Head and neck cancers: Potential to improve outcomes

Medicare recipients with head and neck cancers commonly do not complete radiation therapy without interruptions, or at all. In the September issue of Archives of Otolaryngology–Head & Neck Surgery, a JAMA/Archives journal, a study led by Hutchinson Center scientists addresses why.

Drs. Megan Fesinmeyer and Scott Ramsey, of the Public Health Sciences Division, and colleagues found patients with this complex group of tumors—that involve the sinuses, lips, mouth, pharynx and larynx—who have surgery before radiation treatment appear more likely to complete therapy. Those who have other illnesses or who have chemotherapy first may be more likely to experience interruptions or discontinuation in radiation treatment.

“Radiotherapy [radiation therapy] alone or as an adjuvant to surgery and/or chemotherapy has been shown to be curative in patients with local or regional head and neck cancers,” the authors said. “Clinical evidence suggests that the radiation dose and duration of treatment is correlated with tumor control and survival. Breaks in radiotherapy have been associated with inferior tumor control in the larynx, pharynx and oral cavity.”

In their study, Fesinmeyer, Ramsey and colleagues from the Hutchinson Center, Swedish Medical Center and University of Washington School of Pharmacy used cancer registries linked to Medicare data to identify 5,086 patients diagnosed with head and neck cancer between 1997 and 2003. After calculating the timing and duration of radiotherapy, they performed analyses to estimate the association between tumor and clinical characteristics and any interruptions or discontinuation of therapy. A substantial percentage of the patients (39.8 percent) had interruptions in radiation therapy or failed to complete the course of therapy.

“We were surprised to find that incomplete radiotherapy was so common in Medicare patients with head and neck cancer," said Fesinmeyer, lead author. “This suggests that there is a lot of potential to increase adherence to radiotherapy regimens and to improve patient outcomes.”

The study reports that patients who had surgery at any tumor site were more likely to complete radiotherapy with no interruptions (70.4 percent vs. 52 percent of those who did not have surgery). However, patients with co-occurring illnesses, those who underwent chemotherapy, and those whose disease had spread to surrounding lymph nodes, were less likely to do so.
 
The authors listed several reasons surgical patients may be more likely to complete radiotherapy:

• Characteristics that make patients good candidates for surgery may also make them more likely to complete radiotherapy.
• Comorbidities decrease survival in patients with head and neck cancer, so surgeons may choose healthier patients to complete more rigorous treatments, such as surgery in addition to radiotherapy.
• Patients who are willing to undergo major surgery to treat their disease may also be more motivated to complete a full course of uninterrupted radiation therapy, despite any toxic effects of treatment that may occur.

The authors conclude that understanding the factors associated with interruptions or failure to complete radiation therapy among patients who do not have surgery will require further research.

[Adapted from a JAMA/Archives news release.]