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Cooper AC, Fazer CA, Chintakuntlawar AV, Fuentes Bayne HE, McGarrah PW, Price KAR. Capecitabine for Salvage Treatment of Patients With Heavily Pretreated Human Papillomavirus-Associated Oropharynx Cancer With Distant Metastases. J Adv Pract Oncol 2023; 14:571-575. [PMID: 38196671 PMCID: PMC10715283 DOI: 10.6004/jadpro.2023.14.7.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Abstract
Background Patients with metastatic human papillomavirus-associated oropharyngeal cancer (HPV-OPC) have a median overall survival exceeding 2 years and are often candidates for multiple lines of palliative therapy. With the approval of immunotherapy as first-line treatment, salvage therapeutic options are limited. We describe our experience using capecitabine as salvage therapy for patients with recurrent or metastatic (R/M) HPV-OPC. Methods We performed a retrospective study of patients with R/M HPV-OPC with distant metastatic disease. Eligible patients were identified from a medical oncology clinical database. Demographic and clinical data were abstracted from the medical record. Survival probabilities were estimated with the Kaplan-Meier method. Results 10 patients were identified. Sites of metastatic disease included lung, liver, mediastinal lymph nodes, bone, abdominal lymph nodes, and soft tissue. Most patients received capecitabine as fourth-line treatment. The median duration from start of capecitabine therapy until death was 10.5 months. Best treatment response was as follows: partial responses (PR) were seen in 4 of 10 (40%), stable disease (SD) in 3 of 10 (30%), and progressive disease (PD) in 2 of 10 (20%). The clinical benefit rate (CR + PR + SD) was 70%. Reasons for discontinuation included disease progression (n = 8) and side effects (n = 2). One patient notably had prolonged benefit from capecitabine and continued to be on treatment for 34 months total. Conclusions Capecitabine is a potential salvage treatment for heavily pretreated patients with R/M HPV-OPC, with some patients experiencing prolonged response. Clinical or molecular predictors of response would be helpful to identify patients likely to benefit; a larger prospective study would be useful to confirm efficacy in this patient population.
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Affiliation(s)
- Anna C Cooper
- From Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Casey A Fazer
- From Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
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Ehlers SL, Gudenkauf LM, Kacel EL, Hanna SM, Sinicrope PS, Patten CA, Morrison EL, Snuggerud J, Bevis D, Kirsch JL, Staab JP, Price KAR, Wahner-Hendrickson AE, Ruddy KJ. Real-World Implementation of Best-Evidence Cancer Distress Management: Truly Comprehensive Cancer Care. J Natl Compr Canc Netw 2023; 21:627-635. [PMID: 37308123 DOI: 10.6004/jnccn.2023.7009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 02/03/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Cancer distress management is an evidence-based component of comprehensive cancer care. Group-delivered cognitive behavioral therapy for cancer distress (CBT-C) is the first distress treatment associated with replicated survival advantages in randomized clinical trials. Despite research supporting patient satisfaction, improved outcomes, and reduced costs, CBT-C has not been tested sufficiently within billable clinical settings, profoundly reducing patient access to best-evidence care. This study aimed to adapt and implement manualized CBT-C as a billable clinical service. PATIENTS AND METHODS A stakeholder-engaged, mixed-methods, hybrid implementation study design was used, and the study was conducted in 3 phases: (1) stakeholder engagement and adaptation of CBT-C delivery, (2) patient and therapist user testing and adaptation of CBT-C content, and (3) implementation of practice-adapted CBT-C as a billable clinical service focused on evaluation of reach, acceptability, and feasibility across stakeholder perspectives. RESULTS A total of 40 individuals and 7 interdisciplinary group stakeholders collectively identified 7 primary barriers (eg, number of sessions, workflow concerns, patient geographic distance from center) and 9 facilitators (eg, favorable financial model, emergence of oncology champions). CBT-C adaptations made before implementation included expanding eligibility criteria beyond breast cancer, reducing number of sessions to 5 (10 total hours), eliminating and adding content, and revising language and images. During implementation, 252 patients were eligible; 100 (40%) enrolled in CBT-C (99% covered by insurance). The primary reason for declining enrollment was geographic distance. Of enrollees, 60 (60%) consented to research participation (75% women; 92% white). All research participants completed at least 60% of content (6 of 10 hours), with 98% reporting they would recommend CBT-C to family and friends. CONCLUSIONS CBT-C implementation as a billable clinical service was acceptable and feasible across cancer care stakeholder measures. Future research is needed to replicate acceptability and feasibility results in more diverse patient groups, test effectiveness in clinical settings, and reduce barriers to access via remote delivery platforms.
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Affiliation(s)
- Shawna L Ehlers
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Lisa M Gudenkauf
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth L Kacel
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Sherrie M Hanna
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Pam S Sinicrope
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Christi A Patten
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Eleshia L Morrison
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Jill Snuggerud
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Danielle Bevis
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Janae L Kirsch
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
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Warsame RM, Asiedu GB, Kumbamu A, Cook J, Hayes SN, Thompson CA, Hobday TJ, Price KAR. Assessment of Discrimination, Bias, and Inclusion in a United States Hematology and Oncology Fellowship Program. JAMA Netw Open 2021; 4:e2133199. [PMID: 34748008 PMCID: PMC8576584 DOI: 10.1001/jamanetworkopen.2021.33199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Medical trainees frequently experience discrimination. Understanding their experiences is essential to improving learning environments. OBJECTIVE To characterize trainee experiences of discrimination and inclusion to inform graduate medical education (GME) policies. DESIGN, SETTING, AND PARTICIPANTS This qualitative study used an anonymous telephone interview technique to gather data from hematology and oncology fellows. All current trainees and recent graduates were eligible. Interviews were conducted anonymously with interviewer and participant in separate locations and recorded and transcribed. Data were analyzed in an iterative process into major themes using a general inductive analysis approach. Demographic information was obtained via anonymous survey. Data collection and analysis were conducted from July 2018 to November 2019. MAIN OUTCOMES AND MEASURES Emergent themes illustrating bias and inclusion in a GME program. RESULTS Among 34 fellows and recent graduates who were approached for this study, 20 consented and 17 were interviewed. Of those interviewed, 10 were men, and the median (range) age was 32 (29-53) years. The racial and ethnic distribution included 6 Asian individuals, 2 Black individuals, 3 Hispanic individuals, 2 multiracial individuals, and 4 White individuals. All fellows reported having experienced and/or witnessed discriminatory behavior. The themes elucidated were (1) foreign fellows perceived as outsiders, (2) US citizens feeling alien at home, (3) gender role-typing, (4) perception of futility of reporting, (5) diversity and inclusion, and (6) coping strategies. The majority of reported biases were from patients. Only 1 trainee reported any incidents. Reasons for not reporting were difficulty characterizing discrimination and doubt action would occur. Participants reported that diversity of cotrainees, involvement in committees, and open discussions promoted inclusivity. CONCLUSIONS AND RELEVANCE In this study, reports of discriminatory behavior toward trainees were common. The anonymous hotline methodology cultivated a safe environment for candid discussions. These findings suggest that GME programs should assess their learning climate regarding bias and inclusivity anonymously and develop processes to support trainees.
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Affiliation(s)
| | - Gladys B. Asiedu
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Ashok Kumbamu
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Joselle Cook
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sharonne N. Hayes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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Price KAR, Nichols AC, Shen CJ, Rammal A, Lang P, Palma DA, Rosenberg AJ, Chera BS, Agrawal N. Novel Strategies to Effectively De-escalate Curative-Intent Therapy for Patients With HPV-Associated Oropharyngeal Cancer: Current and Future Directions. Am Soc Clin Oncol Educ Book 2020; 40:1-13. [PMID: 32213088 DOI: 10.1200/edbk_280687] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The treatment of patients with HPV-associated oropharyngeal cancer (HPV-OPC) is rapidly evolving and challenging the standard of care of definitive radiotherapy with concurrent cisplatin. There are numerous promising de-escalation strategies under investigation, including deintensified definitive chemoradiotherapy, transoral surgery followed by de-escalated adjuvant therapy, and induction chemotherapy followed by de-escalated locoregional therapy. Definitive radiotherapy alone or with cetuximab is not recommended for curative-intent treatment of patients with locally advanced HPV-OPC. The results of ongoing phase III studies are awaited to help answer key questions and address ongoing controversies to transform the treatment of patients with HPV-OPC. Strategies for de-escalation under investigation include the incorporation of immunotherapy and the use of novel biomarkers for patient selection for de-escalation.
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Affiliation(s)
| | - Anthony C Nichols
- Department of Otolaryngology-Head and Neck Surgery, University of Western Ontario, London, Ontario, Canada
| | - Colette J Shen
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Almoaidbellah Rammal
- Department of Otolaryngology-Head and Neck Surgery, University of Western Ontario, London, Ontario, Canada
| | - Pencilla Lang
- Division of Radiation Oncology, Department of Oncology, University of Western Ontario, London, Ontario, Canada
| | - David A Palma
- Division of Radiation Oncology, Department of Oncology, University of Western Ontario, London, Ontario, Canada
| | - Ari J Rosenberg
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL
| | - Bhisham S Chera
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Nishant Agrawal
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Chicago, Chicago, IL
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Moore EJ, Van Abel KM, Routman DM, Lohse CM, Price KAR, Neben-Wittich M, Chintakuntlawar AV, Price DL, Kasperbauer JL, Garcia JJ, Hinni ML, Patel SH, Janus JR, Foote RL, Ma DJ. Human papillomavirus oropharynx carcinoma: Aggressive de-escalation of adjuvant therapy. Head Neck 2020; 43:229-237. [PMID: 32969095 DOI: 10.1002/hed.26477] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/24/2020] [Accepted: 09/09/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Aggressive dose de-escalated adjuvant radiation therapy (RT) in patients with human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV(+)OPSCC). METHODS Patients with HPV(+)OPSCC on a phase II clinical trial of primary surgery and neck dissection followed by dose de-escalated RT (N = 79) were compared with a cohort of patients who received standard adjuvant therapy (N = 115). Local recurrence-free, regional recurrence-free, distant metastases-free survival, and progression-free survival (PFS) were assessed. RESULTS Of 194 patients, 23 experienced progression at a median of 1.1 years following surgery (interquartile range [IQR] 0.7-2.0; range 0.3-5.4); 10 patients in the de-escalated cohort and 13 patients in the standard cohort. The 3-year PFS rate for the de-escalated cohort was 87%, and in the standard cohort was 90% (hazard ratio [HR] 1.18, 95% confidence interval (CI) [0.50-2.75]). CONCLUSION Patients with HPV(+)OPSCC who undergo surgical resection and neck dissection and meet criteria for adjuvant therapy can undergo aggressive dose de-escalation of RT without increasing risk of progression locally, regionally or at distant sites.
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Affiliation(s)
- Eric J Moore
- Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kathryn M Van Abel
- Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David M Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Christine M Lohse
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Daniel L Price
- Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Michael L Hinni
- Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic, Scottsdale, Arizona, USA
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Jeffrey R Janus
- Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Dan J Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
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Van Abel KM, Quick MH, Graner DE, Lohse CM, Price DL, Price KAR, Ma DJ, Moore EJ. Outcomes following TORS for HPV-positive oropharyngeal carcinoma: PEGs, tracheostomies, and beyond. Am J Otolaryngol 2019; 40:729-734. [PMID: 31303455 DOI: 10.1016/j.amjoto.2019.07.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/02/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To review swallowing, airway and speech outcomes following transoral robotic surgery (TORS) ± adjuvant therapy for human papillomavirus associated oropharyngeal squamous cell carcinoma (HPV[+]OPSCC). METHODS Patients underwent TORS ± standard adjuvant therapy from 5/1/2007-5/31/2015. Clinical data were recorded and descriptive analysis was performed. RESULTS 267 patients met criteria. All patients underwent surgery at Mayo, however, only 41/81 and 71/119 patients received RT and CRT at a Mayo Clinic site. A PEG was placed in 77 patients (3 prior to any treatment, 74 reactively during adjuvant therapy), with 3 PEG dependent and 3 partially PEG reliant at last follow-up. Tracheostomy was performed in 30 (11%) patients; 28 were decannulated. Swallow evaluations were completed for 20/81 undergoing RT and 50/119 undergoing CRT at a median of 3.8 and 7.6 months post-treatment, respectively. An unrestricted oral diet was reported by 5% following RT and 12% following CRT on the Functional Oral Intake Scale. HN-PSS normalcy of diet scores indicated a diet beyond soft chewable foods for 27% following RT and 46% following CRT. No restriction of place, food, or companion was reported for the HN-PSS for public eating in 13% after RT and 33% after CRT. Aspiration of thin liquid was present in 17% and 28% following RT and CRT, respectively. HN-PSS understandability of speech was "always understandable" in 60% and 63%, following RT and CRT, respectively. Hoarseness was reported in 56% and 45% following RT and CRT respectively. CONCLUSION Long-term PEG and tracheostomy dependence in this cohort is low. However, these outcomes under-represent the decrement in patient speech and swallowing following TORS ± standard adjuvant therapy for HPV(+)OPSCC.
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Affiliation(s)
- Kathryn M Van Abel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, MN 55905, USA.
| | - Melanie H Quick
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, MN 55905, USA
| | - Darlene E Graner
- Department of Neurology, Mayo Clinic School of Medicine, Rochester, MN 55905, USA
| | - Christine M Lohse
- Department of Health Sciences Research, Mayo Clinic School of Medicine, Rochester, MN 55905, USA
| | - Daniel L Price
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, MN 55905, USA
| | - Katharine A R Price
- Division of Medical Oncology, Mayo Clinic School of Medicine, Rochester, MN 55905, USA
| | - Dan J Ma
- Department of Radiation Oncology, Mayo Clinic School of Medicine, Rochester, MN 55905, USA
| | - Eric J Moore
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, MN 55905, USA
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Price KAR, Cohen EEW. Mechanisms of and therapeutic approaches for overcoming resistance to epidermal growth factor receptor (EGFR)-targeted therapy in squamous cell carcinoma of the head and neck (SCCHN). Oral Oncol 2015; 51:399-408. [PMID: 25725588 DOI: 10.1016/j.oraloncology.2015.01.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 01/19/2015] [Accepted: 01/28/2015] [Indexed: 01/07/2023]
Abstract
The majority of squamous cell carcinoma of the head and neck (SCCHN) overexpress epidermal growth factor receptor (EGFR), which has been associated with poor treatment response and survival. However, only modest success has been achieved with the use of single agents that target EGFR, possibly due to primary and acquired resistance. This review will discuss key mechanisms of and therapeutic approaches to overcoming resistance to EGFR-targeted therapy in SCCHN. Recent preclinical and clinical investigations have demonstrated that other ErbB family receptors (eg, HER2 and HER3) and other horizontal resistance mechanisms, as well as activation of downstream signaling pathways, epigenetic events, and nuclear EGFR, are possible mediators of resistance to anti-EGFR therapeutics. Key downstream pathways that may be implicated in EGFR resistance include phosphatidylinositol-3-kinase/protein kinase B, vascular endothelial growth factor (VEGF), and mammalian target of rapamycin (mTOR). Multiple agents that target EGFR and other ErbB family members (ie, lapatinib, afatinib, and dacomitinib), as well as combination therapies that target EGFR and selected other pathways (eg, VEGF, mTOR, and c-Met) are being investigated clinically. In addition, several phase II and III trials continue to investigate strategies to enhance the efficacy of EGFR-targeted therapy in SCCHN.
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Affiliation(s)
| | - Ezra E W Cohen
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
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Abstract
Metastatic disease to the pancreas is rare among solid tumors and has not been well described for salivary cancers. We report a patient who developed an isolated metastatic lesion in the pancreas from acinic cell carcinoma of the salivary gland, presenting as acute pancreatitis.
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Affiliation(s)
- Jessica L Geiger
- Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minn., USA
| | - Joaquín J García
- Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, Minn., USA
| | - Katharine A R Price
- Department of Division of Medical Oncology, Mayo Clinic Rochester, Rochester, Minn., USA
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9
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Geiger JL, Lazim AF, Walsh FJ, Foote RL, Moore EJ, Okuno SH, Olsen KD, Kasperbauer JL, Price DL, Garces YI, Ma DJ, Neben-Wittich MA, Molina JR, Garcia JJ, Price KAR. Adjuvant chemoradiation therapy with high-dose versus weekly cisplatin for resected, locally-advanced HPV/p16-positive and negative head and neck squamous cell carcinoma. Oral Oncol 2014; 50:311-8. [PMID: 24467937 DOI: 10.1016/j.oraloncology.2014.01.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 12/31/2013] [Accepted: 01/03/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Standard treatment for patients with poor-risk, resected head and neck squamous cell carcinoma (HNSCC) is adjuvant radiation therapy combined with high-dose cisplatin. Many patients are treated with weekly cisplatin; it is not known whether weekly and high-dose cisplatin are equivalent. This study compares the outcomes of patients with locally-advanced HPV-negative HNSCC and HPV/p16-positive oropharynx HNSCC treated with adjuvant chemoradiation therapy with either high-dose or weekly cisplatin. MATERIALS AND METHODS Retrospective review of patients with Stage III/IV HNSCC who had surgery followed by adjuvant chemoradiation therapy at Mayo Clinic, Rochester. HPV and/or p16 status was available for all oropharynx patients. RESULTS 104 Patients (51 high-dose, 53 weekly) were analyzed. The 3-year overall survival was 84% and 75% for patients who received high dose and weekly cisplatin, respectively (p=0.30). The 3-year recurrence free survival was 71% and 74% in the high dose and weekly cisplatin group, respectively (p=0.95). Patients with HPV/p16-positive oropharynx cancer who received adjuvant chemoradiation therapy with high-dose and weekly cisplatin had three-year overall survival rates of 91% and 86% (p=0.56), and 3-year recurrence free survival of 84% and 82% (p=0.93). Extracapsular extension did not affect prognosis in either group. CONCLUSIONS No significant survival difference was seen between patients with locally advanced HNSCC treated with adjuvant chemoradiation therapy with high-dose or weekly cisplatin, although there was a trend for improved survival with high-dose cisplatin. Weekly cisplatin in the adjuvant setting may be a better treatment for patients with HPV-positive oropharynx cancer to preserve survival and minimize toxicity.
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Affiliation(s)
- Jessica L Geiger
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Ahmed F Lazim
- Department of Pathology, Al Jumhori Teaching Hospital, Mosul, Iraq
| | - Francis J Walsh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Eric J Moore
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, United States
| | - Scott H Okuno
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Kerry D Olsen
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, United States
| | - Jan L Kasperbauer
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, United States
| | - Daniel L Price
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, United States
| | - Yolanda I Garces
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Daniel J Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | | | - Julian R Molina
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Joaquin J Garcia
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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Abstract
Head and neck squamous cell carcinoma is now the 8th most common cancer affecting men in the United States largely due to a rising epidemic of oropharynx cancer (tonsil and tongue base) associated with the human papillomavirus (HPV). The median overall survival for recurrent or metastatic head and neck cancer (R/M HNSCC) remains less than 1 year despite modern chemotherapy and targeted agents. Palliative chemotherapy and the epidermal growth factor receptor inhibitor, cetuximab, constitute the backbone of treatment for patients with R/M HNSCC. Platinum doublets studied in phase III trials include cisplatin/5-FU, cisplatin/paclitaxel, and cisplatin/pemetrexed. Platinum chemotherapy in combination with 5-fluorouracil and cetuximab has resulted in the longest median overall survival. Combination platinum regimens increase response rates and toxicity but not survival and should be reserved for patients who are symptomatic from their disease for whom the benefit of a partial response may be worth the cost of increased treatment-related side effects. For many patients who are asymptomatic with a low disease burden, single agent regimens are appropriate to balance treatment with side effects. Drugs commonly used as single agents in the treatment of R/M HNSCC include docetaxel, paclitaxel, cetuximab, capecitabine, pemetrexed, and methotrexate. Best supportive care alone is often appropriate for poor performance status patients. Palliative radiation therapy is beneficial for treating symptomatic metastatic sites. Aggressive symptom management is imperative for all patients and often should include referral to experts in palliative care and pain management. New therapies currently under investigation include mTOR inhibitors, anti-angiogenic agents, and IGF1R inhibitors. Given the poor prognosis for most patients with R/M HNSCC, enrollment in clinical trials investigating novel approaches to therapy should be encouraged.
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Abstract
Patients with unresectable stage III nonsmall cell lung cancer (T4, N3, or bulky N2) live longer if they receive chemotherapy before or concurrent with thoracic irradiation. Randomized clinical trials have shown that concurrent chemoradiation is superior to sequential chemotherapy followed by radiation, with a 20% reduction in the risk of death compared with the sequential approach. However, concurrent chemoradiation is more toxic than the sequential approach, with an increased risk of radiation esophagitis, pneumonitis, and cytopenias, including febrile neutropenia. The phase III trials showing the superiority of the concurrent approach all used cisplatin-based chemotherapy and enrolled patients with a good performance status. For patients who are not eligible for cisplatin, or who have a poor performance status, weight loss, or poor lung function, a sequential approach may be used with full doses of chemotherapy followed by radiation. Another approach currently being studied in phase III trials is to use lower doses of chemotherapy concurrent with radiation followed by full-dose chemotherapy after radiation, so-called concurrent followed by consolidation therapy. Treatment should be planned by the radiation and medical oncologist with careful selection of approach based on the patient's fitness, comorbid medical illness, and size and location of the tumor. The goal of treatment is to maximize efficacy and minimize toxicity that may interfere with delivery of drug or radiation. In the future, more effective, less toxic chemotherapy drugs and better radiation techniques should improve outcomes for patients with unresectable stage III non-small cell lung cancer (NSCLC).
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Affiliation(s)
- Katharine A R Price
- Department of Medicine, Thoracic Oncology Service, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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