Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Background: Prolonged delays in the initiation of treatment (TTI) for advanced head and neck cancer precipitate disease progression and upstaging. Delays not only necessitate more aggressive therapeutic interventions but also heighten patient anxiety, compounding the emotional and physical toll of treatment. Constrained by limited operating capacity, our institution turned to neoadjuvant capecitabine as a "window of opportunity" therapy while awaiting definitive surgery to reduce TTI and potentially improve survival. We sought to assess TTI and survival among patients with operable head and neck squamous cell carcinoma (HNSCC) treated with capecitabine in a window-of-opportunity setting.
Methods: This quality improvement initiative comprised a retrospective cohort of patients with operable stage III/IVa HNSCC at two academic hospitals in Montreal, Canada. Two surgical cohorts were established: one receiving capecitabine, while the other followed the standard of care. Data from various stages of the preoperative timeline were collected and analyzed to determine TTI and identify bottlenecks in the process. Additionally, the impact of capecitabine treatment and prolonged TTI on survival rates was documented and studied using Cox regression and Kaplan-Meier survival analysis.
Results: Between January 2015 and May 2024, 228 non-recurrent surgical cases that met the inclusion criteria were analyzed. Thirteen patients were treated with capecitabine, while 214 patients received standard care. Median TTI was 18 days in the capecitabine cohort, with TTI at 44 days in the standard-of-care cohort (p<0.001). The former cohort exhibited higher survival rates (92.3%) and disease-free survival (DFS) rates (84.6%) compared to the latter cohort, which had survival and DFS rates of 67.1% and 57.3%, respectively (p=0.068, p=0.086). Interestingly, prolonged TTI was associated with improved survival (HR 0.989, 95% CI 0.981–0.999, p=0.0283). However, in multivariate analyses accounting for pathological staging, this association did not achieve statistical significance (HR 0.991, 95% CI 0.982–1.001, p=0.064).
Conclusions: Our findings demonstrate that capecitabine, when administered in a window-of-opportunity setting, not only accelerates TTI but also may improve overall survival and DFS compared to patients who undergo surgery without preoperative therapy. Although these differences did not reach statistical significance, they suggest a trend toward the potential of neoadjuvant treatment as a valuable strategy for expediting early therapeutic intervention and improving long-term prognosis. These results provide a compelling basis for further optimization of preoperative timelines in head and neck oncology, aiming to enhance patient outcomes while alleviating the burden on healthcare resources.