Racial Parities in Outcomes after Radiotherapy for Head and Neck Cancer

Reporter: Abigail T. Berman, MD
The Abramson Cancer Center of the University of Pennsylvania
Last Modified: October 1, 2013

Presenting Author: Gene-Fu F. Liu, MD
Presenting Author Affiliation: Honolulu, HI

If you or a friend of family was recently diagnosed with a head and neck cancer, you know that the treatment can be challenging, using a combination of surgery, radiation, and/or chemotherapy. Many head and neck cancers, despite being advanced at the time of diagnosis, can be cured. There are certain established risk factors for the development of head and neck cancer, such as smoking and alcohol consumption. Many head and neck cancers are also associated with the HPV virus. Race has been shown to be a risk factor in how well patients do after treatment for a variety of cancers; however, performing studies that examine risk factors must be done meticulously, as there are associated aspects of any patient’s cancer (Is he or she a smoker? How big is the tumor?) that can also affect the survival after treatment. These factors are known as confounders and must be accounted for when analyzing the effect of race on survival after treatment.

The authors performed this study because previous studies have shown that African American patients have been reported to have lower survival in across multiple types of cancer, including squamous cell carcinoma of the head and neck (HNSCC), where African American patients have been reported to have survival almost half that of Caucasian patients. However, these conclusions were often based on series in which AAs were a minority of patients. The authors performed a single-institution study where they reviewed 366 AA (60.8%) and 236 CA (39.2%) patients with HNSCC treated from 1990-2012.

They found that, interestingly, Caucasian and African American patients presented with a similar proportion of early (stage I-II; 19%) and advanced disease (stage III-IVB; 81%). They found that African American patients had similar—and not lower—outcomes than Caucasian patients. They found at 2 years Compared to CA patients, AA patients experienced similar oncologic outcomes for the entire cohort. Specifically, they had similar locoregional control, freedom from metastases (disease spread), progression-free survival, and overall survival. When they adjusted for all the possible factors that could be affecting survival—they found that race was not a prognostic factor. Despite these similar outcomes, African American patients had a higher incidence of adverse socioeconomic factors, including lower median incomes ($28,203 vs $42,774) and a higher probability of tobacco (88.4% vs 80.7%), alcohol (76.1% vs 66.3%), and illicit drug abuse (15.3% vs 8.5%; P = .01). African American patients also had overall poorer heath, as measured by a higher incidence of high to very high Charlson Comorbidity Index scores. African American patients had similar to improved treatment compliance compared to Caucasian patients. Both races had a similar frequency of radiation treatment delay > 5 days (27.4% vs 25.9%).

This study proves that the same treatment can be applied to both races and that outcomes are good in both races. Even though African American patients in this study had, on average, lower income and higher probability of tobacco use, they did not have lower survival following treatment for head and neck cancer. While earlier, smaller studies showed lower outcomes in African Americans, this study shows that at a treatment center with a greater minority representation, they may be able to overcome existing healthcare disparities through improved communication and equivalent treatment compliance. It will be interesting to see if these same results could be duplicated by looking at many hospitals, some of which do not have a large minority population.

Key Words: Quality of Life, radiation treatment, Gynecologic Cancer Treatment

Psychological and Social Work Encounters Predict Higher Patient-Reported Functional Quality of Life in Gynecological Cancer Treatment

Reporter: Lauren Hertan

Date: September 24th, 2013
Presenter: Surbhi Grover
Presenter Affiliation: University of Pennsylvania

Abstract #: 182

Patients who have undergone radiation therapy for gynecologic malignancy can have significant long term side effects from their treatments. This is becoming more apparent as treatments improve and patients are living longer. It has been reported that physician assessment of patient’s side effects does not always do an accurate job of capturing what is truly occurring both during and after treatment. As such, there is an increasing need to obtain patient-reported symptoms and assessment of quality of life.

In the current study, the authors compared patient-reported and physician-reported symptoms and quality of life over the course of treatment. Additionally, they assessed the impact of encounters with psychologists and social workers.

This was a prospective study of 41 patients treated with radiation therapy for gynecological cancer at the University of Pennsylvania between 2009 and 2012. The majority of patients were treated for cervical or endometrial cancer and slightly over half also received chemotherapy. All patients were given a series of validated health related quality of life questionnaires before, during, and 3 months after treatment.

When the patient-reported symptoms from the questionnaires were compared to physician assessment of patient’s symptoms, obtained from the patient’s medical record, overall there was minimal correlation. Over the course of treatment, patient-reported quality of life decreased. However, by 3 months after completion of treatment, quality of life was improved compared to pre-treatment.

To determine the significance of interaction with social workers and psychologist, data were collected regarding the number of visits that occurred with one of these providers over the course of treatment. 23 patients had at least one interaction with a social worker or psychologist during treatment. Patients with higher numbers of interactions with these providers noted improved functional well being scores from before to after treatment.

Patient and physician-reported symptoms and quality of life are minimally correlated, emphasizing the need for collection of patient reported health related quality of life. Additionally, it was noted that side-effects and quality of life temporarily decreased while on treatment, however improved over baseline after treatment. Lastly, interaction with social work or psychologists appears to have value with respect to improving patient functional well being and quality of life. More research is needed to determine the optimal role of social workers and psychologists in the care of patients undergoing radiation therapy for gynecological malignancies.

Key words: vaginal stenosis, anal cancer, pelvic radiation, Vaginal Dilator

Prospective Study of Vaginal Dilator Use Following Pelvic Radiotherapy for Gastrointestinal Malignancies

Reporter: Lauren Hertan

Date: September 24th, 2013
Presenter: Karyn A. Goodman
Presenter Affiliation: Memorial Sloan-Kettering Cancer Center

Abstract #: 181

Vaginal stenosis (narrowing, shortening and/or loss of elasticity) after radiation therapy to the pelvis can significantly impact long-term quality of life. Studies have been done to evaluate the incidence of vaginal stenosis in women with gynecologic cancer (e.g. cervical, endometrial, etc), however, limited research has been done looking at women who have been treated for pelvic gastrointestinal cancers, such as rectal or anal cancer. One known treatment for vaginal stenosis is the regular use of a vaginal dilator, which is inserted into the vagina for 10 minutes, three times a week. However, it is also known that compliance to this recommended treatment is low.

The current study was a prospective study designed to determine the incidence of vaginal stenosis and the effectiveness of vaginal dilators, in women treated with radiation to the pelvis for gastrointestinal (rectal or anal) cancers. Among the 63 women evaluated, they found that overall there was a 62.3% rate of vaginal stenosis at 1 month after finishing radiation, with patients treated for anal cancer having a higher rate (77.1%) than patients treated for rectal cancer (42.3%).

Additionally, vaginal dilator use over the course of the year following radiation therapy was measured. In the first three months, they found that 58% of patients were using the dilator as recommended, however this dropped to 24% at a year after treatment. The authors assessed the factors that were associated with vaginal dilator use and found that patients who were treated for anal cancer were more likely to use the vaginal dilator than patients with rectal cancer. Additionally they found that women who were sexually active were more likely to use the vaginal dilator than women who were not sexually active.

Another key point of the study was to assess how effective vaginal dilator use was in this group of patients. Prior to starting radiation therapy, each patient underwent evaluation to determine the maximum size of dilator that could be easily inserted into the vagina. The effectiveness of vaginal dilator use was determined by comparing the pre-treatment vaginal dilator size to the size that could be easily inserted post treatment. Encouragingly, they found that by 1 year following radiation, 80% of patients treated for rectal cancer and 69% of patients treated for anal cancer were able to return to their pre-treatment vaginal dilator size. The authors also assessed the factors that were associated with return to pre-treatment vaginal dilator size at one year.

They found that younger age, higher education (having a college degree or higher), being sexually active prior to treatment, use of vaginal moisturizers and compliance with use of a vaginal dilator use were all associated with better outcomes.

Overall, this study identified there is a high incidence of vaginal stenosis following radiation therapy to the pelvis for gastrointestinal cancer, particularly for patients being treated for anal cancer. Fortunately, use of vaginal dilators appears to be an effective treatment, despite low rates of compliance. Further research is needed to identify how to improve patients’ use of the dilators as well as to determine the optimal frequency and duration of use.


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