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ORIGINAL ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 2  |  Page : 359-362

Clinical outcome and survival of head and neck cancer patients treated at Clinical Oncology Department, Menoufia University


Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission30-Jun-2013
Date of Acceptance27-Aug-2013
Date of Web Publication26-Sep-2014

Correspondence Address:
Amira H Hegazy
MBBCh, Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Menoufia University, Menufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.141709

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  Abstract 

Objective
The aim of the study was to evaluate the effect of clinicopathological characteristics of head and neck cancer (HNC) patients of Menoufia University on patient response to treatment and relapse status and to determine the overall survival rate and mean survival time.
Background
HNC arises from the mucosa of the upper aerodigestive tract. In Egypt, it constitutes about 17% of all malignant tumors. It affects both sexes and all races. Tobacco and alcohol continue to remain the two major risk factors of HNC.
Patients and methods
This study included 120 patients of HNC presented to Clinical Oncology Department, Menoufia University from January 2005 to December 2010; the data were collected from the files regarding patients and disease characteristics and treatment modalities, and then clinical outcome and survival data were reported.
Results
It was found that most of patients were men (70%), smokers (51.7%), and 60 years of age or less (61.7%). The majority of patients had hemoglobin level greater than 12 g/dl (70%) and pathological grade II (52.5%). The commonest site of malignancy among the group of patients was the larynx (31.7%). Stage III disease represented most of the patients (36.7%) in our study. The patients were treated either by radiotherapy, chemoradiotherapy, induction chemotherapy followed by chemoradiotherapy, or chemotherapy. It was found that complete response rate was 25.8% and partial response rate was 13.3%. There was statistically significant association between hemoglobin level, stage of disease, radiotherapy fractionation, and response to treatment (P = 0.04, <0.001, <0.001, respectively). There was also statistically significant difference between different age groups, stages, and response regarding overall survival rate (P = <0.001 for all factors).
Conclusion
Hemoglobin level, stage, and radiotherapy fractionation are strong factors affecting patient response.

Keywords: Clinical outcome and survival, head and neck cancer


How to cite this article:
El Din KK, El-Fetouh MA, Ahmed S, Hegazy AH. Clinical outcome and survival of head and neck cancer patients treated at Clinical Oncology Department, Menoufia University. Menoufia Med J 2014;27:359-62

How to cite this URL:
El Din KK, El-Fetouh MA, Ahmed S, Hegazy AH. Clinical outcome and survival of head and neck cancer patients treated at Clinical Oncology Department, Menoufia University. Menoufia Med J [serial online] 2014 [cited 2020 Jul 5];27:359-62. Available from: http://www.mmj.eg.net/text.asp?2014/27/2/359/141709


  Introduction Top


'Head and neck cancer' (HNC) is a collective term defined on anatomical-topographical basis to describe the malignant tumors of the upper aerodigestive tract. This anatomical region includes the oral cavity, pharynx, and larynx. A major subgroup of the HNCs is the one referred to as 'oral cancers' arising in the mucous membranes of the mouth - that is, lip, the base of tongue, tongue, gum, floor of mouth, and palate - and pharynx (comprising the oropharynx, hypopharynx, and nasopharynx) [1].

In Egypt, HNC represents about 17% of all malignant tumors [2].

Patients with squamous cell carcinoma of the head and neck (SCCHN) often present with advanced locoregional disease, defined as either stage III (T3N0M0 or T1-T3N1M0) or stage IV (T4N0-N1M0 or T1-T4N2-N3M0) [3].

Despite several decades of progress and significant improvements in treatment and supportive care, the prognosis has remained poor for this group of patients. Combined modality treatment with chemoradiotherapy (CRT) has become the standard of care for locally advanced disease. Three years after standard CRT, only ~45% of patients with SCCHN are alive and disease free. Between 30 and 40% patients develop locoregional recurrences, and 20-30% patients develop distant metastases. Failure to control advanced tumors (T3, T4, and/or N2-N3) occurs by two biologically distinct pathways: locoregional recurrence and metastatic spread. The optimal delivery of combined modality therapy has remained controversial with respect to both the schedule and content of therapy. Three major approaches have been investigated: primary induction chemotherapy before definitive surgery and/or radiotherapy (RT), concomitant treatment with chemotherapy and RT, and sequential therapy consisting of induction chemotherapy and CRT [4].


  Patients and methods Top


This study included 120 patients of HNC presented to Clinical Oncology Department, Menoufia University from January 2005 to December 2010; the data were collected from the files regarding patients characteristics (age, sex, special habits with emphasis on smoking and alcohol intake, hemoglobin level, and comorbidities), disease characteristics(tumor size, grade, nodal status, tumor site, extracapsular extension, margin status, and stage), treatment modalities offered to patients (surgery, concomitant CRT, sequential therapy or RT, treatment offered for metastatic disease, treatment-related acute and late toxicities, interval from diagnosis to start of treatment), and the occurrence of second malignancy.

The clinical outcome and survival were reported with comment on time to relapse, type of relapse, site of metastasis, and overall survival.

Response to treatment was assessed according to the revised RECIST guideline (version 1.1) as follows:

  1. Complete response (CR): Disappearance of all target lesions and any pathological lymph nodes (whether target or nontarget) must have reduction in short axis to less than 10 mm.
  2. Partial response: At least a 30% decrease in the sum of diameters of target lesions, taking as reference the baseline sum diameters.


Statistical analysis

Data analysis was performed using SPSS program for windows version 16 (SPSS Inc., ICN, Chicago, Illinois, USA). Tests used in analysis were Pearson c2 -test and Fisher's exact test. They were used to determine the significance of associations between categorical variables and response. Progression-free survival was analyzed using the Kaplan-Meier curves. It was calculated from the date of diagnosis to the date of progression or the date of death (all causes), whichever occur first; patients who were not progressed at final follow-up were censored. Differences between groups were assessed by means of the log-rank test. Two-sided P-value less than 0.05 was considered statistically significant.


  Results Top


This study included 120 patients; only 79 patients were available for assessment. It was found that most of the patients were men (70%), smokers (51.7%), and 60 years of age or less (61.7%). The majority of patients had hemoglobin level greater than 12 g/dl (70%) and pathological grade II (52.5%).

The commonest site of malignancy among the group of patients was the larynx (31.7%).

Stage III disease represented most of the patients (36.7%) in our study.

With respect to response, CR rate was 25.8% and partial response rate was 13.3%.

It was found that there was significant association between hemoglobin level, stage of disease, and response (P = 0.04 and P < 0.001, respectively) [Table 1].
Table 1: Effects of hemoglobin level and tumor stage on degree of response among head and neck cancer patients

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With respect to survival, the median survival time was 52 months [Figure 1], and there was statistically significant difference between the age group and survival time (P < 0.001) [Figure 2].
Figure 1:

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Figure 2:

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Response emerged as strong indicator of survival, as there was statistically significant association between response and survival time (P < 0.001) [Figure 3].
Figure 3:

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  Discussion Top


HNCs account for 3-5% of all cancer cases in the USA annually [5]. In Egypt, primary HNCs constitute about 17% of all malignant tumors [2].

In our clinical audit, 120 patients were included; 79 patients only were available for assessment.

There was interruption of treatment (gap). There was statistically nonsignificant correlation between gap during RT treatment and response. This is in contrast to the finding of Royal College of Radiologists, which confirms that SCCHN region is one of the tumor types of category 1, for which there is evidence that prolongation of overall treatment time affects treatment outcome or local tumor control (cure rate) [6].

It was found that hemoglobin level is a strong indicator of response, as there was statistically significant association between hemoglobin level and response; patients who had hemoglobin level greater than 12 g/dl showed better response than patients with hemoglobin level less than 12 g/dl (CR rate is 46.3 vs. 24%). This is supported by most studies that have reported low pretreatment hemoglobin levels to be a poor prognostic factor for tumor control and/or patient survival [7].

There was also statistically significant association between response and stage of disease [CR rate in patients with stage I and II (early stage) disease was 79.3%, whereas CR rate in patients with advanced disease (stage III and IV) was 16%]. This is supported by the data that confirm higher T stage to be correlated with poorer prognosis [8].

There was statistically significant association between response and RT fractionation; patients who received hypofractionated RT had the best response (CR rate is 100%). This is explained as all patients who received hypofractionated RT were early-stage laryngeal cancer (T1 and T2), and this is supported by results of prospective randomized study on radiation fraction size and overall treatment time for early glottis carcinoma, which revealed that use of hypofractionated RT 2.25 Gy/fx with shorter overall treatment time showed superior local control compared with conventional RT without worse toxicity [9], followed by hyperfractionated RT (CR rate is 33.3%). This may be explained as all patients who received hyperfractionated RT (1.1 Gy) were locally advanced HNC (stage III, IV) and most of them developed grade 3-4 toxicity and showed gap during the course of RT; in addition, these patients received gemcitabine (100 mg/m 2 ) weekly concomitant with RT with over-added toxicity. However, patients who received standard fractionation RT had shown the worst response (CR rate is 26.7%).

With respect to survival time, in our study the median survival time was 52 months.

There was statistically significant association between survival time and age group; the median survival time for patients of age group 1 (≤60 years) and 2 (>60 years) was 60 and 24 months, respectively. This is because of poor tolerance of old-aged patients to treatment and the associated comorbidities that increase the risk of death from other causes, and this is coincident with meta-analysis of chemotherapy in head and neck (MACH-NC) and meta-analysis of RT in carcinoma of head and neck (MARCH), which revealed that the treatment benefit of concomitant chemotherapy and altered fractionation RT decreases with increasing age. Patients aged 71 years or more did not benefit from altered fractionation RT or from concomitant chemotherapy [10].

There was statistically significant correlation between survival time and response.


  Conclusion Top


From this audit, we recommend administration of new RT techniques to decrease side effects, and hence avoid interruption during the RT course and increase efficacy to treatment, good supportive care and follow-up of patients with good diet to avoid nutritional deficiency and weight loss, and correction of anemia and maintenance of hemoglobin level greater than 12 g/dl during the course of RT to improve outcome and tumor control.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.Dobrossy L. Epidemiology of head and neck cancer: magnitude of the problem. Cancer Metastasis Rev 2005; 24 :9-17.  Back to cited text no. 1
    
2. El-Bolkainy N, Nouh A, El-Bolkainy T. Head and neck cancer in topographic pathology of cancer. 3rd ed. 2005.  Back to cited text no. 2
    
3. Greene FL, Page DL, Fleming ID, et al. AJCC cancer staging handbook. AJCC cancer staging manual. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002.  Back to cited text no. 3
    
4. Posner MR, Haddad RI, Wirth L, et al. Induction chemotherapy in locally advanced squamous cell cancer of the head and neck: evolution of the sequential treatment approach. Semin Oncol 2004; 31 :778-785.  Back to cited text no. 4
    
5. Jemal A, Siegel R, Ward E, et al. Cancer statistics. CA Cancer J Clin 2008; 58 :71-96.  Back to cited text no. 5
    
6. Hendry JH, Bentzen SM, Dale RG, et al. A modeled comparison of the effects of using different ways to compensate for missed treatment days in radiotherapy. Clin Oncol 1996; 8 :297-307.  Back to cited text no. 6
    
7. Chua DT, Sham JS, Choy DT, et al. Prognostic impact of hemoglobin levels on treatment outcome in patients with nasopharyngeal carcinoma treated with sequential chemoradiotherapy or radiotherapy alone. Cancer 2004; 101 :307-316.  Back to cited text no. 7
    
8. O′Brien CJ, Lauer CS, Fredricks S, et al. Tumor thickness influences prognosis of T1 and T2 oral cavity cancer-but what thickness? Head Neck 2003; 25 :937-945,  Back to cited text no. 8
    
9. Yamazaki H, Nishiyama K, Tanaka E, et al. Radiotherapy for early glottis carcinoma (T1N0M0): results of prospective randomized study of radiation fraction size and overall treatment time. Int J Radiat Oncol Biol Phys 2006; 64 :77-82.  Back to cited text no. 9
    
10.Bourhis J, Le Maitre A, Pignon J, et al. Impact of age on treatment effect in locally advanced head and neck (HNC): two individual patient data meta-analysis. Proc Am Soc Oncol 2006; 24 :280s.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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Abstract
Introduction
Patients and methods
Results
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Acknowledgements
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