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Head and Neck Squamous Cell Carcinoma in Elderly Patients
A Long-term Retrospective Review of 273 Cases
Jerome Sarini, MD;
Charles Fournier;
Jean-Louis Lefebvre, MD;
Guillaume Bonafos, MD;
Jean Ton Van, MD;
Bernard Coche-Dequéant, MD
Arch Otolaryngol Head Neck Surg. 2001;127:1089-1092.
ABSTRACT
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Background The prolongation of life expectancy results in an increasing number
of malignant neoplasms occurring in the elderly population. For a long time
these patients were not considered good candidates to receive aggressive therapy
and probably were inadequately treated in many instances.
Objective To assess the outcome of patients older than 74 years who had had head
and neck squamous cell carcinoma.
Materials and Methods In our database of 4610 consecutive patients with head and neck squamous
cell carcinomas who were evaluated and treated at the Centre Oscar Lambret,
Northern France Comprehensive Cancer Center, Lille, over a 10-year period
(1974-1983), we identified 273 patients who were 75 years or older. The outcome
was updated for all patients included in the database.
Results A significantly higher proportion of females were noted in the older
patient group (43/273, 15.8%) than in younger patient group (192/4337, 4.4%, P<.001). There were no differences for primary site
except for hypopharyngeal squamous cell carcinoma that occurred less frequently
in the elderly patients (8.8% vs 14.5%, borderline significance P = .02). There were no differences for TNM stage grouping, histological
classification, incidences of previous cancer, and comorbidities. Surgery
was performed in a smaller proportion of older patients (13.9% vs 27.4%, P<.001, for the primary site and 15.4% vs 35.6%, P<.001, for those occurring in the neck) as well as
chemotherapy that was delivered in 5.5% vs 17.7% (P<.001).
On the contrary, there was no difference in radiotherapeutic treatments. Tolerance
to treatment was similar and there was the same proportion of persistent diseases
2 months after completion of the overall treatment (27.8% vs 25.4%, P = .94). Pooling local, regional, and distant failures
and metachronous cancers, there was a borderline lower incidence in older
patients (57.1% vs 64.2%, P = .02), which is explained
by an obvious shorter life expectancy. If survival is not meaningful in such
a comparison (5-year survival 23.8% vs 36.4%), then the causes of deaths may
be compared. Among the 4067 patients who were dead at the last update, index
tumor evolution-related deaths numbered 130 (48.1% of dead patients in this
cohort) in older patients compared with 2045 (53.9% of dead patients in this
cohort), which was not significantly different. There was no difference in
treatment-related deaths (11.1% vs 9.3%). Fewer intercurrent disease-related
deaths occurred in the older patients (19.7% vs 11.8%).
Conclusions Head and neck squamous cell carcinoma in elderly patients did not seem
to have a significantly different outcome when compared with head and neck
squamous cell carcinoma occurring in younger patients. When properly monitored,
conventional therapies seem feasible in older patients.
INTRODUCTION
IN DEVELOPED countries, the prolongation of life expectancy results
in an increasing number of patients older than 75 years who have cancer.1-2 Most head and neck squamous cell carcinomas
(HNSCCs) commonly arise between the fifth to seventh decades of life, but
their occurrence in the elderly population is not rare. Because morbidity
rates often increase with age, therapeutic selection is more difficult. For
a long time surgical procedures were available for cancer treatment but anaesthetic
risks and functional consequences were unacceptable. Currently, progress in
anesthetic risks and reanimation and improvements in surgical reconstruction
allow an increased choice of surgery during decision making especially in
the older population.
There are few publications in the literature concerning HNSCC outcome
in the older population. This part of the population is never included in
randomized trials. Thus, to our knowledge, the outcome of HNSCC in older persons
has never been evaluated using scientific methods.
All studies in the elderly population were retrospective. We found in
each study some interesting results that were globally found in our study.
PATIENTS, MATERIALS, AND METHODS
From 1974 to 1983, 4610 new patients with HNSCC were evaluated, treated,
and followed up at the Centre Oscar Lambret, Northern France Comprehensive
Cancer Center, Lille, for tumors of the oral cavity, oropharynx, hypopharynx,
or larynx. At admission the patients' ages ranged between 18 and 98 years.
Ninety percent of the patients were aged from 41 to 74 years. As a result,
we selected 40 years and 75 years as the cutoff points to define the patient
age groups on a chronological basis rather than an epidemiological basis.
Two hundred seventy-three patients fulfilled the criteria to be considered
in the so-called older patients group, presenting with a squamous cell carcinoma
of the oral cavity, oropharynx, hypopharynx, or larynx. The rest of the database
was the control group. We compared demographics, treatments, and outcomes
(ie, disease control, causes of death, and survival).
Tumors were classified according to the American Joint Committee on
Cancer/Union Internationale Contre le Cancer 1997 recommendations. Clinical
staging was assessed at the time of decision making by the multidisciplinary
team. Those patients who had had undergone an excisional biopsy for pathologic
diagnosis and had no visible disease at admission were classified as TX. Immediate
response to initial treatment was assessed 2 months after completion of the
overall planned treatment.
All patients were followed up until death or at least 5 years after
treatment. In the absence of information on the precise cause of death, all
patients with confirmed or suspected disease evolution at the last examination
were considered dead of cancer. In the absence of any information on the cause
of death, patients were considered dead of unknown causes only if they had
been examined and considered free of disease at Centre Oscar Lambret within
a period of 3 months before their deaths. All patients dead of intercurrent
disease were not considered dead of cancer if they had no suggestion of cancer
evolution at the last examination and if the nature of the intercurrent disease
had been well documented.
The database was divided into 2 (273 patients aged  75 years; and
4337 other patients aged  74 years) or 3 groups (194 young patients aged 40
years; 4143 middle-aged patients aged >40 years but <75 years; and 273
older patients aged 75 years).
Percentages were compared using the  2 test with optional
Yates correction. Survival rates were assessed using the nonparametric Kaplan-Meier
method. The log rank test was used for survival comparisons.
RESULTS
DEMOGRAPHICS
Comparisons were made on 2 patient groups. The sex ratio differs significantly
between the older and the other patients (female-male ratio, 6:1 vs 1:25, P<.001). Primary site distribution seemed to be similar
in both patient groups, even if there was a trend toward fewer patients with
cancer of the hypopharynx and more patients with cancer of the oral cavity
in the older patient group (Table 1).
Cancer stage grouping was equally distributed between the older patients and
the other patients regardless of age—31.1 % vs 29.8 % for those with
stages I and II, 37.9 % vs 37 % for those with stage III, and 31 % vs 33.2
% for those with stage IV, respectively. More precisely the following breakdown
was noted for the TNM stages in older patients and other patients: T3, 48.5%
vs 51.1%; T4, 11% vs 7.2%; N0, 59.7% vs 52.1%; and M+, 0.7% vs 2.8%, respectively
(P = .09).
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Table 1. Primary Site Distribution
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Despite a longer duration of life before diagnosis, there was no significant
difference in previous cancers (10.3% vs 9.1%). There were fewer simultaneous
cancers in older patients than in the other patients (7.3% vs 11.3%) with
borderline significance (P = .06). Finally, there
was no difference for comorbid conditions between the 2 groups.
TREATMENT
Decision making varied according to the patient's age. Surgery was less
often used for older patients than for the other patients: 13.9% vs 27.4%
(P<.001) for the primary site and 15.4% vs 35.6%
(P<.001) for cancers of the neck. Irradiation
was equally used in both groups but the combination of surgery and irradiation
or chemoradiotherapy was less frequently used in older patients than in the
other patients: 22.3% vs 9.7% and 14.1% vs 0.2%, respectively. Chemotherapy
was less frequently used for older patients than for the other patients: 5.5%
vs 17.6% (P<.001), and chemotherapy was mainly
used for palliative treatment in the older patients.
OUTCOME
There was no significant difference for immediate response to treatment:
complete response rates 2 months after completion of the overall planned treatment
numbered 76.6 % in young patients vs 71.7 % in middle-aged patients vs 72.2
% in older patients. Treatment-related deaths progressively increased according
to the patient's age, 4.6% vs 9.5% vs 11.1%, respectively (P = .04). As expected because of a shorter life expectancy after treatment,
metachronous cancers appeared less frequently in older patients than in younger
and middle-aged patients—8% vs 17.5% and 17.6%, respectively.
Causes of death are given in Table
2. At last information, 270 older patients (98.9%) had died while
173 younger patients (89%) and 3624 middle-aged patients (87.5%) had died.
As far as index tumor progression-related deaths were concerned, there was
no statistical difference between the 2 first groups with deaths in approximately
55% (57.9 % in the younger patients and 53.7% in the middle-aged patients)
but a notable difference with older patients for whom the evolution of the
index tumor was the cause of only 48.1% of the deaths. This may be explained
by a bias caused by the observed increase in deaths of intercurrent disease
or an unknown cause (most probably death caused by the effects of aging) in
the older population (19.7 % and 14.1% of deaths, respectively) when compared
with the younger groups (11.7% and 11.1 % of deaths, respectively). If the
comparison was made only between patients younger than 75 years and those
older than 75 years, the ultimate control disease was statistically better
in the older group (31.8% vs 22.8%, P = .02).
If as foreseeable, the median survival was shorter in older patients
(14 months), there was no major difference between younger patients and middle-aged
patients (21 vs 19 months) (Table 3).
When considering overall survival, older patients had a significantly worse
5-year survival than either younger or middle-aged patients (16.5% vs 30.1%
vs 25.1%, respectively, P<.001).
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Table 3. Overall and Median Survival
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COMMENT
The incidence of cancer of the head and neck in older patients is difficult
to establish since few reports have been published. The definition itself
of the so-called older patient population is somewhat controversial. We have
selected 75 years as the cutoff point because 90% of the patients with HNSCC
were aged between 41 and 74 years. This age seems to be considered by many
authors2-4 as appropriate,
even if some of authors selected a younger age limit5
and others an older one.6-8
In addition, some articles focused on only 1 therapeutic method, that is,
either radiotherapy7-9
or surgery.3, 5-6
The evolution of the occurrence of cancer of the head and neck in older patients
is also difficult to predict.
Some articles reported an increased rate of the older population in
general1 or specifically in the population
with HNSCC.2 In the Northern France Head and
Neck Cancer Registry, there was a trend for stability in older patients with
HNSCC from 6.2% in 1987 to 7% in 1997.
In our experience, we have found some differences between the populations
of patients younger than or older than 75 years at the time of diagnosis.
In our experience, the sex ratio, rarely mentioned in reports, showed a higher
proportion of females in the group of older patients compared with the younger
patients (female-male ratio, 1:6 vs 1:23, P<.001).
This sex ratio change in the older population is explained by a longer
life expectancy for females. Rew10 considers
cancer in old patients as a degenerative disease. This theory too could explain
the higher rate of females in older patients. Currently, HNSCCs are alcohol-
and tobacco-related cancers. But older patients with HNSCC seemed less likely
to be smokers.11 In older patients, we observed
less simultaneous cancers when compared with younger patients (7.3% and 11.3%,
respectively, with a borderline significance P =
.06). Other characteristics were similar (tumor extension, comorbidities,
or previous cancer), but there were fewer cases of cancer of the hypopharynx
and more cases of cancer of the oral cavity in older patients than in younger
patients (8.8% vs 14.5% and 39.9% vs 33.8%, respectively) that were particularly
frequent in females (and rarely associated to tobacco and alcohol abuse).
For a long time it has been anticipated that poor tolerance to treatment
in older patients led to undertreatment.2 This
is obvious in our report; although there were not more comorbidities, these
patients underwent fewer combined treatments. Surprisingly, they did not do
worse after these suboptimal treatments. There is a consensus to consider
as often as possible these older patients as candidates for conventional protocols
even if there are conflicting data in the literature on the incidence of treatment-related
deaths.3, 6 In addition, in reported
series there are confusing data about the real cause of posttreatments deaths
(either directly linked to the treatment or caused by a preexisting intercurrent
disease).5 Age by itself is an unreliable parameter
for decision making. Obviously, the psychological profile is important.12 Linn et al13 reported
that the nutritional profile was a definitive and relevant indicator for older
patient selection.
For many authors,7-9,11
radiotherapy is usually available in the elderly population for HNSCC treatment.
Older patients were able to tolerate radical courses of radiotherapy as well
as younger patients11 except for severe functional
acute toxic reaction.9 It explains the large
number of older patients treated with radiotherapy in our experience (227/273).
A subset of them (21/227) had had radiotherapy carried out with palliative
intent (exclusive treatment with a total dose delivered of <4500 rad).
Finally, survival is not easy to assess in a population that has, by
definition, a rather short life expectancy whether or not they present with
a malignant neoplasm. Even cause-specific survival does not seem relevant.6
CONCLUSION
Each time the patient's psychological and biological profile allows
it, HNSCCs occurring in the elderly population should be treated with conventional
protocols.
AUTHOR INFORMATION
Accepted for publication March 27, 2001.
Corresponding author and reprints: Jerome Sarini, MD, Centre Oscar
Lambret, Lille, 3, rue Combemale, 59000 Lille, France.
From the Head and Neck Department (Drs Sarini, Lefebvre, Bonafos, Van,
and Coche-Dequéant), Biostatistics Unit (Mr Fournier), and Radiotherapy
Department (Dr Coche-Dequéant), Centre Oscar Lambret, Northern France
Comprehensive Cancer Center, Lille.
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