Ghanem AI, Mannari A, Schymick MA, Burmeister C, Ghanem T, Chang S, and Siddiqui F. The effect of treatment package time in head and neck cancer patients treated with adjuvant radiation therapy and concurrent systemic therapy. Int J Radiat Oncol Biol Phys 2017; 99(2):E204.
Int J Radiat Oncol Biol Phys
Purpose/Objective(s): In patients with head and neck squamous cell carcinoma (HNSCC), the “treatment package time” (TPT), defined as the number of days from surgery to end of adjuvant radiation therapy (RT), has been shown to impact outcomes with TPT above 100 days resulting in worse survival. However, these studies were restricted to cases receiving only adjuvant RT with no data for those receiving concurrent systemic therapy (CRT). We analyzed the influence of TPT on survival endpoints for HNSCC treated by surgery followed by CRT.
Materials/Methods: After IRB approval, we used our institutional database to identify HNSCC cases treated with curative surgical resection followed by CRT. The addition of concurrent systemic therapy was due to the presence of positive margins (PM) and/or extracapsular nodal extension (EC). Those with deficient surgical, pathological or follow up data were excluded. For each case we calculated a provisional risk score (RS) based on NCCN defined adverse features; 2 points each were assigned for PM and EC and 1 point for each of the remaining adverse features (T3/4, N2/3, perineural invasion (PNI) and lympho-vascular invasion (LVI). TPT was assessed by calculating the number of days elapsed between surgery date and the last day of CRT for each case. We used %findcut SAS macro tool to search for the cutoff TPT that was associated with significant overall survival (OS) and recurrence free survival (RFS) benefit. According to the TPT optimal cutoff point two groups were formed and Kaplan-Meier curves, log rank tests as well as univariate and multivariate (MVA) analyses were used to assess OS and RFS.
Results: We identified 103 cases that met inclusion criteria treated between 2008 & 2015 with a median follow-up time of 59 months. Oropharyngeal tumors (OP) were 43%, oral cavity (OC) 40% and laryngeal 17%. HPV positive disease was detected in 22% of patients (50 % of OP). CRT included platinum and cetuximab that were utilized in 72% & 28%, respectively. Optimal TPT was found to be less than 100 days (nZ62) with significantly better OS (pZ0.011) and RFS (pZ0.043) compared toTPT≥100 days (nZ41). Also 2&5 years OS and RFS were significantly better for TPT (91% vs. 68% &74% vs. 46% for OS; p<0.05). Study groups were balanced for all characters except that those with TPT<100 days have more OP location; whereas the other group had higher smoking incidence, OC and T4 tumors (p<0.05).On MVA excluding risk score; EC, LVI&PNI were associated with inferior OS. Nevertheless, when RS was included, after excluding its components; TPT<100 days and high RS were independent predictors for worse OS (p<0.05). T4, EC and high RS were all significantly related to inferior RFS (p<0.05).
Conclusion: Shorter treatment package time <100 days is associated with better survival outcomes in HNSCC with high risk features even when systemic therapy is added to adjuvant RT. Thus, multidisciplinary coordinated care must be provided to ensure the earliest start of CRT with minimal treatment breaks.
Author Disclosure: A.I. Ghanem: None. A. Mannari: None. M.A. Schymick: None. C. Burmeister: None. T. Ghanem: None. S. Chang: None. F. Siddiqui: Employee; Children’s Hospital of Michigan. Research Grant; Varian Medical Systems, Inc.. Honoraria; Varian Medical Systems, Inc.. Travel Expenses; Varian Medical Systems, Inc.. ; American College of Radiology, ASTRO, Henry Ford Health System Board of Governors, HFHS Bylaws and Governance Committee. Serve as liaison between Health System le.