Clinical Investigation
Effectiveness of Chemoradiation for Head and Neck Cancer in an Older Patient Population

This work was presented as a digital poster at the 55th Annual Meeting of the American Society for Radiation Oncology, Atlanta, GA, September 22-25, 2013.
https://doi.org/10.1016/j.ijrobp.2014.01.053Get rights and content

Purpose

The purpose of this study was to compare chemoradiation therapy (CRT) with radiation therapy (RT) only in an older patient population with head and neck squamous cell carcinoma (HNSCC).

Methods and Materials

Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database (1992-2007), we identified a retrospective cohort of nonmetastatic HNSCC patients and divided them into treatment groups. Comparisons were made between CRT and RT cohorts. Propensity scores for CRT were estimated from covariates associated with receipt of treatment using multivariable logistic regression. Standardized mortality ratio weights (SMRW) were created from the propensity scores and used to balance groups on measured confounders. Multivariable and SMR-weighted Cox proportional hazard models were used to estimate the hazard ratio (HR) of death for receipt of CRT versus RT among the whole group and for separate patient and tumor categories.

Results

The final cohort of 10,599 patients was 68% male and 89% white. Median age was 74 years. Seventy-four percent were treated with RT, 26% were treated with CRT. Median follow-up points for CRT and RT survivors were 4.6 and 6.3 years, respectively. On multivariable analysis, HR for death with CRT was 1.13 (95% confidence interval [CI]: 1.07-1.20; P<.01). Using the SMRW model, the HR for death with CRT was 1.08 (95% CI: 1.02-1.15; P=.01).

Conclusions

Although the addition of chemotherapy to radiation has proven efficacious in many randomized controlled trials, it may be less effective in an older patient population treated outside of a controlled trial setting.

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.

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  • 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.

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