International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationEffectiveness of Chemoradiation for Head and Neck Cancer in an Older Patient Population
Introduction
An increasing number of head and neck squamous cell carcinoma (HNSCC) patients are older (65 years and above). Currently, approximately 47% of HNSCC patients in the United States are above the age of 65 (1). The incidence of HNSCC among older patients is expected to increase 34% over the next 10 years and 64% over the next 20 years (2). These patients are often not included in clinical trials because they commonly have complicating medical issues such as comorbidities, decreased functional status, poorer performance status, decreased quality of life, and limited life expectancy 3, 4.
Over the last 2 decades there have been a number of randomized controlled trials demonstrating the efficacy of adding chemotherapy to radiation therapy (CRT) for locally advanced HNSCC 5, 6, 7, 8, 9, 10, 11, 12, 13. A meta-analysis of 93 randomized studies demonstrated a 6.5% survival benefit for the addition of chemotherapy concurrently with radiation therapy (RT) (14). In a subset analysis by age, a survival benefit was not observed in patients over the age of 71 (14). Only 4% of the 17,346 patients analyzed were 71 years or older, because most of the studies either excluded older patients or accrued very few of them (15). Thus, it is unclear whether the efficacy of combining chemotherapy with radiation can be extrapolated to older HNSCC patients.
To further study the effectiveness of CRT, we conducted a large population-based study using the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare registry data. Accordingly, cancer registry Medicare-linked data were used to identify clinically distinct treatment cohorts and compare survival outcomes of those who received CRT to those who received RT alone (both definitively and postoperatively).
Section snippets
Data source
This study was conducted with data from the National Cancer Institute's (NCI) SEER-Medicare program. The SEER system of population-based cancer registries currently covers approximately 28% of the US cancer population. Linkage of the SEER database to administrative and claims data for those also enrolled in Medicare allows for the inclusion and analysis of patient's comorbid health conditions, treatment utilization, and select outcomes. In addition, Medicare contains information of many
Patient characteristics
Within the final cohort of 10,599 patients, 74% were treated with RT, 26% were treated with CRT. Sixty-eight percent of patients were male, and 89% were white. Median age was 74 years, 54% had no co-morbidities, 55% were married, and 84% were not Medicaid eligible. Median follow-up points for CRT and RT were 4.6 and 6.3 years, respectively. At baseline (prior to PS analysis), age, sex, race, Medicaid eligibility, and SEER region were statistically different based on receipt of CRT or RT (Table 1
Discussion
The decision of whether to offer older HNSCC patients CRT is a problem many oncologists face. The lack of data on an increasing population of older patients may leave clinicians in a quandary as to how to best treat this important demographic. In situations where clinical trial efficacy data do not apply to a particular patient population, comparative effectiveness analyses may help (24).
In this comparative effectiveness analysis, we did not observe an improvement in patient survival associated
Conclusions
In conclusion, in a large population-based cohort, we observed no survival benefit in older HNSCC patients associated with CRT compared to RT even when controlling for known variables (stage, age, CCI, and others). This hypothesis-generating data should lead to prospective studies in this growing population of patients. Unmeasured variables in this study such as functional status, frailty, smoking status, and toxicity need to be studied further. Future work should extend this research to
Acknowledgments
The authors acknowledge Hojin Yang, MS, from the Lineberger Comprehensive Cancer Center, for providing support for this study.
References (33)
- et al.
Cancer in the elderly: Why so badly treated?
Lancet
(1990) - et al.
Chemoradiotherapy for locally advanced head and neck cancer: 10-year follow-up of the UK Head and Neck (UKHAN1) trial
Lancet Oncol
(2010) - et al.
Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): An update on 93 randomised trials and 17,346 patients
Radiother Oncol
(2009) - et al.
Head and neck cancer in the elderly population
Semin Radiat Oncol
(2012) - et al.
Patterns of care in older patients with squamous cell carcinoma of the head and neck: A Surveillance Epidemiology and End Results-Medicare analysis
J Geriatr Oncol
(2013) - et al.
A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation
J Chronic Dis
(1987) - et al.
Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases
J Clin Epidemiol
(1992) - et al.
Impact of age on acute toxicity induced by bio- or chemo-radiotherapy in patients with head and neck cancer
Oral Oncol
(2012) - et al.
Patterns of care in elderly head-and-neck cancer radiation oncology patients: A single-center cohort study
Int J Radiat Oncol Biol Phys
(2011) - et al.
Patterns of care and outcomes associated with intensity-modulated radiation therapy versus conventional radiation therapy for older patients with head-and-neck cancer
Int J Radiat Oncol Biol Phys
(2012)
Future of cancer incidence in the United States: Burdens upon an aging, changing nation
J Clin Oncol
Comorbidity and survival of elderly head and neck carcinoma patients
Cancer
Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer
N Engl J Med
Randomized trial of radiation therapy versus concomitant chemotherapy and radiation therapy for advanced-stage oropharynx carcinoma
J Natl Cancer Inst
An intergroup phase III comparison of standard radiation therapy and two schedules of concurrent chemoradiotherapy in patients with unresectable squamous cell head and neck cancer
J Clin Oncol
Cited by (0)
This study was supported by the Integrated Cancer Information and Surveillance System, University of North Carolina Lineberger Comprehensive Cancer Center, with funding provided by the University Cancer Research Fund via the state of North Carolina. Additional support was provided by the University of North Carolina Geriatric Oncology Workgroup and Department of Radiation Oncology.
Conflict of interests: none.