Primary surgery is linked with survival benefit in patients with advanced throat cancer

Researchers will tell the Congress that a nationwide study in Taiwan found that, five years after diagnosis, radical surgery was associated with significant overall survival benefits among patients whose cancers of the throat had started to spread. However, fewer than half of the patients in the study received surgery.

Dr Chih-Tao Cheng, MD, a medical researcher at the Koo Foundation Sun Yat-Sen Cancer Center in Taipei City, Taiwan, will say: "The emphasis on organ preservation has led to declining use of surgery. Concurrent chemoradiotherapy (CCRT) has become the standard approach for head and neck cancers which cannot be operated on, and it is being used alone even where surgery is possible. With the improvement of surgical techniques, including minimally invasive procedures, there's a need to re-visit the various treatment options and look at the overall survival of different treatment groups," he will say.

The study included cancers of the oropharynx and hypopharynx. The oropharynx connects the back of the mouth to the top of the throat and includes the back of the tongue and tonsils. The hypopharynx is the lower throat, which connects the oropharynx to the start of the windpipe, or trachea and the oesophagus, which carries food from the mouth to the stomach.

Dr Cheng and his colleagues used the Taiwan National Health Insurance Claims Database and the Taiwan Cancer Registry Database to identify all newly-diagnosed oropharyngeal and hypopharyngeal cancer patients in Taiwan. They found 2,387 oropharyngeal and 2,315 hypopharyngeal cancer patients diagnosed between 2004 and 2009. They followed the patients until 2012.

The analysis they will present today is based on 1,698 patients with oropharyngeal and 1,619 with hypopharyngeal cancer. All had stage III or IVa disease. Stage III means cancers are either at least 4 cm across or, in hypopharyngeal cancer, have affected the movement of vocal cords. Stage IVa means the cancer has grown into other organs nearby.

This observational study found that radical surgery was performed on slightly more than one-third of oropharyngeal cancer patients: 35% of 424 stage III patients, and 38% of 1,274 stage IVa patients. Approximately half of the hypopharyngeal cancer patients had surgery: 55% of stage III patients and 49% of stage IVa patients.

The researchers then compared outcomes in those who had surgery and those who did not, regardless of whether they received CCRT. In both surgery and no-surgery groups, therefore, patients may or may not have received CCRT.

For both cancers, patients who had surgery were significantly more likely to be alive five years after diagnosis than those who did not. In stage III oropharyngeal cancer, rates of overall survival at five years were 59% for those who had surgery versus 48% for those who did not. In stage IVa oropharyngeal cancer, rates were 51% among those who had surgery versus 40% without.

Similarly, in stage III hypopharyngeal cancer, 54% of those who had surgery were alive at five years, compared to 33% of those who did not. In stage IVa hypopharyngeal cancer, those figures were 39% and 26%, respectively.

Dr Cheng will say that multidisciplinary treatment now includes surgery, chemotherapy, radiotherapy and targeted therapy. "Substantial improvements in the treatment of head and neck cancer have been made in the past two decades. However, overall survival rates for locoregionally advanced head and neck cancer remain unsatisfactory. We found that primary surgery was associated with better overall cancer survival in most subset analyses, which suggests that surgery may provide a survival benefit."

He will add: "Many patients do not agree to surgery because of a fear of functional impairment such as the impact on speech and swallowing. This study suggests that avoiding surgery may significantly reduce their chance of survival."

Head-to-head comparisons of primary surgery versus CCRT in these cancers have faced problems in recruiting patients, partly because of the low incidence of these diseases and the diversity of treatment standards. On this observational approach, Dr Cheng will say, "We should be aware of confounding factors involved in the link between surgery and improved survival. These factors include gender, age, cancer stage, association with human papillomavirus (HPV), and the site of the tumour."

He will stress that more research is needed. "Recommending primary surgery or CCRT for advanced oropharyngeal and hypopharyngeal cancer patients remains controversial. These preliminary results were in line with our expectations, but further well-designed studies are required to confirm our findings."

Professor Peter Naredi, the ECCO scientific co-chair of the Congress, who was not involved in the research, commented: "Dr Cheng and co-workers bring up several important questions in their study. The patients in this study have advanced cancer and the treatment is troublesome and the risk for functional impairment large. It clearly shows how important it is to bring these patients to a multidisciplinary treatment board to discuss the best treatment. The study indicates that surgery must be prioritised as a treatment option for these patients. I also hope that these results will make it easier to recruit patients into future randomised trials so we can learn what the best treatment option is."

ESMO spokesperson, Dr Lisa Licitra, Chief of the Head and Neck Cancer Medical Oncology Unit and head and neck research programme at the Istituto Nazionale Tumori in Milan, Italy, commented: "Surgical treatment of advanced head and neck is a well-recognised weapon that is very often followed by radiotherapy with or without chemotherapy, followed by the assessment of risk from pathology samples. In some selected cases (judged by tumour site, stage or age) surgery can be avoided and chemo- and radiotherapy represents the standard of care. Treatment decision-making requires very strong collaborative working in experienced multidisciplinary teams. Indeed, patient outcomes have been reported repeatedly to be better in centres treating a high number of these patients. These data further underline the need to perform prospective research to elucidate the role of surgery and radiotherapy within the curative treatment approaches."

NOTES

[1] The European Cancer Congress is the 18th congress of the European CanCer Organisation (ECCO) and the 40th congress of the European Society for Medical Oncology (ESMO).

[2] This study was funded by the health and welfare surcharge on tobacco products in Taiwan. A surcharge of approximately €0.5 is added to each packet of cigarettes with the aim of discouraging smoking. The money collected is used in cancer prevention and healthcare.