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Radiotherapy, surgery comparable options for oropharyngeal cancer
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Definitive radiotherapy and primary surgery demonstrated comparable survival outcomes, toxicity and treatment costs among patients with oropharyngeal squamous cell carcinoma, according to study results.
“One of the key questions in treating oropharyngeal cancer is how to maximize functional outcomes when preserving oncologic success, and it is in this domain that patient-specific factors play the critical role,” David S. Sher, MD, associate professor in the department of radiation oncology and division of outcomes and health services research at UT Southwestern Medical Center, told HemOnc Today. “From a surgical standpoint, what will be the functional deficit after resection? Will soft palate be excised, leading to voice and swallowing dysfunction? Is the tumor large enough that a close or positive margin will require higher-dose radiotherapy, despite surgery? And similarly, is the likelihood of extranodal extension in the neck so high that chemoradiotherapy will be required, even after surgery?”
Many patients have comorbidities, including pre-existing hearing deficits or kidney issues, that may increase the risks of concurrent radiotherapy and chemotherapy, according to Sher.
“In this population, the use of surgery to minimize the likelihood of concurrent treatment is often preferred,” he said. “In a healthy patient who is highly likely to have an excellent functional outcome after surgery and a low risk of adverse pathologic features, the ability to use postoperative radiotherapy alone may have meaningful short- and long-term benefits.”
Sher and colleagues investigated OS and toxic events among 884 patients (mean age, 61.5 years; 82.2% men; 95.3% white) diagnosed between 2007 and 2014, 608 of whom received definitive radiotherapy and 276 of whom underwent primary surgery.
Results showed a 3-year OS rate of 76% for radiotherapy and 81% for surgery (HR = 0.76; 95% CI, 0.54-1.01).
In multivariable regression, older age was associated with poorer survival (oldest vs. youngest quartile, HR = 1.81; 95% CI, 1.17-2.8).
Women also experienced significantly poorer OS (HR = 1.69; 95% CI, 1.19-2.39), whereas patients with higher socioeconomic status demonstrated a nonsignificant trend toward improved survival (highest vs. lowest income quartile, HR = 0.68; 95% CI, 0.42-1.11).
The researchers observed no association between treatment approach and survival.
However, gastrostomy dependence within the first year was more likely among patients in the radiotherapy group (64.3% vs. 46%, adjusted OR = 0.57; 95% CI, 0.42-0.77). When chemotherapy was included as an effect modifier, this trend failed to persist.
“It was very clear that patients treated with primary radiotherapy had a higher short-term use of gastrostomy tubes than patients treated with surgery, and we identified concurrent chemotherapy use as the main driver of enteral feeding,” Sher said. “One possible explanation for this result is simply that patients treated with chemoradiotherapy have these tubes routinely placed prophylactically, rather than when they are truly needed. So, the difference may not completely reflect increased swallowing dysfunction during and after definitive radiation. Nevertheless, the difference in gastrostomy use was clearly significant and clinically meaningful, and we hope this information can inform patient and physician decision-making.”
No association occurred between treatment type and either esophageal stricture or osteoradionecrosis risk, according to the findings.
Investigation of resource use showed mean costs of approximately $100,000 for commercial health plan payers and $5,000 for patients, with no differences between the two treatment strategies.
“I really do believe there are two separate take-home messages in this paper,” Sher said. “First, the comparability of long-term oncologic and functional outcomes really speaks to how patients have two equally viable options to cure their cancer. The vast majority of patients — 90% — are swallowing on their own by the end of the first year, and risks for bone or esophageal toxicity are very low, less than 10%, and similar between the treatments. Patients and physicians need to discuss the risks and benefits of both options, and our results strengthen the argument for multidisciplinary collaboration in arriving at the optimal patient-specific recommendation.”
The second main conclusion is that the costs of treatment are very high, according to Sher.
“Given that most of these patients aren’t working for the majority of the treatment and convalescence, this financial toxicity is impressive and needs to be addressed by providers and our health care system as a whole,” he said. – by Rob Volansky
For more information:
David J. Sher, MD, MPH, can be reached at Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5810 Forest Park Drive, Dallas, TX 75390; david.sher@utsouthwestern.edu.
Disclosures: The authors report no relevant financial disclosures.
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