Institutional clinical trial accrual volume and survival of patients with head and neck cancer

Imaging and Biomarker Surveillance for Head and Neck Squamous Cell Carcinoma: A Systematic Review and American Radium Society Appropriate Use Criteria Statement

Surveillance for survivors of head and neck cancer (HNC) is focused on early detection of recurrent or second primary malignancies. After initial restaging confirms disease-free status, the use of surveillance imaging for asymptomatic patients with HNC is controversial. Our objective was to comprehensively review literature pertaining to imaging and biomarker surveillance of asymptomatic patients treated for head and neck squamous cell carcinoma and to convene a multidisciplinary expert panel to provide appropriate use criteria for surveillance in representative clinical scenarios. The evidence base for the appropriate use criteria was gathered through a librarian-mediated search of literature published from 1990 to 2022 focused on surveillance imaging and circulating tumor-specific DNA for nonmetastatic head and neck squamous cell carcinoma using MEDLINE (Ovid), Embase, Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials. The systematic review was reported according to PRISMA guidelines. Using the modified Delphi process, the expert panel voted on appropriate use criteria, providing recommendations for appropriate use of surveillance imaging and human papillomavirus (HPV) circulating tumor DNA. Of 5178 studies identified, 80 met inclusion criteria (5 meta-analyses/systematic reviews, 1 randomized control trial, 1 post hoc analysis, 25 prospective, and 48 retrospective cohort studies [with ≥50 patients]), reporting on 27,525 patients. No large, randomized, prospective trials examined whether asymptomatic patients who receive surveillance imaging or HPV circulating tumor DNA monitoring benefit from earlier detection of recurrence or second primary tumors in terms of disease-specific or quality-of-life outcomes. In the absence of prospective data, surveillance imaging for HNC survivors should rely on individualized recurrence-risk assessment accounting for initial disease staging, HPV disease status, and tobacco use history. There is an emerging surveillance role for circulating tumor biomarkers.

A proposed framework for the implementation of head and neck cancer treatment at a new cancer center from a radiation oncology perspective

BACKGROUND

Establishing a new head and neck cancer (HNC) treatment center requires multidisciplinary team management and expertise. To our knowledge, there are no clear recommendations or guidelines in the literature for the commencement of HNC radiation therapy (RT) at a new cancer center. We propose a novel framework outlining the necessary components required to set-up a new radiation therapy HNC treatment.

METHODS

We reviewed the infrastructure and methodology in the commencement of HNC radiation therapy in our cancer care center and invited several external, experienced metropolitan head and neck radiation oncologists to develop a novel consensus guideline that may be used by new RT centers to treat HNC. Recommendations were presented to our internal and external staff specialists using a survey questionnaire with ratings utilized to determine consensus using pre-defined thresholds as per the American Society of Clinical Oncology Guidelines Methodology Manual.

CONCLUSION

This consensus recommendation aims to improve RT utilization whilst advocating for optimal patient outcomes by presenting a framework for new radiation therapy centers ready to step up and manage the treatment of head and neck cancer patients. We propose these evidence-based consensus guidelines endorsed by external HNC radiation oncologists.

Treatment Delay and HPV Status on OPSCC With Upfront Surgery: Analysis of National Cancer Database

OBJECTIVE

Evaluate the effect of treatment delay on survival in human papillomavirus (HPV)-positive and HPV-negative oropharyngeal squamous cell carcinoma (OPSCC) patients undergoing primary surgical resection.

STUDY DESIGN

Retrospective cohort study using the 2010-2017 National Cancer Database.

SETTING

Multicenter database study.

METHODS

Patients >18 years old with OPSCC and known HPV status, treated surgically with or without postoperative radiation/chemotherapy were included. Two cohorts based on HPV status were grouped by time to treatment initiation (TD-TI, ≤30, 31-60, ≥61 days) and surgery to radiotherapy (TS-RT, ≤42, 43-66, ≥67 days). Univariate, Kaplan-Meier, and multivariate analyses assessed correlations between demographic and clinical factors with overall survival in treatment delay groups.

RESULTS

Included were 1643 HPV-positive OPSCC patients and 391 HPV-negative OPSCC patients. No associations between survival and gender, age, race, insurance, or radiotherapy length were observed. Regardless of HPV status, larger tumor size (>2 cm) and lymphovascular invasion predicted worse survival. HPV negative patients with >4 lymph nodes involved had 2.5× greater mortality risk (P = .039). Robotic surgery was associated with improved survival only in HPV positive patients (hazard ratio [HR]: 0.41, P < .001). In HPV positive patients, higher TD-TI related to lower mean survival, although this was not significant on multivariate analysis. HPV negative patients with >42 days of TS-RT had decreased survival (43-66 days, HR 1.63, P = .049; ≥67 days, HR 2.10, P = .032).

CONCLUSION

Longer TS-RT was associated with lower overall survival in HPV negative patients. Treatment delay was not associated with survival in HPV positive OPSCC according to multivariate analysis. These findings enhance knowledge about treatment delay effects in OPSCC, aiding providers in decisions and patient communication.

Impact of Adjuvant Radiotherapy Setting on Quality-of-Life in Head and Neck Squamous Cell Carcinoma

OBJECTIVE

To determine differences in post-treatment QoL across treatment settings in patients receiving adjuvant radiation therapy for head and neck squamous cell carcinoma (HNSCC).

METHODS

This was a prospective observational cohort study of patients with HNSCC initially evaluated in a head and neck surgical oncologic and reconstructive clinic at an academic medical center (AMC). Participants were enrolled prior to treatment in a prospective registry collecting demographic, social, and clinical data. Physical and social-emotional QoL (phys-QoL and soc-QoL, respectively) was measured using the University of Washington-QoL questionnaire at pre-treatment and post-treatment visits.

RESULTS

A cohort of 177 patients, primarily male and White with an average age of 61.2 ± 11.2 years, met inclusion criteria. Most patients presented with oral cavity tumors (n = 132, 74.6%), had non-HPV-mediated disease (n = 97, 61.8%), and were classified as Stage IVa (n = 72, 42.8%). After controlling for covariates, patients treated at community medical centers (CMCs) reported a 7.15-point lower phys-QoL compared with those treated at AMCs (95% CI: -13.96 to -0.35, p = 0.040) up to 12 months post-treatment. Additionally, patients who were treated at CMCs had a 5.77-point (-11.86-0.31, p = 0.063) lower soc-QoL score compared with those treated at an AMC, which was not statistically significant.

CONCLUSION

This study revealed that HNSCC patients treated with radiation at AMCs reported significantly greater phys-QoL in their first-year post-treatment compared to those treated at CMCs, but soc-QoL did not differ significantly. Further observational studies are needed to explore potential factors, including treatment planning and cancer resource engagement, behind disparities between AMCs and CMCs.

LEVEL OF EVIDENCE

Step 3 Laryngoscope, 2024.

Uncovering the armpit of SBRT: An institutional experience with stereotactic radiation of axillary metastases

Purpose/objectives

The growing use of stereotactic body radiotherapy (SBRT) in metastatic cancer has led to its use in varying anatomic locations. The objective of this study was to review our institutional SBRT experience for axillary metastases (AM), focusing on outcomes and process.

Materials/methods

Patients treated with SBRT to AM from 2014 to 2022 were reviewed. Cumulative incidence functions were used to estimate the incidence of local failure (LF), with death as competing risk. Kaplan-Meier method was used to estimate progression-free (PFS) and overall survival (OS). Univariate regression analysis examined predictors of LF.

Results

We analyzed 37 patients with 39 AM who received SBRT. Patients were predominantly female (60 %) and elderly (median age: 72). Median follow-up was 14.6 months. Common primary cancers included breast (43 %), skin (19 %), and lung (14 %). Treatment indication included oligoprogression (46 %), oligometastases (35 %) and symptomatic progression (19 %). A minority had prior overlapping radiation (18 %) or surgery (11 %). Most had prior systemic therapy (70 %).Significant heterogeneity in planning technique was identified; a minority of patient received 4-D CT scans (46 %), MR-simulation (21 %), or contrast (10 %). Median dose was 40 Gy (interquartile range (IQR): 35-40) in 5 fractions, (BED10 = 72 Gy). Seventeen cases (44 %) utilized a low-dose elective volume to cover remaining axilla.At first assessment, 87 % had partial or complete response, with a single progression. Of symptomatic patients (n = 14), 57 % had complete resolution and 21 % had improvement. One and 2-year LF rate were 16 % and 20 %, respectively. Univariable analysis showed increasing BED reduced risk of LF. Median OS was 21.0 months (95 % [Confidence Interval (CI)] 17.3-not reached) and median PFS was 7.0 months (95 % [CI] 4.3-11.3). Two grade 3 events were identified, and no grade 4/5.

Conclusion

Using SBRT for AM demonstrated low rates of toxicity and LF, and respectable symptom improvement. Variation in treatment delivery has prompted development of an institutional protocol to standardize technique and increase efficiency. Limited followup may limit detection of local failure and late toxicity.

Impact of facility volume on survival in primary endoscopic surgery for sinonasal squamous cell carcinoma

OBJECTIVES

To evaluate the impact of facility volume on outcomes following primary endoscopic surgical management of sinonasal squamous cell carcinoma (SNSCC).

METHODS

The 2010-2016 National Cancer DataBase (NCDB) was queried for patients diagnosed with T1-T4a SNSCC surgically treated endoscopically as the primary treatment modality. Factors associated with overall survival (OS) were evaluated, including facility volume.

RESULTS

A total of 330 patients who underwent endoscopic surgical management of SNSCC were treated at 356 unique facilities designated as either low-volume (LVC; treating 1-2 cases; 0-75th percentile), intermediate-volume centers (IVC; 3-4 cases total; 75th-90th percentile), or 144 high-volume (HVC; treating 5+ cases total; >90th percentile) centers. HVC treated patients with higher T staging (42.1 % vs. 29.8 %) and tumors in the maxillary sinus (26.9 % vs. 13.2 %) and ethmoid sinus (10.3 % vs. ≤8.3 %), while LVCs treated lower T stage tumors (70.2 % vs. 57.9 %) and tumors that were located in the nasal cavity (70.2-78.5 % vs. 62.8 %). On multivariable analysis, factors associated with decreased OS included higher T stage (T3/T4a vs. T1/T2; OR 1.92, 95 % CI 1.06-3.47) and older age (>65 vs. <65; OR 2.69, 95 % CI 1.62-4.49). Cases treated at high-volume centers were not associated with a higher likelihood of OS when compared to low-volume centers (OR 0.70, 95 % CI 0.36-1.35).

CONCLUSIONS

HVC are treating more primary tumors of the maxillary and ethmoid sinuses and tumors with higher T stages with endoscopic approaches, although this does not appear to be associated with increased OS.

SHORT SUMMARY

Sinonasal squamous cell carcinoma (SNSCC) presents late in disease process with poor prognosis. We investigated the impact of facility volume on outcomes following endoscopic treatment of SNSCC. High-volume centers treat more advanced and complex disease with comparable OS.

Choice of Adjuvant Radiotherapy Facility in Major Salivary Gland Cancer

OBJECTIVE

Undergoing surgery and adjuvant radiotherapy (aRT) at the same facility has been associated with higher overall survival (OS) in head and neck squamous cell carcinoma. Our study investigates whether undergoing surgery and aRT at the same academic facility is associated with higher OS in major salivary gland cancer (MSGC).

METHODS

The 2006-2018 National Cancer Database was queried for patients with MSGC undergoing surgery at an academic facility and then aRT. Multivariable binary logistic and Cox proportional hazards regression models were implemented.

RESULTS

Of 2801 patients satisfying inclusion criteria, 2130 (76.0%) underwent surgery and aRT at the same academic facility. Residence in a less populated area (adjusted odds ratio [aOR] 1.69, 95% confidence interval [CI] 1.16-2.45), treatment without adjuvant chemotherapy (aOR 1.97, 95% CI 1.41-2.76), and aRT duration (aOR 1.02, 95% CI 1.01-1.04) were associated with undergoing surgery and aRT at different facilities on multivariable logistic regression adjusting for patient demographics, clinicopathologic features, and adjuvant therapy (p < 0.01). Five-year OS was higher in patients undergoing surgery and aRT at the same academic facility (68.8% vs. 61.9%, p < 0.001). Undergoing surgery and aRT at different facilities remained associated with worse OS on multivariable Cox regression (aHR 1.41, 95% CI 1.10-1.81, p = 0.007).

CONCLUSION

Undergoing surgery and aRT at the same academic facility is associated with higher OS in MSGC. Although undergoing surgery and aRT at the same academic facility is impractical for all patients, academic physicians should consider same-facility treatment for complex patients who would most benefit from clear multidisciplinary communication.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Increasing radiation therapy and lower survival for human papillomavirus-related oropharynx cancer associated with a shift to community cancer center care

BACKGROUND

Studies have shown lower overall survival for patients with head and neck cancer treated at low-volume or community cancer centers. As the incidence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma steadily rises in the United States, we hypothesized that a greater proportion of patients with HPV-related oropharyngeal squamous cell carcinoma is being treated at community cancer centers, with a shift toward primary nonsurgical treatment.

METHODS

This cohort study included patients from the US National Cancer Database who received a diagnosis of HPV-related oropharyngeal squamous cell carcinoma from 2010 to 2019 and underwent treatment at a community cancer center or academic cancer center. The proportion of patients with HPV-related oropharyngeal squamous cell carcinoma treated at community cancer centers and receiving primary nonsurgical treatment was analyzed over time. Four-year overall survival was compared between community cancer centers and academic cancer centers.

RESULTS

The majority (67.4%) of 20 298 patients were treated at an academic cancer center, yet the proportion of patients treated at community cancer centers increased by 10% from 2010 to 2019 (P < .01 for trend). The proportion of patients undergoing primary nonsurgical treatment increased from 62.1% to 73.7% from 2010 to 2019 (P < .01 for trend), and patients were statistically significantly more likely to undergo nonsurgical treatment at community cancer centers than at academic cancer centers (adjusted odds ratio = 1.20, 95% confidence interval = 1.18 to 1.22). Treatment at community cancer centers was associated with worse survival overall (adjusted hazard ratio = 1.19, 95% confidence interval = 1.09 to 1.31), specifically for patients receiving primary nonsurgical treatment (adjusted hazard ratio = 1.22, 95% confidence interval = 1.11 to 1.34).

CONCLUSIONS

Treatment of HPV-related oropharyngeal squamous cell carcinoma has recently shifted to community cancer centers, with an increase in the proportion of nonsurgical treatment and worse overall survival at these centers compared with academic cancer centers. Concentration of care for HPV-related oropharyngeal squamous cell carcinoma at academic cancer centers and dedicated head and neck cancer centers may increase access to all available treatment modalities and improve survival.

Effect of distance of treatment center on survival for HPV-negative head and neck cancer patients

BACKGROUND

In rural states, travel burden for complex cancer care required for head and neck squamous cell carcinoma (HNSCC) may affect patient survival, but its impact is unknown.

METHODS

Patients with HPV-negative HNSCC were retrospectively identified from a statewide, population-based study. Euclidian distance from the home address to the treatment center was calculated for radiation therapy, surgery, and chemotherapy. Multivariable Cox proportional hazards models were used to examine the risk of 5-year mortality with increasing travel quartiles.

RESULTS

There were 936 patients with HPV-negative HNSCC with a mean age of 60. Patients traveled a median distance of 10.2, 11.1, and 10.9 miles to receive radiation therapy, surgery, and chemotherapy, respectively. Patients in the fourth distance quartile were more likely to live in a rural location (p < 0.001) and receive treatment at an academic hospital (p < 0.001). Adjusted overall survival (OS) improved proportionally to distance traveled, with improved OS remaining significant for patients who traveled the furthest for care (third and fourth quartile by distance). Relative to patients in the first quartile, patients in the fourth had a reduced risk of mortality with radiation (HR 0.59, 95% CI 0.42-0.83; p = 0.002), surgery (HR 0.47, 95% CI 0.30-0.75; p = 0.001), and chemotherapy (HR 0.56, 95% CI 0.35-0.91; p = 0.020).

CONCLUSION

For patients in this population-based cohort, those traveling greater distances for treatment of HPV-negative HNSCC had improved OS. This analysis suggests that the benefits of coordinated, multidisciplinary care may outweigh the barriers of travel burden for these patients.

Systemic anticancer treatment in the Netherlands: Few hospitals treat many patients, many hospitals treat few patients

INTRODUCTION

The correlation between patient volume and clinical outcomes is well known for various oncological treatments, especially in the surgical field. The current level of centralisation of systemic treatment of (hemato-)oncology indications in Dutch hospitals is unknown.

OBJECTIVES

The aim of this study was to gain insight in patient volumes per hospital of patients treated with systemic anticancer treatment in the Netherlands.

METHODS

National claims data (Vektis) of all 73 Dutch hospitals that provide systemic anticancer medication in the Netherlands for the time period 2019 were used. The distribution of volumes of patients treated with anticancer medication for 38 different haematological or oncological indications was analysed. Hospitals were categorized into academic/specialised, general, and top clinical. Two volume cut off points (10 and 30 patients) were used to identify hospitals treating relatively few patients with anticancer medication. Four indications were investigated in more detail.

RESULTS

A wide distribution in patient volumes within hospitals was observed. Top clinical hospitals generally treated the most patients per hospital, followed by general and academic/specialised oncology hospitals. The volume cut off points showed that in 19 indications (50%) the majority (>50%) of all hospitals treated less than 10 patients and in 25 indications (66%) the majority of all hospitals treated less than 30 patients with anticancer medication. Four case studies demonstrated that relatively few hospitals treat many patients while many hospitals treat few patients with anticancer medication.

CONCLUSION

In the majority of oncology indications, a large proportion of Dutch hospitals treat small numbers of unique patients with anticancer medication. The high level of fragmentation gives ground for further exploration and discussion on how the organisation of care can support optimization of the efficiency and quality of care. Professional groups, policy makers, patients, and healthcare insurers should consider per indication whether centralisation is warranted.

Radiotherapy and Systemic Therapies: Focus on Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) is a complex clinical entity, and its treatment strategy remains a challenge. The best practice management for individual HNSCC patients should be discussed within a multidisciplinary team. In the locally advanced disease, radiation therapy (RT) with or without concomitant cisplatin-based chemotherapy is the current standard of care for most patients treated definitively or adjuvantly after surgery. Intensity-modulated photon therapy (IMRT) is the recommended RT technique due to its ability to offer considerable treatment conformality while sparing surrounding normal critical tissues. At present, the development of novel treatment strategies, as well as alternative systemic agent combinations, is an urgent need to improve the therapeutic ratio in HNSCC patients. Despite the immune landscape suggesting a strong rationale for the use of immunotherapy agents in HNSCC, evidence-based data demonstrate that combining RT with immune checkpoint inhibitors as the primary treatment modality has not been shown to induce significant benefit on survival clinical outcomes. The objective of this article is to review the current literature on the treatment of patients with HNSCC. We initially provided a comprehensive overview of the standard of care. We then focused on the integration of systemic therapies with RT, highlighting the latest published evidence and ongoing trials which investigate different combination strategies in the definitive setting. Our hope is to summarize relevant literature in order to provide a foundation for interpreting emerging data and designing future trials to maximize care, both in disease control and patient quality of life.

Artificial intelligence-supported applications in head and neck cancer radiotherapy treatment planning and dose optimisation

INTRODUCTION

The aim of this review is to describe how various AI-supported applications are used in head and neck cancer radiotherapy treatment planning, and the impact on dose management in regards to target volume and nearby organs at risk (OARs).

METHODS

Literature searches were conducted in databases and publisher portals Pubmed, Science Direct, CINAHL, Ovid, and ProQuest to peer reviewed studies published between 2015 and 2021.

RESULTS

Out of 464 potential ones, ten articles covering the topic were selected. The benefit of using deep learning-based methods to automatically segment OARs is that it makes the process more efficient producing clinically acceptable OAR doses. In some cases automated treatment planning systems can outperform traditional systems in dose prediction.

CONCLUSIONS

Based on the selected articles, in general AI-based systems produced time savings. Also, AI-based solutions perform at the same level or better than traditional planning systems considering auto-segmentation, treatment planning and dose prediction. However, their clinical implementation into routine standard of care should be carefully validated IMPLICATIONS TO PRACTICE: AI has a primary benefit in reducing treatment planning time and improving plan quality allowing dose reduction to the OARs thereby enhancing patients' quality of life. It has a secondary benefit of reducing radiation therapists' time spent annotating thereby saving their time for e.g. patient encounters.

High surgical volume is associated with improved survival in head and neck cancer

OBJECTIVES

Examine the relationship between hospital volume and overall mortality in a surgical cohort of head and neck squamous cell carcinoma (HNSCC) patients.

MATERIALS & METHODS

A retrospective review of the NCDB was completed for adults with previously untreated HNSCC diagnosed between 2004 and 2016. Mean annual hospital volume was calculated using the number of head and neck cancer cases treated at a given facility divided by the number of years the facility reported to the NCDB. Facilities were separated into three categories based on their volume percentile, informed by inflection points from a natural cubic spline: Hospital Group 1 (<50%); Hospital Group 2 (50-90%); Hospital Group 3 (90%+). Cox proportional hazard models were used to examine the association between volume percentiles (continuous or categorical) with patient overall survival, adjusting for important patient and facility variables known to impact survival.

RESULTS

Risk of death decreased by 2.97% for every 10% increase in facility percentile after adjusting for other risk factors. Patients treated at facilities in Hospital Group 1 had a 23.1% increase in risk of mortality (HR 1.231 [95% CI 1.12-1.35]) relative those at facilities in Hospital Group 3. No significant difference in mortality risk was found between Hospital Group 2 versus Hospital Group 3 (HR 1.031 [95% CI 0.97-1.10]).

CONCLUSIONS

Survival of HNSCC patients is significantly improved when treated at facilities >50th percentile in annual hospital volume. This may support the regionalization of care to high volume head and neck centers with comprehensive facilities and supportive services to maximize patient outcomes.

Traditional risk factors and nodal yield-still relevant with high-quality risk-adapted adjuvant treatment for locally advanced head and neck cancer?

OBJECTIVE

Patients with locally advanced head and neck cancer (LAHNC) often undergo multimodal therapy including radical resection of the primary tumor and neck dissection (ND) followed by risk-adapted adjuvant radio(chemo)therapy (R(C)T). Quality parameters influencing local control and survival of these patients have been postulated: resection status (R status), extranodal extension (ENE), interval to adjuvant treatment ≤6 weeks, R(C)T given when indicated, and nodal yield (NY) ≥18 lymph nodes per neck. For other solid tumors the trend is towards less extensive lymph node surgery to avoid toxicity such as lymphedema, damage to peripheral nerves, dysesthesia, or paresthesia. The present study aims to investigate whether the number of nodes removed during neck dissection for LAHNC is still predictive for outcome when patients receive risk-adapted adjuvant treatment according to current guidelines.

METHODS

Between 2008 and 2015, 468 patients with LAHNC undergoing R(C)T with curative intent were prospectively registered in a database (UICC III/IV). Among them, 359 patients received adjuvant treatment and 295 underwent neck dissection. There were 119 (40%) patients with an oropharyngeal primary, 49 (17%) with cancer of the larynx/hypopharynx, 88 (30%) of the oral cavity, and 39 (13%) of the nasal/paranasal sinuses and cancer of unknown primary (CUP). Median follow-up was 45.6 months. Histopathology revealed an R1 status in 65 (22%) cases and ENE in 93 (31%) cases. 150 (51%) patients received RCT; the median time to adjuvant treatment from the day of tumor resection was 44 days (35-54) and overall treatment time (OTT; time from surgery to the last day of R(C)T) was 90 days (82-101). Factors influencing disease-free survival (DFS) were adjusted and analyzed using CART analysis (removed nodes, number of positive nodes, body mass index (BMI), ENE, T and N classification, R status, and primary site). Local control (LC), distant metastases-free survival (DMFS), and overall survival (OS) were analyzed using Kaplan-Meier statistics and multivariate analysis (MVA) for factors predictive for DFS and OS.

RESULTS

CART analysis (Classification and Regression Trees) showed that T classification (T3/4) is the most important predictor for DFS, followed by age (> 61 years) and BMI (< 17.4). Primary site (OPC vs. other) and number of removed nodes (< 17) were shown to be less important for DFS, while ECE, N classification, and R status seem to be of little relevance. MVA revealed number of positive nodes, non-OPC, and T3/4 to be negative predictive factors for DFS. For OS, the number of positive nodes and non-OPC primary were predictive. Five-year rates were 86.1% for LC, 87.9% DMFS, 76.5% DFS, and 67.2% for OS.

CONCLUSION

In this patient cohort, the number of removed nodes is not relevant for DFS and OS, while the number of positive nodes and T classification have a negative impact on these endpoints. The high-risk factors positive resection margin and ECE seem to lose their negative impact on DFS and OS. High-quality care in head and oncology is only possible within a close multidisciplinary team and network.

Facility Volume as a Prognosticator of Survival in Locally Advanced Papillary Thyroid Cancer

OBJECTIVES

To evaluate the influence of facility case-volume on survival in patients with locally advanced papillary thyroid cancer (PTC), and to identify prognostic case-volume thresholds for facilities managing this patient population.

STUDY DESIGN

Retrospective database study.

METHODS

The 2004-2017 National Cancer Database was queried for patients receiving definitive surgery for locally advanced PTC. Using K-means clustering and multivariable Cox proportional-hazards (CPH) regression, two groups with distinct spectrums of facility case-volumes were generated. Multivariable CPH regression and Kaplan-Meier analysis assessed for the influence of facility case-volume and the prognostic value of its stratification on overall survival (OS).

RESULTS

Of 48,899 patients treated at 1304 facilities, there were 34,312 (70.2%) females and the mean age was 48.0 ± 16.0 years. Increased facility volume was significantly associated with reduced all-cause mortality (HR 0.996; 95% CI, 0.992-0.999; p = 0.008). Five facility clusters were generated, from which two distinct cohorts were identified: low (LVF; <27 cases/year) and high (HVF; ≥27 cases/year) facility case-volume. Patients at HVFs were associated with reduced mortality compared to those at LVFs (HR 0.791; 95% CI, 0.678-0.923, p = 0.003). Kaplan-Meier analysis of propensity score-matched N0 and N1 patients demonstrated higher OS in HVF cohorts (all p < 0.001).

CONCLUSIONS

Facility case-volume was an independent predictor of improved OS in locally advanced PTC, indicating a possible survival benefit at high-volume medical centers. Specifically, independent of a number of sociodemographic and clinical factors, facilities that treated ≥27 cases per year were associated with increased OS. Patients with locally advanced PTC may, therefore, benefit from referrals to higher-volume facilities.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:443-450, 2023.

E pluribus unum: prospective acceptability benchmarking from the Contouring Collaborative for Consensus in Radiation Oncology crowdsourced initiative for multiobserver segmentation

Purpose

Contouring Collaborative for Consensus in Radiation Oncology (C3RO) is a crowdsourced challenge engaging radiation oncologists across various expertise levels in segmentation. An obstacle to artificial intelligence (AI) development is the paucity of multiexpert datasets; consequently, we sought to characterize whether aggregate segmentations generated from multiple nonexperts could meet or exceed recognized expert agreement.

Approach

Participants who contoured ≥ 1 region of interest (ROI) for the breast, sarcoma, head and neck (H&N), gynecologic (GYN), or gastrointestinal (GI) cases were identified as a nonexpert or recognized expert. Cohort-specific ROIs were combined into single simultaneous truth and performance level estimation (STAPLE) consensus segmentations.STAPLE nonexpert ROIs were evaluated againstSTAPLE expert contours using Dice similarity coefficient (DSC). The expert interobserver DSC (IODSC expert ) was calculated as an acceptability threshold betweenSTAPLE nonexpert andSTAPLE expert . To determine the number of nonexperts required to match theIODSC expert for each ROI, a single consensus contour was generated using variable numbers of nonexperts and then compared to theIODSC expert .

Results

For all cases, the DSC values forSTAPLE nonexpert versusSTAPLE expert were higher than comparator expertIODSC expert for most ROIs. The minimum number of nonexpert segmentations needed for a consensus ROI to achieveIODSC expert acceptability criteria ranged between 2 and 4 for breast, 3 and 5 for sarcoma, 3 and 5 for H&N, 3 and 5 for GYN, and 3 for GI.

Conclusions

Multiple nonexpert-generated consensus ROIs met or exceeded expert-derived acceptability thresholds. Five nonexperts could potentially generate consensus segmentations for most ROIs with performance approximating experts, suggesting nonexpert segmentations as feasible cost-effective AI inputs.

Treating Head and Neck Cancer in the Age of Immunotherapy: A 2023 Update

Most patients diagnosed with head and neck squamous cell carcinoma (HNSCC) will present with locally advanced disease, requiring multimodality therapy. While this approach has a curative intent, a significant subset of these patients will develop locoregional failure and/or distant metastases. The prognosis of these patients is poor, and therapeutic options other than palliative chemotherapy are urgently needed. Epidermal growth factor receptor (EGFR) overexpression is an important factor in the pathogenesis of HNSCC, and a decade ago, the EGFR targeting monoclonal antibody cetuximab was approved for the treatment of late-stage HNSCC in different settings. In 2016, the anti-programmed death-1 (PD-1) immune checkpoint inhibitors nivolumab and pembrolizumab were both approved for the treatment of patients with recurrent or metastatic HNSCC with disease progression on or after platinum-containing chemotherapy, and in 2019, pembrolizumab was approved for first-line treatment (either as monotherapy in PD-L1 expressing tumors, or in combination with chemotherapy). Currently, trials are ongoing to include immune checkpoint inhibition in the (neo)adjuvant treatment of HNSCC as well as in novel combinations with other drugs in the recurrent/metastatic setting to improve response rates and survival and help overcome resistance mechanisms to immune checkpoint blockade. This article provides a comprehensive review of the management of head and neck cancers in the current era of immunotherapy.

Deep Learning-Based Dose Prediction for Automated, Individualized Quality Assurance of Head and Neck Radiation Therapy Plans

PURPOSE

This study aimed to use deep learning-based dose prediction to assess head and neck (HN) plan quality and identify suboptimal plans.

METHODS AND MATERIALS

A total of 245 volumetric modulated arc therapy HN plans were created using RapidPlan knowledge-based planning (KBP). A subset of 112 high-quality plans was selected under the supervision of an HN radiation oncologist. We trained a 3D Dense Dilated U-Net architecture to predict 3-dimensional dose distributions using 3-fold cross-validation on 90 plans. Model inputs included computed tomography images, target prescriptions, and contours for targets and organs at risk (OARs). The model's performance was assessed on the remaining 22 test plans. We then tested the application of the dose prediction model for automated review of plan quality. Dose distributions were predicted on 14 clinical plans. The predicted versus clinical OAR dose metrics were compared to flag OARs with suboptimal normal tissue sparing using a 2 Gy dose difference or 3% dose-volume threshold. OAR flags were compared with manual flags by 3 HN radiation oncologists.

RESULTS

The predicted dose distributions were of comparable quality to the KBP plans. The differences between the predicted and KBP-planned D_1%,D_95%, and D_99% across the targets were within -2.53% ± 1.34%, -0.42% ± 1.27%, and -0.12% ± 1.97%, respectively, and the OAR mean and maximum doses were within -0.33 ± 1.40 Gy and -0.96 ± 2.08 Gy, respectively. For the plan quality assessment study, radiation oncologists flagged 47 OARs for possible plan improvement. There was high interphysician variability; 83% of physician-flagged OARs were flagged by only one of 3 physicians. The comparative dose prediction model flagged 63 OARs, including 30 of 47 physician-flagged OARs.

CONCLUSIONS

Deep learning can predict high-quality dose distributions, which can be used as comparative dose distributions for automated, individualized assessment of HN plan quality.

Determinants of Commercial Prices for Common Radiation Therapy Procedures

PURPOSE

Using hospital-reported price data, we analyzed whether various market factors including radiation oncology practice consolidation were associated with higher commercial prices for radiation therapy (RT).

METHODS AND MATERIALS

We evaluated commercial prices paid by private insurers for 4 common RT procedures-intensity modulated RT (IMRT) planning, IMRT delivery, 3-dimensional RT (3D-RT) planning, and 3D-RT delivery-reported among the 2096 hospitals in the United States that deliver RT according to the Medicare Provider of Service file. To assess price variation within hospitals, we evaluated the ratio of the 90th percentile price to the 10th percentile price among different private insurers. To assess regional variation, we similarly compared median commercial prices at the 90th and 10th percentile hospitals in each Hospital Referral Region. We generated multivariable models to test the association of various hospital, health system, regional, and market factors on median hospital commercial prices.

RESULTS

A total of 1004 hospitals (47.9%) reported at least 1 commercial price for any of the 4 RT procedures considered in this study. National median commercial prices for IMRT planning and IMRT delivery were $4073 (interquartile ratio [IQR], $2242-$6305) and $1666 (IQR, $1014-$2619), respectively. Prices for 3D-RT planning and 3D-RT delivery were $2824 (IQR, $1339-$4738) and $616 (IQR, $419-877), respectively. Within hospitals, the 90th percentile price paid by a private insurer was 2.3 to 2.5 times higher on average than the 10th percentile price, depending on the procedure. Within each Hospital Referral Region, the median price at the 90th percentile hospital was between 2.4 and 3.2 times higher than at the 10th percentile hospital. On multivariable analysis, higher prices were generally observed at hospitals with for-profit ownership, teaching status, and affiliation with large health systems. Levels of radiation oncology practice consolidation were not significantly associated with any prices.

CONCLUSIONS

Commercial prices for common RT procedures vary by more than a factor of 2 depending on a patient's private insurer and hospital of choice. Higher prices were more likely to be found at for-profit hospitals, teaching hospitals, and hospitals affiliated with large health systems.

Systematic review of intraoperative radiation therapy for head and neck cancer

Multidisciplinary treatments with surgery, radiation therapy, and chemotherapy are the cornerstones in the management of locally advanced head and neck malignancies. In most cases, radiation is delivered via external beam radiation therapy (EBRT). Intraoperative radiation therapy (IORT), on the other hand, is the delivery of precise doses of radiation to selected target volumes within the exposed surgical field while at the operating room. Most studies on its use on head and neck cancers are limited to single-institutional retrospective case series. We performed a systematic review to consolidate the existing literature on IORT for head and neck malignancies. Fifty-two studies representing a mixed population of 2,389 patients were included in this review. IORT via electrons (intraoperative electron radiation therapy), brachytherapy (intraoperative high dose-rate brachytherapy) or photons was administered in numerous settings, but most commonly as part of a reirradiation regimen following salvage surgery for recurrent tumours. Often, additional EBRT was also planned postoperatively. This review illustrates that IORT is a promising treatment modality in head and neck cancer. Multiple single-institutional studies spanning several decades have demonstrated benefit in terms of local control with reasonable toxicity. However, randomised trials comparing it with current standards of care are still needed.

Are there differences in revision stapes surgery outcomes between university and county clinics? A study from the quality register for otosclerosis surgery in Sweden

Purpose

The aim of the study was to investigate hearing outcomes in stapes revision surgery with regard to the type of clinic (university clinic or county clinic). Furthermore, the aim was to investigate the risk of complications with a focus on tinnitus, hearing deterioration, and taste disturbance 1 year after surgery.

Methods

The study is based on data from the Swedish Quality Register for Otosclerosis Surgery (SQOS). Two study protocols were completed by the surgeon, and a questionnaire was distributed to the patients 1 year after surgery. A total of 156 revisions were available for analysis with both preoperative and postoperative audiometry data.

Results

Seventy-five percent of the patients reported better to much better hearing 1 year after revision surgery. An air bone gap ≤ 20 dB postoperatively was seen in 77% of the patients. Four percent had hearing deterioration ≥ 20 dB PTA4 AC. Eleven percent had worsened or newly developed tinnitus, 5% had taste disturbance, and 3% had dizziness 1 year after surgery. Preoperative and postoperative hearing did not differ between patients operated on in university vs. county clinics.

Conclusions

Revision surgery in otosclerosis is a challenge for otologists, but no differences in hearing outcomes between university and county clinics were found in this nationwide study. The risk of hearing deterioration and deafness is higher than in primary stapes surgery, and revision surgery should be recommended primarily in cases with a large air–bone gap and moderate to severe preoperative hearing loss.

Head and neck radiotherapy quality assurance conference for dedicated review of delineated targets and organs at risk: results of a prospective study

Purpose

Head and neck (HN) radiotherapy (RT) is complex, involving multiple target and organ at risk (OAR) structures delineated by the radiation oncologist. Site-agnostic peer review after RT plan completion is often inadequate for thorough review of these structures. In-depth review of RT contours is critical to maintain high-quality RT and optimal patient outcomes.

Materials and Methods

In August 2020, the HN RT Quality Assurance Conference, a weekly teleconference that included at least one radiation oncology HN specialist, was activated at our institution. Targets and OARs were reviewed in detail prior to RT plan creation. A parallel implementation study recorded patient factors and outcomes of these reviews. A major change was any modification to the high-dose planning target volume (PTV) or the prescription dose/fractionation; a minor change was modification to the intermediate-dose PTV, low-dose PTV, or any OAR. We analysed the results of consecutive RT contour review in the first 20 months since its initiation.

Results

A total of 208 patients treated by 8 providers were reviewed: 86·5% from the primary tertiary care hospital and 13·5% from regional practices. A major change was recommended in 14·4% and implemented in 25 of 30 cases (83·3%). A minor change was recommended in 17·3% and implemented in 32 of 36 cases (88·9%). A survey of participants found that all (n = 11) strongly agreed or agreed that the conference was useful.

Conclusion

Dedicated review of RT targets/OARs with a HN subspecialist is associated with substantial rates of suggested and implemented modifications to the contours.

THE MULTIDISCIPLINARY TEAM (MDT) IN THE TREATMENT OF HEAD AND NECK CANCER - A SINGLE-INSTITUTION EXPERIENCE

Head and neck cancers are associated with significant morbidity and mortality despite advancements in treatment in recent decades. A multidisciplinary approach to the treatment of these diseases is thus of essential importance and is becoming the gold standard. Head and neck tumors also endanger relevant structures of the upper aerodigestive tracts, including bodily functions such as voice, speech, swallowing, and breathing. Damage to these functions can significantly influence quality of life. Thus, our study examined not only the roles of head and neck surgeons, oncologists and radiotherapists, but also the importance of the participation of different scientific professions such as anesthesiologists, psychologists, nutritionists, stomatologists, and speech therapists in the work of a multidisciplinary team (MDT). Their participation results in a significant improvement of patient quality of life. We also present our experiences in the organization and work of the MDT as part of the Center for Head and Neck Tumors of the Zagreb Clinical Hospital Center.

Multi-institution model (big model) versus single-institution model of knowledge-based volumetric modulated arc therapy (VMAT) planning for prostate cancer

We established a multi-institution model (big model) of knowledge-based treatment planning with over 500 treatment plans from five institutions in volumetric modulated arc therapy (VMAT) for prostate cancer. This study aimed to clarify the efficacy of using a large number of registered treatment plans for sharing the big model. The big model was created with 561 clinically approved VMAT plans for prostate cancer from five institutions (A: 150, B: 153, C: 49, D: 60, and E: 149) with different planning strategies. The dosimetric parameters of planning target volume (PTV), rectum, and bladder for two validation VMAT plans generated with the big model were compared with those from each institutional model (single-institution model). The goodness-of-fit of regression lines (R2 and χ2 values) and ratios of the outliers of Cook’s distance (CD) > 4.0, modified Z-score (mZ) > 3.5, studentized residual (SR) > 3.0, and areal difference of estimate (dA) > 3.0 for regression scatter plots in the big model and single-institution model were also evaluated. The mean ± standard deviation (SD) of dosimetric parameters were as follows (big model vs. single-institution model): 79.0 ± 1.6 vs. 78.7 ± 0.5 (D50) and 0.13 ± 0.06 vs. 0.13 ± 0.07 (Homogeneity Index) for the PTV; 6.6 ± 4.0 vs. 8.4 ± 3.6 (V90) and 32.4 ± 3.8 vs. 46.6 ± 15.4 (V50) for the rectum; and 13.8 ± 1.8 vs. 13.3 ± 4.3 (V90) and 39.9 ± 2.0 vs. 38.4 ± 5.2 (V50) for the bladder. The R2 values in the big model were 0.251 and 0.755 for rectum and bladder, respectively, which were comparable to those from each institution model. The respective χ2 values in the big model were 1.009 and 1.002, which were closer to 1.0 than those from each institution model. The ratios of the outliers in the big model were also comparable to those from each institution model. The big model could generate a comparable VMAT plan quality compared with each single-institution model and therefore could possibly be shared with other institutions.

Consensus Quality Measures and Dose Constraints for Head and Neck Cancer with an emphasis on Oropharyngeal and Laryngeal Cancer from the Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology Expert Panel

PURPOSE

Safeguarding high-quality care using evidence-based radiation therapy for patients with head and neck cancer is crucial to improving oncologic outcomes, including survival and quality of life.

METHODS AND MATERIALS

The Veterans Administration (VA) National Radiation Oncology Program established the VA Radiation Oncology Quality Surveillance Program (VAROQS) to develop clinical quality measures (QM) in head and neck cancer. As part of the development of QM, the VA commissioned, along with the American Society for Radiation Oncology, a blue-ribbon panel comprising experts in head and neck cancer, to develop QM.

RESULTS

We describe the methods used to develop QM and the final consensus QM, as well as aspirational and surveillance QM, which capture all aspects of the continuum of patient care from initial patient work-up, radiation treatment planning and delivery, and follow-up care, as well as dose volume constraints.

CONCLUSION

These QM are intended for use as part of ongoing quality surveillance for veterans receiving radiation therapy throughout the VA as well as outside the VA. They may also be used by the non-VA community as a basic measure of quality care for head and neck cancer patients receiving radiation.

Treatment Options in Early Stage (Stage I and II) of Oropharyngeal Cancer: A Narrative Review

Objective: to show an overview on the treatments’ options for stage I and II oropharyngeal carcinomasquamous cell carcinoma (OPSCC). Background: The traditional primary treatment modality of OPSCC at early stages is intensity modulated radiation therapy (IMRT). Trans-oral robotic surgery (TORS) has offered as an alternative, less invasive surgical option. Patients with human papilloma virus (HPV)-positive OPSCC have distinct staging with better overall survival in comparison with HPV-negative OPSCC patients. Methods: a comprehensive review of the English language literature was performed using PubMed, EMBASE, the Cochrane Library, and CENTRAL electronic databases. Conclusions: Many trials started examining the role of TORS in de-escalating treatment to optimize functional consequences while maintaining oncologic outcome. The head–neck surgeon has to know the current role of TORS in HPV-positive and negative OPSCC and the ongoing trials that will influence its future implementation. The feasibility of this treatment, the outcomes ensured, and the side effects are key factors to consider for each patient. The variables reported in this narrative review are pieces of a bigger puzzle called tailored, evidence-based driven medicine. Future evidence will help in the construction of robust and adaptive algorithms in order to ensure the adequate treatment for the OPSCC at early stages.

Development and Clinical Implementation of an Automated Virtual Integrative Planner for Radiation Therapy of Head and Neck Cancer

Purpose

Head and neck (HN) radiation (RT) treatment planning is complex and resource intensive. Deviations and inconsistent plan quality significantly affect clinical outcomes. We sought to develop a novel automated virtual integrative (AVI) knowledge-based planning application to reduce planning time, increase consistency, and improve baseline quality.

Methods and Materials

An in-house write-enabled script was developed from a library of 668 previously treated HN RT plans. Prospective hazard analysis was performed, and mitigation strategies were implemented before clinical release. The AVI-planner software was retrospectively validated in a cohort of 52 recent HN cases. A physician panel evaluated planning limitations during initial deployment, and feedback was enacted via software refinements. A final second set of plans was generated and evaluated. Kolmogorov-Smirnov test in addition to generalized evaluation metric and weighted experience score were used to compare normal tissue sparing between final AVI planner versus respective clinically treated and historically accepted plans. A t test was used to compare the interactive time, complexity, and monitor units for AVI planner versus manual optimization.

Results

Initially, 86% of plans were acceptable to treat, with 10% minor and 4% major revisions or rejection recommended. Variability was noted in plan quality among HN subsites, with high initial quality for oropharynx and oral cavity plans. Plans needing revisions were comprised of sinonasal, nasopharynx, P-16 negative squamous cell carcinoma unknown primary, or cutaneous primary sites. Normal tissue sparing varied within subsites, but AVI planner significantly lowered mean larynx dose (median, 18.5 vs 19.7 Gy; P < .01) compared with clinical plans. AVI planner significantly reduced interactive optimization time (mean, 2 vs 85 minutes; P < .01).

Conclusions

AVI planner reliably generated clinically acceptable RT plans for oral cavity, salivary, oropharynx, larynx, and hypopharynx cancers. Physician-driven iterative learning processes resulted in favorable evolution in HN RT plan quality with significant time savings and improved consistency using AVI planner.

Disadvantaged Subgroups Within the Global Head and Neck Cancer Population: How Can We Optimize Care?

Within the global head and neck cancer population, there are subgroups of patients with poorer cancer outcomes independent from tumor characteristics. In this article, we review three such groups. The first group comprises patients with nasopharyngeal cancer in low- and middle-income countries where access to high-volume, well-resourced radiotherapy centers is limited. We discuss a recent study that is aiming to improve outcomes through the instigation of a comprehensive radiotherapy quality assurance program. The second group comprises patients with low socioeconomic status in a high-income country who experience substantial financial toxicity, defined as financial hardship for patients due to health care costs. We review causes and consequences of financial toxicity and discuss how it can be mitigated. The third group comprises older patients who may poorly tolerate and not benefit from intensive standard-of-care treatment. We discuss the role of geriatric assessment, particularly in relation to the use of chemotherapy. Through better recognition and understanding of disadvantaged groups within the global head and neck cancer population, we will be better placed to instigate the necessary changes to improve outcomes and quality of life for patients with head and neck cancer.

Prognostic Impact of Primary Tumor Extent and Postoperative Radiation Facility Location in Major Salivary Gland Malignancies

Introduction

The treatment of primary salivary malignancies often requires a multimodality approach. The purpose of this analysis was to evaluate the interaction between primary tumor extent and the treatment location of postoperative radiotherapy (PORT) in patients with primary salivary malignancies with respect to survival outcomes.

Methods

Patients with primary salivary malignancies who underwent upfront surgery followed by radiation were queried in the National Cancer Database (NCDB). Patients were stratified by pathologic T stage and whether PORT was performed at the same or different facility as the definitive surgery. Survival outcomes were compared using the Kaplan-Meier method and Cox proportional hazards regression.

Results

A total of 5,553 patients were selected, of which 1,159 had pathologic T4 (pT4) tumors. Patients who received PORT at the same facility compared with a different facility demonstrated superior overall survival (OS) on log-rank analysis (p=0.003). On subgroup analysis, patients with pT4 tumors had superior OS (p=0.015), whereas patients with smaller T1-3 tumors did not. PORT receipt at the same surgical facility was not a significant predictor of OS on multivariable analysis when all patients were included (p=0.057). However, among patients with pT4 tumors, OS was improved in patients who got PORT at the same facility as their surgery (p=0.015), with 10-year survival rates of 38.3 (95% confidence interval (CI): 33%-44%) versus 31% (95%CI: 24%-38%).

Conclusion

OS was improved in patients with primary salivary malignancies who received PORT at the same facility as their surgery, but the difference appears to be primarily driven by patients with pT4 primary tumors.

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.

Head and neck cancer

Head and neck cancer is the seventh most common type of cancer worldwide and comprise of a diverse group of tumours affecting the upper aerodigestive tract. Although many different histologies exist, the most common is squamous cell carcinoma. Predominant risk factors include tobacco use, alcohol abuse, and oncogenic viruses, including human papillomavirus and Epstein-Barr virus. Head and neck malignancies remain challenging to treat, requiring a multidisciplinary approach, with surgery, radiotherapy, and systemic therapy serving as key components of the treatment of locally advanced disease. Although many treatment principles overlap, treatment is generally site-specific and histology-specific. This Seminar outlines the current understanding of head and neck cancer and focuses on treatment principles, while also discussing future directions to improve the outcomes of patients with these malignancies.

Head and neck cancers: Monitoring quality and reporting outcomes

INTRODUCTION

Head and neck cancers (HNC) require high level multidisciplinary care to achieve optimal outcomes. Reporting of quality indicators (QIs) has been instigated by some health services in an effort to improve quality of care. The aim of this study was to determine the quality of care provided to patients with HNC at a single institution by analysing compliance with QIs and to explore the feasibility and utility of collecting this data.

METHODS

This was a single institution retrospective chart review of all patients with squamous cell HNC at Townsville Hospital who were treated with curative intent between June 2011 and June 2019. Data was entered into a RedCap database and then exported to Stata V16 for analysis.

RESULTS

A total of 537 patients were included in the overall study, with six patients who had a synchronous non-HNC and two patients who received previous radiotherapy (RT) to the head and neck region excluded from the outcome analysis. Overall, compliance with pre-treatment, treatment and post-treatment QIs was high, with the exception of smoking cessation support (66%), post-treatment dental review and time to post-operative RT (33% of patients within 6 weeks). The 5-year overall survival was 69.4% (CI; 64-73.2%). The cumulative incidence of locoregional relapse for the overall study cohort was 18% (CI; 14.8-21.4%).

CONCLUSION

Collecting and evaluating quality metrics is feasible and helps identify areas for improvement. Centres treating HNC patients should strive towards monitoring quality against benchmarks and demonstrate transparency in outcome data.

Radioresistance and genomic alterations in head and neck squamous cell cancer: Sub-analysis of the ProfiLER protocol

BACKGROUND

Genome analysis could provide tools to assess predictive molecular biomarkers of radioresistance.

METHODS

Head and neck squamous cell carcinoma patients included in ProfiLER study and who underwent a curative radiotherapy were screened. Univariate and Cox multivariate analyses were performed to explore the relationships between molecular abnormalities, infield relapse and complete tumor response after radiation.

RESULTS

One hundred and forty-three patients were analyzed. PIK3CA mutation and genomic instability of MAP kinases pathway were found to be prognostic factors of loco-regional relapse in multivariate analysis with respectively HR 0.33, 95% CI 0.13-0.83, p = 0.005 and HR 0.61, 95% CI 0.38-0.96, p = 0.025. Instability of apoptosis pathway was found to be a prognostic factor of complete response after radiotherapy with HR 0.24, 95% CI 0.07-0.88, p = 0.04.

CONCLUSION

This sub analysis suggests that PIK3CA mutation, variation of copy number of MAP kinases and apoptosis pathways play a significant role in the radioresistance phenomenon.

Recurrence Patterns After IMRT/VMAT in Head and Neck Cancer

Purpose

Intensity-modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT), two advanced modes of high-precision radiotherapy (RT), have become standard of care in the treatment of head and neck cancer. The development in RT techniques has markedly increased the complexity of target volume definition and accurate treatment delivery. The aim of this study was to indirectly investigate the quality of current TV delineation and RT delivery by analyzing the patterns of treatment failure for head and neck cancer patients in our high-volume RT center.

Methods

Between 2004 and 2014, 385 patients with pharyngeal, laryngeal, and oral cavity tumors were curatively treated with primary RT (IMRT/VMAT). We retrospectively investigated locoregional recurrences (LRR), distant metastases (DM), and overall survival (OS).

Results

Median follow-up was 6.4 years (IQR 4.7–8.3 years) during which time 122 patients (31.7%) developed LRR (22.1%) and DM (17.7%). The estimated 2- and 5-year locoregional control was 78.2% (95% CI 73.3, 82.3) and 74.2% (95% CI 69.0, 78.8). One patient developed a local recurrence outside the high-dose volume and five patients developed a regional recurrence outside the high-dose volume. Four patients (1.0%) suffered a recurrence in the electively irradiated neck and two patients had a recurrence outside the electively irradiated neck. No marginal failures were observed. The estimated 2- and 5-year DM-free survival rates were 83.3% (95% CI 78.9, 86.9) and 80.0% (95% CI 75.2, 84.0). The estimated 2- and 5-year OS rates were 73.6% (95% CI 68.9, 77.8) and 52. 6% (95% CI 47.3, 57.6). Median OS was 5.5 years (95% CI 4.5, 6.7).

Conclusion

Target volume definition and treatment delivery were performed accurately, as only few recurrences occurred outside the high-dose regions and no marginal failures were observed. Research on dose intensification and identification of high-risk subvolumes might decrease the risk of locoregional relapses. The results of this study may serve as reference data for comparison with future studies, such as dose escalation or proton therapy trials.

Can Radiation Therapy Quality Assurance Improve Nasopharyngeal Cancer Outcomes in Low- and Middle-Income Countries: Reporting the First Phase of a Prospective International Atomic Energy Agency Study

PURPOSE

Most new nasopharyngeal cancer cases occur in low-income and middle-income countries, and these patients experience poorer overall survival than that of new nasopharyngeal cancer cases in high-income countries. The goal of this research project is to determine whether the introduction of a radiation therapy quality assurance program can ultimately improve outcomes for nasopharyngeal cancer patients in lower-income and middle-income countries. This study reports the results of the first phase of the International Atomic Energy Agency Coordinated Research Project (325-E3-TM-47712).

METHODS AND MATERIALS

This prospective study has 2 phases. Phase 1 is a survey of radiation therapy resources, patient characteristics and treatment, and results of radiation therapy quality assurance performed by the expert panel. An educational workshop reviewing phase 1 results for each center was completed before accrual of patients for phase 2. The ultimate aim of the study is to compare the first and second cohort of patients to see if quality assurance can result in fewer major protocol deviations and a 15% improvement in patients' 3-year progression-free survival.

RESULTS

Of 14 participating centers, 13 (93%) had computed tomography simulators and linear accelerators (LINAC) with intensity modulated radiation therapy (IMRT) capacity, median 3 LINAC (range, 1-13), and median 10 radiation oncologists (range, 5-51). The annual number of nasopharyngeal cancer cases irradiated was median 54 (range, 10-627). Five of 14 centers (36%) had no local radiation therapy quality assurance. For the current phase 1 study, 134 patients were evaluated, 82.1% had MRI staging, 99.3% had metastatic workup, 65.6% undifferentiated histology, 51% stage 3 and 49% stage 4. Radiation therapy quality assurance revealed 81 (60.4%) of 134 patients had major protocol violations in gross tumor volume and high dose planning target volume contours and/or dosimetry, 28.4% patients had borderline plans, 15 (11.2%) acceptable, and only 6 (4.2%) had inevitable compromise due to tumor extent.

CONCLUSIONS

This is the first International Atomic Energy Agency study to address the fundamental issue of treatment quality rather than altered treatment regimens. The high rate of unacceptable radiation therapy plans is a major concern, and we hope phase 2 will show a significant reduction and improved patient outcomes.

Impact of Treatment Parameters on Racial Survival Differences in Oropharyngeal Cancer: National Cancer Database Study

OBJECTIVE

To investigate how differences in treatment parameters account for survival differences between races of patients with oropharyngeal squamous cell carcinoma (OPSCC).

STUDY DESIGN

Retrospective cohort study.

SETTING

National Cancer Database.

METHODS

Data of patients with OPSCC undergoing radiation therapy (RT) or concurrent chemoradiation therapy as primary treatment were obtained from the National Cancer Database from 2004 to 2016. We analyzed 4 treatment-related time intervals to determine their impact on survival between races when controlling for human papilloma virus (HPV) status. Cox proportional hazards models, stepwise logistic regressions, covariate adjustments, and propensity score matching were performed.

RESULTS

A total of 3152 patients were identified (2877 White, 275 Black). In HPV- cases, Black patients with prolonged radiation duration had a significantly worse overall survival as compared with White patients (hazard ratio, 1.77; 95% CI, 1.03-3.05; P = .039). In a logistic regression model, the only covariate that was significantly associated with prolonged RT was facility type. When further adjusted for facility type, the survival difference between Black and White patients with HPV- status and prolonged RT times was no longer significant (hazard ratio, 1.55; 95% CI, 0.90-2.69; P = .116).

CONCLUSIONS

There is a significant disparity in overall survival between Black and White patients with HPV- OPSCC when RT duration is prolonged. Clinicians should be aware of the negative impact of prolonged RT, especially in Black patients, so that they can attempt to decrease treatment-related time intervals. Facility type was also found to affect the outcomes of patients with OPSCC, and efforts should be made to improve patient access to well-equipped, high-volume facilities.

Outcomes between intensity-modulated radiation therapy versus 3D-conformal in early stage glottic cancer

BACKGROUND

The purpose of this study is to evaluate practice patterns and outcomes between intensity-modulated radiation therapy (IMRT) and 3D-conformal radiation (3D-CRT) in early stage glottic cancer.

METHODS

The linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify and compare patient and disease profiles, mortality, and toxicity in patients with T1-2 larynx cancer undergoing definitive radiation (RT).

RESULTS

A total of 1520 patients underwent definitive radiation with 3D-CRT (n = 1309) or IMRT (n = 211). Non-white race, those with a Charlson Comorbidity Index ≥2, T2 disease, and those treated at community practices were more likely to undergo IMRT. Rates of IMRT increased from 2006 to 2015, while relative rates of 3D-CRT decreased. Two-year CSS was superior with 3D-CRT (hazard ratio [HR], 0.38; 95% confidence interval [CI], 0.22-0.65; p < 0.001). There was no difference in OS between 3D-CRT and IMRT (p = 0.119).

CONCLUSIONS

Patients receiving 3D-CRT had improved CSS compared to IMRT with no difference in OS.

Clinically Applicable Segmentation of Head and Neck Anatomy for Radiotherapy: Deep Learning Algorithm Development and Validation Study

BACKGROUND

Over half a million individuals are diagnosed with head and neck cancer each year globally. Radiotherapy is an important curative treatment for this disease, but it requires manual time to delineate radiosensitive organs at risk. This planning process can delay treatment while also introducing interoperator variability, resulting in downstream radiation dose differences. Although auto-segmentation algorithms offer a potentially time-saving solution, the challenges in defining, quantifying, and achieving expert performance remain.

OBJECTIVE

Adopting a deep learning approach, we aim to demonstrate a 3D U-Net architecture that achieves expert-level performance in delineating 21 distinct head and neck organs at risk commonly segmented in clinical practice.

METHODS

The model was trained on a data set of 663 deidentified computed tomography scans acquired in routine clinical practice and with both segmentations taken from clinical practice and segmentations created by experienced radiographers as part of this research, all in accordance with consensus organ at risk definitions.

RESULTS

We demonstrated the model's clinical applicability by assessing its performance on a test set of 21 computed tomography scans from clinical practice, each with 21 organs at risk segmented by 2 independent experts. We also introduced surface Dice similarity coefficient, a new metric for the comparison of organ delineation, to quantify the deviation between organ at risk surface contours rather than volumes, better reflecting the clinical task of correcting errors in automated organ segmentations. The model's generalizability was then demonstrated on 2 distinct open-source data sets, reflecting different centers and countries to model training.

CONCLUSIONS

Deep learning is an effective and clinically applicable technique for the segmentation of the head and neck anatomy for radiotherapy. With appropriate validation studies and regulatory approvals, this system could improve the efficiency, consistency, and safety of radiotherapy pathways.

Practice Consolidation Among U.S. Radiation Oncologists Over Time

PURPOSE

Health care practices across the United States have been consolidating in response to various market forces. The degree of practice consolidation varies widely across specialties but has not been well studied within radiation oncology. This study used Medicare data to characterize the extent of practice consolidation among radiation oncologists and to investigate associated market factors.

METHODS AND MATERIALS

We utilized Medicare Provider Enrollment, Chain, and Ownership System data to assess the practice size and billing patterns of U.S. radiation oncologists in 2013 and again in 2017. Individual practices were categorized by the number of radiation oncologists practicing together: solo practices had 1 radiation oncologist, small practices 2 to 10, and large practices 11 or more. Market consolidation within each hospital referral region (HRR) across the country was quantified using the Herfindahl-Hirschman Index. Hospital and market level data were obtained for each HRR, and factors associated with the growth of radiation oncology practices over time were calculated via multivariable linear regression.

RESULTS

Across the United States, radiation oncology practices appear to be highly consolidated. The mean Herfindahl-Hirschman Index was 0.4711 in 2013-indicating high levels of consolidation at baseline-and increased further to 0.4865 by 2017. Between 2013 and 2017, the number of practices with radiation oncologists in the United States decreased 3.8%, from 1679 to 1615, whereas the number of practicing radiation oncologists increased 9.4%, from 4948 to 5415. Over the study period, the number of solo practices fell 11% (from 708 in 2013 to 627 in 2017), whereas the number of large practices (those with 11 or more radiation oncologists) increased 50% (from 60 to 90). Large practices likewise grew to employ a greater share of all radiation oncologists (23.9%-32.4%) and accounted for a larger proportion of total Medicare billing (21%-26%). Two market factors were predictive for increases in the mean radiation oncology practice size. HRRs with greater hospital market consolidation and those with lower levels of baseline radiation oncology consolidation were more likely to experience higher levels of growth over the study period.

CONCLUSIONS

Radiation oncologists are increasingly working in larger practices. By 2017, nearly one-third of all practicing radiation oncologists in the United States were employed by just the 90 largest practices. Radiation oncology, as a field, is highly concentrated, and represents one of the most consolidated specialties across the country. The implications of practice consolidation among radiation oncologists warrants further investigation.

Prophylactic gastrostomy in locally advanced head and neck cancer: results of a national survey among radiation oncologists

BACKGROUND

Nutritional complications in patients with locally advanced head and neck cancer (LA-HNC) treated by concurrent chemoradiotherapy (CCRT) often lead to placement of a prophylactic gastrostomy (PG) tube, while indication lacks harmonization. Our aim was to explore the current PG tube utilization among Belgian radiation oncology centers.

METHODS

A survey was distributed to all 24 Belgian Radiation oncology departments, with questions about the number of patient treated per year, whether the PG indication is discussed at the multidisciplinary board, placement technique, time of starting nutrition and removal, its impact on swallowing function and importance of clinical factors. For the latter Relative Importance and Discordance Indexes were calculated to describe the ranking and agreement.

RESULTS

All 24 centers submitted the questionnaire. Twenty three treat more than 20 head and neck (HNC) patients per year, while four (1 in 21-50; 3 in 51-100) are not discussing the gastrostomy tube indication at the multidisciplinary board. For the latter, endoscopic placement (68%) is the dominant technique, followed by the radiologic (16%) and laparoscopic (16%) methods. Seventy-five percent start the enteral nutrition when clinically indicated, 17% immediately and 8% from the start of radiotherapy. Majority of specialists (19/24) keep the gastrostomy tube until the patient assume an adequate oral feeding. Fifteen centres are considering PG decrease swallowing function. Regarding factors and their importance in the decision for the PG, foreseen irradiated volume reached highest importance, followed by 'anatomical site', 'patients' choice' and 'postoperative versus definitive' and 'local expertise', with decreasing importance respectively. Disagreement indexes showed moderate variation.

CONCLUSIONS

The use of a PG tube for LAHNC patients treated by CCRT shows disparity at national level. Prospective studies are needed to ensure proper indication of this supportive measure.

Impact of FDG-PET/CT on restaging and response evaluation of locally advanced head and neck cancer patient management

Background:

Head and neck cancer (HNC) accounts for 5% of all new cancer cases and most were locally advanced. Positron emission tomography/computed tomography (PET/CT) in radiotherapy practice in locally advanced head and neck squamous cell carcinoma (HNSCC) is being used in staging and proper contouring. Proper staging is essential for accurate treatment decision.

Methods:

This is a prospective phase II study conducted as a single institute centre to evaluate the role of PET/CT-treatment in staging, contouring and response evaluation of 30 patients with locally advanced HNSCC in contrast to CT scan. Our cases did not undergo radical surgery for the primary tumour, and biopsy was taken with PET/CT post-treatment to evaluate response.

Results:

Median age of patients was 49·4 years (minimum age of 32 years and maximum of 68 years). Males were predominant 22 (73·3%). Nasopharynx was the predominant site 16/30 (53·3%). PET/CT changed the overall staging in 40% of the patients (upstaged in 36·7% and downstaged in 3·3%). Gross tumour volume (GTV) of PET/CT was smaller in 23 patients (76·7%) and larger in 5 (16·7%) than the GTV of conventional CT, whereas GTV of lymph nodes of PET/CT was larger in 20 patients (67·7%) and smaller in 4 (13·3%). PET/CT study detected bone metastasis in two nasopharyngeal carcinoma patients and two cases of 2nd primary tumours which were not detected using conventional CT. The Cox-regression model showed that the median standardised uptake volume (SUV) of the initial tumour had been a dependent predictor of death in patients with HNSCC (p-value = 0·033) where the risk of death was 0·725 times among patients with high SUV of the initial tumour. Consequently, the size of GTV of the tumour was significant in the prediction of death (p = 0·018).

Conclusions:

18F-FDG-PET/CT is useful for staging, radiotherapy delineation as well as aiding proper decision making, in addition to assessment of treatment response in HNSCC patients.

The influence of facility volume on patient treatments and survival outcomes in nasopharyngeal carcinoma

BACKGROUND

This study evaluates the influence of facility case-volume on nasopharyngeal carcinoma (NPC) treatments and overall survival (OS).

METHODS

The 2004-2015 National Cancer Database was queried for patients with NPC receiving definitive treatment.

RESULTS

A total of 8260 patients (5-year OS: 63.4%) were included. The 1114 unique facilities were categorized into 854 low-volume (treating 1-8 patients), 200 intermediate-volume (treating 9-23 patients), and 60 high-volume (treating 24-187 patients) facilities. Kaplan-Meier log-rank analysis demonstrated significantly improved OS with high-volume facilities (p < 0.001). On cox proportional-hazard multivariate regression after adjusting for age, sex, income, insurance, comorbidity index, histology, AJCC clinical stage, and treatment type, high-volume facilities were associated with lower mortality risk than low-volume (HR = 0.865, p = 0.019) and intermediate-volume facilities (HR = 0.916, p = 0.004). Propensity score matching analysis confirmed this association (p < 0.001).

CONCLUSION

Higher facility volume was an independent predictor of improved OS in NPC, suggesting a possible survival benefit of referrals to high-volume medical centers.

Standardization for oncologic head and neck surgery

The inherent variability in performing specific surgical procedures for head and neck cancer remains a barrier for accurately assessing treatment outcomes, particularly in clinical trials. While non-surgical modalities for cancer therapeutics have evolved to become far more uniform, there remains the challenge to standardize surgery. The purpose of this review is to identify the barriers in achieving uniformity and to highlight efforts by surgical groups to standardize selected operations and nomenclature. While further improvements in standardization will remain a challenge, we must encourage surgical groups to focus on strategies that provide such a level.

Accuracy of parotid gland FNA cytology and reliability of the Milan System for Reporting Salivary Gland Cytopathology in clinical practice

Background

Differentiating between malignant and benign salivary gland tumors with fine‐needle aspiration cytology (FNAC) can be challenging. This study was aimed at testing the validity of the Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) and at assessing possible differences in the sensitivity and specificity of parotid gland FNAC between dedicated head and neck (H&N) centers, subdivided into head and neck oncology centers (HNOCs) and head and neck oncology affiliated centers (HNOACs), and general hospitals (GHs).

Methods

The Dutch Pathology Registry (PALGA) database was searched for patients who had undergone a salivary gland resection between January 1, 2006, and January 1, 2017, and had a preoperative FNAC result. The FNAC reports were retrospectively assigned to MSRSGC categories. The risk of malignancy (ROM) was calculated for each category. The sensitivity and specificity for diagnosing malignancy were calculated and compared among HNOCs, HNOACs, and GHs.

Results

In all, 12,898 FNAC aspirates were evaluated. The ROMs for each category were as follows: 12.5% in MSRSGC I, 10.3% in MSRSGC II, 29% in MSRSGC III, 2.3% in MSRSGC IVa, 28.6% in MSRSGC IVb, 83% in MSRSGC V, and 99.3% in MSRSGC VI. The sensitivity of FNAC was highest in HNOCs (88.1%), HNOACs scored lower (79.7%), and GHs had a sensitivity of 75.0%.

Conclusions

The MSRSGC is a valid tool for reporting parotid gland FNAC; therefore, these results strongly advocate its use. On the basis of the higher sensitivity of FNAC in dedicated H&N centers, the authors recommend that GHs use the presented management strategies to help to minimize the chances of a preoperative misdiagnosis.

The Milan System for Reporting Salivary Gland Cytopathology is a valid tool for reporting parotid gland fine‐needle aspiration cytology. The sensitivity of fine‐needle aspiration cytology is higher at dedicated head and neck centers.

Delay to surgery after neoadjuvant chemotherapy in head and neck squamous cell carcinoma affects oncologic outcomes

BACKGROUND

Neoadjuvant chemotherapy (NAC) is used in head and neck squamous cell carcinoma (HNSCC) for downstaging advanced disease and decreasing distant metastasis (DM). To the authors' knowledge, no study has specifically examined the impact of a delayed time to surgery (TTS) after NAC on oncologic outcomes. They thus aimed to identify a cutoff for TTS after NAC and its effect on survival indices.

METHODS

This was a retrospective review of all patients with HNSCC receiving NAC followed by surgery with curative intent between March 2016 and March 2019 at the MD Anderson Cancer Center. Receiver operating characteristic analysis was used to identify a cutoff for TTS, and this cutoff was used to analyze the overall survival (OS), locoregional recurrence rate, DM-free rate, and disease-free survival (DFS). A multivariate Cox regression analysis was performed.

RESULTS

One hundred one patients were analyzed with a median follow-up of 24.7 months. The 3-year OS and locoregional recurrence rates did not differ with a TTS ≥ 34 days. However, the 3-year DM-free rate was significantly worse (56% vs 90%; P = .001) in the group with a TTS ≥ 34 days, and the 3-year DFS was significantly lower (26% vs 64%; P = .006). In a multivariate analysis, a TTS ≥ 34 days (hazard ratio [HR], 4.92; 95% confidence interval [CI], 1.84-13.13) and extracapsular extension (HR, 3.01; 95% CI, 1.13-8.00) were significant independent predictors of a poorer DM-free rate. Weight loss > 10% (HR, 5.53; 95% CI, 1.02-30.24) was the only independent predictor for a TTS ≥ 34 days.

CONCLUSIONS

Emphasis should be placed on early definitive locoregional treatment after NAC, particularly in patients who do not respond to NAC. There is a need to validate these findings and establish new benchmarks for the interval between NAC and surgery.

Clinical Acceptability of Automated Radiation Treatment Planning for Head and Neck Cancer Using the Radiation Planning Assistant

PURPOSE

Radiation treatment planning for head and neck cancer is a complex process with much variability; automated treatment planning is a promising option to improve plan quality and efficiency. This study compared radiation plans generated from a fully automated radiation treatment planning system to plans generated manually that had been clinically approved and delivered.

METHODS AND MATERIALS

The study cohort consisted of 50 patients treated by a specialized head and neck cancer team at a tertiary care center. An automated radiation treatment planning system, the Radiation Planning Assistant, was used to create autoplans for all patients using their original, approved contours. Common dose-volume histogram (DVH) criteria were used to compare the quality of autoplans to the clinical plans. Fourteen radiation oncologists, each from a different institution, then reviewed and compared the autoplans and clinical plans in a blinded fashion.

RESULTS

Autoplans and clinical plans were very similar with regard to DVH metrics for coverage and critical structure constraints. Physician reviewers found both the clinical plans and autoplans acceptable for use; overall, 78% of the clinical plans and 88% of the autoplans were found to be usable as is (without any edits). When asked to choose which plan would be preferred for approval, 27% of physician reviewers selected the clinical plan, 47% selected the autoplan, 25% said both were equivalent, and 0% said neither. Hence, overall, 72% of physician reviewers believed the autoplan or either the clinical or autoplan was preferable.

CONCLUSIONS

Automated radiation treatment planning creates consistent, clinically acceptable treatment plans that meet DVH criteria and are found to be appropriate on physician review.

Radiotherapy Remains Underused in the Treatment of Soft-Tissue Sarcomas: Disparities in Practice Patterns in the United States

BACKGROUND

Practice patterns of radiation therapy (RT) use for soft-tissue sarcoma (STS) remain quite variable, despite clinical practice guidelines recommending the addition of RT to surgery for patients with high-grade STS, particularly for larger tumors. Using the National Cancer Database (NCDB), we assessed patterns of overall RT use, neoadjuvant versus adjuvant treatment, and specific RT modalities in this population.

PATIENTS AND METHODS

Patients aged ≥18 years with stage II/III STS in 2004 through 2015 were identified from the NCDB. Patterns of care were assessed using multivariable logistic regression analysis.

RESULTS

Of 27,426 total patients, 11,654 (42%) were treated with surgery alone versus 15,772 (58%) with RT in addition to surgery, with no overall increase in RT use over the study period. Notable clinical predictors of receipt of RT included tumor size (>5 cm), grade III, and tumors arising in the extremities. Conversely, female sex, older age (≥70 years), Black race, noncommercial insurance coverage, farther distance to treatment, and poor performance status were negative predictors of RT use. Of those receiving RT, 27% were treated with neoadjuvant RT and 73% with adjuvant RT. The proportion of those receiving neoadjuvant RT increased over time. Relevant factors associated with neoadjuvant RT included treatment at academic centers, larger tumor size, and extremity tumors. Of those who received RT with a modality specified as either intensity-modulated RT (IMRT) or 3D conformal RT (3DCRT), 61% were treated with IMRT and 39% with 3DCRT. The proportion of patients treated with IMRT increased over time. Relevant factors associated with IMRT use included treatment at academic centers, commercial insurance coverage, and larger and nonextremity tumors.

CONCLUSIONS

Although use of neoadjuvant RT and IMRT has increased over time, a significant number of patients with STS are not receiving adjuvant or neoadjuvant RT. Our findings also note potential sociodemographic disparities and highlight the concern that not all patients with STS are being equally considered for RT.