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Clinician experience linked to survival after radiation therapy for head and neck cancers
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Patients with head and neck cancers who underwent radiation therapy at historically high-accruing centers demonstrated better survival outcomes than those treated at historically low-accruing centers, according to study results.
Because radiation therapy is complex, treatment planning varies considerably between institutions. National Comprehensive Cancer Network guidelines recommend patients with head and neck cancers undergo treatment at centers with high levels of expertise, yet the affect provider experience has on survival has not been established, according to study background.
Evan J. Wuthrick
Evan J. Wuthrick, MD, assistant professor in the department of radiation oncology at The Ohio State University Medical Center, and colleagues studied the effect of institutional experience on OS in patients with stage III or stage IV head and neck cancers. All patients were enrolled in a Radiation Therapy Oncology Group-led randomized trial that compared cisplatin with standard vs. accelerated fractionated radiotherapy.
As a surrogate for experience, investigators classified institutions as historically low or high accruing centers based on the accrual of 21 affiliated trials conducted between 1997 and 2002.
The analysis included 471 patients. Of these patients, 321 were treated at one of 88 historically low-accruing centers, and 150 patients were treated at one of 13 historically high-accruing centers.
Results showed patients treated at high-accruing centers demonstrated a lower rate of 5-year locoregional failure (20.8% vs. 36.4%) and a higher rate of 5-year OS (69.1% vs. 51%).
After adjusting for several prognostic factors — including age, smoking and HPV status — patients treated at historically low-accruing centers demonstrated a 91% increased risk for death.
“This information challenges us as cancer care providers to figure out what are the key components to this difference,” Wuthrick told HemOnc Today. “Is it specialized nursing? Experience of the physics staff? Physician decision-making? Presence of a tumor board? Dietetics and other ancillary services?
“It also challenges us as radiation oncologists to provide continuing medical education to smaller centers focused on target delineation and treatment planning in head and neck cancer, provide online contouring atlases and develop robust auto-contouring software to minimize this outcomes gap while challenging larger institutions to make their specialized services available to more patients through housing and other programs.”
The study results demonstrated that deviations from protocol therapy were more common at the low-accruing centers, which independently increased the risk for death. However, the findings did not explain the survival benefit from the treatment provided at the high-accruing centers.
Instead, the results indicated that experienced providers — such as those who would practice in the high-accruing centers — are more likely to execute a superior treatment plan and, therefore, provide better support for patients throughout their treatment.
Researchers found that unacceptable radiotherapy protocol noncompliance was 11% in the low-accruing centers vs. 5% in the high-accruing centers (P=.04).
All patients treated in this study received 3-D conformal radiotherapy. However, modern radiation technology has improved. Intensity-modulated radiation therapy — now used regularly — requires a higher level of expertise, meaning the study may have underestimated the effect of experience on outcomes, according to the researchers.
It is understandable that some patients may choose to undergo treatment at a local center rather than seeking care at a center farther away that is larger and has more experience caring for patients with head and neck cancers, June Corry, MD, chair of head and neck services at Peter MacCallum Cancer Centre in Melbourne, Australia, and colleagues wrote in an accompanying editorial.
“There may be financial, physical, social and emotional impediments that need to be addressed. There may also be an unwillingness on the part of many small centers to acknowledge the limitations of the services that they can reasonably provide,” Corry and colleagues wrote. “Notwithstanding these considerations, we believe that the evidence is now compelling to recommend that curative treatment of patients with complex head and neck cancers be consolidated at high-volume centers to achieve optimal outcomes. A practical approach to achieve this that also recognizes the benefit to patients of treatment close to home would be to link small centers to high-volume centers in a network arrangement.” – by Anthony SanFilippo
Evan J. Wuthrick, MD, can be reached at 300 W. 10th Ave., Suite 088A, Columbus, OH 43210; evan.wuthrick@osumc.edu.
Disclosure: The researchers report consultant/advisory roles with, research funding/honoraria from, and employment relationships with Amgen, Bayer, Bionomics, BioStat Solutions, Bristol-Myers Squibb, Eli Lilly, Genentech, GlaxoSmithKline, ImClone Systems, Merck Serono, Pfizer, Threshold Pharmaceutical and Varian.
Perspective
Back to TopBarbara A. Burtness, MD
Head and neck cancers that are locoregionally advanced are curable either through surgery with risk-based postoperative radiation therapy or with definitive chemoradiation. The emergence of treatment-responsive HPV-associated disease in patients with a lesser burden of comorbidity results in a cohort of patients with a quite high expectation of cure. Thus, it is of interest that previous trials have demonstrated that definitive surgery at low-volume centers, or radiation treatment planning deviations, are associated with increased risk for recurrence and death.The legacy RTOG investigators have added to the body of literature that supports referral of patients with locally advanced head and neck cancers to high-volume centers with a post-hoc analysis of patients treated on R0129, a randomized trial of chemoradiation with standard fractionation vs. chemoradiation with altered fractionation.
In this analysis, radiotherapy plans were reviewed for protocol compliance for total dose, elapsed days, spinal cord dose and field borders. Field borders were scored on primary tumor coverage, coverage of lymphatic space posterior to the spinal cord, and spinal cord and supraclavicular lymph node coverage. Investigators also examined outcome by protocol accrual from a given center.
Low-accruing centers apparently saw patients with better performance status and lower T stage. Nonetheless, survival was significantly worse at low-accruing centers. Low-accruing centers (< 12 accruals/year) had a higher rate of identified treatment planning deviations. Even after adjustment for this, the hazard for death was increased 72% with treatment at low-accruing centers, suggesting that supportive care and multidisciplinary management at more experienced centers is advantageous.
Treatment planning and supportive care for patients with locally advanced head and neck cancers are demanding, and they require experience and well-structured treatment teams. If the future holds the possibility of reduced dose or field radiation for selected favorable-prognosis patients with HPV-associated disease, the impact of treatment planning deviations likely will be heightened in those settings. Multidisciplinary care of locally advanced head and neck cancers appears to be one of the forms of cancer care best delivered at a high-volume center.
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