|Year : 2019 | Volume
| Issue : 1 | Page : 16-19
Different definitive radiotherapy approaches in indian elderly head and neck cancer patients: Experience from an Indian Center
Kazi Sazzad Manir1, Swapnendu Basu2, Sourav Guha2, Manish Goswami2, Jyotirup Goswami1, Suman Mallik1
1 Department of Radiation Oncology, Narayana Superspecialty Hospital, Howrah, West Bengal, India
2 Department of Radiation Oncology, Medica Cancer Hospital, Siliguri, West Bengal, India
|Date of Web Publication||26-Jul-2019|
Kazi Sazzad Manir
Department of Radiation Oncology, Narayana Superspecialty Hospital, 120, 1, Andul Road, Howrah - 711 103, West Bengal
Source of Support: None, Conflict of Interest: None
Introduction: Treatment of Squamous Cell Carcinoma of Head and Neck (SCCHN) in elderly age group is challenging. Role of either curative concurrent chemoradiation (ChTRT) or Accelerated Fractionation Radiotherapy(ACRT) in this subgroup is not clearly defined. Materials and Methods: Between July 2015 and December 2017, we treated 61 elderly (>70 years) SCCHN patients (excluding T1/T2N0M0 Ca Glottis). 18 patients had been excluded from analysis for <6-month follow-up. 3 patients were excluded as they did not complete Radiotherapy (RT). We retrospectively analyzed 40 patients who were treated with definitive RT (ChTRT /ACRT /RT only ). Clinical outcomes and acute toxicities (≥ Grade 2 in Common Terminology Criteria for Adverse Events v5.0 scale) were compared between different treatment groups. Results: Our study population had a median follow-up of 8 months (6–32 months), median age of 73 years (70–93 years) with 52.5% patients of Stage IVA, and 40% oropharyngeal malignancies. 66.7% patients were able to take all intended ChT cycles. 22% patients in ChTRT, 10% patients in ACRT, and 16% patients in RT only arm has acute (≥ Grade 2) skin reaction. For mucositis, the incidences were 38.9%, 30%, and 8.3%, respectively. For dysphagia, the incidences were 44.4%, 40%, and 50%, respectively. For pain, the incidences were 50%, 40%, and 50%, respectively. One patient (7.5%, in ChTRT arm) died due to severe dysphagia after completion of RT. 7.5% patient had significant treatment delay (>7 days). Complete response rate was better in ChTRT arm than others (94.4%, 80%, and 75%, respectively) Median progression-free survival (PFS) was better in ChTRT arm (5 months with a range of 3.4–6.6 months) than ACRT and RT only arm (both arms had median PFS of 3 months). Conclusion: All radical RT approaches are feasible and effective in Indian elderly SCCHN patients. Definitive ChTRT is better in terms of CR rate and PFS but with more acute toxicities. Radical treatment strategy of elderly should be guided by clinical judgments not by chronological age.
Keywords: Elderly, head and neck cancer, radical radiotherapy
|How to cite this article:|
Manir KS, Basu S, Guha S, Goswami M, Goswami J, Mallik S. Different definitive radiotherapy approaches in indian elderly head and neck cancer patients: Experience from an Indian Center. J Head Neck Physicians Surg 2019;7:16-9
|How to cite this URL:|
Manir KS, Basu S, Guha S, Goswami M, Goswami J, Mallik S. Different definitive radiotherapy approaches in indian elderly head and neck cancer patients: Experience from an Indian Center. J Head Neck Physicians Surg [serial online] 2019 [cited 2019 Dec 12];7:16-9. Available from: http://www.jhnps.org/text.asp?2019/7/1/16/263510
| Introduction|| |
Squamous cell carcinoma of head and neck cancer (SCCHN) is an aggressive malignancy in the upper aerodigestive tract. Like any other malignancies, risk of developing SCCHN increases with age and majority of head neck cancer occur in fifth to sixth decade. The average age for smoking-related SCCHN diagnosis is 60 years (median age: 63 years) whereas the average age for smokeless tobacco-related SCCHN is 78 years. One of the other reasons for increasing incidence in elderly age group is growing of aged population worldwide due to increased life expectancy. Concurrent Chemoradiation (ChTRT) is the standard treatment of locally advanced SCCHN. Altered fractionation, in the form of either accelerated fractionation (ACRT) or hyperfractionation, though inferior to ChTRT in respect of outcome, are other feasible curative options in candidates not suitable for concurrent chemotherapy. Radical therapeutic approaches in elderly are always challenging due to poor performance status and associated comorbidities. There is no consensus of selecting patients for either CTRT or altered fractionation RT in this age group.
In this report, we tried to analyze our experience regarding outcome and toxicities related with different curative RT protocols in elderly SCCHN patients.
| Materials and Methods|| |
In this retrospective single institutional audit, we collected records of all nonmetastatic (except Carcinoma Glottic cT1-2N0M0) SCCHN patients ≥70 years of age with Eastern Cooperative Oncology Group Performance Status 0–1 treated with definitive radiotherapy (either ChTRT or ACRT or RT only) protocols between July 2015 and December 2017. Patients having <6-month follow-up were excluded from this study. Outcome and toxicity data were collected along with treatment details. Statistical analysis was done using frequency distribution table, i.e., Chi-square tests. Survival analysis, for example, recurrence-free survival (RFS) was done using Kaplan–Meyer survival plot and log-rank test. Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 Grade ≥ was recorded as quantal end point for toxicity analysis.
| Results|| |
During the above-mentioned timeframe, a total of 53 eligible patients got curative radical RT at our institute. Of which, we analyzed data of 40 patients having ≥6-month follow-up. 18 patients received ChTRT. 10 patients received ACRT, and 12 patients received conventional fractionated RT (RT only). There was no statistically significant difference in baseline parameters among the three groups [Table 1].
RT treatment details are elaborated in [Table 2]. In ChTRT Group, 77.8% patient received injection cisplatin (weekly 30–40 mg/m2) which is standard protocol in our institution. 22.2% patients received injection carboplatin (area under curve 2) due to poor renal clearance. Only 16.7% patients were able to complete 100% of intended cycles of concurrent chemotherapy. 72.2% patients completed >50% of intended cycles and 11.1% patients completed <50% intended chemotherapy cycles.
Response evaluation and follow-up
Median follow-up of total study population was 6.5 months (6–32 months). In ChTRT group, median follow-up was 7.5 months (6–31 months). Likewise, median follow-up of ACRT and RT group are 6.5 months (6–32 months) and 7 months (6–31 months), respectively. There was no significant difference between the groups in terms of response and recurrence rates [Table 3].
We only analyzed RFS due to short follow-up. Group-wise median and mean RFS data are detailed in [Table 4]. Kaplan–Meier survival plot is illustrated in [Figure 1]. We analyzed log-rank test (Mantel-Cox) to test equality of survival data among groups. In overall comparison, there was no significant difference found (P = 0.928).
|Table 4: Mean and median recurrence-free survival (months) in different groups|
Click here to view
|Figure 1: Kaplan Meyer Survival Plot (RFS in months) in different groups|
Click here to view
Due to short-term follow-up, we only analyzed acute toxicity data [Table 5]. There was only nonsignificant trend of higher incidence of acute events in ChTRT group. Least toxicity events were observed in RT only group.
| Discussion|| |
We report single institutional experience of outcome and toxicity of different radical curative protocols in elderly SCCHN patients. Though there is an increase incidence of elderly SCCHN patients in recent times due to increased life expectancy, curative treatment in elderly head and neck cancer patients is still challenging. Poor performance status, associated comorbidity, poor mental health, and poor compliance might create the situation more complex. There is also paucity of prospective clinical data in this subset of population. Major RT trials did not include elderly patients. Available literatures are mostly retrospective conflicting and inconsistent results.
A meta-analysis of 1589 SQCCHN patients by Pignon et al. treated with ChTRT showed that overall survival (OS) and most toxicities were similar in 50–75 years or above age groups. In their update published in 2009 with 17,346 patients, authors showed less effect of ChT in elderly age with more late toxicity events. In another retrospective review, researchers showed that after a median follow-up of 29 months, OS progression-free survival, local control rate, and distant metastasis-free survival and toxicity stratified by age of ≥65, ≥70, or ≥75 years revealed no differences. Although there is increased concern about high toxicity events in curative radical RT protocols, outcome results in elderly subgroup are not drastically different from younger population. Another retrospective study found no difference between >75 years and younger age groups treating with accelerated concomitant RT regimen.
In our retrospective audit, we found similar response and outcome which corroborate with findings from different retrospective audits, review, and pooled data analysis from prospective studies.,,,, We compared ChTRT, ACRT, and RT only groups. We found no significant difference in outcome and toxicity. There were significant treatment delays (≥7 days) in ChTRT and RT only groups, not in ACRT group. This observation might be related to small sample size of the study.
| Conclusion|| |
Radical curative RT is feasible in elderly SQCCHNC patients with acceptable toxicites and outcome. Majority ChTRT patients were able to tolerate concurrent ChT. Definitive ChTRT is better (non significant trend) in terms of CR rate & RFS but with more acute toxicities.
We like to thank all our patients who participated in this audit. We are thankful to all faculty members of Radiation Oncology Department, Medica Cancer Hospital, Siliguri for their sincere support.
Financial support and sponsorship
Conflict of interest
There is no conflict of interest.
This material has never been published and is not currently under evaluation in any other peer reviewed publication.
The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
| References|| |
Vigneswaran N, Tilashalski K, Rodu B, Cole P. Tobacco use and cancer. A reappraisal. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:178-82.
Lacas B, Bourhis J, Overgaard J, Zhang Q, Grégoire V, Nankivell M, et al.
Role of radiotherapy fractionation in head and neck cancers (MARCH): An updated meta-analysis. Lancet Oncol 2017;18:1221-37.
Pignon JP, le Maître A, Maillard E, Bourhis J. MACH-NC Collaborative Group. Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): An update on 93 randomised trials and 17,346 patients. Radiother Oncol 2009;92:4-14.
Müller von der Grün J, Martin D, Stöver T, Ghanaati S, Rödel C, Balermpas P. Chemoradiotherapy as definitive treatment for elderly patients with head and neck cancer. Biomed Res Int 2018;2018:3508795.
Metges JP, Eschwege F, de Crevoisier R, Lusinchi A, Bourhis J, Wibault P. Radiotherapy in head and neck cancer in the elderly: A challenge. Crit Rev Oncol Hematol 2000;34:195-203.
Allal AS, Maire D, Becker M, Dulguerov P. Feasibility and early results of accelerated radiotherapy for head and neck carcinoma in the elderly. Cancer 2000;88:648-52.
Baumann M. Is curative radiation therapy in elderly patients limited by increased normal tissue toxicity? Radiother Oncol 1998;46:225-7.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]