Assessing Care Value for Older Patients Receiving Radiotherapy With or Without Cisplatin or Cetuximab for Locoregionally Advanced Head and Neck Cancer

Abstract

IMPORTANCE Clinicians frequently use radiotherapy with cetuximab over radiotherapy only or radiotherapy with cisplatin because of a perceived survival and tolerability advantage, but scant data are available to support this perception. OBJECTIVE To measure the 3 aspects of value (quality, outcomes, and cost) in older patients receiving radiotherapy only, radiotherapy with cisplatin, or radiotherapy with cetuximab for locoregionally advanced head and neck cancer. DESIGN, SETTING, AND PARTICIPANTS For this cohort study, patient records were obtained from the Surveillance, Epidemiology, and End Results Program (SEER)-Medicare outcomes and claims database from January 1, 2004, to December 31, 2014. Participants were 65 years or older; received a diagnosis between 2006 and 2013 of stages III to IVB head and neck cancer; had only 1 cancer on record; and did not undergo surgical intervention. Data analysis was conducted from February 5, 2018, to March 27, 2019.EXPOSURES Patients were divided into exposure arms on the basis of their first-line therapy or identified chemoradiotherapy and radiotherapy regimen. MAIN OUTCOMES AND MEASURESOverall survival was analyzed by propensity score matching Cox proportional hazards regression models, quality by measuring 90-day emergency department (ED) visit and inpatient admission rates, and costs by assessing 90-day total Medicare spending. RESULTSThe overall cohort included 1091 patients, of whom 815 (74.7%) were male; the mean (SD) age was 73.9 (6.6) years. Patients receiving radiotherapy with cisplatin had higher overall survival compared with those receiving radiotherapy only (adjusted hazard ratio [HR], 0.64; 95% CI, 0.47-0.87). This finding was not seen in patients receiving radiotherapy with cetuximab (adjusted HR, 0.95; 95% CI, 0.75-1.20), compared with the radiotherapy only group, and it persisted after stratifying patients by age. The ED visit (adjusted incidence rate ratio [IRR], 1.72; 95% CI, 1.30-2.30) and inpatient admission (adjusted IRR, 1.48; 95% CI, 1.12-1.98) rates in the 90 days after treatment start were higher in patients receiving radiotherapy with cisplatin compared with those treated with radiotherapy only. Patients receiving radiotherapy with cetuximab had a higher rate of ED visits (adjusted IRR, 1.38; 95% CI, 1.05-1.82) compared with those in the radiotherapy only group. The 90-day after-treatment spending for patients receiving radiotherapy with cetuximab was $48 620

Propensity score matching in otolaryngologic literature: A systematic review and critical appraisal

“….The Cox models were then stratified by matched pair, and CIs were calculated using robust SEs to account for correlated observations." [35] test for trend was used to assess the presence of a statistically significant linear trend in proportion of studies using PSM over time. Continuous variables were assessed for normality using the Shapiro-Wilk test and summarized with median and quartiles.…”

The dogma of Cetuximab and Radiotherapy in head and neck cancer – A dawn to dusk journey

“…A Surveillance Epidemiology and End Results (SEER) data assessing care value for older patients receiving radiotherapy alone or with cisplatin or with Cetuximab for LA-HNSCC [53] observed no survival difference but a higher rate of emergency admissions and higher spending in patients receiving Cetuximab-RT.…”

Microscopic Extranodal Extension in HPV‐Negative Head and Neck Cancer and the Role of Adjuvant Chemoradiation

“…Furthermore, the type of cytotoxic systemic therapy is not reported in the NCDB. We performed a sensitivity analysis to exclude patients receiving targeted therapy (eg, cetuximab) after 2013 (when anti–epidermal growth factor receptor [EGFR]–based therapies began to be classified separately from cytotoxic chemotherapies in the NCDB 30 ); however, patients with concurrent EGFR‐ and RT‐based therapy were likely included in our cohort for patients diagnosed prior to 2013 and may have contributed to the observed lack of OS benefit seem with CRT 27–29 . The amount of cisplatin that patients receive is also not reported in the NCDB.…”

“…To evaluate whether the association of CRT with OS was moderated by other adverse oncologic characteristics, interaction effects between adjuvant therapy and T-category, N-category, number of metastatically involved LNs, and tumor subsites were analyzed. To ensure that study findings were not biased by the use of less efficacious systemic agents (eg, cetuximab-based therapy, which is associated with worse outcomes than cisplatin in a variety of settings and was not used in EORTC 22931 or RTOG 9501), [27][28][29] we performed a sensitivity analysis excluding those known to have received targeted therapy (eg, cetuximab) with adjuvant RT. 30 A 2-sided P value \.05 was considered statistically significant.…”