Use of Multidisciplinary Care for HNSCC Inconsistent

Use of multidisciplinary care (MDC) in the treatment of elderly patients with head and neck squamous cell carcinoma (HNSCC) increased during the last 2 decades, but use still varied by stage and type of disease, researchers reported.

A retrospective study by Thomas Galloway, MD, of Fox Chase Cancer Center in Philadelphia, and colleagues looked at the use of MDC among 28,293 patients age 66 and older with HNSCC taken from the Statistics, Epidemiology, and End Results-Medicare linked database from January 1991 to December 2011.

The study, online in JAMA Otolaryngology-Head & Neck Surgery, found that use of MDC more than doubled, from 24% in 1991 to 52% in 2001 (P<0.001). However, although 60% of patients with localized disease received MDC, only 28% of those with advanced-stage disease did.

The study defined MDC in a stage-dependent manner with localized disease requiring consultations with radiation and surgical oncologists, and advanced-stage disease also including consultation with a medical oncologist.

“The reasons for this are likely multifactorial,” Galloway told MedPage Today. “In some ways, multidisciplinary care in some early tumors happens without trying. For example, someone with early larynx disease initially is seen by a surgeon, secures a biopsy, and is referred to radiation for treatment. In contrast, with late tumors there are data to suggest that time matters. There is a desire to proceed in getting treatment started, and then do multidisciplinary care after the first thrust of treatment has already happened.”

Different types of HNSCC, whether an oral cavity tumor or laryngeal tumor, all have their own unique facets that may increase or decrease the likelihood of MDC care, Galloway explained.

Among patients with localized tumors, those with primary cancer of the larynx were most likely to receive MDC (70%) and those who had cancer of the oral cavity were most likely not to receive MDC (67%).

A multivariable analysis showed that MDC was associated with male sex (odds ratio [OR] 1.16, 95% CI 1.08-1.24), age over 70 (70-74 years; OR 1.14, 95% CI 1.06-1.23), nasopharyngeal primary tumor (OR 1.34, 95% CI 1.09-1.65), and Charlson Comorbidity Index greater than 1 (OR 1.13, 95% CI 1.05-1.21).

In contrast, not receiving MDC was associated with oropharyngeal cancer (OR 0.79, 95% CI 0.70-0.89) and oral cavity tumors (OR 0.13, 95% CI 0.11-0.14) as well as having advanced-stage disease (OR 0.16, 95% CI 0.73-0.91).

Finally, receipt of MDC was associated with more than a 10-day delay in median time to treatment initiation for patients with stages III and IV disease and an 11-day delay for patients with localized disease.

“It is nice to see that the application of multidisciplinary care is increasing and patients are getting this care more now than they were 10 or 20 years ago,” Galloway said. “Although they are getting multidisciplinary care more now than in the past, the relatively infrequent use of a speech language pathologist is something that really stands out.”

Use of speech language pathology was considered in a subset analysis, which showed that only 2% of patients underwent this evaluation before initiation of definitive therapy.

“Use of MDC has improved, but it hasn’t improved to a level we are happy with,” Galloway said, adding that although use of MDC may have improved even more since the end of the study period in 2011, it is still not as widely applied as it should be.

Writing in an accompanying editorial, Ryan Jackson, MD, of Washington University School of Medicine in St. Louis, and Mark Varvares, MD, of Massachusetts Eye and Ear and Harvard Medical School in Boston, supported the use of MDC in patients with HNSCC, but said the study was limited by the fact that MDC was defined “arbitrarily.”

“There was heterogeneity in what constituted a surgeon because patients qualified for surgical consultation if evaluated by an otolaryngologist, oral surgeon, or head and neck surgeon,” the editorialists wrote.

“Surgeons, whether otolaryngology or oral oncology trained, with experience in head and neck surgical oncology often have discrete skill sets, expertise, and available resources to offer an informed surgical opinion,” they continued. “These traits become increasingly important when decision-making must take into account such expertise as reconstructive surgery, including microvascular expertise, and endoscopic surgery techniques, such as endoscopic skull base surgery and transoral robotic surgery.”

Additionally, Jackson and Varvares said, the study’s use of the 7th edition of the American Joint Committee on Cancer’s Cancer Staging Manual means that many oral cavity cases may have been upstaged and many oropharyngeal cases may have been downstaged compared with the staging that would occur with use of the more recent 8th edition of the manual. “Therefore, it is not possible to draw currently relevant conclusions on the adherence to MDC as defined by dichotomizing patients to localized and advanced stages of disease based on the 7th edition criteria,” the editorialists wrote.

In addition, they said, because HNSCC care is so complex, defining what constitutes MDC is also complicated: “Before we determine the importance of MDC from an oncologic outcome and patient satisfaction standpoint, we must better define what we believe constitutes MDC evaluation and treatment,” Jackson and Varvares said. “Once defined, demonstration of the presumed survival advantage that accompanies MDC could be investigated.”