Aspiration pneumonia after concurrent chemoradiotherapy for head and neck cancer

Abstract

Background Aspiration pneumonia represents an under-reported complication of chemoradiotherapy in head-and-neck cancer. This study evaluated the incidence, risk factors, and mortality of aspiration pneumonia in a large cohort of head-and-neck cancer patients treated with concurrent chemoradiotherapy. Methods Patients with head-and-neck cancer diagnosed between 2000 and 2009 were identified from the SEER-Medicare database. Aspiration pneumonia was identified from Medicare billing claims. The cumulative incidence, risk factors, and survival after aspiration pneumonia were estimated and compared to a non-cancer population. Results Of 3,513 head-and-neck cancer patients, 801 patients developed aspiration pneumonia at a median time of 5 months after initiating treatment. The 1- and 5-year cumulative incidence of aspiration pneumonia was 15.8% and 23.8% for head-and-neck cancer patients and 3.6% and 8.7% for non-cancer controls, respectively. Among cancer patients multivariate analysis identified independent risk factors (p<0.05) for aspiration pneumonia including hypopharyngeal and nasopharyngeal tumors, male gender, older age, increased comorbidity, no surgery prior to radiation, and care received at a teaching hospital. Among cancer patients who experienced aspiration pneumonia, 674 (84%) were hospitalized of which 301 (45%) were admitted to an intensive care unit. Thirty-day mortality after hospitalization for aspiration pneumonia was 32.5%. Aspiration pneumonia was associated with a 42% increased risk of death (HR=1.42, p<0.001) after controlling for confounders. Conclusions This study found that nearly one-quarter of elderly patients will develop aspiration pneumonia within 5 years of chemoradiotherapy for head-and-neck cancer. A better understanding of mitigating factors will help identify patients at risk for this potentially lethal complication.

Risk factors for aspiration pneumonia after definitive chemoradiotherapy or bio-radiotherapy for locally advanced head and neck cancer: a monocentric case control study

“…Second, differential diagnosis between aspiration pneumonia and other types of pneumonia was often difficult because the definitions of aspiration pneumonia varied among previous reports [9–11]. Third, the median follow-up of 2.4 years was shorter than in previous studies [4, 7]. The ability of our predictive model might change upon a long-term follow-up.…”

“…Several risk factors for aspiration pneumonia in patients with HNC after CRT were reported in previous studies [7, 9, 17]. However, evaluation of the long-term risk factors was often difficult in patients with HNC because these patients’ characteristics varied according to the multimodal therapies that they had received, including surgery, CRT, and RT.…”

“…reported that approximately 52% of patients who received RT and 69% who received CRT suffered from dysphasia after treatment, and aspiration pneumonia accounted for 19% of non-cancer-related deaths. Additionally, Xu et al [7]. suggested that aspiration pneumonia was a poor prognostic factor for patients with HNC who received CRT.…”

Long-Term, Prospective Performance of the MD Anderson Dysphagia Inventory in “Low-Intermediate Risk” Oropharyngeal Carcinoma After Intensity Modulated Radiation Therapy

“…Dysphagia in particular appears most highly correlated with long-term functional and quality of life outcomes [15–17]. A recent SEER analysis provided population-level evidence that an alarmingly large proportion of head and neck cancer patients develop aspiration pneumonia (i.e., 23.8% 5-year aspiration pneumonia risk after chemoradiation) resulting in substantial morbidity and excess mortality [18]. Due in part to these toxicity and quality of life concerns, it is clear that prospective collection of both functional and patient-reported outcomes (PROs) is imperative if valid comparisons are to be made between treatment algorithms and patients are to be counseled appropriately on their therapeutic options [19–22].…”

Beyond mean pharyngeal constrictor dose for beam path toxicity in non-target swallowing muscles: Dose–volume correlates of chronic radiation-associated dysphagia (RAD) after oropharyngeal intensity modulated radiotherapy

“…Patients with severe RAD may require lifelong tube feeding[5], or suffer potentially life-threatening aspiration[3, 4]. Population level data suggest 3-fold elevated risk of aspiration pneumonia in head and neck cancer (HNC) patients treated with chemoradiotherapy (CRT) relative to non-cancer controls, and 42% excess mortality among cancer survivors who develop pneumonia[6]. Pooled analysis of Radiation Therapy Oncology Group (RTOG) trials of CRT for HNC reported unacceptably high rates of severe late toxicity (i.e., 43% of patients with adequate baseline function had grade 3–4 late laryngopharyngeal toxicity) suggesting that further dose intensification cannot be safely achieved without new technique(s) to protect against late effects[7].…”