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Year : 2015  |  Volume : 52  |  Issue : 3  |  Page : 387--390

Head and neck cancer in geriatric patients: Analysis of the pattern of care given at a tertiary cancer care center

S Thiagarajan1, TPS Babu1, S Chakraborthy2, VM Patil3, A Bhattacharjee4, S Balasubramanian1,  
1 Department of Surgical Oncology, Malabar Cancer Centre, Thalassery, Kannur, Kerala, India
2 Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
3 Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
4 Department of Biostatistics, Malabar Cancer Centre, Thalassery, Kannur, Kerala, India

Correspondence Address:
S Thiagarajan
Department of Surgical Oncology, Malabar Cancer Centre, Thalassery, Kannur, Kerala
India

Abstract

Background And Aim: The percentage of elderly people with head and neck cancers (HNC) is on the rise. This makes HNC in this group of patients an important issue for healthcare providers. The present study was planned to analyze the patterns of care given to the geriatric patients and to identify the factors influencing the decision making process. Materials And Methods: Data of all the elderly patients (≥65 years) registered in the year 2012, with histologically proven HNC (all sites, stages, histopathological types, except lymphoma, sarcoma and cervical metastasis of unknown origin) receiving treatment (definitive/palliative) were collected. Results: A total of 270 patients were included in this study. The median age was 72 years (range: 65–101), with predominant male population (70%, n = 190). Oral cavity squamous cell carcinoma (SCC) was the most common cancer (57%, n = 154). Eastern Co-Operative Oncology Group performance status (PS) of 0–2 was seen in 91% of the patients. Co-morbidities were present in 139 (51.5%) patients. 50% (n = 134) of the patients received palliative intent treatment, 45% (n = 123) definitive treatment, whereas in 5% (n = 13) the intent was not mentioned. Age, a clinical stage and PS significantly influenced the decision making on the intent of treatment. 208 (77%) patients completed their treatment irrespective of the intent. Age was the only factor influencing treatment completion irrespective of the intent. Conclusion: Geriatric HNC patients frequently present with advanced disease, having multiple co-morbidities. Hence, a multidisciplinary team management of these patients is essential, also taking into account of the social and financial support available to these patients.



How to cite this article:
Thiagarajan S, Babu T, Chakraborthy S, Patil V M, Bhattacharjee A, Balasubramanian S. Head and neck cancer in geriatric patients: Analysis of the pattern of care given at a tertiary cancer care center.Indian J Cancer 2015;52:387-390


How to cite this URL:
Thiagarajan S, Babu T, Chakraborthy S, Patil V M, Bhattacharjee A, Balasubramanian S. Head and neck cancer in geriatric patients: Analysis of the pattern of care given at a tertiary cancer care center. Indian J Cancer [serial online] 2015 [cited 2019 Oct 22 ];52:387-390
Available from: http://www.indianjcancer.com/text.asp?2015/52/3/387/176734


Full Text

 Introduction



Geriatric patients account for an increasing proportion of head and neck cancer (HNC) burden.[1] About 24% of the head and neck squamous cell carcinoma (HNSCC) are seen in patients older than 70 years.[2] Given the lack of representation of this population in randomized controlled trials, as well as concerns regarding the tolerance to potentially morbid multimodality treatment, many patients end up receiving palliative treatment.[3] Although developing nations account for >60% of the global head neck cancer burden,[4] there is limited data available on the treatment of elderly patients in such setting. Like most developing nations, India stands poised at the edge of a demographic transition.[5] As a result, it is expected that by 2025, the annual age specific incidence in the elderly (≥65 years) would increase by almost 30,000 when compared to the levels in 2012.[4] The present study was therefore planned to analyze the patterns of care given to the geriatric patients and to identify the factors influencing the decision making process.

 Materials and Methods



An institutional review board approval was obtained prior to the start of this retrospective audit. The aim of this study was to analyze the types of HNC in elderly patients (≥65 years), patterns of care given and to assess the factors influencing the treatment intent (definitive vs. palliative). All patients ≥65 years with histologically proven HNC (all sites, stages, histopathological types) receiving treatment (definitive/palliative) at our institute in the year 2012 were included in the study. Keeping the objectives of the study in mind, we included all HNC including, epithelial malignancies arising from the paranasal sinuses, nasal cavity, oral cavity, pharynx and larynx along with tumors of the skin and its appendages, thyroid and parotid. Patients with lymphoma, head and neck sarcoma and cervical nodal metastasis with unknown primary were excluded from this study. The data regarding the number of registered patients with HNC were retrieved from the cancer registry. The demographic and clinical data were obtained from the case records, kept in the Medical Records Department.

Statistical analysis was performed using the software SPSS 20.0 (IBM, Armonk, NY). The variables for univariate analysis were selected based on their clinical relevance and was done using Chi-square test. All significant (P < 0.05) variables were subsequently tested (multivariate) with Binomial logistic regression analysis using forward step-wise selection.

 Results



Of 678 patients registered in the year 2012 with HNC at our institute, 270 (42%) were eligible for the study. The demographic details and clinical features are summarized in [Table 1]. Treatment intent was radical in 123 (45%) of the patients and palliative in 134 (50%). In 13 (5%) patients intent was not recorded. Treatment details are given in [Table 1]. Though most of our elderly patients were treatment naïve at presentation (n = 216, 80%), 44 (16%) patients had received prior treatment or presented with recurrence after initial treatment and 10 patients had a second primary (4%). About 57% of the patients who were not treatment naïve received palliative intent treatment, in comparison to 28% who were treatment naïve (P = 0.02).{Table 1}

Age

The median age of the patients was 72 years (range: 65–101) and 68% (n = 184/270) of the patients were ≤75 years at presentation [Table 1]. Patients ≤75 years received definitive treatment predominantly (55%) (P < 0.001). 67% of the patients >75 years received palliative intent treatment in comparison to the patients ≤75 years (41%). Age was a significant factor influencing the treatment intent, especially in patients with Stage III and IV disease. Overall, age was found to influence the treatment decision significantly [Figure 1], [Table 2].{Figure 1}{Table 2}

Surgery was performed in 20% patients (n = 56/270), of which 44 (79%) patients were ≤75 years and 12 (21%) were >75 years. Among those patients who received radiotherapy with radical intent (definitive and adjuvant) [Table 1], 63 (89%) patients were ≤75 years (P < 0.001).

Among patients receiving palliative intent RT [Table 1], 54 (n = 55%) patients were ≤75 years, and 44 patients (45%) were >75 years. Concurrent/neoadjuvant chemotherapy (n = 14/1 respectively) was delivered in patients ≤75 years only. Palliative chemotherapy was given to 45 patients, of which 69% (n = 34) were ≤75, and 14 patients were >75 years, (P = 0.06).

Sex

Most of the elderly patients were men (70%, n = 190) and the sex of the patient had no bearing on the decision making of the intent of treatment.

Habits

Majority of our patients (n = 239, 88%) in this series had some habit, in the form of smoking, chewing or alcohol consumption, either alone or in combination. Most of them had more than one habits at presentation. Presence of habits did not influence the decision making for the treatment intent.

Co-morbidities

A total of 139 (52%) patients presented with at least one co-morbidities, of which 54 patients had more than one co-morbidities at presentation. The most commonly associated comorbidities were hypertension, diabetes mellitus and coronary heart disease. Presence of co-morbidity, even when it was more than one, did not influence the performance status (PS). The presence of comorbidities also did not influence the decision making (P = 0.62).

Site and histopathology type

Oral cavity (n = 154/270, 57%) was the most commonly affected site followed by larynx, oropharynx, hypopharynx and thyroid. Buccal mucosa (BM) - GBS complex was the most common subsite in the oral cavity to be involved (n = 93/154, 60%). Squamous cell carcinoma (SCC) (n = 245, 91%) was the most common histopathologic type. The other histopathological subtypes are shown in [Table 1]. Neither site nor the histopathological type had an influence on the decision making for the treatment intent.

Performance status

Performance status was one of the factors influencing the decision making of the treatment intent in multivariate analysis [Figure 1], [Table 2]. 91% (n = 247/270) of the patients had Eastern Co-Operative Oncology Group PS 0–2 at presentation. Among 134 patients who received palliative treatment, 54 (40%) had PS 1, 60 (45%) had PS 2 and 20 (15%) had a PS >2. 122 patients received radical treatment of which 101 (83%) had PS 1 and 20 (17%) had a PS 2, and 1 patient had, PS 3. PS was significantly influencing the treatment decision in all the age groups. Patients receiving palliative RT were predominant with PS >2 (P = 0.02). Chemotherapy was given in concurrent/adjuvant setting only in patients with PS ≤ 2 (P = 0.009).

Clinical stage

Majority of the patients (n = 208, 77%) presented with advanced disease (stage III/IV) [Table 1]. Overall, patients presenting with early stage disease received radical treatment often, whereas those with advanced disease received palliative intent treatment predominantly (P < 0.001) [Figure 1], [Table 2]. All stage I patients received radical intent treatment, including those patients with PS 3, that is, PS >2. 62% and 33% of stage II, III and IVA patients with PS ≤2 received radical and palliative intent treatment respectively, when PS >2 most of these patients (75%) received palliative intent treatment. All stage IVB and IVC patients received palliative intent treatment irrespective of PS.

Treatment completion

Irrespective of treatment intent, 208 (77%) of the patients completed the planned treatment. Of the 123 patients who received radical intent treatment, 97 (79%) completed their treatment. Among 134 patients who received palliative intent treatment, 83% (n = 110) could complete the treatment offered. Among patients receiving radical intent treatment, age alone was found to influence treatment completion (P = 0.05). None of the factors were influencing treatment completion among patients receiving palliative intent treatment. Overall, age was the only factor influencing treatment completion, irrespective of the intent (P = 0.02). 31% of patients >75 years did not complete the given treatment, irrespective of intent (definitive/palliative).

 Discussion



The definition of elderly is not clearly given in the literature. The National Institute on Aging and the National Institutes of Health have used the cut-off of ≥65 years for defining a patient as the elderly.[6] This elderly population can be divided further into three subgroups of, young old (65–75 years), older old (76–85) and oldest old (>85 years).[6] Age along with PS and clinical stage of the disease were found to be important in the decision making of the treatment intent in our study [Figure 1]. Age was also the only factor influencing treatment completion irrespective of the treatment intent.

Elderly population is a very heterogeneous group. Apart from the chronological age of the patients, their physiological age should also be considered. The physiological age should be defined individually for each patient based on their performance status, comorbidities and presence of age related changes. Age alone was found to be an important factor for treatment selection in several studies [7],[8] Derks, et al., showed that age itself independently influenced treatment choice. They divided patients into two groups of 45–60 and ≥70 years and found that 89% and 62% of the patients received definitive treatment respectively.[7] Italiano et al., in their study pointed out that age itself was a specific factor for patients not undergoing standard treatment.[8] However, several studies have showed that standard treatment with curative intent can be safely performed in elderly patients with a good PS and in those without severe comorbidities.[9],[10],[11],[12] Despite this, there is insufficient data from clinical trials, as of today, to guide the treatment decision-making process in elderly patients.[11],[12]

It's well documented that HNC is commonly seen among males. In general, the male to female ratio varies between 8:1 and 15:1.[10],[13] However, this ratio is altered among the elderly patients, with a relatively higher proportion of female patients.[14] This could be attributed to the longer life expectancy of women in comparison to men. Lusinchi, et al. reported a ratio of 5:4 in their study.[15] In our study, this ratio was 7:3. History of tobacco usage and alcohol consumption in patients with HNSCC has been reported in up to 70% of the patients,[16],[17] which is similar to the findings in the present series.

No significant differences have been reported in the literature regarding site wise distribution of HNC among elderly patients in comparison to younger patients.[18] There was no major difference in the present series too, in comparison to the younger age group patients presenting with HNC, based on our hospital based cancer registry data. Nearly two-third of HNC presented with locally advanced disease.[19] Majority of the patients in our study also presented with advanced disease, which is consistent with the existing data from India.[20]

The presence of comorbidities among geriatric HNC patients is higher (30–89%) than in comparison with the younger patients.[21] The treatment is modified in accordance with the associated comorbid condition; in order to reduce the treatment related toxicity or complication. Studies have shown that the presence of co-morbid conditions has had an impact on the clinical decision making and the treatment offered.[22],[23] In the present study, co-morbidities were evenly distributed in all age groups and its presence did not significantly alter the decision making.

The present series is one of the first of its kind, reporting the patterns of care in geriatric patients with HNC from a developing nation. The limitations are its retrospective and mono-institutional design. Routine comprehensive geriatric assessments (CGA) were not performed for these patients, which reduce the reproducibility of the decision making process. However, results of this audit provide further impetus to our efforts in ensuring the use of routine CGA in our geriatric HNC patients, especially as 45% of our patients receive radical intent treatment.

 Conclusions



A significant proportion of HNC patients belong to the geriatric age group. 42% of our patients were ≥65 years at presentation. Oral cavity (especially BM-GBS complex) SCC was the predominant cancer in these patients too. 45% of these patients received definitive intent treatment. Age, PS and clinical stage of the disease, together, significantly influenced the decision making of the treatment intent in these elderly patients. It is important to consider the elderly patients, like others, for treatment without being biased by their age alone after taking into consideration of all other essential factors, namely the functional status, co-morbid conditions, nutritional status, cognitive function, socio-economic issues along with patients and their relatives wishes. They should ideally be evaluated in a multidisciplinary setting before initiating any treatment. A prospective trial in this direction is essential at this juncture to formulate guidelines for treating the geriatric HNC patients.

 Acknowledgments



The authors would like to acknowledge the Cancer Registry and the Medical Records Department, Malabar Cancer Centre, for their help in retrieving the case numbers and files for the study.

References

1Balducci L. Management of cancer in elderly. Oncology (Williston Park) 2006;20:135-43.
2Muir CS, Fraumeni JF Jr, Doll R. The interpretation of time trends. Cancer Surv 1994;19-20:5-21.
3Bernardi D, Errante D, Barzan L, et al. Head and neck cancer in elderly patients. Cancer Ther 2005;3:85-4.
4Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, et al.GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 11. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://www.globocan.iarc.fr. [Last accessed on 2014 Dec 04].
5Srinath Reddy K, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. Lancet 2005;366:1744-9.
6Parker SL, Tong T, Bolden S, Wingo PA. Cancer statistics, 1997. CA Cancer J Clin 1997;47:5-27.
7Derks W, de Leeuw JR, Hordijk GJ, Winnubst JA. Reasons for non-standard treatment in elderly patients with advanced head and neck cancer. Eur Arch Otorhinolaryngol 2005;262:21-6.
8Italiano A, Ortholan C, Dassonville O, Poissonnet G, Thariat J, Benezery K, et al. Head and neck squamous cell carcinoma in patients aged≥80 years: Patterns of care and survival. Cancer 2008;113:3160-8.
9Huang SH, O'Sullivan B, Waldron J, Lockwood G, Bayley A, Kim J, et al. Patterns of care in elderly head-and-neck cancer radiation oncology patients: A single-center cohort study. Int J Radiat Oncol Biol Phys 2011;79:46-51.
10Pignon T, Horiot JC, Van den Bogaert W, Van Glabbeke M, Scalliet P. No age limit for radical radiotherapy in head and neck tumours. Eur J Cancer 1996;32A: 2075-81.
11Peters TT, van der Laan BF, Plaat BE, Wedman J, Langendijk JA, Halmos GB. The impact of comorbidity on treatment-related side effects in older patients with laryngeal cancer. Oral Oncol 2011;47:56-61.
12Milet PR, Mallet Y, El Bedoui S, Penel N, Servent V, Lefebvre JL. Head and neck cancer surgery in the elderly – Does age influence the postoperative course? Oral Oncol 2010;46:92-5.
13León X, Quer M, Agudelo D, López-Pousa A, De Juan M, Diez S, et al. Influence of age on laryngeal carcinoma. Ann Otol Rhinol Laryngol 1998;107:164-9.
14Sarini J, Fournier C, Lefebvre JL, Bonafos G, Van JT, Coche-Dequéant B. Head and neck squamous cell carcinoma in elderly patients: A long-term retrospective review of 273 cases. Arch Otolaryngol Head Neck Surg 2001;127:1089-92.
15Lusinchi A, Bourhis J, Wibault P, Le Ridant AM, Eschwege F. Radiation therapy for head and neck cancers in the elderly. Int J Radiat Oncol Biol Phys 1990;18:819-23.
16Thiagarajan S, Nair S, Nair D, Chaturvedi P, Kane SV, Agarwal JP, et al. Predictors of prognosis for squamous cell carcinoma of oral tongue. J Surg Oncol 2014;109:639-44.
17Carvalho AL, Singh B, Spiro RH, Kowalski LP, Shah JP. Cancer of the oral cavity: A comparison between institutions in a developing and a developed nation. Head Neck 2004;26:31-8.
18Piccirillo JF. Importance of comorbidity in head and neck cancer. Laryngoscope 2000;110:593-602.
19Ries LA, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, et al. SEER Cancer Statistics Review, 1975-2000. Bethesda, MD: National Cancer Institute; 2003. Available from: http://www.seer.cancer.gov/csr/1975_2000 (Accessed in Dec 2014).
20Agarwal SP, Rao YN, Gupta S. Fifty years of cancer control in India. 1st ed: National Cancer Control Program (NCCP); 2002. p. 41-7.
21Townsley CA, Selby R, Siu LL. Systematic review of barriers to the recruitment of older patients with cancer onto clinical trials. J Clin Oncol 2005;23:3112-24.
22Guralnik JM. Assessing the impact of comorbidity in the older population. Ann Epidemiol 1996;6:376-80.
23Fried LP, Bandeen-Roche K, Kasper JD, Guralnik JM. Association of comorbidity with disability in older women: The Women's Health and Aging Study. J Clin Epidemiol 1999;52:27-37.