age as a prognostic factor for head and neck squamous cell carcinoma: should older patients be...

Age as a prognostic factor for head and neck squamous cell carcinoma:

should older patients be treated differently?

Udi Cinamon 1, Michael P. Hier 2, Martin J. Black 2

1 - Department of Otolaryngology, Head & Neck Surgery, Wolfson Medical Center, Holon, Israel2 - Department of Otolaryngology, Head & Neck Surgery, Jewish General Hospital, McGill University, Montreal

Special thanks to CISEPO (Canada International Scientific Exchange Program)

Old age: Jim Barry

Children should not be treated as small adults

!!!

Should elderly patients be treated differently?

Introduction: Improved medical care New surgical techniques, i.e., reconstructive

surgery Progress in the field of anesthesia

Enable a more aggressive treatment to patients

with HNSCC.

HOWEVERHOWEVER

Feasibility = appropriateness?Feasibility = appropriateness?

Epidemiology:

Age

Age

Incidence

Mortality

7575

In Israel / Canada the average age: 75-♂ / 82-♀

Living in an aging society:

We may expect to treat more seniors with HNSCCWe may expect to treat more seniors with HNSCC

Objective:Objective:

To explore the issue of proper treatment

in an aging society. To address the question:

feasibility = appropriateness?feasibility = appropriateness?

Methods:

A retrospective study of the treatment outcome

for patients that were primarily treated on our

service 1990-1999.

Patients ≥ 75 years with HNSCC

of the oral cavity, pharynx and larynx.

Results:

40 Pts

75-99 years (average, 82.2)

26♂ and 14♀

Distribution of patients according to stage and

primary site of tumor.

Larynx Oropharynx Hypopharynx

Oral cavity

Unknown Primary

Total Ave. Age

(years) Stage

I 6 - 9 - 15 79.6

Stage II

- - 3 - 3 82.3

Stage III

2 2 1 - 5 81.5

Stage IV

1 8 7 1 17 81.9

Total 9 10 20 1 40 82.2 Ave. Age

(years)

81.6 82.9 80 79 82.2 _

Co-morbidityCo-morbidityPre – treatment medical evaluation according to the ASA Classification of Physical Status system.

ASA classification Number of patients (%) I: normal healthy patient 0 (0%) II: mild systemic disease 27 (68.5%) III: severe systemic disease that limits activity but is not incapacitating

10 (25%)

IV: severe systemic disease that is a constant threat to life

3 (7.5%)

V: moribund patient who is not expected to survive 24h with or without operation

0 (0%)

ASA (American Society of Anesthesiologsts)

Treatment modalities and staging.

Stage Number of patients treatment I 6 Radiotherapy I 9 Surgery II 2 Surgery II 1 Surgery +

Radiotherapy III 1 Surgery +

Radiotherapy III 3 Surgery III 1 Radiotherapy IV 5 Surgery +

Radiotherapy IV 4 Radiotherapy IV 4 Surgery IV 4 Palliative

Radiotherapy

Major complications for 36 Pts treated for cure

Post operative mortality - 2 Cessation of radiotherapy - 1 Free flap complication - 1 Hospital stay > 6 weeks - 3

Treatment outcome and survival data:

4 Pts - Stage IV received palliative radiotherapy.

Dead of disease after 4 months (2-6 mon.).

2 Pts that were treated with a curative intention:

Postoperative mortality

34 Pts that were treated with a curative intention: 11 - Recurrence 2 - Metastasis

Survival of the 34 Pts. was 4.7 years (3 mon.–11y) .

Treatment outcome and survival data: • Stage I: 15 Pts: Average follow up - 6 years. • 3 Pts had a recurrence and treated. None died from cancer related causes.

• Stage II: 3 Pts: one died after 2 years with no evidence of disease. Second patient recurred after one year, treated, and is alive 4 years after with

NED. The third recurred locally after 9 months, for which he was treated surgically. He had a fatal myocardial infarction a week after his operation.

• Stage III: 5 Pts: One had a jejunum free flap and died of post-operative complications.

• Two are alive with NED after 6 years, another died after 4 years with NED, the fourth had a recurrence after 5 years and died soon after from an un-related cause.

• Stage IV: 13 Pts: five were dead of disease within 3-15 months, two with distant metastasis. One patient recurred had a fatal MI a week after been treated surgically.

One died 9 months after treatment having an acute MI. Two died with NED after 4 and 6 years. One patient was free of disease for 10 years and died from lung cancer. Three patients are living with NED after 5, 6, and 7 years, the latter had a recurrence after one year that was treated surgically.

Discussion:

An intention to cure HNSCC necessitates a vigorous treatment which by itself may jeopardize the patient.

Investigation of the association between age and treatment-outcome reveals conflicting opinions.

Main outcome of studies:

Koch et al.(1995), McGuirt & Davis (1995):

Older Pts have more complications.

Clayman et al. (1998):

same complication rate and

almost the same recurrence & mets rate.

Main outcome of studies:

Shaari et al. (1998,1999), Blackwell et al.(2002), studies of surgical+free flap outcome:

Seniors have more medical complications and almost the same flap/surgical complication rate.

 Sarini et al. (2001); 273 Pts≥75y.

Decision making according to age:

older→less aggressive treat; more XRT/ less surgery

Almost the same results as younger Pts.

Main outcome of studies:

Hirano & Mori (1998):

The treatment outcome of 37 patients that were eligible for curative treatment but preferred palliative treatment was significantly worse compared to those treated for cure.

Summary:Summary:

Decision making:

Age was not an exclusion factor from receiving curative treatment.

Pts. medically eligible → for curative treatment.

The survival of Pts. treated for cure was 4.7 years, while the life

expectancy of the general population (of 82 y old) is about the

same (6.3 y).

Conclusion:

Seniors having HNSCC do benefit from curative treatment.

Therefore, exclusion from receiving such treatment should be

based, as for younger subjects, on a careful individual basis.

Thank You