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