Going Off Guidelines: An NCDB Analysis of Missed Adjuvant Therapy Among Surgically Treated Oral Cavity Cancer

Abstract

Objective. Patient factors associated with failure to receive adjuvant therapy after oral cavity cancer resection remain understudied. Here, we identified rates of missed adjuvant therapy, determined factors associated with missed therapy, and assessed associations with survival.Study Design. Retrospective cohort.Setting. National Cancer Database.Methods. Patients with resected oral cavity squamous cell carcinoma and known adjuvant therapy status were included. T3-4 stage, N2-3 stage, and lymphovascular invasion were considered indications for adjuvant radiation. Extranodal extension or positive margins were considered indications for chemoradiation. Patient factors were examined for associations with missed adjuvant therapy. Overall survival was evaluated by Cox proportional hazard analysis.Results. A total of 53,503 patients were included. 27.5% missed adjuvant therapy altogether, and 26.7% with a documented indication for chemoradiation missed chemotherapy. Factors associated with missed adjuvant therapy were age, white race, low income, metropolitan population, increasing comorbidities, travel distance, lip primary, and treatment at the academic facility. Factors associated with missed chemotherapy were age, female sex, nontongue subsite, and treatment at a nonacademic center. Among patients with indications for adjuvant radiation, missed radiation was associated with worse overall survival (hazard ratio [HR]: 1.42, 95% confidence interval [CI]: 1.31-1.53). Among patients with indications for adjuvant chemoradiation, missed chemotherapy was associated with worse overall survival (HR: 1.19, 95% CI: 1.09-1.29). Conclusion.Missed adjuvant therapy occurs frequently after oral cavity resection. Patients treated at academic centers may be at risk of missed therapy related to travel distance, though these patients are more likely to receive adjuvant chemotherapy when indicated. Missed adjuvant therapy is associated with worse survival.

Surgical Resection Improves Overall Survival in cT4b Major Salivary Gland Cancer

“…The NCDB does not report medical comorbidities, imaging studies, quality of life, tumor board recommendations, PNI, type of local involvement (eg, skull base extension or internal carotid artery encasement), and institutional protocols used to ascertain surgical margin status. 80 Confirming negative surgical margins for large tumors is challenging and the possibility of occult microscopic disease persists. Participation in palliative care, clinical trials, and experimental therapies may have impacted treatment decisions.…”

“…Classification criteria of MSGC are also heterogenous and continuously evolving, complicating retrospective analysis of longitudinal databases such as the NCDB. The NCDB does not report medical comorbidities, imaging studies, quality of life, tumor board recommendations, PNI, type of local involvement (eg, skull base extension or internal carotid artery encasement), and institutional protocols used to ascertain surgical margin status 80 . Confirming negative surgical margins for large tumors is challenging and the possibility of occult microscopic disease persists.…”

Patterns and Trends in Adjuvant Therapy for Major Salivary Gland Cancer

“…11,27,36,48 The NCDB does not report PNI, a pathologic marker for which aRT is indicated. 11,27 Patients were considered to have missed aRT if they had ≥ 1 indication for aRT but did not receive any adjuvant therapy. Possible indications for adjuvant chemotherapy were extrapolated from the EORTC 22931 and RTOG 9501 clinical trials and included pENE and PSM.…”

“…Possible indications for adjuvant chemotherapy were extrapolated from the EORTC 22931 and RTOG 9501 clinical trials and included pENE and PSM. 11,[27][28][29][30][31]49…”

“…Comprehensive Cancer Network (NCCN). 27,37 Studies of head and neck squamous cell carcinoma (HNSCC), for example, have identified that as many as 40% of patients miss aRT and have poorer survival. 27,[38][39][40] Our study of the National Cancer Database (NCDB) investigates adjuvant therapy indications, utilization, and associated survival disparities in MSGC.…”