The Older Adult With Locoregionally Advanced Head and Neck Squamous Cell Carcinoma: Knowledge Gaps and Future Direction in Assessment and Treatment

Abstract

Older adults with squamous cell carcinomas of the head and neck (HNSCC) pose unique treatment and supportive care challenges to oncologists and other cancer care providers. The majority of patients with HNSCC present with locoregionally advanced (LA) disease, for which combined modality treatment integrating chemotherapy and radiation therapy is often necessary to maximize tumor control. However, applying these approaches to an older population with concomitant comorbidities and higher risk for functional impairments remains challenging, and is exacerbated by the paucity of studies involving older adults. The purpose of this paper is to identify knowledge gaps in the evaluation and management of older adults with HNSCC and their caregivers, particularly those undergoing concurrent chemoradiation, through a review of the literature conducted by clinicians, researchers, and patient advocates. The findings highlight the importance of a geriatric assessment and the therapeutic paradigms and challenges relevant to this population. Furthermore, we identify the need for additional research and interventions related to key supportive care issues that arise during and after treatment in older adults with LA-HNSCC. Based on our findings, we prioritized these issues to guide future patient-oriented research endeavors to address these knowledge gaps and thus better serve this growing patient population.

What's Love Got to do with it? Marital status and survival of head and neck cancer

“…A previous study on sarcoma survivors alluded to this (Alamanda, Song, & Holt, ), and this idea also needs to be further tested among HNC survivors. It is known that the ability of HNC survivors, especially the older patients, to provide or arrange transportation for themselves may be impacted by their cancer (Maggiore et al, ). How marital support moderates this impact is yet to be determined; however, this is important as there is evidence to suggest that ability to travel longer distances to receive cancer care confers survival advantage to HNC survivors and cancer survivors in general (Graboyes et al, ; Lamont et al, ).…”

Demographic predictors of head and neck cancer survival differ in the elderly

“…In this study, 72.0% of elderly patients received minimally adequate treatment compared to 82.7% in the younger cohorts. Comorbidities can affect treatment recommendations and are more common in the elderly, but provider biases, including ageism, are also a concern . Despite selecting a given treatment plan, elderly patients experience more severe treatment side effects, which may lead to substandard or incomplete treatment .…”

A snapshot of the evolving epidemiology of oropharynx cancers

“…Because of these predictions, the management of older adults with HPV‐positive oropharyngeal cancers, both during and after treatment, represents an increasingly important issue facing the medical community. The challenges in managing older adults with head and neck cancer, regardless of their HPV status, are well documented . Older patients are more likely to be frail, have multiple comorbidities and a poorer nutritional status, require numerous medications at the baseline, bear higher risks of acute toxicity from cisplatin‐based chemotherapy and long‐term toxicity after concomitant chemoradiation, have poor tolerance of multimodal therapy, and have less social support than younger patients .…”

“…In addition, older patients with HPV‐positive oropharyngeal cancer are likely heterogeneous in their health and functional status, lifetime exposure to tobacco and alcohol, and ability to tolerate multimodality therapy. Thus, geriatric assessment tools that include evaluations of health, cognition, functional status, and mobility or other novel metrics need to be developed and validated in prospective trials to better triage therapy for these patients.…”

“…The challenges in managing older adults with head and neck cancer, regardless of their HPV status, are well documented. 15 Older patients are more likely to be frail, have multiple comorbidities and a poorer nutritional status, require numerous medications at the baseline, bear higher risks of acute toxicity from cisplatin-based chemotherapy and long-term toxicity after concomitant chemoradiation, have poor tolerance of multimodal therapy, and have less social support than younger patients. 16,17 Moreover, most oncologists and head and neck surgeons have minimal to no specific training with respect to the management of either oncologic or nononcologic issues in the geriatric population.…”