Adjuvant radiation therapy delays linked to shorter survival for adults with oral cancer
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Key takeaways:
- Failure to start adjuvant therapy within 6 weeks of surgery appeared linked to worse survival.
- Eighty percent of patients waited more than 42 days after surgery to start adjuvant radiation.
Delayed initiation of postoperative radiation therapy appeared associated with poorer outcomes among patients with oral cavity cancer, according to results of a cohort study.
Patients who had to wait more than 6 weeks after surgery to begin radiation exhibited significantly higher risk for disease progression and death at 3 years, findings published in JAMA Otolaryngology – Head & Neck Surgery showed.
Background
National Comprehensive Cancer Network guidelines recommend that patients who undergo resection for head and neck cancer begin adjuvant radiation therapy within 42 days of surgery, according to study background.
Treatment of head and neck cancer also typically requires a high level of multidisciplinary care coordination, Gabriel S. Dayan, MD, of the division of otolaryngology — head and neck surgery at Centre Hospitalier de l’Université de Montréal, and colleagues wrote.
“Despite this, population database studies in the U.S. have shown that most patients with [head and neck cancer] do not complete treatment without delays,” Dayan and colleagues wrote. “However, to our knowledge, there has yet to be a study investigating treatment times and adherence to NCCN guidelines for [head and neck cancer] in Canada, nor the outcomes of treatment delays within the Canadian public health care system.”
Methodology
Dayan and colleagues conducted a retrospective multicenter cohort analysis to determine the frequency of adjuvant radiation therapy treatment delays and its impact on OS among individuals who underwent oral cavity cancer surgery.
The study included 1,368 adults (median age, 61 years; range, 54-70; 65% men) who underwent primary curative-intent surgical resection followed by adjuvant radiation therapy, with or without systemic adjuvant chemotherapy or immunotherapy, at eight academic medical centers in Canada between 2015 and 2019.
Researchers evaluated two treatment intervals — time from surgery to initiation of postoperative radiation therapy interval (S-PORT) and radiation therapy interval (RTI).
Investigators defined prolonged wait times as more than 42 days for S-PORT and more than 46 days for RTI based on recommendations from NCCN guidelines.
OS served as the study’s primary outcome measurement. DFS served as the key secondary outcome.
Key findings
Researchers calculated a median S-PORT interval of 56 days (interquartile range, 46-68) for the entire study cohort.
Eighty percent of the cohort waited more than 42 days from the time of surgery until the start of adjuvant radiation therapy.
Further analysis revealed a median RTI of 43 days (interquartile range, 41-47) for the study cohort, with more than one-quarter (26%) of patients experiencing an RTI of more than 46 days.
Investigators reported wide variation in median S-PORT intervals among the institutions included in the analysis (range, 48 days to 64 days). They reported less interinstitutional variation in median RTI (range, 40 days to 44 days).
After median follow-up of 34 months, approximately two-thirds (68%) of patients achieved 3-year OS.
Patients with longer S-PORT interval appeared less likely to survive 3 years than those who received adjuvant radiation therapy within the NCCN-recommended timeframe (66% vs. 77%; OR = 1.75; 95% CI, 1.27-2.42).
Researchers reported a 3-year DFS rate of 59% for the study cohort. Again, those with longer S-PORT intervals appeared less likely than those who started adjuvant radiation within 42 days of surgery to remain disease free at 3 years (57% vs. 67%; OR = 1.65; 95% CI, 1.23-2.2).
Multivariate analysis showed prolonged S-PORT to be independently associated with OS (HR = 1.39; 95% CI, 1.07-1.8) and DFS (HR = 1.29; 95% CI, 1.04-1.61).
The analysis revealed no association between prolonged RTI and OS or DFS.
Clinical implications
The results support previous research that demonstrated an association between time to initiation of adjuvant radiation therapy and treatment outcomes among individuals with head and neck cancer.
The findings suggest the relationship persists in a universal health care system like the one in Canada, according to Dayan and colleagues.
“Failure to initiate adjuvant radiation therapy within 6 weeks, as recommended by the NCCN, was independently associated with worse OS and DFS,” Dayan and colleagues wrote.
“Most patients in Canada and the U.S. do not fall within this less-than-6-week category. Unlike patient and tumor-intrinsic factors associated with mortality in [head and neck cancer], treatment delays represent a modifiable risk factor and should be prioritized by the multidisciplinary teams.”
The analysis by Dayan and colleagues fills in methodologic gaps of prior research with its large sample size and multicenter design, Evan M. Graboyes, MD, MPH, of Medical University of South Carolina, and Sue S. Yom, MD, PhD, MAS, of University of California, San Francisco, wrote in an accompanying editorial.
“It is clear that deep multidisciplinary engagement, meaningful partnerships around quality goals, and (inter)national communication and sharing of data such as that provided by Dayan [and colleagues] will be required for progress,” Graboyes and Yom wrote. “To meaningfully improve time to [postoperative radiation therapy], the field of head and neck surgery must improve its surgical technologies and reconstructive paradigms to enhance postoperative healing, minimize postsurgical complications, and ensure the readiness of postsurgical patients for the timely initiation of adjuvant therapy.”
References:
- Dayan GS, et al. JAMA Otolaryngol Head Neck Surg. 2023;doi:10.1001/jamaoto.2023.1936.
- Graboyes EM, et al. JAMA Otolaryngol Head Neck Surg. 2023;doi:10.1001/jamaoto.2023.1942.
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Dayan GS, et al. JAMA Otolaryngol Head Neck Surg. 2023;doi:10.1001/jamaoto.2023.1936.
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