Patterns-of-Care Analysis for Radiotherapy of Elderly Head-and-Neck Cancer Patients: A Trinational Survey in Germany, Austria and Switzerland

Abstract

ObjectivesThe number of elderly head-and-neck squamous cell carcinoma (HNSCC) patients is increasing, and clinical trials defining the standard of care either excluded or underrepresented elderly patients. This leaves physicians with a challenging and highly individual treatment decision largely lacking clinical evidence.MethodsA tri-national patterns-of-care survey was sent to all members of the German (DEGRO), Austrian (ÖGRO), and Swiss (SRO/SSRO) national societies of radiation oncology. The online questionnaire consisted of 27 questions on the treatment of elderly HNSCC patients, including 6 case-based questions. Frequency distributions and subgroup comparisons were calculated using SPSS statistics software.ResultsA total of 132 answers were collected, including 46(35%) form universities, 52(39%) from non-university-hospitals and 34(26%) from private practices. 83(63%) treat 1-5 and 42(32%) >5 elderly HNSCC patients per month. Target volumes are defined analog current guidelines by 65(50%) of responders and altered based on age/comorbidities or tumor stage by 36(28%) and 28(22%), respectively. Chemotherapy is routinely administered by 108(84%) if indicated, with weekly 40mg/m2 of cisplatin being the favored regimen by 68(53%) in the definitive situation and 60(47%) in the adjuvant setting. Hypofractionation and hyperfractionation/acceleration are used by 26(20%) and 11(9%), respectively. Only 7(5%) clinicians routinely recommend inpatient treatment for elderly HNSCC patients. In a typical definitive patient case, 73(63%) responders recommended chemoradiation with bilateral elective node irradiation analog current guidelines. In an adjuvant example case recommendations regarding elective volume and chemotherapy were heterogeneous. Differences between responders’ institutions concern the frequency of PET-CT in staging, preventive port-catheter and PEG implantation, the choice of chemotherapy regimens and the use of alternative fractionations.ConclusionTreatment of elderly HNSCC-patients in the German-speaking countries mainly follows guidelines established for younger patients. Algorithms for patient stratification and treatment de-escalation for “unfit” elderly patients are needed.

Prognostic value of tumor-infiltrating immune cells and immune checkpoints in elderly head-and-neck squamous cell carcinoma patients undergoing definitive (chemo)radiotherapy

“…With about 450,000 deaths per year, head-and-neck squamous cell carcinoma (HNSCC) constitutes a relevant global health issue [1,2]. There is a continuous increase of elderly HNSCC patients for whom treatment concepts of younger patients cannot simply be extrapolated, as elderly patients exhibit significant clinical and tumor-related differences and have been underrepresented or excluded from most treatmentdefining clinical trials [3][4][5][6][7]. Radiotherapy, either alone or with concomitant chemotherapy, constitutes a key treatment for HNSCC [5,6,8,9].…”

Evaluation of Concomitant Systemic Treatment in Older Adults With Head and Neck Squamous Cell Carcinoma Undergoing Definitive Radiotherapy

“…The overall decreasing benefit of concomitant chemotherapy with higher patient age, as observed in the MACH-NC study, may be related to 2 factors: more (early) non–cancer-related deaths in older adults with HNSCCs that could mask improved locoregional control after chemoradiation, 28 and increased chemotherapy-related toxic effects potentially increasing the risk of premature radiotherapy termination in the short-term 29 , 30 and eventually even increasing the hazard of non–cancer-related deaths in the long-term. 31 , 32 A potential explanation for the discrepant results between the MACH-NC and our study could be related to differences in the patient population (eg, probably higher proportion of patients with HPV-positive oropharyngeal carcinoma with no or limited alcohol and tobacco consumption in our cohort), improved supportive measures over time, 33 more frequent use of chemotherapy regimens that are less toxic and easier to manage (eg, cisplatin weekly), 34 , 35 , 36 and more modern radiotherapy treatment. 37 …”

“…41 Multiple different chemotherapy regimens have been administered in the patient cohort analyzed in this study, reflecting the considerable heterogeneity between different treatment centers, especially given the lack of clear evidence or treatment recommendations in older adults with HNSCCs. 34,42 Although the MACH-NC study did not support superiority of multiagent chemotherapy, and both US and European guidelines recommend the use of cisplatin in case of absent contraindications, 43,44 there was a high proportion of older patients receiving multiagent chemotherapy in our cohort study. The higher prevalence of contraindications against cisplatin use in older patients (due to the higher prevalence of preexisting kidney disease or ototoxicity) may also have contributed to a higher use of multiagent protocols without cisplatin, such as mitomycin C plus fluorouracil, carboplatin plus paclitaxel, or carboplatin plus fluorouracil, all regimens with evidence from prospective trials in younger patients with HNSCC.…”

Wöchentliche versus dreiwöchentliche Cisplatingabe bei der postoperativen Radiochemotherapie von lokal fortgeschrittenen Kopf-Hals-Plattenepithelkarzinomen – Ergebnisse der JCOG1008-Studie

“…Gerade bei älteren Patienten mit Komorbiditäten müssen für das klassische Cisplatinschema 100 mg/m 2 an Tag 1, 22 und 43 kritisch mögliche minimale Vorteile hinsichtlich der lokoregionären Kontrolle mit dem höheren Risiko höhergradiger Toxizitäten (und dadurch gegebenenfalls auch häufigeren therapiebedingten Todesfällen) abgewogen werden [ 15 ]. Das wöchentliche Schema mit 40 mg/m 2 stellt speziell für diese Patientenpopulation in der postoperativen Situation wegen der geringeren Akuttoxizität ein attraktives Behandlungskonzept dar.…”