Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Background: Immunotherapy is emerging as a primary curative treatment option for head and neck squamous cell carcinoma (HNSCC). However, data regarding delayed treatment-related complications from immune checkpoint inhibition (ICI) specific to HNSCC is limited, and the incidence of metrics such as gastrostomy tube (GT) dependency, emergency department (ED) visits, and hospital admissions remain poorly defined.
Objective: This retrospective matched cohort study compares treatment-related complications in patients who underwent immunotherapy with radiation (IRT) versus concurrent chemoradiation (CRT) with cisplatin for primary treatment of locally advanced, non-metastatic HNSCC.
Methods: Patients treated with IRT within the context of various clinical trials at our institution (2017-2023) were propensity-matched to those treated with CRT using age, cancer stage, p16 status, smoking history, and tumor subsite as covariates. Outcomes included GT placement/duration, ED visits, and admissions up to 12 months post-treatment. We used Chi-squared test with Yates’ continuity correction to compare frequency of complications and Wilcoxon rank sum test with continuity correction to compare rates of ED visits/admissions.
Results: Thirty-four IRT patients met inclusion criteria and were matched with 34 CRT patients (mean age 62.2 years, 88.2% male, majority oropharyngeal cancer (94.1%), p16-positive disease (89.7%), T3 (38.2%) or T4 (29.4%) and N1 (50.0%) or N2 (45.6%) staging). Covariates were well-matched between groups. Similar percentages of IRT and CRT patients had GT placed (61.8% vs. 73.5%, p = 0.44). Among those who required GT, rates of GT dependency were similar at 3 months (65% vs 50%, p = 0.49) and 6 months (55% vs. 30.4%, p = 0.19); however, at 12 months post-treatment, IRT patients were more likely to be GT dependent compared to CRT patients (31.6% vs. 4.3%, p = 0.05) and non-significantly trended towards longer median GT dependency duration (194 vs. 150 days, p = 0.28). Within 12 months post-treatment, a similar percentage of IRT and CRT patients had at least one ED visit (31.4% vs. 40.0%, p = 0.62) and at least one admission (34.3% vs. 48.6%, p = 0.33). However, among those who had an ED visit/admission, IRT patients had significantly higher numbers of ED visits per patient (median 3, range 1-7) compared to CRT patients (median 1, range 1-2, p = 0.01) and trended towards higher numbers of admissions (median 1, range 1-3 for both IRT and CRT, p = 0.06). Among IRT patients, primary reasons for ED visits/admissions were general/acute medical issues (including hypotension, heart palpitations, anaphylaxis, immune-related nephritis/kidney injury, sepsis/shock; 30.8%), swallowing dysfunction (23.1%), and GT-issues (19.2%). Among CRT patients, primary reasons were swallowing dysfunction (30.2%), general/acute medical issues (including constipation, hemoptysis, NSTEMI, acute kidney injury; 18.6%), and GT-issues (16.3%). Median total admission duration was comparable between IRT (9.0 days) and CRT (7.0 days, p = 0.92).
Conclusions: IRT patients are more likely to experience prolonged GT dependency and higher rates of ED visits/admissions compared to CRT patients. As more clinical trials incorporate ICIs into the primary treatment of HNSCC, these data underscore the importance of vigilant monitoring for complications in IRT patients through at least one year post-treatment.