While primary surgical resection remains the mainstay of
cancer management in patients with oral squamous cell cancers (OSCCs),
recurrence rates are high in the setting of adverse pathologic features.
Adjuvant postoperative radiotherapy (PORT) is therefore critical to improving
oncologic outcomes. Nevertheless, many patients may refuse PORT, not be offered
PORT, or receive suboptimal dosing. The
study carried out by Musaddiq Awan and team aimed to identify factors
associated with PORT omission in patients with advanced stage OSCCs and
evaluate its effect on survival.
The 2015 participant user file from the National Cancer
Database (NCDB) was analyzed. Patients with standard keratinizing OSCC who
underwent up-front definitive surgery were included. To obtain a homogenous
cohort with unambiguous pathological indications for PORT, patients with
pathological stage III or IV OSCC were included. Patients with pathological
T1-2N1 disease were excluded.
A total of 89,402 patients diagnosed with OSCC were
identified, of whom 7084 patients met inclusion criteria. All patients had
American Joint Committee on Cancer (AJCC) pathological stage III (n = 820, 12%)
or stage IV (n = 6264, 88%) disease.
A total of 2140 patients (30%) did not undergo any PORT.
Reasons for omission included: 1614 (76%) for whom PORT was listed as not part
of the first course of treatment, 346 (16%) who refused recommended PORT, 103
(5%) for whom PORT was contraindicated owing to patient risk factors, and 68
(3%) for whom radiation was recommended and not given without documented
For analysis, 56 Gy or lower was considered incomplete total
PORT dosing. Receipt of PORT higher than 56 Gy as compared with no PORT was
significantly associated with improved overall survival in every age category
when adjusting for relevant covariates. Despite this, PORT omission increased
for each decade from 60 to 90 years. Age younger than 65 years and distance less
than 25 miles from the treatment facility were the most significant
sociodemographic factors associated with receipt of PORT.
Nearly one-third of patients included in this study, and
more than 40% of patients older than 70 years, did not receive PORT despite
clear National Comprehensive Cancer Network recommendations. Importantly, this
omission was associated with decreased survival in every age category. While
the addition of PORT adds treatment-related morbidity and requires an
individualized informed risk and benefit assessment, there appears to be
substantial, and possibly preventable, mortality related to PORT omission.
While PORT omission was associated with decreased survival,
it is important to recognize that its usage may be a surrogate for differences
in access to care. Omission of PORT in the present study was associated with
older age and distance from the treatment facility. Omission may therefore be
related to the extended duration of current PORT regimens (6-7 weeks) combined
with long travel distances and physical challenges related to advancing age.
These factors could serve as targets for further investigation with potential
interventions focusing on education, accessibility, and care coordination.
This study suggested that PORT is inappropriately omitted in
a large portion of patients with advanced-stage OSCC, and this omission is associated
with reduced patient survival and requires further investigation.