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One in four patients with head, neck cancers do not receive guideline-directed adjuvant therapy
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About 25% of patients with surgically resected head and neck cancers that exhibit adverse pathologic features do not receive guideline-directed adjuvant therapy with chemoradiation or radiotherapy, according to study results.
Researchers reported lower rates of adjuvant therapy use at academic and high-volume centers, suggesting considerable heterogeneity in physician practices. Patient-level factors also are associated with variations in receipt of adjuvant therapy.
Guidelines issued by the National Comprehensive Cancer Network recommend adjuvant therapy in the form of chemoradiation or radiotherapy for patients with surgically resected head and neck cancers that demonstrate adverse pathologic features.
Michelle M. Chen
Michelle M. Chen, MD, an otolaryngology resident at Stanford School of Medicine, and colleagues reviewed the National Cancer Data Base to assess trends and patterns in adjuvant therapy use for 73,088 patients treated between 1998 and 2011.
Overall, 41.5% of patients received adjuvant radiotherapy, 33.5% received adjuvant chemoradiation and 25% received no adjuvant therapy.
Results showed use of adjuvant chemoradiation therapy for head and neck cancers increased considerably during the 13-year study period. Use of chemoradiation increased sixfold among patients with oral cavity cancer and fivefold among patients with laryngeal cancers.
Researchers determined receipt of any type of adjuvant therapy was independently associated with improved OS (HR=0.84; 95% CI, 0.81-0.86).
Multivariate analysis showed patients who lived ≥34 miles from the cancer center where they were treated (OR=1.66; 95% CI, 1.59-1.74), had Medicare/Medicaid insurance (OR=1.05; 95% CI, 1.01-1.11), or were treated at an academic center (OR=1.26; 95% CI, 1.2-1.31) or high-volume center (OR=1.1; 95% CI, 1.05-1.15) were less likely to receive adjuvant therapy.
“[The results suggest] insurance status and a greater distance from head and neck cancer care centers may serve as barriers to receiving guideline-based care,” Chen and colleagues wrote. “Academic and high-volume centers have lower rates of adjuvant therapy, demonstrating heterogeneity in physician practices. Further evaluation of the underlying etiologies of these differences in practice patterns is needed to standardize practice patterns and potentially improve the quality of care received by patients with head and neck cancer.”
Disclosure: The study was funded by the James G. Hirsch, MD, Endowed Medical Student Research Fellowship at Yale University School of Medicine. The researchers report no relevant financial disclosures.
Perspective
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Christina Rodriguez, MD
Chen and colleagues describe trends in the use of adjuvant therapy among patients with resected high-risk squamous cell carcinomas of the oral cavity, oropharynx, hypopharynx and larynx from 1998 to 2011. Two large prospective, randomized trials completed by the RTOG and EORTC and jointly published in 2004 demonstrated a benefit to cisplatin-based chemoradiation in the high-risk population, and they serve as the basis for National Comprehensive Cancer Network guideline recommendations (Cooper JS. N Engl J Med. 2004;350:1937-1944. Bernier J. N Engl J Med. 2004;350-1945-1952).
Perhaps the most disturbing finding in this registry study is the demonstration of disparity in the administration of appropriate therapy for marginalized patient populations. This observation is not new in head and neck cancers, wherein ethnic minorities and the socio-economically disadvantaged are overrepresented.
Chen and colleagues noted that type of insurance and residential proximity to health care centers influenced the administration of adjuvant therapy. In today’s era of health care system scrutiny, findings such as these will help to inform further studies and policy changes that would eliminate barriers to appropriate care, and improve healthcare outcomes in the underserved patient subset.
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