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Surgical salvage improves OS in recurrent metastatic OPSCC
Surgical salvage was associated with prolonged OS in patients with recurrent locoregional or distant metastatic oropharyngeal squamous cell carcinoma regardless of HPV tumor status or site of disease recurrence, according to a retrospective study.
Despite improved survival outcomes with chemoradiation, locoregional and distant metastatic recurrence occurs in approximately 24% to 27% of patients with HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) within 3 years, according to study background.
Carole Fakhry
Carole Fakhry, MD, MPH, assistant professor of otolaryngology-head and neck surgery and assistant professor of oncology at Johns Hopkins University, and colleagues sought to evaluate the efficacy of surgical and nonsurgical salvage therapies as well as their prognostic roles with regard to HPV tumor status.
OS after diagnosis of the first disease recurrence served as the study’s primary endpoint.
Median follow-up time after the recurrence was 15.8 months (range, 0.2-105.8 months).
The researchers identified 108 patients who were treated at either Johns Hopkins Hospital or the Greater Baltimore Medical Center between 2000 and 2012. Sixty-five patients had locoregional metastatic recurrence and 43 had distant metastatic recurrence. A majority of patients had HPV-positive tumors (74.1%).
Site distribution of disease recurrence did not differ based on HPV tumor status, however HPV-positive tumor status was associated with a longer time to disease recurrence (P < .01).
OS after disease recurrence was independently associated with surgical salvage (adjusted HR = 0.26; 95% CI, 0.12-0.61), HPV-positive tumor status (adjusted HR = 0.23; 95% CI, 0.09-0.58) and longer time to disease recurrence (≥1 year; adjusted HR = 0.36; 95% CI, 0.18-0.74).
Surgical salvage was associated with improved OS compared with nonsurgical treatment options among patients with both locoregional (adjusted HR = 0.15; 95% CI, 0.04-0.56) and distant (adjusted HR = 0.19; 95% CI, 0.05-0.75) metastatic disease recurrence. Surgical salvage was associated with improved OS in patients with HPV-negative (P = .003) and HPV-positive disease (P = .03).
“We found even at the time of recurrence, HPV-positive patients and HPV-negative patients retained the demographic differences noted at the time of primary disease,” Fakhry told HemOnc Today. “This is important, because HPV-positive patients who recur do not appear to be the ones that most closely resemble HPV-negative patients in their characteristics at presentation. Whereas the radiation therapy oncology group (RTOG) recently reported that both HPV-positive and HPV-negative patients presented within the first year, in this study we found that while both presented within the first 2 years, there was a statistical difference in the time HPV-positive and HPV-negative patients presented with recurrence.
“This is likely due to differences in imaging protocols in clinical trials (RTOG) vs. in clinical care (this study). Of note, time to recurrence was a significant prognostic factor, even after accounting for all significant clinical variables including HPV status. With regard to prognosis, HPV tumor status remained a strong prognostic factor despite recurrence.”
Fakhry added that surgical salvage significantly improved survival for HPV-positive and HPV-negative oropharyngeal cancer patients and that it was associated with improved survival even for distant metastatic disease.
Overall, patients who underwent surgical salvage demonstrated a 3-year OS rate of 61.8%, whereas 24.1% of patients who underwent nonsurgical treatment achieved 3-year OS (P < .001). Median OS was approximately 8.45 years for patients who underwent salvage surgery vs. 1.22 years for those who received nonsurgical treatment.
Although there was an insignificant survival improvement associated with surgical salvage compared with nonsurgical treatment among patients who experienced locoregional recurrence, patients with distant metastatic disease recurrence achieved significantly improved survival with surgical salvage (P = .001). Median OS was approximately 2.97 years for patients with distant metastatic disease recurrence who underwent surgical salvage compared with approximately 1.04 years for patients who received nonsurgical treatment.
The researchers noted further prospective studies would potentially help support the retrospective study findings.
“There is little data on recurrent oropharyngeal cancer with HPV tumor status,” Fakhry said. “This is the second study with such data and differs from RTOG in that clinical data representative of routine clinical care is reported in this study. Additionally, surgical salvage for oropharyngeal cancer was perhaps not justifiable in recent times due to the poor survival estimates for recurrent oropharyngeal cancer.
“However, these data, especially for distant metastatic oropharyngeal cancer challenge these previous evidence-based practices. Further prospective evaluation of treatment modalities for recurrent oropharynx cancer are warranted.” – by Anthony SanFilippo
References:
Ang KK, et al. N Engl J Med. 2010;363:24-35.
Ang KK, et al. J Clin Oncol. 2014;32:2940-2950.
For more information:
Carole Fakhry, MD, MPH, can be reached at the Johns Hopkins Outpatient Center, 601 N. Caroline St., Baltimore, MD, 21287; email: cfakhry@jhmi.edu.
Disclosure: The researchers report no relevant financial disclosures.