Evaluating compliance with process-related quality metrics and survival in oral cavity squamous cell carcinoma: Multi-institutional oral cavity collaboration study.

BACKGROUND: Process-related measures have been proposed as quality metrics in head and neck cancer care. A recent single-institution study identified four key metrics associated with increased survival. This study sought to validate the association of these quality metrics with survival in a multi-institutional cohort. METHODS: Multicenter retrospective study of patients with oral cavity squamous cell (1/2005-1/2015). Baseline patient and disease characteristics and compliance with quality metrics was evaluated. Association between compliance with quality metrics with overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) was evaluated using Cox proportional hazards models. RESULTS: Failure to comply with two or more of the quality metrics was associated with worse OS, DFS, and DSS. Adherence to all or all but one of the quality metrics was found to be associated with improved survival. CONCLUSIONS: Process-related quality metrics are associated with increased survival in patients with oral cavity squamous cell carcinoma in a multi-institutional cohort.

Long-term outcomes in oral cavity squamous cell carcinoma with adjuvant and salvage radiotherapy after surgery.

OBJECTIVE: Early-stage oral cavity squamous cell carcinoma (OCSCC) represents a heterogeneous group of patients, and locoregional recurrence rates are as high as 25% with surgery alone. Radiotherapy (RT) is typically reserved as part of salvage multimodality therapy after salvage surgery because it is generally thought that there is no significant detriment to salvage therapy. Our aim was to examine outcomes for recurrent OCSCC treated with salvage surgery and radiation and compare them to outcomes for patients treated with adjuvant postoperative RT upfront. METHODS: We identified 425 patients with OCSCC treated with postoperative RT at our institution. The 5-year rates of local failure, locoregional failure (LRF), survival, and distant metastasis (DM) were the main outcome measures. We performed a landmark analysis and examined the same outcomes in the adjuvant versus salvage cohorts using Cox proportional hazards and Fine-Gray competing risk method. RESULTS: The adjuvant cohort had higher tumor (T) (P < 0.0001) and nodal (N) (P < 0.0001) stage than the salvage cohort's stage at initial presentation. On multivariate analysis, a strategy of salvage RT experienced poorer overall survival (OS) compared to upfront adjuvant RT (hazard ratio [HR] 1.84; 95% confidence interval [CI], 1.26-2.70; P = 0.002). Moreover, salvage surgery followed by RT patients experienced increasing risk of LRF (HR 1.56; 95% CI, 1.18-2.06; P = 0.002) and (DM) (HR 1.53; 95% CI, 1.08-2.17; P = 0.02) on multivariate analysis. Additional analysis was performed excluding salvage cohort with advanced disease at initial presentation (T3-T4 and N2). Salvage RT treatment selection for early-stage OCSCC continued to experience significantly poorer OS as compared to adjuvant RT (HR 1.48; 95% CI, 1.002-2.19; P = 0.049). CONCLUSION: Early-stage OCSCC patients who are observed and experienced recurrence requiring salvage therapy (surgery and RT) have worse oncologic outcomes than locally advanced patients receiving upfront adjuvant RT. Prospective randomized studies are needed to identify high-risk subset of early-stage OCSCC comparing adjuvant RT versus observation, followed by salvage surgery and RT at recurrence. LEVEL OF EVIDENCE: 4. Laryngoscope, 2539-2545, 2018.

Variable impact of intracavitary brachytherapy fractionation schedule on biologically effective dose to organs at risk in patients with cervical cancer.

PURPOSE: To determine the effect of intracavitary brachytherapy (ICBT) fractionation schedule on biologically effective dose to organs at risk. METHODS AND MATERIALS: We reviewed records from 26 patients who had CT imaging during ICBT for International Federation of Gynecology and Obstetrics stage IB2-IVA cervical cancer. Using α/ß=10, we calculated hypothetical nominal doses to achieve a biologically effective dose at 2 Gy per fraction (EQD2α/ß=10) of 40 Gy to Point A for high-dose-rate ICBT with 1-15 fractions. Corresponding minimum EQD2α/ß=3s to the maximally irradiated 2 cc of rectum, bladder, and sigmoid were calculated for each fractionation scheme and added to EQD2α/ß=3 from external beam radiotherapy. Total EQD2α/ß=3s were compared with American Brachytherapy Society suggested dose constraints (rectum/sigmoid, ≤75 Gy; bladder, ≤90 Gy). RESULTS: Except for rectal EQD2α/ß=3 in three patients, the rectal, bladder, and sigmoid EQD2α/ß=3s decreased with increasing fractionation in all patients. Although the total rectal EQD2α/ß=3s were less than the American Brachytherapy Society rectal dose constraint in all patients at all fractionation schedules, the total bladder EQD2α/ß=3s routinely exceeded the bladder dose constraint, even at maximum fractionation. By contrast, increasing fractionation decreased the number of patients with doses exceeding the sigmoid dose constraint by 48%. CONCLUSIONS: The relationship between ICBT fractionation schedule and relative EQD2α/ß=3s to rectum, bladder, and sigmoid depends on individual anatomy. Fractionation optimization can improve therapeutic ratios by minimizing the risk or severity of toxic effects. For patients in whom many fractions optimize the therapeutic ratio, low-dose-rate or pulsed-dose-rate brachytherapy may be preferred.