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.

Hearing Outcomes in a Deintensification Trial of Adjuvant Therapy for HPV-Related Oropharyngeal Squamous Cell Carcinoma

OBJECTIVE

To explore whether deintensification of adjuvant therapy reduces ototoxicity among patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC).

STUDY DESIGN

Retrospective cohort study.

SETTING

Single academic center.

METHODS

The ototoxicity rate among adult patients with HPV-related OPSCC enrolled in the Minimalist Trial (MINT), a prospective phase 2 trial of surgery followed by risk-adjusted deintensified adjuvant therapy (42 Gy radiation given alone or with a single 100 mg/m² dose of cisplatin), was compared to that among a historical cohort treated with standard adjuvant therapy (60-66 Gy radiation with up to three 100 mg/m² doses of cisplatin). Ototoxicity was defined as Common Terminology Criteria for Adverse Events v5.0 ≥ Grade 2. Mixed model analysis was performed to investigate the association between deintensified adjuvant therapy and treatment-related hearing loss.

RESULTS

A total of 29 patients (58 ears) were analyzed in the MINT cohort, and 27 patients (54 ears) in the historical cohort. The ototoxicity rate was 5% (n = 3/58 ears) in the MINT cohort and 46% (n = 25/54 ears) in the historical cohort (difference, 41%; 95% confidence interval [CI] = 27%-56%). Patients in the MINT cohort demonstrated a 95% decrease in risk of ototoxicity compared to those in the historical cohort (adjusted odds ratio: 0.05, 95% CI = 0.01-0.31). Differences in estimated marginal mean threshold shifts were statistically and clinically significant at frequencies ≥ 3 kHz.

CONCLUSION

The deintensified adjuvant therapy given in MINT led to less ototoxicity than standard adjuvant therapy among patients with HPV-related OPSCC.

An integrated approach to seismic risk assessment using random forest and hierarchical analysis: Pisco, Peru

As Peru is subject to large seismic movements owing to its geographic condition, determining seismic risk levels is a priority task for designing appropriate management plans. These actions become especially relevant when analyzing Pisco, a Peruvian city which has been heavily affected by various seismic events through the years. Hence, this project aims at estimating the associated seismic risk level and its previous requirements, such as hazard and vulnerability. To this end, a hybrid approach of machine learning (i.e., Random Forest) and hierarchical analysis (i.e., the Saaty matrix) was used. Risk levels were calculated through a double-entry table that establishes the relation between hazard and vulnerability levels. Results suggest that the city of Pisco exhibits both medium (lower city areas) and high (higher city areas) hazard levels in similar proportion. In addition, the coast area is considered a very-high hazard zone. Regarding vulnerability, the central area of the city exhibits a medium vulnerability level, whereas the periphery denotes high and very-high vulnerability levels. The interrelation of these components results in overall high-risk levels, with very-high levels in some central areas of the city. Finally, the results from this research study are expected to be useful for the authorities in charge of fostering specific activities in each sector and, simultaneously, as a motivator for future studies within this field.

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Implementation of RF for assessing seismic hazard.

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Implementation of AHP for assessing seismic vulnerability.

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The hazard level in Pisco is similar and constant in the short term.

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High and very-high risk zones have been identified in the city of Pisco.

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Pisco’s seismic risk level is sensitive to the vulnerability of its population.

Abstract 2142: Prognostic and predictive applications from mesenchymal gene expression subtype analysis for early-stage, HPV(-) head and neck squamous cell carcinoma

Introduction: Although often presented as one disease for genomic studies, head and neck squamous cell carcinoma (HNSCC) is treated according to clinical factors such as anatomic subsite, and tumor stage. Oral cavity squamous cell carcinoma (OCSCC) comprises 1/3 of all HNSCC and is predominantly HPV(-). Depending upon clinical stage, OCSCC treatment involves surgical resection +/- neck dissection, followed by radiation +/- chemotherapy. Our group and others previously described four mRNA expression patterns (classical, atypical, basal, and mesenchymal), each with unique genomic features and prognosis. Here, we further examine the clinical utility of gene expression subtyping in HNSCC and introduce the potential for predictive applications in HPV(-) HNSCC according to clinically relevant subgroups including oral cavity cancer.

Experimental Procedures: Multiple independent HNSCC datasets were obtained from public repositories, totaling 562 patients, including from MD Andersen (MDA) (GSE41117) and the Cancer Genome Atlas (TCGA) sourced from the Genome Data Commons. Cases were included for further analysis if they had N stage and overall survival values. Samples were assigned molecular subtypes (basal, mesenchymal, atypical or classical) using a reduced gene set version of the classifier reported earlier. HPV status was determined by HPV gene expression. The clinical endpoint was overall survival at censured at 36 months. Kaplan-Meier (KM) plots and logrank tests were used to investigate associations between clinical variables and survival. Cox models were used to adjust for potential confounders. All statistics were performed using the survival package in R.

Results: Of the 418 training patients from the TCGA dataset that met analysis criteria, nearly 20% presented with stage I and II tumors. In the clinically relevant subgroup of node(-) OCSCC patients, mesenchymal subtype was associated with worse survival (HR 2.4, p=0.021), offering a novel and potentially actionable biomarker in otherwise early-stage and low risk disease. Associations in the MDA validation cohort confirmed the association. Node(-) non-mesenchymal OCSCC patients had far better survival (no deaths observed) compared to node(-) mesenchymal and all node(+) patients which had similarly poor survival. Differential responses as a function of radiation will be presented.

Summary and Conclusions: This study confirms that the mesenchymal subtype is associated with worse outcomes across all cases of HNSCC. However, we demonstrate that mesenchymal subtype is associated with poor survival, even in the clinically relevant setting of early-stage, node(-) OCSCC treated with surgical resection. These findings highlight the potential value of gene expression subtyping as an adjunct to pathology for deciding which treatment option is best suited for patients with HNSCC.

Citation Format: D. Neil Neil Hayes, MD, MS, MPH, Greg Mayhew, Josh Uronis, Jose Zevallos. Prognostic and predictive applications from mesenchymal gene expression subtype analysis for early-stage, HPV(-) head and neck squamous cell carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2142.

UNMASC: tumor-only variant calling with unmatched normal controls

Despite years of progress, mutation detection in cancer samples continues to require significant manual review as a final step. Expert review is particularly challenging in cases where tumors are sequenced without matched normal control DNA. Attempts have been made to call somatic point mutations without a matched normal sample by removing well-known germline variants, utilizing unmatched normal controls, and constructing decision rules to classify sequencing errors and private germline variants. With budgetary constraints related to computational and sequencing costs, finding the appropriate number of controls is a crucial step to identifying somatic variants. Our approach utilizes public databases for canonical somatic variants as well as germline variants and leverages information gathered about nearby positions in the normal controls. Drawing from our cohort of targeted capture panel sequencing of tumor and normal samples with varying tumortypes and demographics, these served as a benchmark for our tumor-only variant calling pipeline to observe the relationship between our ability to correctly classify variants against a number of unmatched normals. With our benchmarked samples, approximately ten normal controls were needed to maintain 94% sensitivity, 99% specificity and 76% positive predictive value, far outperforming comparable methods. Our approach, called UNMASC, also serves as a supplement to traditional tumor with matched normal variant calling workflows and can potentially extend to other concerns arising from analyzing next generation sequencing data.

nab-Paclitaxel and cisplatin followed by cisplatin and radiation (Arm 1) and nab-paclitaxel followed by cetuximab and radiation (Arm 2) for locally advanced head and neck squamous-cell carcinoma: a multicenter, non-randomized phase 2 trial

In locally advanced head and neck squamous-cell carcinoma (LA-HNSCC), clinical complete response (cCR) at the primary site, assessed by clinical examination, after induction chemotherapy predicts for a low relapse risk after subsequent chemoradiotherapy. Prior studies showed a cCR rate of 77% with induction nanoparticle albumin-bound (nab)-paclitaxel given with cisplatin and 5-fluorouracil (APF). The primary aims of this non-randomized phase 2 trial were to determine the cCR rate after induction nab-paclitaxel and cisplatin (Arm 1) and after nab-paclitaxel monotherapy (Arm 2). Eligibility required LA-HNSCC, T2-T4 stage classification, and suitable (Arm 1) or unsuitable (Arm 2) candidates for cisplatin. Arm 1 patients received nab-paclitaxel and cisplatin, then cisplatin with radiation. Arm 2 patients received nab-paclitaxel, then cetuximab with radiation. The primary endpoint was cCR after two cycles of induction chemotherapy. Each arm enrolled forty patients. cCR at the primary site occurred in 28 patients (70%) after nab-paclitaxel and cisplatin and in 8 patients (20%) after nab-paclitaxel monotherapy. The overall clinical response rate was 98% after nab-paclitaxel and cisplatin and 90% after nab-paclitaxel monotherapy. In subset analyses, cCR rates by T stage classifications (T2, T3, T4) were 54, 86, and 69% after nab-paclitaxel and cisplatin, and 14, 11, and 26% after nab-paclitaxel. cCR rates by human papillomavirus status (p16 positive oropharynx vs other) were 72 and 64% after nab-paclitaxel and cisplatin and 35 and 9% after nab-paclitaxel. The cCR rate after nab-paclitaxel and cisplatin was similar to APF; however, the cCR rate after nab-paclitaxel monotherapy was lower. The trial was registered at ClinicalTrials.gov NCT02573493 on October 9, 2015.

Low-risk human papilloma virus positive oropharyngeal cancer with one positive lymph node: Equivalent outcomes in patients treated with surgery and radiation therapy versus surgery alone

BACKGROUND

For human papilloma virus positive (HPV+) oropharyngeal squamous cell carcinoma (OPSCC), management recommendations for patients with a single metastatic lymph node <6 cm in diameter remain nebulous, leading to treatment heterogeneity in this common subgroup of patients.

METHODS

We utilized the National Cancer Database to perform survival and multivariable analyses of patients with HPV+ OPSCC with one positive lymph node <6 cm and negative surgical margins.

RESULTS

We found that 5-year survival is comparable between patients who receive surgery and adjuvant radiation versus surgery alone. In multivariable analyses, we found no significant difference in the hazard ratio of overall survival after adjusting for various potential confounders.

CONCLUSIONS

These data suggest that patients with margin-negative HPV+ OPSCC with a single positive lymph node <6 cm have comparable survival with or without adjuvant radiation. Future studies exploring outcomes for this specific group in randomized-controlled trials will be critical for further evaluating these initial observations.

Risk and Rate of Occult Contralateral Nodal Disease in Surgically Treated Patients With Human Papillomavirus-Related Squamous Cell Carcinoma of the Base of the Tongue

Importance

The optimal treatment strategy for patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) of the base of the tongue (BOT) has not been sufficiently studied.

Objective

To investigate the rate of and risk factors for occult contralateral nodal disease in patients with HPV-related BOT OPSCC undergoing transoral surgery and bilateral neck dissections.

Design, Setting, and Participants

This retrospective case series reviewed the medical records of patients with HPV-related BOT OPSCC who underwent transoral surgery and bilateral neck dissections from January 1, 2002, through December 31, 2018, at the tertiary care center of Washington University School of Medicine in St Louis. Patients had a median follow-up of 30.0 months (interquartile range, 11.0-60.4 months). Patients with recurrent disease or multiple synchronous OPSCC primary tumors were excluded for a total of 89 patients. Data were analyzed from January 1 through June 1, 2019.

Main Outcomes and Measures

The primary outcome was the rate of contralateral occult nodal disease. Secondary outcomes were potential risk factors for contralateral occult nodal disease and regional recurrence rates.

Results

Eighty-nine patients were included in the series, of whom 81 (91.0%) were men. The mean (SD) age was 60 (9) years. Overall, 34 patients (38.2%) had pathologic contralateral nodal metastases. Seventy patients had no clinical evidence of contralateral nodal disease. Of these 70, occult nodes were identified in 15 (21.4%). Risk of contralateral disease was higher when the primary tumor crossed midline (odds ratio, 6.23; 95% CI, 1.71-22.77). Of the 55 patients with no occult disease identified, only 2 (3.6%) received radiotherapy to the contralateral neck, and no regional recurrence of disease was noted.

Conclusions and Relevance

Given the rate of occult contralateral nodal disease of 21.4%, it appears that contralateral elective neck dissection or radiotherapy should be recommended in patients with HPV-related BOT OPSCC. Patients with a pathologically negative result of contralateral neck dissection may not benefit from radiotherapy to that nodal basin. Future prospective investigations should evaluate functional and oncologic outcomes of contralateral elective neck dissection compared with elective radiotherapy in the contralateral neck for HPV-related BOT OPSCC.

Transoral Robotic Surgery and De-escalation of Cancer Treatment

This article outlines the ways that transoral robotic surgery and transoral laser microsurgery relate to treatment de-escalation in the treatment of head and neck cancer. Treatment de-escalation has particular importance in context of human papillomavirus-related oropharynx squamous cell carcinoma, which responds well to therapy but leaves many survivors with decades of treatment-related sequelae. We compare these less invasive transoral approaches with previously used open approaches to the oropharynx. We discuss the topic of treatment de-escalation in human papillomavirus-related disease and outline completed and ongoing clinical trials investigating the choice of primary treatment modality and de-escalation of adjuvant therapy.

The association of smoking and outcomes in HPV-positive oropharyngeal cancer: A systematic review

PURPOSE

While smoking is linked to worse outcomes for human papillomavirus (HPV)-related oropharyngeal squamous cell cancer (OPSCC), the magnitude of this association and the amount of smoking exposure necessary to confer clinically significant differences in outcomes is unclear. Recent studies suggested that greater tobacco exposure results in higher risk of cancer progression and death. Our study objective was to perform a systematic review of the association between smoking and HPV-related OPSCC outcomes.

MATERIALS AND METHODS

A literature search was conducted in April 2019 to identify relevant articles using Embase, Medline, Scopus, CENTRAL, and Cochrane databases. All studies were independently screened by two investigators to identify studies that assessed HPV-positive patients as an independent cohort, specified smoking measures, and reported locoregional recurrence (LRR), overall survival (OS), disease-specific survival (DSS), or disease-free survival (DFS) in association with smoking.

RESULTS

Of 1130 studies identified, 10 met final inclusion criteria with 2321 total patients, mean age 57.5 years. Smoking measures included ever vs never, current vs never/former smokers, ≤10 vs >10 pack-year, and continuous pack-years. Of these studies, 8 (80%) showed a significant effect of smoking on increasing recurrence and mortality. Adjusted HRs for LRR ranged from 0.6 to 5.2, OS from 1.3 to 4.0, DSS from 2.3 to 7.2, and DFS from 1.02 to 4.2 among heavier smokers compared to lighter/non-smokers.

CONCLUSIONS

While there was significant variability in smoking metrics and reported outcomes, all studies reporting statistically significant HRs showed that smoking was associated with worse outcomes. Further studies using uniform smoking measures are necessary to better understand this association.

Decline in circulating viral and human tumor markers after resection of head and neck carcinoma

BACKGROUND

DNA sequencing panels can simultaneously quantify human and viral tumor markers in blood. We explored changes in levels of plasma tumor markers following surgical resection of head and neck carcinoma.

METHODS

In preresection and postresection plasmas, targeted DNA sequencing quantified variants in 28 human cancer genes and levels of oncogenic pathogens (human papillomavirus [HPV], Epstein-Barr virus [EBV], Helicobacter pylori) from 21 patients with head and neck squamous cell carcinoma.

RESULTS

Preresection, 11 of 21 patients (52%) had detectable tumor markers in plasma, most commonly TP53 mutation or HPV genome. Several days postresection, levels fell to undetectable in 8 of 10 evaluable patients, while two high-stage patients retained circulating tumor markers.

CONCLUSIONS

Modern sequencing technology can simultaneously quantify human gene variants and oncogenic viral genomes in plasma. Falling levels of cancer-specific markers upon resection can help identify viral and human markers to track at subsequent timepoints as a means to evaluate efficacy of interventions.

Abstract 5460: Detecting somatic DNA copy number differences with cyclic shift testing

The most basic differential expression analysis involves the identification of genes that exhibit distinct expression patterns in two cohorts. Surprisingly, even though there are numerous computational methods for detecting and assessing the statistical significance of somatic DNA copy number (CN) gains and losses in a single cohort, there are no tools for detecting and assessing the statistical significance of CN differences between two cohorts. Instead, typically each cohort is analyzed separately and distinct findings are presented as evidence of CN differences.

Cyclic shift testing was originally introduced as a method to identify and assess the statistical significance of recurrent somatic CN gains and losses. Subsequent work explored theoretical statistical underpinnings of cyclic shift testing. Here we extend the previous results by showing that cyclic shift testing can be applied to detect and assess the statistical significance of CN differences between two cohorts.

Human papilloma virus (HPV) infection is a risk factor for head and neck squamous cell carcinoma (HNSC), and it is known that HPV+ and HPV- HNSC have distinct mutational and gene expression profiles. We apply cyclic shift testing to detect and assess the statistical significance of CN differences between HPV+ and HPV- HNSC using data from The Cancer Genome Atlas HNSC cohort. Our approach detects statistically significant CN differences in regions that are known to contain HNSC drivers (7p, 9p21, 11q13, 11q14-qter), as well as regions of chr14, chr16, and others that are less well characterized.

Citation Format: Vonn Walter, Hyo Young Choi, Xiaobei Zhao, Jose Zevallos, D. Neil Hayes. Detecting somatic DNA copy number differences with cyclic shift testing [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5460.

Phase II Trial of De-Intensified Chemoradiotherapy for Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma

PURPOSE

To report the results of a phase II clinical trial of de-intensified chemoradiotherapy for patients with human papillomavirus-associated oropharyngeal squamous cell carcinoma.

MATERIALS AND METHODS

Major inclusion criteria were (1) having American Joint Committee on Cancer (AJCC) 7th edition T0-T3, N0-N2c, M0 (AJCC 8th edition T0-T3, N0-N2, M0), (2) being p16 positive, and (3) reporting minimal or remote smoking history. Treatment was limited to 60 Gy intensity-modulated radiotherapy with concurrent intravenous cisplatin 30 mg/m2 once per week. Patients with T0-T2 N0-1 (AJCC 7th edition) did not receive chemotherapy. All patients had a 10- to 12-week post-treatment positron emission tomography/computed tomography to assess for neck dissection. The primary end point was 2-year progression-free survival. Secondary end points included 2-year local-regional control, distant metastasis-free survival and overall survival, and patient-reported outcomes (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire and the patient-reported outcomes version of the Common Terminology Criteria for Adverse Events).

RESULTS

One hundred fourteen patients were enrolled (median follow-up of 31.8 months), with 81% having a minimum follow-up of 2 years. Eighty percent of patients had 10 or fewer tobacco pack-years. Two-year local-regional control, distant metastasis-free survival, progression-free survival, and overall survival were as follows: 95%, 91%, 86%, and 95%, respectively. Mean pre- and 2-year post-treatment European Organisation for Research and Treatment of Cancer quality of life scores were as follows: global, 79/84 (lower worse); swallowing, 8/9 (higher worse); and dry mouth, 14/45 (higher worse). Mean pre- and 2-year post-treatment patient-reported outcomes version of the Common Terminology Criteria for Adverse Events scores (0 to 4 scale, higher worse) were as follows: swallowing, 0.5/0.7, and dry mouth, 0.4/1.3. Thirty-four percent of patients required a feeding tube (median, 10.5 weeks; none permanent). There were no grade 3 or higher late adverse events.

CONCLUSION

Clinical outcomes with a de-intensified chemoradiotherapy regimen of 60 Gy intensity-modulated radiotherapy with concurrent low-dose cisplatin are favorable in patients with human papillomavirus-associated oropharyngeal squamous cell carcinoma. Neither neoadjuvant chemotherapy nor routine surgery is needed to obtain favorable results with de-escalation.

Eliminating Postoperative Radiation to the Pathologically Node-Negative Neck: Long-Term Results of a Prospective Phase II Study

PURPOSE

The volume treated with postoperative radiation therapy (PORT) is a mediator of toxicity, and reduced volumes result in improved quality of life (QOL). In this phase II trial, treatment volumes were reduced by omitting PORT to the pathologically negative (PN0) neck in patients with primary head and neck squamous cell carcinoma.

METHODS

Patients with head and neck squamous cell carcinoma who underwent surgical resection and neck dissection with a PN0 neck and high-risk features mandating PORT to the primary and/or involved neck were eligible. The primary end point was greater than 90% disease control in the unirradiated neck. QOL was evaluated using the MD Anderson Dysphagia Inventory and the University of Michigan patient-reported xerostomia questionnaire.

RESULTS

Seventy-three patients were enrolled, and 72 were evaluable. Median age was 56 years (range, 31 to 81 years); 58 patients were male, and 47 (65%) had a smoking history. Sites included oral cavity (n = 14), oropharynx (n = 37), hypopharynx (n = 4), larynx (n = 16), and unknown primary tumor (n = 1). According to the American Joint Committee on Cancer Staging Manual (7^th edition), 67 patients (93%) had stage III/IV disease, and 71% of tumors involved or crossed midline. No patient had contralateral neck PORT. In 17 patients (24%), only the primary site was treated. At a median follow-up of 53 months, two patients experienced treatment failure of the PN0 unirradiated neck; they also experienced treatment failure locally. Unirradiated neck control was 97% (95% CI, 93.4% to 100.0%). Five-year rates of local control, regional control, progression-free survival, and overall survival were 84%, 93%, 60%, and 64%, respectively. QOL measures were not significantly different from baseline at 12 and 24 months post-PORT (P > .05).

CONCLUSION

Eliminating PORT to the PN0 neck resulted in excellent control rates in the unirradiated neck without long-term adverse effects on global QOL.

Mature results of the LCCC1413 phase II trial of de-intensified chemoradiotherapy for HPV-associated oropharyngeal squamous cell carcinoma

6022

Background: To report the mature results from a prospective phase II clinical trial of highly de-intensified chemoradiotherapy (CRT) for patients with HPV-associated oropharyngeal squamous cell carcinoma (OPSCC). Methods: The major inclusion criteria were: 1) T0-T3, N0-N2, M0, 2) p16 positive, and 3) minimal/remote smoking history. Treatment was limited to 60 Gy intensity modulated radiotherapy with concurrent weekly intravenous cisplatin 30 mg/m2(second choice was cetuximab). Patients with T0-T2 N0-1 disease did not receive chemotherapy. All patients had a 10 to 12-week post-treatment PET/CT to determine need for planned neck dissection. The primary study endpoint was 2 year progression free survival (PFS). Secondary endpoint measures include 2 year local control (LC), regional control (RC), distant metastasis free survival (DMFS), cause specific survival (CSS) and overall survival (OS), and patient reported symptoms (PRO-CTCAE) and quality of life (EORTC QLQ-C30 & H&N35). Results: 114 patients were enrolled (median f/u of 28.8 months, range 2.6 to 51.4) with 84 having a minimum follow-up of 2 years. Smoking status was as follows: 47% never, 33% ≤ 10 pack years, and 19% > 10 pack years. Post-treatment PET/CT complete response rate was 93% at the primary site and 80% in the neck. Eleven patients had planned neck dissection with 4 having pathological residual disease. Two year LC, RC, DMFS, PFS, CSS, and OS were the following: 96%, 99%, 91%, 88%, 97%, and 95%. Neither smoking status nor receipt of cetuximab correlated with recurrence. Four patients with recurrent disease had PIK3CA mutations. Thirty four percent of patients required a feeding tube (none permanent) for a median of 10.5 weeks. Mean pre- and 2-year post-treatment EORTC QOL scores were: Global 79/83 (lower worse), Swallowing 8/9 (higher worse), Dry Mouth 14/45 (higher worse), and Sticky Saliva 9/28 (higher worse). Mean pre- and 2 year post-treatment PRO-CTCAE (0 to 4 scale, higher worse) scores were: Swallowing 0.5/0.7 and Dry mouth 0.4/1.4. There were no ≥ Grade 3 late adverse events. Conclusions: Clinical outcomes with a highly de-intensified CRT regimen of 60 Gy IMRT with concurrent low-dose cisplatin are excellent in patients with HPV-associated OPSCC. Clinical trial information: NCT02281955.

Extranodal extension is a strong prognosticator in HPV-positive oropharyngeal squamous cell carcinoma

OBJECTIVE

To comprehensively examine the prognostic significance of extranodal extension (ENE) in human papillomavirus-positive oropharyngeal squamous cell carcinoma (HPV-positive OPSCC).

METHODS

Retrospective cohort of cases diagnosed with HPV-positive OPSCC from 2010 to 2015 in the National Cancer Database. Inclusion of all OPSCC HPV-positive cases with appropriate International Classification of Diseases-0-3 codes that received surgery with a neck dissection. Univariate and multivariable analyses were conducted. Hazard ratios (HR) for the independent effects of ENE and N stage on overall survival were estimated by Cox proportional hazards regression.

RESULTS

Cases that were ENE-negative had the highest 5-year survival (92.6%; 95% confidence interval [CI]: 90.5%-94.7%). ENE-positive cases had the lowest 5-year survival (84.0%; 95% CI: 80.7%-87.4%). After adjusting for confounding variables, ENE-positivity was associated with almost twice the hazard of death (HR = 1.90; 95% CI: 1.35-2.67) compared to ENE-negative cases. Nodal (N) category 1, ENE-positive status was associated with an increased risk of death (HR = 1.88; 95% CI: 1.26-2.80) compared with N1, ENE-negative status. Compared to N1/ENE-negative cases, N2/ENE-positive cases had the poorest survival (HR: 2.93; 95% CI: 1.94-4.43). Both microscopic and macroscopic ENE were associated with worse outcomes compared to node-positive/ENE-negative status.

CONCLUSION

The implementation of the American Joint Committee on Cancer 8th edition staging system provides a much-improved framework to develop and discuss treatment plans for HPV-positive OPSCC. We feel that careful consideration should be given to the importance of ENE in patients with HPV-positive OPSCC.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:939-945, 2020.

Association of Posttreatment Lymphopenia and Elevated Neutrophil-to-Lymphocyte Ratio With Poor Clinical Outcomes in Patients With Human Papillomavirus-Negative Oropharyngeal Cancers

IMPORTANCE

Better biomarkers are needed for human papillomavirus (HPV)-negative oropharyngeal cancer (OPC) to identify patients at risk of recurrence. Lymphopenia and an elevated ratio of neutrophils to lymphocytes (NLR) have been associated with poor disease outcomes in a number of solid tumors.

OBJECTIVE

To test the hypothesis that postradiotherapy lymphopenia and elevated NLR are associated with poor clinical outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This single-institution retrospective analysis included patients with HPV-negative OPC treated from January 1, 1997, through January 4, 2017. Median follow-up was 37 months (range, 2-197 months). A total of 108 patients with HPV-negative OPC and at least 1 complete blood cell count 2 to 12 months after the start of radiotherapy were included. Data were analyzed from August 26 to September 7, 2017.

INTERVENTIONS

Surgery followed by radiotherapy vs definitive radiotherapy, with or without chemotherapy.

MAIN OUTCOMES AND MEASURES

Absolute lymphocyte (ALC) and absolute neutrophil (ANC) counts were tested as variables affecting locoregional control, recurrence-free survival, and overall survival.

RESULTS

Of a total of 108 patients included in the analysis (87.0% male; mean age, 56 years [range, 35-84 years]), 57 received surgery followed by postoperative radiotherapy and 51 received definitive radiotherapy. During treatment, 67 of 79 patients (84.8%) had grades 3 to 4 lymphopenia and 17 of 79 (21.5%) had grade 4 lymphopenia. The ANC recovered by 6 months after radiotherapy, but ALC remained depressed to 1 year after radiotherapy. Posttreatment lymphopenia and elevated NLR were associated with worse recurrence-free and overall survival. The estimated 3-year LRC in patients with and without grades 3 to 4 lymphopenia at 3 months after radiotherapy start was 73% vs 82% (hazard ratio [HR], 0.58; 95% CI, 0.19-1.8); estimated 3-year recurrence-free survival, 36% vs 63% (HR, 0.45; 95% CI, 0.23-0.87); and estimated 3-year overall survival, 34% vs 64% (HR, 0.45; 95% CI, 0.23-0.88). In multivariable analysis, an association with worse overall survival was found for definitive radiotherapy (HR, 3.3; 95% CI, 1.6-7.1) and grades 3 to 4 lymphopenia (HR, 2.6; 95% CI, 1.3-5.5) at 3 months after radiotherapy.

CONCLUSIONS AND RELEVANCE

Lymphopenia and NLR as early as 3 months after treatment start may serve as biomarkers of clinical outcomes in patients with HPV-negative OPC. These patients may benefit from adjuvant treatment intensification or closer surveillance.

Patterns of care and survival outcomes for laryngeal small cell cancer

BACKGROUND

To determine practice patterns and outcomes of laryngeal small cell cancer (LSCC) across the United States.

METHODS

Patients with LSCC were identified in the National Cancer Database. Overall survival (OS) was compared with Kaplan-Meier analysis and Cox regression.

RESULTS

From 2004 to 2014, the 5-year OS for early stage (n = 47), locally advanced stage (n = 133), and metastatic disease (n = 53) was 34%, 26%, and 9%, respectively. Chemoradiation was given in 66% of cases. Chemotherapy was less likely given in early stage disease (P = .001), and definitive radiation was less likely given in metastatic disease (P < .001). Definitive radiation improved median OS in locally advanced LSCC (20 vs. 7 months, log-rank P = .04). In multivariable modeling, radiation dose ≥40 Gy was associated with better OS (P < .001).

CONCLUSION

Chemoradiation was the most common practice for treating locally advanced LSCC, and radiation dose ≥40 Gy was associated with improved OS.

Human Papillomavirus Testing in Head and Neck Carcinomas: ASCO Clinical Practice Guideline Endorsement of the College of American Pathologists Guideline

Purpose

The College of American Pathologists produced an evidence-based guideline on testing, application, interpretation, and reporting of human papillomavirus (HPV) and surrogate marker tests in head and neck carcinomas that was determined to be relevant to the American Society of Clinical Oncology (ASCO) membership.

Methods

The College of American Pathologists HPV Testing in Head and Neck Carcinomas guideline was reviewed by ASCO content experts for clinical accuracy and by methodologists for developmental rigor. On favorable review, an ASCO Expert Panel was convened to review the guideline contents and recommendations.

Results

The ASCO Expert Panel determined that the recommendations from the HPV Testing in Head and Neck Carcinomas guideline, published in 2018, are clear, thorough, and based upon the most relevant scientific evidence. ASCO endorsed the guideline and added minor qualifying statements.

Recommendations

It is recommended that HPV tumor status should be determined for newly diagnosed oropharyngeal squamous cell carcinomas. HPV tumor status testing may be performed by surrogate marker p16 immunohistochemistry either on the primary tumor or from cervical nodal metastases only if an oropharyngeal primary tumor is present. The threshold for positivity is at least 70% nuclear and cytoplasmic expression with at least moderate to strong intensity. Additional confirmatory testing may be done at the discretion of the pathologist and/or treating clinician. Pathologists should not routinely determine HPV tumor status in nonsquamous carcinomas of the oropharynx or non–oropharyngeal squamous cell carcinomas of the head and neck. When there is uncertainty of histologic type or whether a poorly differentiated oropharyngeal tumor is nonsquamous, HPV tumor status testing may be warranted and at the discretion of the pathologist and/or treating clinician. Additional information is available at: www.asco.org/head-neck-cancer-guidelines .

Abstract 3584: Statistical considerations in tumor only variant calling

Targeted exome sequencing and variant calling involves comparing a patient’s tumor and normal sequencing to identify mutated loci within clinically actionable (CA) genes. However sequencing matched normal (MN) increases the marginal cost greatly relative to the amount of genomic information provided since most bases are unchanged. MN may not be available or in some cases poor quality of the MN sequencing may hinder the interpretation of results. Without the MN control, with the expected mix of sequencing errors, artifacts, and mis-mapped regions, germline (GM) variants will further contaminate the list of variant calls (VCs) with up to 10,000 alternate loci. Some reports address TO sequencing challenges and these have significant limitations. In general, more controls leads to both higher computational costs and risk of selecting low quality controls. We aim to return several dozen VCs using a reasonable number of controls. We propose using information obtained from pooling high quality normal samples and GM/somatic databases and applying a set of filtering criteria for a cohort of tumor only (TO) samples to exclude the majority of false positive (FP) VCs while retaining those that are CA. Through benchmarking paired tumor normal (PTN) samples, we aim to find the minimum controls needed to reach an adequate sensitivity (SENS), specificity (SPEC), and final number of VCs. We selected a cohort of patients with clinically validated mutations from a clinical trial of NGS in cancer (LCCC1108: NCT01457196). From a cohort we selected a subset of 100 patients with a spectrum of clinical and genomic parameters relevant to a robust method. All patients were PTN samples as well as CLIA confirmation of relevant CA mutations. We developed a set of filtering and annotations processes to allow VC annotation of the cohort which did not include the MN and compared to results obtained from PTN sequencing. Samples were sequenced using hybrid capture technology and Illumina brand paired-end sequencing. VCs were combined using Strelka, UNCseqR, and Cadabra and annotated with Oncotator. SENS and SPEC are used to quantify the pipeline’s performance by treating the filtered PTN VCs and clinically validated as gold standard. Overlaps in the tumor and pooled normal cohort (PNC) samples were avoided. With respect to a larger set of high quality mutations called by the PTN pipeline, the TO method documented on average 95% SENS and &gt;99% SPEC for variant detection. The method showed a tradeoff between SENS and FP rate allowing for small drops in SENS for large decreases in the numbers of FP (4-5% decrease in SENS from 99% to 95%) resulted in 90% decrease in FP VCs with a final average of 70 filtered VCs per sample. Results suggest that analyzing PTN targeted exome NGS samples as TO and obtaining a disjoint PNC selected based on sequencing quality metrics can achieve high SENS and SPEC with a reasonable number of filtered VCs. Also benchmarking aids in excluding controls from the PNC that may miss CA calls.

Citation Format: Paul Little, D. Neil Hayes, Joel Parker, Jose Zevallos. Statistical considerations in tumor only variant calling [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3584. doi:10.1158/1538-7445.AM2017-3584

Multimodality risk adapted therapy with induction carboplatin/paclitaxel/lapatinib for SCCHN amenable to transoral surgery

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Background: Induction chemotherapy in SCCHN has mostly been studied prior to XRT where proof of improved survival is lacking. Regimens using weekly platinum, taxane and targeted therapy have resulted in high RR. Attempts are frequently made to intensify or de-intensify, but few have adapted therapy by response. Methods: Patients with transorally resectable, treatment naïve SCCHN and node positivity or T > 3 were treated weekly 6 times with Carboplatin AUC 2, paclitaxel 135mg/m2 and daily lapatinib 1000mg followed by transoral resection. Subjects with pN0/1 received no radiation; those with close margins, ECE, pN2a-b, PNI/LVSI were treated with weekly cisplatin 30mg/m2 and XRT with involved-field XRT allowed while those with pN2c/3 were treated with cisplatin 100mg/m2 Q3W and standard XRT. Primary endpoint was clinical RR (cRR) following induction chemotherapy. Results: Primary sites: oropharynx (OP) (30), supraglottic larynx (5), oral cavity (4) and hypophyarnx (1). Of OP patients, 17 were HPV low risk. Grade 3/4 toxicity during induction: decreased WBC (7), fatigue (3), diarrhea (2), febrile neutropenia (2), neuropathy (2), rash (2) and 1 each of ALT and AST increased, hyperglycemia, hypotension, nausea, PPDE. 39/40 proceeded to surgical resection (1 patient refused for non-study reasons). 29/39 subjects who were projected to require XRT were able to avoid it. 8/10 subjects with study-defined indication for adjuvant XRT received it. cRR 37/40, pRR 14/40. Clinical and pathologic responses correlated poorly (see table). With median FU of 1.7 years, there has been no recurrence or death. Mean VRQOL was 91.7 before induction, 92.3 before surgery and 92.3 1 year post surgery. Mean MDADI was 82.8 before induction, 85.9 before surgery and 84.5 1 year post surgery. Conclusions: The regimen led to excellent feasibility of surgical resection, high cRR and a real pCR. cR predicted poorly for pR. Most patients were able to avoid XRT. Speech and swallowing function were preserved. NCT01612351. Clinical trial information: NCT01612351. [Table: see text]

Two-year clinical outcomes of de-intensified chemoradiotherapy for low-risk HPV-associated oropharyngeal squamous cell carcinoma

6044

Background: We here-in report 2 year cancer control outcomes from a prospective phase II clinical trial evaluating de-intensified chemoradiotherapy (CRT) for patients with favorable risk, HPV-associated oropharyngeal squamous cell carcinoma (OPSCC). Methods: The major inclusion criteria were: T0-T3, N0-N2c, M0, HPV or p16 positive, and minimal smoking history. Treatment was limited to 60 Gy intensity modulated radiotherapy with concurrent weekly intravenous cisplatin (30 mg/m2). Patients neither received induction chemotherapy nor definitive surgery. The primary study endpoint was pathologic complete response rate (pCR) based on required biopsy of the primary site and dissection of pretreatment positive lymph node regions, regardless of radiographic response. Secondary endpoint measures included 2 year local control (LC), regional control (RC), cause specific survival (CSS), distant metastasis free survival (DMFS), and overall survival (OS), and patient reported symptoms (PRO-CTCAE) and quality of life (EORTC QLQ-C30 & H&N35). Results: Forty-four patients enrolled and the median f/u was 36 months (range 5-53 months, 93% with > / = 1 year, 88% > / = 2 years). We have previously reported the pCR to be ~ 86%. Two year LC, RC, CSS, DMFS, and OS are the following: 100%, 100%, 100%, 100%, and 95%. All 6 patients who had pathological partial responses are alive with no evidence of disease with a median f/u of 34 months (range 9-48 months). Two patients have died (stroke and glioblastoma). Mean pre and 2-year post EORTC QOL scores were: Global 80/82 (lower worse), Swallowing 11/10 (higher worse), Dry Mouth 16/54, and Sticky Saliva 6/33. 39% of patients required a feeding tube (none permanent) for a median of 15 weeks (5 - 22 weeks). Mean pre and 2 year post PRO-CTCAE (1 to 4 scale, higher worse) scores were: Swallowing 0.4/0.8 and Dry mouth 0.4/1.8. There were no > / = Grade 3 late adverse events. Conclusions: The 2-year clinical outcomes with decreased intensity of therapy with 60 Gy of IMRT and weekly low-dose cisplatin are excellent in favorable risk OPSCC with evidence of better preservation of quality of life as compared to standard therapies. Clinical trial information: NCT01530997 .

Population assessment of head and neck cancer outcomes by race and HPV status in chance

6045

Background: Growing literature suggests that racial disparities exist in patients with head and neck squamous cell carcinoma (HNSCC). Currently, there are many hospital-based cohorts assessing racial disparities, however only a limited number of population-based cohorts exist. This study aims to explore the association between clinical characteristics and patient demographics with overall survival by race and HPV status. Methods: Patients were identified from the Carolina Head and Neck Cancer Study (CHANCE), a population based case-control study with enrollment from 2001-2006 in North Carolina. Vital status was determined by linkage with the National Death Index. Survival was considered at 5 years after diagnosis or study enrollment. We used Kaplan-Meyer analyses and Cox proportional hazards regression modeling to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI). Results: A total of 1361 HNSCC patients with no baseline metastasis and adequate survival time were identified. Of these, 1010 patients were white while 351 patients were black. Black patients were statistically more likely to be younger at age of diagnosis, have a history of tobacco or alcohol use, be uninsured, and not have completed high school (p-value < 0.001). In an unadjusted cox regression analysis, blacks had 1.50 times (95% CI 1.01-1.57) decreased overall survival than whites. Adjusting for gender, stage of disease, age, treatment, and smoking status, this relationship remained (HR 1.30, CI 1.1-1.6). In a subset analysis of male patients by disease site, there was decreased overall survival in black patients in oral cavity cases (p < 0.01). This relationship trended towards significant in pharynx cancer (p = 0.054) and was not found in laryngeal cancer. In pharyngeal cases only, there was decreased overall survival in black patients with HPV+ disease (p = 0.03) but not in HPV- cases (p = 0.33). Conclusions: This is the first population-based study that confirms racial disparities in HPV+ HNSCC. We also found worse overall survival prognosis for black patients with oral cavity cancer and a similar trend in pharynx cancer. Further studies are needed to evaluate if this difference is driven by either biological or socioeconomic factors.

Gene expression subtypes in early stage oral cavity squamous cell carcinoma and subclinical nodal metastasis

e17525

Background: Patients with early stage oral cavity squamous cell carcinoma (OCSCC) without clinical or radiographic evidence of cervical lymphadenopathy present as a therapeutic dilemma. Although studies show a survival advantage with elective neck dissection, about 70% of patients have pathologically negative nodes. In this study, we examine four previously described head and neck squamous cell carcinoma gene expression subtypes [basal (BA), mesenchymal (MS), atypical (AT), and classical (CL)] and subclinical nodal metastasis in early stage, clinically node negative OCSCC. Since the MS subtype is characterized by expression of epithelial to mesenchymal transition (EMT) genes, which is important in the initiation of nodal metastasis, we hypothesize the MS subtype is associated with higher rates of nodal metastasis and worse overall survival. Methods: Using a previously validated integrative genomic analysis, we determined gene expression subtype for T1-T2, clinically node negative OCSCC cases undergoing elective neck dissection from the Cancer Genome Atlas (TCGA) database. We compared rates of pathologically positive lymph nodes and survival in stage by gene expression subtype. Results: We identified 67 T1-T2, clinically N0 cases with pathologic node data. Most of OCSCC cases were BA (N = 24) or MS (N = 26) subtype. Few were either AT (N = 9) or CL (N = 8) subtype. Three of the BA subtype and 11 of the MS subtype tumors were pathologically node positive. MS tumors were 3.38 times (95% Confidence Interval (CI): 1.08-10.69) as likely to have pathologically positive lymph nodes compared to the BA subtype. The MS subtype was associated with worse overall survival (hazard ratio: 2.33, 95% CI 0.79-6.87) compared with the BA subtype. Conclusions: Our findings suggest gene expression subtypes can potentially identify early stage OCSCC patients at higher risk for subclinical nodal metastasis and may reflect high EMT gene expression associated with this phenotype. Gene expression subtype, along with tumor mutation and clinical profiles, could be used to determine the need for neck dissection in early stage OCSCC, and could translate into a reduction in treatment morbidity and length of hospitalization.