Management of Older Patients with Head and Neck Cancer - a Forest of Confusing Evidence

Whenever reading about the management of any oncology population of geriatric patients, two facts are usually pulled out early and in close proximity: 1) the world’s population as a whole is getting older and 2) definitive evidence of treatment efficacy in this population is limited, as older, more comorbid patients are usually excluded from clinical trials. Both of these facts are true, but knowing that helps little when confronted with an older patient with cancer. And when taking a deep dive into the limited evidence surrounding the subject, one can frequently become even more confused.

A recent review by Drs Ryo Ishii, Akira Ohkoshi and Yukio Katori from Tokyo University’s Department of Otolaryngology-Head and Neck Surgery eloquently summarises this problem with a specific focus on head and neck cancer. 

First of all, how do we define “elderly?” As with many definitions, individual guidelines vary. ASCO, the European Medicines Agency, and the Japan Clinical Oncology Group (JCOG) defined the term as someone >65 years old. Meanwhile, the EORTC Older Patient Task Force defined “elderly” as someone >70 years old. However, assessing suitability for therapy is much more complex than merely noting their age.

Several validated tools exist to aid practitioners in the assessment of elderly patients beyond the simplistic and inadequate European Cooperative Group (ECOG) or Karnofsky performance status scores. The Comprehensive Geriatric Assessment (CGA) is the gold standard, assessing patients across several domains, including medical, physical, psychological, socioeconomic, environmental and function. However, as its name suggests, the CGA is time-consuming and difficult to apply to every elderly patient. As a result, several screening tools have been developed, including the G8, Vulnerable Elders Survey-13 and the Flemish version of the Triage Risk Screening tool. All of these tools aim to provide simple and time-efficient tools to assess the risk of functional decline and — in the case of the G8 — determine whether a CGA is recommended.

Image courtesy of Auris Nasus Larynx

However, few studies of these screening tools have focussed on head and neck cancer (HNC). A pilot study by Neve et al. found that the G8 identified twice as many patients (17 vs 7) as vulnerable as the multidisciplinary meeting (MDM). Another prospective study published by the authors also demonstrated a significant difference in overall survival for eldery patients with HNC deemed abnormal by the G8 screening tool (below).

Image courtesy of Auris Nasus Larynx

So, we can see that the decision-making process for elderly patients with cancer is already fraught with difficulty. This difficulty is, in many ways, compounded for patients with head and neck cancer. Surgical, radiological or systemic treatment of HNC can be incredibly disfiguring and distressing, commonly resulting in impairment of swallowing and speech. Elderly patients are particularly prone to airway and oesophageal complications, and outcomes are poor; for example, reviews of short- and long-term outcomes found that elderly patients with oropharyngeal or laryngeal cancer were between 50% and 90% more likely to suffer airway obstruction within one year of treatment. The authors also reinforce that any treatment decision must take patient preference into account, as some patients will elect for palliative treatment — or even no treatment at all — to prioritise quality of life and minimise the risk of permanent disfigurement. 

So, how does this affect the management of elderly patients with HNC?

Again, the evidence is frequently baffling and contradictory. Combined chemoradiotherapy (CCRT) is commonly used as definitive or adjuvant treatment for those with early-stage disease. However, the benefit of either CRRT or radiotherapy alone in this population has long been an area of controversy. The majority of evidence in this space is retrospective, but two prospective studies by Stromberger et al. (2021) and de Vries et al. (2022) found that greater comorbidity, lower functional status and definitive CRT as treatment were all associated with both lower survival and lower quality of life. Due to the higher risk of swallowing difficulties and aspiration pneumonia in elderly patients, nutritional therapy, oropharyngeal rehabilitation and oral care are of particular importance in this population. 

On the other hand, for patients receiving adjuvant chemoradiotherapy, the SEER database by Woody et al. suggested that chemoradiotherapy for patients >70 with resected HNC conveyed a significant overall survival (OS) benefit (HR 0.74, p=0.04). This suggests that elderly patients should not automatically be disqualified from receiving more intensive anticancer therapy purely based on age, but patient selection needs to be carefully considered.

Historically, in the metastatic setting, clinicians had a lower threshold to transition to symptom-based supportive care in elderly patients due to the inherent toxicity — and low effectiveness — of chemotherapy. The emergence of immunotherapy regiments, including 5-flurouracil + pembrolizumab (KEYNOTE-048) and single agent nivolumab (CHECKMATE 141) have significantly changed this outlook, allowing more elderly patients to receive palliative therapy for HCN not amenable to definitive therapy. Similarly, hypofractionated or “quad shot” radiotherapy may be an option for those patients deemed too frail for definitive therapy.

Finally, elderly patients with HCN must be discussed in a multidisciplinary team (MDT) context. Now the standard of care for the management of cancer patients worldwide, most MDTs should include at minimum representatives from surgical, radiological, pathological, radiation and medical oncology teams. Larger MDTs for HCN could also include dental specialists, dieticians, social workers, speech pathologists, psychologists and specialised nurses. For elderly patients, it is important to involve a geriatrician as well, as they are frequently those with the most experience conducting CGAs.

The Bottom Line:

The treatment of elderly patients with HCN is extremely challenging, combining the issues of two already-complex cohorts of patients. Multidisciplinary management is a must in order to maximise outcomes and balance quality and quantity of life. The use of geriatric screening tools and early engagement of specialists in an MDT can help guide treatment decisions in the face of confusing, sometimes contradictory evidence.

Source:

Ishii, R., Ohkoshi, A., & Katori, Y. (2024). Treatment of elderly patients with head and neck cancer in an aging society: Focus on geriatric assessment and surgical treatment. Auris Nasus Larynx, 51(4), 647-658. https://doi.org/10.1016/j.anl.2024.04.005

Other sources in this article:

Neve, M., Jameson, M. B., Govender, S., & Hartopeanu, C. (2016). Impact of geriatric assessment on the management of older adults with head and neck cancer: A pilot study. Journal of Geriatric Oncology, 7(6), 457-462. https://doi.org/10.1016/j.jgo.2016.05.006

Motz, K., Herbert, R. J., Fakhry, C., Quon, H., Kang, H., Kiess, A. P., Eisele, D. W., Koch, W. M., Frick, K. D., & Gourin, C. G. (2018). Short- and long-term outcomes of oropharyngeal cancer care in the elderly. The Laryngoscope, 128(9), 2084-2093. https://doi.org/10.1002/lary.27153

Gourin, C. G., Starmer, H. M., Herbert, R. J., Frick, K. D., Forastiere, A. A., Eisele, D. W., & Quon, H. (2015). Short- and long-term outcomes of laryngeal cancer care in the elderly. The Laryngoscope, 125(4), 924-933. https://doi.org/10.1002/lary.25012

Stromberger C, Yedikat B, Coordes A, Tinhofer I, Kalinauskaite G, Budach V, Zschaeck S, Raguse J-D, Kofla G, Heiland M, Stsefanenka A, Beck-Broichsitter B, Dommerich S, Senger C and Beck M (2021) Prognostic Factors Predict Oncological Outcome in Older Patients With Head and Neck Cancer Undergoing Chemoradiation Treatment. Front. Oncol. 10:566318. doi: 10.3389/fonc.2020.566318

de Vries J, Bras L, Sidorenkov G, et al. Association of Deficits Identified by Geriatric Assessment With Deterioration of Health-Related Quality of Life in Patients Treated for Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg. 2021;147(12):1089–1099. doi:10.1001/jamaoto.2021.2837

Woody, N. M., Ward, M. C., Koyfman, S. A., Reddy, C. A., Geiger, J., Joshi, N., Burkey, B., Scharpf, J., Lamarre, E., Prendes, B., & Adelstein, D. J. (2017). Adjuvant Chemoradiation After Surgical Resection in Elderly Patients With High-Risk Squamous Cell Carcinoma of the Head and Neck: A National Cancer Database Analysis. International Journal of Radiation Oncology*Biology*Physics, 98(4), 784-792. https://doi.org/10.1016/j.ijrobp.2017.03.019