Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Background: The global population is aging, thus, it is anticipated that there will be an increase in elderly patients with head and neck cancers. It is now recognised that that patient age alone does not accurately stratify patients nor their expected outcomes. Therefore it is necessary to devise better ways to sub stratify the elderly head and neck cancer population.
Frailty as a concept defines patients with decreased physiologic reserves outside the normal process of aging who are less able to tolerate stressors such as a head and neck cancer or its associated treatment. Previous work in a non head and neck cancer setting has demonstrated that frail patients are less likely to receive timely, guideline directed care when compared to their not-frail counterparts. This adversely impacts their outcomes.
This study sought to analyse the incidence of frailty among patients presenting with a new mucosal head and neck squamous cell carcinoma (SCC). Secondary aims were to establish if patient presentation, treatment pathway, treatment decisions and survival outcomes were different among frail and not-frail patients.
Methods: Analysis of a prospectively managed dataset of consecutive patients presenting with a new mucosal head and neck SCC at a single institution over a 1-year period. Study findings are reported according to the STROBE checklist. Frailty was assessed retrospectively using the 5-item Modified Frailty Index (5mFI) and not known at the time of patient diagnosis or treatment planning.
Results: Two-hundred and thirty-two patients were included with a mean age of 64.2 years (±12.4 years). Sixty-one patients (26.3%) were classed as frail using the 5mFI. Frail patients were older (70.6 ± 9.9 years vs. 61.9 ± 12.5 years; p<0.001) and more likely to present with T3/4 disease (40/61, 65.7% vs. 84/171, 49.1%; p=0.027). Frail patients were more likely to receive palliative intent treatment (10/61, 16.4% vs. 8/171, 4.7%; p=0.003). Among those treated with curative intent (n=214), time to treatment was not different among frail and not-frail patients. Frail patients were more likely to receive radiation monotherapy (10/51, 17.7% vs. 9/163, 7.7%) and not-frail patients were more likely to have surgical management with or without adjuvant therapy (101/163, 62.0% vs. 27/51, 52.9%) (p=0.022). Completion of intended treatment did not vary by frail status. The 3-year OS (49.7% vs. 76.7%; p<0.001) and 3-year DFS (38.9% vs. 71.1%; p<0.001) was reduced among frail patients. Multivariable cox-regression demonstrated frail patients had independently reduced 3-year OS (HR 2.74, 95% CI 1.63 – 4.59; p<0.001) and 3-year DFS (HR 2.66, 95% CI 1.68 – 4.21; p<0.001).
Conclusion: Frail patients presented with more locally advanced primary tumours which may potentially indicate barriers to accessing timely care in this population. Multidisciplinary treatment decisions were different among the frail cohort of patients. The effect of these changes in patient care on survival outcomes is unclear although frailty was associated with a significant reduction in OS and DFS. Future work will need to assess the rationale for different multidisciplinary care decisions among the approximately one-quarter of head and neck cancer patients who are frail.