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Table of Contents
LETTER TO EDITOR
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 859-860

Should we add chemotherapy to radiation therapy in older adults with locally advanced head-and-neck squamous cell carcinoma?


1 Department of Medical Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
2 Department of Surgical Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India

Date of Submission18-Oct-2020
Date of Decision20-Oct-2020
Date of Acceptance20-Oct-2020
Date of Web Publication25-Dec-2020

Correspondence Address:
Manikandan Dhanushkodi
Department of Medical Oncology, Cancer Institute (WIA), 38, Sardar Patel Road, Chennai - 600 020, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_324_20

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How to cite this article:
Dhanushkodi M, Vaidhyalingam V, Krishnamurthy A. Should we add chemotherapy to radiation therapy in older adults with locally advanced head-and-neck squamous cell carcinoma?. Cancer Res Stat Treat 2020;3:859-60

How to cite this URL:
Dhanushkodi M, Vaidhyalingam V, Krishnamurthy A. Should we add chemotherapy to radiation therapy in older adults with locally advanced head-and-neck squamous cell carcinoma?. Cancer Res Stat Treat [serial online] 2020 [cited 2021 Jan 18];3:859-60. Available from: https://www.crstonline.com/text.asp?2020/3/4/859/304993



We would like to congratulate Singh et al. for comparing the efficacy and toxicity of cisplatin-based radiation between the older (aged =/>60 years) and younger adults (aged <60 years) based on a post hoc analysis of a randomized controlled trial and Srinivasalu et al. for the accompanying editorial.[1],[2]

A total of 17 older adult patients with locally advanced head-and-neck cancer with a median age of 61 years (range, 60–67 years) were included in this analysis. This cohort was compared against another cohort of 283 younger adult patients. The younger cohort had a roughly equal representation of the weekly cisplatin (51%) and 3-weekly cisplatin (49%) regimens. However, 12 (71%) of the older adults received 100 mg/m2 3-weekly cisplatin and 5 (29%) received 30 mg/m2 weekly cisplatin. Could this disparity have led to the improved 2-year locoregional control (100%) in the older adults? Why was baseline audiometry used as a demographic variable? Interestingly, although more than three-fourth of the older patients did not have a formal audiometric evaluation, it did not impact their ototoxicity outcomes.

The study showed no difference in grade 3/4 toxicities between the two cohorts, except for the higher (statistically insignificant) leukopenia/neutropenia observed in the older cohort with similar outcomes. Could the similar toxicities be due to the higher dose reduction (18% in older vs. 8% in younger adults)? Why did younger adults have a higher rate of grade 3/4 odynophagia (48% vs. 23%)?

Grade 3 weight loss as per the Common Terminology Criteria for Adverse Events version 4.03 includes weight loss of >20% or the need for tube feeding. The authors mention that 63.4% of the older adults needed tube feeding, but grade 3 or higher weight loss was observed in none.

It would be interesting to know the authors' views about why the Japanese study by Kiyota et al. showed an improved outcome (non-inferior) with weekly cisplatin contrary to the Indian study by Noronha et al. that showed an inferior outcome with weekly cisplatin?[3],[4]

The limitations of the study include its design (unplanned, post hoc analysis), small sample size (n = 17), exclusion of patients aged >70 years, the disparity in the cisplatin dose in the older cohort, a considerable difference in the size of the two cohorts (17 patients in the older cohort vs. 283 in the younger cohort), statistically significant difference in the proportion of oral cavity primaries (53% in older vs. 89% in younger adults), lack of quality of life analysis, and lack of geriatric assessment scales for the older adults. Post hoc analyses are hypothesis-generating, which could represent mere coincidences and mandate the testing of these hypotheses in a randomized controlled study.[5]

Despite the above limitations, some of which have already been alluded to by the authors in the article, the results of this subset analysis of the randomized controlled trial have the potential to refine the real-world practice of managing older adults with locally advanced head-and-neck cancers. The clear take-home message is that well-selected older patients should not be denied the option of concurrent chemoradiation (3 weekly cisplatin 100 mg/m2) merely because of their chronological age.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Singh GK, Noronha V, Patil VM, Menon N, Joshi A, Prabhash K. Safety and efficacy of concurrent chemoradiotherapy for head and neck cancers in older versus younger patients: Post hoc analysis of a randomized controlled trial. Cancer Res Stat Treat 2020;3:482-8.  Back to cited text no. 1
  [Full text]  
2.
Srinivasalu VK, Pavithran K. Does chemoradiotherapy benefit older patients with squamous cell carcinomas of the head-and-neck? Cancer Res Stat Treat 2020;3:580-2.  Back to cited text no. 2
  [Full text]  
3.
Kiyota N, Tahara M, Fujii H, Yamazaki T, Mitani H, Iwae S, et al. Phase II/III trial of post-operative chemoradiotherapy comparing 3-weekly cisplatin with weekly cisplatin in high-risk patients with squamous cell carcinoma of head and neck (JCOG1008). J Clin Oncol 2020;38:6502.  Back to cited text no. 3
    
4.
Noronha V, Joshi A, Patil VM, Agarwal J, Ghosh-Laskar S, Budrukkar A, et al. Once-a-week versus once-every-3-weeks cisplatin chemoradiation for locally advanced head and neck cancer: A Phase III randomized noninferiority trial. J Clin Oncol 2018;36:1064-72.  Back to cited text no. 4
    
5.
Curran-Everett D, Milgrom H. Post-hoc data analysis: Benefits and limitations. Curr Opin Allergy Clin Immunol 2013;13:223-4.  Back to cited text no. 5
    




 

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