatment intervals >100 days did not significantly decrease RFS or OS in either stage group. Advanced-stage disease was significantly associated with worsened OS (HR, 6.6; 95% CI, 2.3-19.1) and RFS (HR, 5.3; 95% CI, 1.5-18.4). Breaks during PORT significantly reduced RFS (HR, 3.6; 95% CI, 1.2-10.8) and OS (HR, 3.2; 95% CI, 1.2-9.0) in the stage II/III subset.

CONCLUSION

Delays to radiotherapy initiation and prolonged treatment time did not affect recurrence or survival in HPV-related oropharyngeal disease. Locoregionally advanced disease was consistently associated with worse outcomes. Breaks during PORT may affect recurrence and survival, although larger studies are needed to confirm this finding.

The Impact of Timing of Concurrent Chemoradiation in Patients With High-Grade Glioma in the Era of the Stupp Protocol

Background: The purpose of this study is to provide a critical review of current evidence for the impact of time to initiation of chemoradiation on overall survival in patients with newly diagnosed high-grade gliomas treated with radiation and concurrent temozolomide chemotherapy.

Methods: A literature search was conducted using PubMed/MEDLINE and EMBASE databases. Studies were included if they provided separate analysis for patients treated with current standard of care: radiation and concurrent temozolomide. Bias assessment was performed for each included study using the Newcastle-Ottawa Assessment Scale, with Karnofsky Performance Status (KPS) and extent of resection used for comparability.

Results: The initial search yielded 575 citations. Based on the inclusion/exclusion criteria, a total of 10 retrospective cohort studies were included in this review for a total of 30,298 patients. Of these, one study described an indirect relationship between time to initiation of treatment and overall survival. One study found decreased survival only with patients with significantly longer time to treatment. Four studies found no significant effect of time to treatment on overall survival. The four remaining studies found that patients with moderate time to initiation had the best overall survival.

Conclusion: This review provides evidence that moderate time to initiation of chemoradiotherapy in patients with high-grade gliomas does not lead to a significant decrease in overall survival, though the effect of significant delays in treatment initiation remains unclear.

The impact of the interval between the induction of chemotherapy and radiotherapy on the survival of patients with nasopharyngeal carcinoma

Background

There have been no reliable scientific studies examining whether the interval between induction chemotherapy (IC) and initiating radiotherapy is associated with poor outcomes of nasopharyngeal carcinoma (NPC).

Patients and methods

In this retrospective study, we included a total of 239 local advanced NPC patients who underwent concurrent chemoradiotherapy and IC. Based on the interval between IC and intensity-modulated radiation therapy (IMRT), the patients were classified into three groups as follows: Group A (≤7 vs >7 days), Group B (≤14 vs >14 days), and Group C (≤ 21 vs >21 days). Univariate and multivariate regression analyses were performed to determine the prognostic factors of survival outcomes. The differences between the two groups were compared by the log-rank test.

Results

The median IC-IMRT interval was 9 days (range, 1–76 days). The median follow-up time was 40 months (range, 4–58 months). The IC-IMRT interval including Group A, Group B, and Group C was not significantly associated with overall survival (OS), distant metastasis-free survival (DMFS), locoregional relapse-free survival (LRFS), or disease-free survival (DFS). Multivariate analysis showed that the tumor stage was the independent significant predictor for OS, DMFS, LRFS, and DFS. But it appears that there was a trend toward improvement in the outcome of ≤7 days group in OS from the Kaplan–Meier curves.

Conclusion

It is also feasible to postpone radiotherapy for 1–3 weeks if patients were unable to receive treatment immediately due to chemotherapy complications such as bone marrow suppression. However, we suggest that patients should start IMRT as soon as possible after IC.

The effect of treatment package time in head and neck cancer patients treated with adjuvant radiotherapy and concurrent systemic therapy

Objectives

In patients with head and neck carcinoma, “treatment package time” (TPT) was proven to impact outcomes in cases receiving adjuvant radiotherapy alone. Its impact in patients receiving radiotherapy with concurrent systemic therapy has not been studied previously. The TPT influence on survival endpoints for patients treated with surgery followed by radiation and concurrent systemic therapy was analyzed.

Methods

Institutional database to identify head and neck carcinoma cases treated with definitive surgery followed by concomitant chemo(bio) radiotherapy (CRT) was used. TPT was the number of days elapsed between surgery and the last day of radiation. %FINDCUT SAS macro tool was used to search for the cutoff TPT that was associated with significant survival benefit. Kaplan–Meier curves, log-rank tests as well as univariate and multivariate analyses were used to assess overall survival (OS) and recurrence free survival (RFS).

Results

One hundred and three cases with a median follow up of 37 months were included in the study. Oropharyngeal tumors were 43%, oral cavity 40% and laryngeal 17% of cases. Concurrent systemic therapy included platinum and cetuximab in 72% and 28%, respectively. Optimal TPT was found to be < 100 days with significantly better OS (P = 0.002) and RFS (P = 0.043) compared to TPT ≥100 days. On multivariate analysis; TPT<100 days, extracapsular nodal extension, high-risk score, lymphovascular space and perineural invasion were independent predictors for worse OS (P < 0.05). T4, extracapsular nodal extension and high-risk score were all significantly detrimental to RFS (P < 0.05).

Conclusions

Addition of concomitant systemic therapy to adjuvant radiotherapy did not compensate for longer TPT in head and neck squamous cell carcinoma. Multidisciplinary coordinated care must be provided to ensure the early start of CRT with minimal treatment breaks.

Hypopharyngeal Cancer Treatment Delays: Benchmarks and Survival Association

Objective

To characterize treatment delays in hypopharyngeal cancer, identify factors associated with delays, and associate delays with overall survival.

Study Design

Retrospective cohort.

Setting

Commission on Cancer hospitals nationwide.

Subjects and Methods

We included patients in the National Cancer Database who were treated for hypopharyngeal cancer with primary radiation, concurrent chemoradiation, or induction chemotherapy and radiation. We identified median durations of diagnosis to treatment initiation (DTI), radiation treatment duration (RTD), and diagnosis to treatment end (DTE). We associated delays with patient, tumor, and treatment factors and overall survival via multivariable logistic and Cox proportional hazards regression, respectively.

Results

A total of 3850 patients treated with primary radiation or concurrent chemoradiation were included. Median durations of DTI, RTD, and DTE were 37, 52, and 92 days, respectively. Nonwhite race was associated with delays in DTI (odds ratio [OR] = 0.64; 95% CI, 0.51-0.80; P < .001) and DTE (OR = 0.60; 95% CI, 0.49-0.75; P < .001). Medicaid insurance was associated with delays in DTI (OR = 1.43; 95% CI, 1.07-1.90; P = .015), RTD (OR = 1.39; 95% CI, 1.06-1.83; P = .018), and DTE (OR = 1.48; 95% CI, 1.12-1.97; P = .007). Delays in RTD (hazard ratio [HR] = 1.24; 95% CI, 1.11-1.37; P < .001), not DTI (HR = 0.92; 95% CI, 0.82-1.03; P = .150) or DTE (HR = 1.01; 95% CI, 0.90-1.15; P = .825), were associated with impaired overall survival. We identified 922 patients who received induction chemotherapy. Delays in DTI, RTD, and DTE were not associated with overall survival in this cohort (HR = 1.10; 95% CI, 0.87-1.39; P = 0.435; HR = 1.05; 95% CI, 0.83-1.32; P = 0.686; HR = 1.11; 95% CI, 0.88-1.41; P = 0.377, respectively).

Conclusions

The median durations identified can serve as national benchmarks. Delays during radiation are associated with impaired overall survival among patients treated with primary radiation or chemoradiation but not patients treated with induction chemotherapy.

Impact of Timing of Adjuvant Chemoradiation for Glioblastoma in a Large Hospital Database

BACKGROUND

Although the standard of care for glioblastoma remains maximal safe resection followed by chemoradiation, conflicting reports have emerged regarding the importance of the time interval between these 2 treatments.

OBJECTIVE

To assess whether differences in the duration between surgery and initiation of chemoradiation for glioblastoma had an impact on overall survival (OS) in a large hospital-based database.

METHODS

The National Cancer Database was queried to identify patients diagnosed with glioblastoma between 2010 and 2012 treated with surgery followed by chemoradiation. Patients who received biopsy only were excluded. The time from surgery to initiation of radiation therapy was divided into 4 equal quartiles of ≤24, 25 to 30, 31 to 37, and &gt;37 d. Patient characteristics were compared between groups using Pearson Chi Square and Fisher's Exact test. OS was analyzed via the Kaplan–Meier method and compared via the log-rank test. Univariable and multivariable Cox regression were performed to assess for impact of covariables on OS.

RESULTS

A total of 11 652 patients were included in the analysis. Median duration from surgery to radiation was 30 d. On multivariable regression, black race, larger tumor, gross-total resection, methyguanine-methyl transferase (MGMT+), and treatment at an academic facility were associated with a duration &gt;30 d. On multivariable analysis, there were no significant differences when comparing start within 24 d to 25 to 30 d (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.90-1.01, P = .13) or &gt; 37 d (HR 0.97, 95% CI 0.91-1.03, P = .26), although a small OS improvement was seen if initiated within 31 to 37 d (HR 0.93, 95% CI 0.88-0.99, P = .02).

CONCLUSION

There was no clear association between duration from surgery to initiation of chemoradiation on OS.

Effect of time to initiation of postoperative radiation therapy on survival in surgically managed head and neck cancer

BACKGROUND

The objective of this study was to determine the effects of National Comprehensive Cancer Network (NCCN) guideline-adherent initiation of postoperative radiation therapy (PORT) and different time-to-PORT intervals on the overall survival (OS) of patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

The National Cancer Data Base was reviewed for the period of 2006-2014, and patients with HNSCC undergoing surgery and PORT were identified. Kaplan-Meier survival estimates, Cox regression analysis, and propensity score matching were used to determine the effects of initiating PORT within 6 weeks of surgery and different time-to-PORT intervals on survival.

RESULTS

This study included 41,291 patients. After adjustments for covariates, starting PORT >6 weeks postoperatively was associated with decreased OS (adjusted hazard ratio [aHR], 1.13; 99% confidence interval [CI], 1.08-1.19). This finding remained in the propensity score-matched subset (hazard ratio, 1.21; 99% CI, 1.15-1.28). In comparison with starting PORT 5 to 6 weeks postoperatively, initiating PORT earlier was not associated with improved survival (aHR for ≤ 4 weeks, 0.93; 99% CI, 0.85-1.02; aHR for 4-5 weeks, 0.92; 99% CI, 0.84-1.01). Increasing durations of delay beyond 7 weeks were associated with small, progressive survival decrements (aHR, 1.09, 1.10, and 1.12 for 7-8, 8-10, and >10 weeks, respectively).

CONCLUSIONS

Nonadherence to NCCN guidelines for initiating PORT within 6 weeks of surgery was associated with decreased survival. There was no survival benefit to initiating PORT earlier within the recommended 6-week timeframe. Increasing durations of delay beyond 7 weeks were associated with small, progressive survival decrements. Cancer 2017;123:4841-50. © 2017 American Cancer Society.

Timing of Adjuvant Radiotherapy in Glioblastoma Patients: A Single-Institution Experience With More Than 400 Patients

BACKGROUND

The standard of care for patients with newly diagnosed glioblastoma (GBM) is maximal safe resection followed by adjuvant radiation therapy (RT) and temozolomide (TMZ).

OBJECTIVE

To investigate whether the timing of adjuvant RT after surgery affected outcome in patients with GBM.

METHODS

We retrospectively reviewed all patients with a diagnosis of GBM at our institution. A total of 447 patients were included in our analysis. Patients were divided into 3 equal groups based on the interval between surgery and RT. The primary outcome was overall survival (OS).

RESULTS

Patients who began RT less than 21 days after surgery tended to be older, have a lower a Karnofsky Performance Status score, and higher recursive partitioning analysis class. These patients were more likely to have undergone biopsy only and received 3-dimensional conformal RT or 2-dimensional RT. The median OS for patients who started RT less than 21 days after surgery, between 21 and 32 days after surgery, and more than 32 days after surgery was 374, 465, and 478 days, respectively (P = .004). On multivariate Cox regression analysis, Karnofsky Performance Status score lower than 70, undergoing biopsy only, recursive partitioning analysis classes IV and V/VI, use of less than 36 Gy RT, and lack of TMZ chemotherapy were predictors of worse OS. The interval between surgery and RT was not significantly associated with OS on multivariate analysis.

CONCLUSION

Patients who begin RT less than 21 days after surgery tend to have worse prognostic factors than those who begin RT later. When accounting for significant covariates, the effect of timing between surgery and RT is not significant.

Key points and time intervals for early diagnosis in symptomatic oral cancer: a systematic review

The aim of this study was to identify key points and time intervals in the patient pathway to the diagnosis of oral cancer, from the detection of a bodily change to the start of treatment. A systematic search of three databases was performed by two researchers independently. Articles reporting original data on patients with symptomatic primary oral or oropharyngeal squamous cell carcinoma that was pathologically confirmed were included. These articles had to include an outcome variable of 'diagnostic delay', 'time interval', or 'waiting time to diagnosis', or report time intervals from first symptom to treatment. Furthermore, the outcome variable had to have a clearly defined start point and end point, with the time measurement presented as a continuous or categorical variable. A total of 1175 reports were identified; 28 articles on oral cancer studies and 13 on oral and oropharyngeal cancer studies were finally included. These papers showed poor quality in terms of questionnaire validation, acknowledgement of biases influencing time-point measurements, and strategies for verification of patient self-reported data. They also showed great heterogeneity. The review findings allowed the definition of key points and time intervals within the Aarhus framework that may better suit the features of the diagnostic process of this neoplasm, particularly when assessing the impact of waiting time to diagnosis.

Clinical impact of prolonged diagnosis to treatment interval (DTI) among patients with oropharyngeal squamous cell carcinoma

PURPOSE/OBJECTIVE(S)

We examined practice patterns using the National Cancer Data Base (NCDB) to determine risk factors for prolonged diagnosis to treatment interval (DTI) and survival outcomes in patients receiving chemoradiation for oropharyngeal squamous cell carcinoma (OPSCC).

METHODS AND MATERIALS

We identified 6606 NCDB patients with Stage III-IV OPSCC receiving chemoradiation from 2003 to 2006. We determined risk factors for prolonged DTI (>30days) using univariate and multivariable logistic regression models. We examined overall survival (OS) using Kaplan Meier and multivariable Cox proportional hazards models.

RESULTS

3586 (54.3%) patients had prolonged DTI. Race, IMRT, insurance status, and high volume facilities were significant risk factors for prolonged DTI. Patients with prolonged DTI had inferior OS compared to DTI⩽30days (Hazard Ratio (HR)=1.12, 95% CI 1.04-1.20, p=0.005). For every week increase in DTI there was a 2.2% (95% CI 1.1-3.3%, p<0.001) increase in risk of death. Patients receiving IMRT, treatment at academic, or high-volume facilities were more likely to experience prolonged DTI (High vs. Low volume: 61.5% vs. 51.8%, adjusted OR 1.38, 95% CI 1.21-1.58; Academic vs. Community: 59.5% vs. 50.6%, adjusted OR 1.26, 95% CI 1.13-1.42; non-IMRT vs. IMRT: 53.4% vs. 56.5%; adjusted OR 1.17, 95% CI 1.04-1.31).

CONCLUSIONS

Our results suggest that prolonged DTI has a significant impact on survival outcomes. We observed disparities in DTI by socioeconomic factors. However, facility level factors such as academic affiliation, high volume, and IMRT also increased risk of DTI. These findings should be considered in developing efficient pathways to mitigate adverse effects of prolonged DTI.

Impact of Timing of Concurrent Chemoradiation for Newly Diagnosed Glioblastoma: A Critical Review of Current Evidence

ABBREVIATIONS

EORTC/NCIC, European Organisation for Research and Treatment of Cancer/National Cancer Institute of CanadaGBM, glioblastomaOS, overall survivalPFS, progression-free survivalSEER, Surveillance, Epidemiology, and End ResultsTMZ, temozolomide.

The Effect of Timing of Concurrent Chemoradiation in Patients With Newly Diagnosed Glioblastoma

BACKGROUND

The effect of timing of initiation of concurrent radiation and chemotherapy after surgery on outcome of patients with glioblastoma (GBM) remains unclear.

OBJECTIVE

To further explore this issue, we analyzed 4 clinical trials for patients newly diagnosed with GBM receiving concurrent and adjuvant temozolomide.

METHODS

The cohort study included 198 adult patients with newly diagnosed supratentorial GBM who were enrolled from 2004 to 2010 in 4 clinical trials consisting of radiation plus temozolomide and an experimental agent. The interval to initiation of therapy was determined from the time of surgical resection. The partitioning deletion/substitution/addition algorithm was used to determine the cutoff points for timing of chemoradiation at which there was a significant difference in overall survival (OS) and progression-free survival (PFS).

RESULTS

The median wait time between surgery and initiation of concurrent chemoradiation was 29.5 days (range, 7-56 days). A short delay in chemoradiation administration (at 30-34 days) was predictive of prolonged OS (hazard ratio [HR]: 0.63, P = .03) and prolonged PFS (HR: 0.68, P = .06) compared with early initiation of concurrent chemoradiation (<30 days), after adjusting for protocol and baseline prognostic variables including extent of resection by multivariate analysis. A longer delay to chemoradiation beyond 34 days was not associated with improved OS or PFS compared with early initiation (HR: 0.94, P = .77 and HR: 0.91, P = .63, respectively).

CONCLUSION

A short delay in the start of concurrent chemoradiation is beyond the classic paradigm of 4 weeks post-resection and may be associated with prolonged OS and PFS.

Treatment results and prognostic factors of patients undergoing postoperative radiotherapy for laryngeal squamous cell carcinoma

Postoperative radiotherapy (PRT) is widely advocated for patients with squamous cell carcinomas of the head and neck that are considered to be at high risk of recurrence after surgical resection. The aims of this study were to evaluate the treatment outcomes of PRT for patients with laryngeal carcinoma and to identify the value of several prognostic factors. We reviewed the records of 256 patients treated for laryngeal squamous cell carcinoma between January 1993 and December 2005. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Log-rank test was employed to identify significant prognostic factors for DFS and OS. The Cox proportional hazards model was applied to identify covariates significantly associated with the aforementioned endpoints. Our results showed the 3-, 5-, and 10-year DFS for all patients were 69.9%, 59.5%, and 34.9%, respectively. The 3-, 5-, and 10-year OS rates were 80.8%, 68.6%, and 38.8%, respectively. Significant prognostic factors for both DFS and OS on univariate analysis were grade, primary site, T stage, N stage, overall stage, lymph node metastasis, overall treatment times of radiation, the interval between surgery and radiotherapy, and radiotherapy equipment. Favorable prognostic factors for both DFS and OS on multivariate analysis were lower overall stage, no cervical lymph node metastasis, and using 60Co as radiotherapy equipment. In conclusion, our data suggest that lower overall stage, no cervical lymph node metastasis, and using 60Co as radiotherapy equipment are favorable prognostic factors for DFS and OS and that reducing the overall treatment times of radiation to 6 weeks or less and the interval between surgery and radiotherapy to less than 3 weeks are simple measures to remarkably improve treatment outcome.

Expression TGM2 and BNIP3 have prognostic significance in laryngeal cancer patients receiving surgery and postoperative radiotherapy: a retrospective study

Background

This study was designed to determine the pattern and correlation between expression of the HIF-1α transcriptional targets TGM2 and BNIP3 in laryngeal cancer, and investigate the association of BNIP3 and TGM2 with clinical outcome in laryngeal squamous cell carcinoma (SCC) patients receiving postoperative radiotherapy.

Methods

Immunostaining with antibodies specific to BNIP3 and TGM2 was performed in formalin-fixed, paraffin-embedded specimens from 148 laryngeal SCC patients. BNIP3 and TGM2 expression was scored as high or low, based on the number of tumor cells stained and the staining intensity. All patients received postoperative radiotherapy. Patient follow up and clinicopathological data were compared using the Chi-squared test, univariate and multivariate analyses, and survival curves were generated using the Kaplan-Meier method and log-rank test.

Results

The 3, 5 and 10-year overall survival rates (OS) for all patients were 77.7%, 71.6%, 56.4%, respectively. Primary tumor site, T stage, overall stage, lymph-node metastasis, BNIP3 expression and TGM2 expression were significant prognostic factors for OS in univariate analysis. Negative cervical lymph nodes, high BNIP3 expression and low TGM2 expression were independent prognostic factors of improved OS in multivariate analysis. BNIP3 expression correlates with TGM2 expression in laryngeal SCC (P = 0.012).

Conclusions

This study indicates that lymph-node metastasis, BNIP3 expression and TGM2 expression are independent prognostic factors in laryngeal SCC patients receiving postoperative radiotherapy. Further studies are required to investigate how BNIP3 and/or TGM2 influence the prognosis of laryngeal SCC patients treated with postoperative radiotherapy, and to determine how TGM2 and BNIP3 expression are regulated.

Prognostic Value of Metabolic Tumor Volume Measured by (18)F-FDG PET/CT in Locally Advanced Head and Neck Squamous Cell Carcinomas Treated by Surgery

PURPOSE

We assessed the prognostic value of metabolic tumor volume (MTV) measured using(18)F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) inpatients with locally advanced head and neck squamous cell carcinoma (HNSCC).

METHODS

We retrospectively reviewed 56 patients (51 men, five women; mean age 56.0 ± 8.8years) who had locally advanced HNSCC and underwent FDG PET/CT for initial evaluation. All patients had surgical resection and radiotherapy with or without concurrent chemotherapy. The peak standardized uptake value (SUVpeak) and MTV of the target lesion, including primary HNSCC andmetastatic cervical lymph nodes, were measured from FDG PET/CT images. We compared SUVpeak, MTV, and clinicopathologic variables such as age, Eastern Cooperative Oncology Group (ECOG) performance status, pN stage, pT stage, TNM stage, histologic grade and treatment modality to disease-free survival (DFS) and overall survival (OS).

RESULTS

On the initial FDG PET/CT scans, the median SUVpeak was 7.8 (range, 1.8-19.0) and MTV was17.0 cm(3) (range, 0.1-131.0 cm(3)). The estimated 2-year DFS and OS rates were 67.2% and 81.8%. The cutoff points of SUVpeak 6.2 and MTV 20.7 cm(3) were the best discriminative values for predicting clinical outcome. MTV and ECOG performance status were significantly related to DFS and OS on univariate and multivariate analyses (p < 0.05).

CONCLUSION

The MTV obtained from initial FDG PET/CT scan is a significant prognostic factor for disease recurrence and mortality in locally advanced HNSCC treated with surgery and radiotherapy with or without chemotherapy.

Postoperative strategies after primary surgery for squamous cell carcinoma of the head and neck

This review discusses the role of adjuvant treatment after curative surgery for patients with head and neck squamous cell carcinoma (HNSCC). In general, patients with unfavourable prognostic factors have a high-risk of loco-regional recurrence and subsequent worse survival after surgery alone and are therefore considered proper candidates for adjuvant treatment by either postoperative radiotherapy alone or postoperative chemoradiation. Selection of the most optimal adjuvant treatment strategy should be based on the most important prognostic factors. In this review, the different treatment strategies will be discussed in general. More specifically, we will discuss the role of the interval between surgery and radiotherapy, the overall treatment time of radiation, the selection of target volumes for radiation and the value of adding concomitant chemotherapy to postoperative radiation.

Short delay in initiation of radiotherapy may not affect outcome of patients with glioblastoma: a secondary analysis from the radiation therapy oncology group database

PURPOSE

To analyze the Radiation Therapy Oncology Group (RTOG) database of patients with glioblastoma and appraise whether outcome was influenced by time to initiation of radiation therapy (RT).

PATIENTS AND METHODS

From 1974 through 2003, adult patients with histologically confirmed supratentorial glioblastoma were enrolled onto 16 RTOG studies. Of 3,052 enrolled patients, 197 patients (6%) were either initially rendered ineligible or had insufficient chronologic data, leaving a cohort of 2,855 patients for the present analysis. We selected four patient groups based on the interval from surgery to the start of RT: <or= 2 weeks, 2 to 3 weeks, 3 to 4 weeks, more than 4 weeks to the protocol eligibility limit of 6 weeks. Survival times were estimated by the Kaplan-Meier method. Multivariate analysis incorporated variables of time interval, recursive partitioning analysis (RPA) class, and treatment regimen.

RESULTS

No decrement in survival could be identified with increasing time to initiation of RT. Among our four temporal groupings, median survival time was unexpectedly and significantly greater in the group with the longest interval (> 4 weeks) than in those with the shortest delay (<or= 2 weeks): respectively, 12.5 months versus 9.2 months (P < .0001). On multivariate analysis, with overall survival as the end point, time interval more than 4 weeks and lower RPA class were both significant predictors of improved outcome. Treatment regimen was not a significant factor.

CONCLUSION

There is no evident reduction in survival by delaying initiation of RT within the relatively narrow constraint of 6 weeks. An unanticipated yet significantly superior outcome was identified for patients for whom RT was delayed beyond 4 weeks from surgery.

Prognostic factors of survival in head and neck cancer patients treated with surgery and postoperative radiation therapy

CONCLUSIONS

Given that radiation therapy (RT) is currently initiated as soon as possible after surgery, our results indicate that the main prognostic factors of survival are pT and pN stages in patients treated with surgery and postoperative RT for locally advanced head and neck squamous cell carcinoma (HNSCC).

OBJECTIVES

To determine the prognostic factors for survival in patients treated with surgery and postoperative RT for locally advanced HNSCC.

PATIENTS AND METHODS

A retrospective study was performed on 308 consecutive patients treated from 1990 to 1998 with surgery and postoperative RT. In addition to histological factors, time-related factors were considered.

RESULTS

The median age of the whole cohort was 56 years (range 35-83). Median follow-up was 98 months. Median interval from surgery to the start of RT was 44 days (range 18-157), while median RT duration was 52 days (range 22-115). From univariate analysis of overall survival, statistically significant prognostic factors were pT stage (p<0.0001), pN stage (p=0.008), RT duration (p=0.01) and total treatment time (p=0.02). Perineural invasion, perivascular invasion, extranodal spread and positive resection margins did not appear to be related to survival. From multivariate analysis, the only statistically independent prognostic factors appeared to be pT and pN stages.

A comparison of outcomes for patients with oral squamous cell carcinoma at intermediate risk of recurrence treated by surgery alone or with post-operative radiotherapy

Controversy remains about which patients at intermediate risk of recurrence of oral squamous cell carcinoma would benefit from radiotherapy. A retrospective review of computerised database and medical records for 462 consecutive patients at the Regional Maxillofacial Unit in Liverpool who were treated with primary surgery with or without post-operative radiotherapy was carried out. We classified 29% (134) of patients as being at 'low' risk of disease recurrence (pT1-2, N0 with clear margins), 29% (135) at 'high' risk (involved margins or lymph node extracapsular spread) and the remaining 42% (193) at 'intermediate' risk. Of those at intermediate risk, 41% (80/193) received adjuvant radiotherapy and their 5 year survival (SE) was 54% (6%) compared to 71% (5%) for those with primary surgery alone (P=0.002). A higher proportion of patients having radiotherapy had loco-regional recurrence (19/80 24%) compared to those treated by surgery alone (17/113 15%). The improved salvage rate for recurrent disease in the surgery alone group (8/17 53%), compared to those receiving radiotherapy (2/19 13%, P=0.05), indicates an advantage in withholding radiotherapy for patients at intermediate risk of recurrence. This study indicates a potential disadvantage associated with the use of postoperative radiotherapy for patients at intermediate risk of recurrence. A randomised trial comparing a watch and wait policy to postoperative radiotherapy in patients with an intermediate risk of recurrence is required to confirm the trend indicated in this retrospective data.

Multicenter validation of recursive partitioning analysis classification for patients with squamous cell head and neck carcinoma treated with surgery and postoperative radiotherapy

PURPOSE

To validate the recursive partitioning analysis (RPA) classification system for squamous cell head and neck cancer as recently reported by the VU University Medical Center.

METHODS AND MATERIALS

In eight Dutch head and neck cancer centers, data necessary to classify patients according to the RPA system were retrospectively collected from the charts of a group of 780 patients treated between 1989 and 2003. The patients in this validation group were classified according to the RPA classification system. For each endpoint, the 5-year values and hazard ratios were calculated and compared with the results of the VU University Medical Center. The RPA classification system was considered valid if the hazard ratio of the validation population was within the 95% confidence interval of the VU University Medical Center study population.

RESULTS

The locoregional control rate was 82%, 75%, and 63% at 5 years for those with class I, II, and III, respectively (p < 0.0001). The hazard ratio for the locoregional control rate relative to class I was 1.44 (95% confidence interval, 0.97-2.16) for class II and 2.37 (95% confidence interval, 1.57-3.57) for class III. Similar results were found for the distant metastasis, overall survival, and disease-free survival rates.

CONCLUSION

The RPA classification system for head and neck squamous cell carcinoma in the postoperative setting, which was originally designed at one center, proved to be valid in a multicenter setting among patients included in a national multicenter study. This validated RPA classification scheme can be used to assess standard treatment strategies for head and neck squamous cell carcinoma in the postoperative setting, as well as in the design of future prospective studies.

A questionnaire survey of current UK practice for adjuvant radiotherapy following surgery for oral and oropharyngeal squamous cell carcinoma

A postal questionnaire was sent to 281 members of the British Association of Head and Neck Oncologists (BAHNO) to survey, which patients should receive adjuvant radiotherapy following primary surgery for oral and oropharyngeal squamous cell carcinoma (O&OSCC). Two hundred and one clinicians were involved in decision making for adjuvant radiotherapy in O&OSCC, of which, 132 (66%) responded. Apart from general agreement that patients with involved margins or extracapsular spread (ECS) should have adjuvant radiotherapy and that in patients with small tumours with clear margins and no neck metastasis, radiotherapy should be avoided, opinion was divided. Considerable variation in opinion in the UK was identified for a subgroup of intermediate risk patients as to whether they should have adjuvant radiotherapy. The majority of respondents (95%) would consider submitting patients to a prospective multi-centre trial. There is a need for research regarding adjuvant radiotherapy for O&OSCC patients at intermediate risk of relapse following primary surgery.

Surgery and Postoperative Radiotherapy for Squamous Cell Carcinoma of the Larynx and Pharynx

OBJECTIVE

To determine the rates of local-regional control, survival, and complications for patients treated with postoperative radiation for squamous carcinomas of the larynx, hypopharynx, and oropharynx.

METHODS

There were 295 patients with previously untreated squamous cell carcinomas of the larynx (n = 199), hypopharynx (n = 80), and oropharynx (n = 16) treated postoperatively with radiotherapy (RT).

RESULTS

Five-year local-regional control rates according to site and pathologic American Joint Committee on Cancer (AJCC) stage were: stage III larynx, 89% versus stage IVA larynx, 85% (P = 0.33); stage III oropharynx/hypopharynx, 76% versus stage IVA oropharynx/hypopharynx, 79% (P = 0.72). Local-regional control rates steadily declined as the number of indications for administering postoperative RT increased. Five-year absolute survival rates versus pathologic AJCC stage for the entire group were: stage III 59% and stage IVA 40% (P = 0.40).

CONCLUSION

Rates of local-regional control, survival, and complications support the use of postoperative radiation in selected patients. Tumor control and survival will hopefully improve further with the addition of chemotherapy to postoperative radiation.

Relationship between delay in radiotherapy and biochemical control in prostate cancer

PURPOSE

The aim of this study was to investigate whether a delay in radiotherapy is associated with a poorer biochemical control for prostate cancer.

METHODS

The time to treatment (TTT) from diagnosis of prostate cancer to radiotherapy was analyzed with respect to prostate-specific antigen (PSA) control in 1024 hormone-naive patients. The Kaplan-Meier PSA control curves for patients with TTT less than the median were compared with those for patients with TTT greater than the median in 3 predefined risk groups. Statistical significant differences in PSA control were further analyzed using Cox multivariate analysis with pretreatment PSA, Gleason score, T stage, and radiotherapy dose as covariates.

RESULTS

The median TTT and median follow-up are 3.7 months and 49 months respectively. Patients with a longer TTT have a statistically significant better PSA control than patients with a shorter TTT if they have intermediate- or high-risk disease. However in multivariate analysis TTT was not found to be significant in predicting PSA control, with pretreatment PSA and Gleason score emerging as highly significant in predicting PSA failure in both intermediate- and high-risk disease.

CONCLUSION

In this study in prostate cancer patients in British Columbia, there was no evidence that a longer time interval between diagnosis and radiotherapy was associated with poorer PSA control.

Postoperative radiotherapy for squamous cell carcinoma of the head and neck

This review discusses the role of postoperative radiotherapy (RT) for patients with squamous cell carcinoma of the head and neck. Patients with unfavorable pathologic features have a high-risk of local-regional recurrence and a decreased likelihood of survival after surgery alone. Postoperative RT reduces the risk of local-regional failure and probably improves survival. Patients who are at high risk for recurrence may benefit from more aggressive altered fractionation schedules to decrease the overall time from surgery to the completion of RT. Adjuvant cisplatin-based chemotherapy also appears to improve the probability of cure in high-risk patients.

The importance of immunohistochemical expression of EGFr in squamous cell carcinoma of the oral cavity treated with surgery and postoperative radiotherapy

PURPOSE

The aim of this study was to investigate the prognostic significance of epidermal growth factor (EGFr) expression in oral cavity squamous cell carcinoma (OCSCC) treated with curative surgery and postoperative radiotherapy.

METHODS AND MATERIALS

This retrospective study included 165 OCSCC patients. The expression of EGFr was assessed on paraffin-embedded tissue of the primary tumor by immunohistochemistry using a monoclonal antibody directed against EGFr. Intensity of the EGFr expression was scored by two authors blinded for the clinical outcome.

RESULTS

In the univariate analysis, locoregional control at 3 years (LRC) in the EGFr-negative cases was 69% compared with 77% in the EGFr-positive cases (p = 0.22). In the multivariate analysis for local control, a significant interaction was found between EGFr and overall treatment time of radiation (OTT). After stratification for EGFr expression, the OTT was of no importance in the EGFr-negative cases, whereas a significant difference in LRC was found in the EGFr-positive cases, in which the LRC after 3 years was 69% and 94% in case of an OTT of 0-42 days and >42 days, respectively (p = 0.009; hazard ratio = 3.42; 95% confidence interval, 1.28-8.96). No significant association was found between EGFr expression and overall survival.

CONCLUSIONS

In the present study, no association was found between EGFr expression and outcome regarding locoregional control and overall survival. However, the results of the present study suggest that patients with squamous cell carcinoma of the oral cavity with high EGFr expression benefit more from a reduction of the overall treatment time of postoperative radiation than those with low EGFr expression.

Examining time intervals between diagnosis and treatment in the management of patients with limited stage small cell lung cancer

OBJECTIVE

To examine time intervals between diagnosis and treatment of limited stage small cell lung cancer (L-SCLC) and to evaluate its effect on clinical outcomes.

MATERIALS AND METHODS

Data on 166 patients with L-SCLC referred to a regional cancer center between January 1991 and December 1999 were analyzed. The time intervals studied were defined as: interval A, first abnormal chest x-ray to pathologic diagnosis: interval B, diagnosis to first oncology consultation; interval C, oncology consultation to first day of thoracic radiotherapy (RT); interval D, oncology consultation to first day of chemotherapy; and interval E, first day of chemo to first day of RT. Cox proportional hazards models were used to examine associations between the time intervals and thoracic relapse (TR) and overall survival (OS) outcomes. Logistic regression analysis was used to model associations between time and complete response (CR) rates.

RESULTS

The median time duration of intervals A to E were 20, 12, 63.5, 15, and 48 days, respectively. When time was analyzed as a continuous variable, no statistically significant association between the interval lengths and outcomes studied was observed. Dichotomizing each interval using the median value as cut-off revealed that interval A >20 days was significantly associated with improved CR (odds ratio = 3.573; P = 0.027) whereas interval B >12 days was associated with a trend toward lower CR (odds ratio = 0.348; P = 0.073).

CONCLUSIONS

Short median times from first abnormal chest x-ray to diagnosis and from diagnosis to oncology consultation indicate that L-SCLC patients were diagnosed and referred promptly in the community setting. OS and TR appeared independent of the time intervals analyzed. Individual variations in disease presentation and tumor biology may explain the observed associations between early pathologic diagnosis and inferior CR rates.

Délais et retards à la radiothérapie : réflexion à propos de trois types de tumeurs

In the following review of the literature, the reasons and consequences of a tendency to the increase of the delay between the diagnosis and the first irradiation session will be studied. The duration of the delay varies according to the protocol of treatment, which itself depends on the tumour. Moreover, all types of radiotherapy are concerned by the increase in delay. A retrospective study enables to determine for a given series of similar tumours and treatments the mean duration of delay and find the excessive duration. The increase of delay phenomenon exists in different countries. We know that before irradiation the tumour grows according to its biological characteristics and the TNM initial determination will no longer be true. On the other hand, effective treatments such as chemotherapy and hormone therapy are increasingly used alone, before or in combination with radiotherapy. Consequently, the classical timing of radiation therapy could be modified often delayed. It is difficult to consider that successive treatments are a real increase of delay and compare its results with previous data from radiotherapy alone. We will study its impact in three types of tumours, including tumours of head and neck, of the breast and prostate, which are the most widely reported. The consequences of prolonged delay are not easily evaluated: one of the more important parameters is the possible modification of the stage of tumour. This phenomenon is not restricted to the studied types of tumours. We will try to find possible ways of reducing abnormal delays before irradiation.

Predictive factors of local-regional recurrences following parotid sparing intensity modulated or 3D conformal radiotherapy for head and neck cancer

BACKGROUND AND PURPOSE

Predictive factors for local-regional (LR) failures after parotid-sparing, Intensity modulated (IMRT) or 3D conformal radiotherapy for head and neck (HN) cancers were assessed.

PATIENTS AND METHODS

One hundred and fifty-eight patients with mostly stages III-IV HN squamous cell carcinoma underwent curative bilateral neck irradiation aimed at sparing the parotid glands. Patient, tumor, and treatment factors were analyzed as predictive factors for LR failure.

RESULTS

Twenty-three patients had LR recurrence (19 in-field and four marginal). No differences were found in the doses delivered to the PTVs of patients with or without in-field recurrences. In univariate analysis, tumor site was highly predictive for LR failure in both postoperative and definitive RT patients. In postoperative RT patients, pathologic tumor size, margin status, extracapsular extension (ECE) and number of lymph node metastases, were also significantly predictive. Multivariate analysis showed tumor site (oropharynx vs. other sites) to be a significant predictor in all patients, and involved margins and number of involved lymph nodes in postoperative patients.

CONCLUSIONS

Clinical rather than dosimetric factors predicted for LR failures in this series, and were similar to those reported following standard RT. These factors may aid in the selection of patients for studies of treatment intensification using IMRT.

Risk-group definition by recursive partitioning analysis of patients with squamous cell head and neck carcinoma treated with surgery and postoperative radiotherapy

BACKGROUND

The objective of this study was to define different prognostic groups with regard to locoregional control (LRC) derived from recursive partitioning analysis (RPA).

METHODS

Eight hundred one patients with squamous cell head and neck carcinoma underwent with primary surgery and received postoperative radiotherapy. For the definition of prognostic groups, the method of classification and regression trees was performed, including a large number of well known prognostic factors.

RESULTS

The final model was composed of six prognostic factors for LRC, resulting in seven terminal nodes. RPA Class I (intermediate risk) consisted of 381 patients who had no N3 lymph nodes, free surgical margins (> 5 mm), and no extranodal spread (ENS). RPA Class II (high risk) consisted of 189 patients who had 1 positive lymph node with ENS or had T1, T2, or T4 tumors with close or positive surgical margins. RPA Class III (very high risk) consisted of 231 patients who had a N3 neck, > or = 2 positive lymph nodes with ENS, or a T3 tumor with close or positive surgical margins. The 5-year LRC rate was 88%, 73% and 58%, in RPA Class I, II, and III, respectively (P < 0.0001). The hazard ratio (HR) relative to RPA Class I was 2.3 (95% confidence interval [95%CI], 1.5-3.6) for RPA Class II and 4.2 (95%CI, 2.8-6.1) for RPA Class III.

CONCLUSIONS

The RPA classification scheme studied allowed for the clear definition of three prognostic groups with regard to LRC and OS. These groups may be useful in the design of future prospective, randomized studies investigating new treatment modalities.

Accelerated versus conventional fractionated postoperative radiotherapy for advanced head and neck cancer: results of a multicenter Phase III study

PURPOSE

To determine whether, in the postoperative setting, accelerated fractionation (AF) radiotherapy (RT) yields a superior locoregional control rate compared with conventional fractionation (CF) RT in locally advanced squamous cell carcinomas of the oral cavity, oropharynx, larynx, or hypopharynx.

METHODS AND MATERIALS

Patients from four institutions with one or more high-risk features (pT4, positive resection margins, pN >1, perineural/lymphovascular invasion, extracapsular extension, subglottic extension) after surgery were randomly assigned to either RT with one daily session of 2 Gy up to 60 Gy in 6 weeks or AF. Accelerated fractionation consisted of a "biphasic concomitant boost" schedule, with the boost delivered during the first and last weeks of treatment, to deliver 64 Gy in 5 weeks. Informed consent was obtained. The primary endpoint of the study was locoregional control. Analysis was on an intention-to-treat basis.

RESULTS

From March 1994 to August 2000, 226 patients were randomized. At a median follow-up of 30.6 months (range, 0-110 months), 2-year locoregional control estimates were 80% +/- 4% for CF and 78% +/- 5% for AF (p = 0.52), and 2-year overall survival estimates were 67% +/- 5% for CF and 64% +/- 5% for AF (p = 0.84). The lack of difference in outcome between the two treatment arms was confirmed by multivariate analysis. However, interaction analysis with median values as cut-offs showed a trend for improved locoregional control for those patients who had a delay in starting RT and who were treated with AF compared with those with a similar delay but who were treated with CF (hazard ratio = 0.5, 95% confidence interval 0.2-1.1). Fifty percent of patients treated with AF developed confluent mucositis, compared with only 27% of those treated with CF (p = 0.006). However, mucositis duration was not different between arms. Although preliminary, actuarial Grade 3+ late toxicity estimates at 2 years were 18% +/- 4% and 27% +/- 6% for CF and AF, respectively (p = 0.10).

CONCLUSION

Accelerated fractionation does not seem to be worthwhile for squamous cell carcinoma of the head and neck after resection; however, AF might be an option for patients who delay starting RT.

[Delays and treatment interruptions: difficulties in administering radiotherapy in an ideal time-period]

Prescribed total radiation dose should be administered within in a specific time-frame and delays in commencing treatment and/or unplanned interruptions in radiation delivery are unacceptable because, in certain cancer sites, treatment-time prolongation can have a deleterious effect on local tumour control, and on patient outcomes. The present review evaluated the causes of initial treatment delays as well as interruptions in the scheduled radiotherapy. The literature search highlighted a significant concern in avoiding treatment-time prolongation in head and neck, cervix, breast and lung cancer. Among the causes involved in delay in radiotherapy commencement factors such as waiting lists, lack of material and human resources, and an increase complexity in planning, simulation and verification are highlighted. Most authors recommend radiotherapy commencement as soon as possible in radical (exclusive irradiation with active tumour present) and palliative situations with a maximum delay of no more than 6 to 8 weeks in the case of adjuvant radiotherapy (post-resection) programs. Interruptions during the course of treatment include: planned unit maintenance and servicing, acute patient toxicity or unexpected malfunction of linear accelerators; this last feature has the most deleterious effect on patients as well as radiotherapy practitioners. Interruptions that impact on the programmed time-course for radiotherapy needs to be compensated-for so as assure the biological equivalence in treatment efficacy with respect to cancer site and stage.

Postoperative irradiation for squamous cell carcinoma of the oral cavity: 35-year experience

BACKGROUND

The purpose of this study was to analyze factors influencing outcome in patients who received postoperative irradiation for advanced squamous cell carcinoma of the oral cavity.

METHODS

Between October 1964 and November 2000, 226 patients with 230 previously untreated primary invasive squamous cell carcinomas of the oral cavity were treated postoperatively with continuous-course external beam irradiation. All patients had a minimum follow-up of 2 years (analysis, November 2002). No patient was lost to follow-up.

RESULTS

The 5-year actuarial rates of locoregional control by pathologic American Joint Committee on Cancer stage were: stage I, 100%; stage II, 84%; stage III, 78%; and stage IV, 66%. Recurrence of cancer above the clavicles developed in 55 patients (24%). In multivariate analysis of locoregional control, positive margins, vascular invasion, perineural invasion, extracapsular extension, and T classification remained significant.

CONCLUSIONS

This article provides additional data defining relatively favorable and unfavorable groups of patients in the postoperative setting. Dose recommendations are re-examined and selectively increased for high-risk patients.

Sequential audits of unacceptable delays in radiation therapy in Australia and New Zealand

Delays in accessing radiation treatment are of concern in Australia and New Zealand, both in terms of the proportion of patients who are actually able to access care, and in the timeliness of starting treatment. For those who are able to access treatment, one in three patients experience an unacceptable delay in starting treatment, and only one in four patients starts radiotherapy within standard good practice times. During the year 2002, more than 15 000 Australians who potentially could have benefited from radiotherapy, did not receive this treatment. For those who were able to access radiotherapy treatment, worsening delays were experienced in Australia, with greater than 40% of patients receiving curative treatment, 30% receiving palliative treatment, and 56% receiving emergency treatment starting outside of standard good practice times. Delays of up to 151 days were experienced in Australia. In Australia, delays in implementing recommendations to improve the infrastructure are resulting in a declining service for cancer patients. In New Zealand, the situation, in general, is improving, although there needs to be an ongoing commitment to grow the service according to the population needs. Urgent implementation of strategic planning is required.

Postoperative radiotherapy in squamous cell carcinoma of the oral cavity: The importance of the overall treatment time

PURPOSE

To test the hypothesis that (1) the distinction between intermediate- and high-risk patients by clustering different prognostic factors results in a significant difference in treatment outcome and (2) a shorter interval between surgery and radiotherapy and shorter overall treatment times of radiation (OTTRT) result in higher rates of locoregional control (LRC).

METHODS AND MATERIALS

Included were patients (n = 217) with previously untreated squamous cell carcinoma of the oral cavity treated with radical surgery and postoperative radiotherapy. Patients with extranodal spread or microscopic residual disease and patients with two or more other risk factors (i.e., N2b-N3, >1 nodal level involved, perineural growth, or stage T3-T4) were classified as high-risk patients. Patients with only one other risk factor were classified as intermediate risk.

RESULTS

In the intermediate-risk group, the 3-year LRC was 87% as compared with 66% in the high-risk group (p = 0.0005). No association was found between interval and LRC. However, the OTTRT was significantly associated with LRC. The 3-year LRC was 87%, 75%, 69%, and 51% when the OTT was <6 weeks, 6-7 weeks, 7-8 weeks, and >8 weeks, respectively (p = 0.0004). The 3-year overall survival (OS) in the intermediate risk patients was 74% compared with 50% in the high-risk group (p = 0.0014). A significant association was also found between the OS and OTTRT. The OS increased from 50% when the OTTRT was >8 weeks to 74% when the OTT was <6 weeks (p = 0.006). Similar results were found with regard to the disease-free survival (DFS). In the multivariate analysis, both risk group and OTT were significantly associated with LRC, DFS, and OS. No significant interaction term was present between these two factors, which means that the OTT was of importance both for the high-risk and the intermediate-risk patients.

CONCLUSION

In the subset of patients with carcinoma of the oral cavity, the classification of high- and intermediate-risk patients by clustering a number of prognostic factors provides important prognostic information regarding LRC, DFS, and OS. The OTT was the most important prognostic factor both in the high-risk and intermediate-risk patients. Reducing the OTT to 6 weeks or less is a rather simple measure to achieve a considerable improvement of the outcome of treatment in this category of patients.

Does delay in starting treatment affect the outcomes of radiotherapy? A systematic review

PURPOSE

The objective of this study was to synthesize what is known about the relationship between delay in radiotherapy (RT) and the outcomes of RT.

METHODS

A systematic review of the world literature was conducted to identify studies that described the association between delay in RT and the probability of local control, metastasis, and/or survival. Studies were classified by clinical and methodologic criteria and their results were combined using a random-effects model.

RESULTS

A total of 46 relevant studies involving 15,782 patients met our minimum methodologic criteria of validity; most (42) were retrospective observational studies. Thirty-nine studies described rates of local recurrence, 21 studies described rates of distant metastasis, and 19 studies described survival. The relationship between delay and the outcomes of RT had been studied in diverse situations, but most frequently in breast cancer (21 studies) and head and neck cancer (12 studies). Combined analysis showed that the 5-year local recurrence rate (LRR) was significantly higher in patients treated with adjuvant RT for breast cancer more than 8 weeks after surgery than in those treated within 8 weeks of surgery (odds ratio [OR] = 1.62, 95% confidence interval [CI], 1.21 to 2.16). Combined analysis also showed that the LRR was significantly higher among patients who received postoperative RT for head and neck cancer more than 6 weeks after surgery than among those treated within 6 weeks of surgery (OR = 2.89; 95% CI, 1.60 to 5.21). There was little evidence about the impact of delay in RT on the risk of metastases or the probability of long-term survival in any situation.

CONCLUSION

Delay in the initiation of RT is associated with an increase [corrected] in LRR in breast cancer and head and neck cancer. Delays in starting RT should be as short as reasonably achievable.

Postoperative radiation therapy for squamous cell carcinoma of the head and neck

PURPOSE

To discuss the role of postoperative radiation therapy (RT) for patients with squamous cell carcinoma of the head and neck.

RESULTS

Patients with adverse pathologic features have a high likelihood of local-regional recurrence and a decreased probability of survival after surgery alone. Postoperative RT reduces the risk of local-regional failure and probably improves survival. Patients who are at high risk for recurrence after surgery benefit from more aggressive dose-fractionation schedules that may include altered fractionation to decrease the overall time from surgery to the completion of RT. Adjuvant chemotherapy also appears to improve the probability of cure in high risk patients.

CONCLUSION

Patients who have a high likelihood of local-regional recurrence after surgery have improved disease control and survival after postoperative RT.