Background
This study aims to provide modern estimates of survival for untreated head and neck cancer (HNC) and to identify patient‐ and tumor‐specific factors associated with not receiving ...definitive treatment.
Methods
Adults with mucosal HNC were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Median overall survival of untreated patients was calculated and stratified by site and stage. Cause‐specific survival and factors associated with no treatment were investigated with advanced statistics.
Results
The study cohort included 6477 patients who received no treatment. Overall, untreated patients had a median survival of 12 months, with significant variability by site and stage. Multivariable analysis identified advanced age, black race, unmarried status, and lack of private insurance as associated with no treatment.
Conclusions
Survival of HNC without treatment is dismal, yet substantial variation exists by tumor site and stage. Higher rates of no treatment among the poor and racial minorities are potentially driven by disparities in care availability and provision.
(1) To compare perioperative outcomes and overall survival of patients with oropharyngeal salivary gland malignancies (OPSGMs) treated with transoral robotic surgery (TORS) versus other approaches. ...(2) To identify clinical factors associated with a robotic surgical approach.
Retrospective analysis of the National Cancer Database (NCDB).
NCDB.
Data obtained from the NCDB were analyzed between 2010 and 2017 for patients with T1-T4a OPSGMs without distant metastases treated surgically. Patients were stratified by surgical approach (TORS vs nonrobotic), and clinicopathologic factors were compared with the
test or chi-square test for continuous or categorical variables, respectively. Overall survival was analyzed by patient demographics and clinical factors according to Kaplan-Meier and Cox proportional hazards models. Factors associated with TORS were assessed with logistic regression.
A total of 785 patients were analyzed. A non-soft palate primary site (odds ratio, 12.9; 95% CI, 6.6-25.2) and treatment at an academic facility (odds ratio, 2.0; 95% CI, 1.2-3.5) were independently associated with TORS. There were no significant differences in the positive margin rate, 30-day mortality, or overall survival between the groups. The 30-day unplanned readmission rate was higher in patients treated with TORS versus nonrobotic resections (5.8% vs 1.7%,
= .0004). When stratified by tumor subsite, there was a significant decrease in hospital length of stay in patients with tongue base tumors undergoing TORS versus nonrobotic resections (
= .029).
This study suggests that TORS may be a viable treatment modality for appropriately selected patients with OPSGM.
A 57-year-old male with a history of previous right alveolus squamous cell carcinoma after reconstruction using a right supraclavicular island flap presented to the head and neck clinic for 3-month ...follow-up with complaint of new protuberant bony growth in his right inferior neck. The growth was causing him substantial discomfort, and he reported sharp pain specifically with head rotation to the left. Physical examination revealed a 3-cm vertically oriented bony protuberance originating from his right clavicle (Figure 1). The lesion was tender to palpation and visibly tented his overlying neck skin. He underwent computed tomography of his neck, which revealed a 2.7-cm bony spicule emanating off his right clavicle (Figure 2).
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.
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.
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.
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.
Highlights • A study cohort of 261, transorally treated, p16-positive oropharynx cancer cases. • No reduced local control in the absence of primary bed radiation for T1-T2 tumors. • Lower gastrostomy ...in the absence of primary bed radiation for T1-T2 tumors. • Reduced local control in the absence of primary bed radiation for T3-T4 tumors.
Background
The diagnosis and management of oral cavity cancer has been well described in developed countries, however, in regions with fewer medical resources, alternative methods may need to be ...used. We outline an approach to evaluation and treatment of oral cavity cancer in low‐resource areas.
Methods
Reviews of the Cochrane and Pubmed databases were performed and literature compiled. Expert opinions from the American and African Head and Neck Societies were also provided.
Results
Treatment guidelines for managing oral cavity cancer in low‐resource regions are outlined and the level of supporting evidence is defined.
Discussion
Successful treatment typically involves the use of upfront surgical resection of the primary lesion and any involved or at‐risk cervical lymph node basins, with adjuvant therapy based on the final pathology findings. In situations where services such as adjuvant therapy and/or appropriate reconstruction are not available, alternative approaches to treatment may be needed.
While smoking is associated with worse outcomes in HPV-positive oropharyngeal squamous cell carcinoma (OPSCC), the magnitude of this association is unclear given the heterogenous smoking definitions ...and outcomes. Our objective was to investigate the association between smoking, survival, and recurrence in HPV-related OPSCC using multiple smoking metrics reported in the literature.
This was a retrospective cohort study of 375 adults with p16+ OPSCC undergoing surgical resection (n = 272) or definitive chemoradiation (n = 103) at a tertiary academic institution from 2006 to 2017. The primary outcome was overall survival (OS). Secondary outcomes included disease-free survival (DFS), disease-specific survival (DSS), and recurrence. We used multiple smoking metrics commonly cited in previous studies, including ever versus never smokers, current versus former/never smokers, ≤10 versus >10 pack-year, ≤20 versus >20 pack-year, and continuous pack-year.
There were 375 patients, median age 58 years, with 326 (87%) males, and median follow-up of 52 months. Of all smoking metrics, >20 pack-year history was the strongest predictor of both OS (HR 2.24, 95% CI: 1.19–4.20) and DFS (HR 1.67, 95% CI: 1.04–2.66) on univariable and multivariable analysis after adjusting for age, overall stage, and comorbidities. Patients with >20 pack-year smoking history were also more likely to have recurrence (HR 1.59, 95% CI: 0.95–2.67) after adjusting for overall stage.
Heavier smoking >20 pack-years was the strongest smoking metric associated with 2-times worse survival and recurrence. Our findings suggest that >20 pack-year smoking history may be a more useful cutoff for risk stratification models but requires further validation.
Positive surgical margins (PSM) are associated with worse survival in oropharyngeal salivary gland malignancies (OPSGM), but existing literature is limited to small series. Our objective was to ...identify risk factors for PSM using the national cancer database (NCDB), including a transoral robotic surgical (TORS) approach.
NCDB was queried for patients with T1-T4a OPSGM undergoing resection between 2010 and 2017. Risk factors for PSM were determined using logistic regression. Overall survival (OS) was analyzed using Kaplan-Meier and Cox proportional hazards models.
Of 785 patients, 165 (21.0 %) had PSM. Age, stage T4a tumors (OR 2.00, 95 % Confidence Interval CI: 1.03–3.88), adenoid cystic carcinoma (OR 2.02, 95 % CI: 1.29–3.18), and treatment at lower volume institutions (OR 1.68, 95 % CI: 1.09–2.59) were all independently associated with PSM. TORS versus a non-robotic approach was not associated with PSM (23.9 % vs 20.4 %, p 0.358), respectively. Positive margins were independently associated with a worse OS than negative margins (HR 1.63, 95 % CI: 1.03–2.59). Adjuvant radiation therapy was associated with improved survival in high grade tumors with positive margins.
This study represents the largest review assessing risk factors for positive margins in OPSGM. Histologic type (adenoid cystic carcinoma), age, T4a tumor stage and treatment at a lower volume institution were all predictive of positive margins. With increasing use of TORS over the last decade, there does not appear to be a greater risk of positive margins using this modality in select patients.
Level of evidence: N/A.
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.
PDF
