TREATMENT TIME & TOBACCO: TWIN TERRORS Of H&N Therapy
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1 TREATMENT TIME & TOBACCO: TWIN TERRORS Of H&N Therapy Anurag K. Singh, MD Professor of Medicine University at Buffalo School of Medicine Professor of Oncology Director of Radiation Research Roswell Park Cancer Institute
2 CASE 53 y/o man T2N2cM0 Base of Tongue Cancer 40 pack years HPV positive Smokes 1.5 ppd Seen November 10 Because of work, wants to start on a wednesday Can t be changed
3 Outline TREATMENT TIME Historical Data RPCI Experience pt 1 3 4% per day over 50 RPCI Experience pt 2 Preventing treatment prolongation works TOBACCO It is bad for you Bad during RT Quitting prior to RT makes a BIG difference
4 Outline TREATMENT TIME Historical Data RPCI Experience pt 1 3 4% per day over 50 RPCI Experience pt 2 Preventing treatment prolongation works TOBACCO It is bad for you Bad during RT Quitting prior to RT makes a BIG difference
5 Treatment Time is Important with RT alone 1. Suwinski, R., et al., Time factor in postoperative radiotherapy: a multivariate locoregional control analysis in 868 patients. Int J Radiat Oncol Biol Phys, (2): p Robertson, A.G., et al., Effect of gap length and position on results of treatment of cancer of the larynx in Scotland by radiotherapy: a linear quadratic analysis. Radiother Oncol, (2): p Hliniak, A., B. Maciejewski, and K.R. Trott, The influence of the number of fractions, overall treatment time and field size on the local control of cancer of the skin. Br J Radiol, (668): p Maciejewski, B., et al., Dose fractionation and regeneration in radiotherapy for cancer of the oral cavity and oropharynx: tumor dose response and repopulation. Int J Radiat Oncol Biol Phys, (3): p Robertson, C., et al., Similar decreases in local tumor control are calculated for treatment protraction and for interruptions in the radiotherapy of carcinoma of the larynx in four centers. Int J Radiat Oncol Biol Phys, (2): p Kwong, D.L., et al., The effect of interruptions and prolonged treatment time in radiotherapy for nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys, (3): p
6 Tx Time & Hgb with ChemoRT Rades. IJROBP patients Stage IV Concurrent ChemoRT Definitive (70) or Post op (83)
7 Prognostic Factors Rades. IJROBP
8 Prognostic Factors Rades. IJROBP
9 Prognostic Factors Rades. IJROBP
10 Outline TREATMENT TIME Historical Data RPCI Experience pt 1 3 4% per day over 50 RPCI Experience pt 2 Preventing treatment prolongation works TOBACCO It is bad for you Bad during RT Quitting prior to RT makes a BIG difference
11 Am Jn Clin Oncol
12 RPCI Study # patients Mostly male Oropharynx, larynx most common Treatment Chemotherapy AND IMRT # patients % Total 78 Median age (range) Sex 62 (37-81) Male 56 72% Female 22 28% Tumor Site Oropharynx 42 54% Larynx 28 36% Hypopharynx 4 5% Oral Cavity 4 5%
13 RPCI Study #1 H&N Cancers Mostly advanced 51% T3 or T4 55% N2 or N3 T Stage # % % % % % N Stage % % 2a 5 6% 2b 21 27% 2c 13 17% 3 4 5%
14 RPCI Study #1 Median follow up was 12 months. Fifteen of 78 (19%) patients experienced locoregional failure. 6 primary site failures, 5 nodal/ regional failures, and 4 failures in both the primary site and regional lymph nodes.
15 RPCI Study #1 Loco regional failure variables Age Sex Disease site Stage Baseline hemoglobin Treatment interruption > 1 week * Statistically significant meaning high level of correlation with loco-regional failures
16 RPCI Study #1 Low hemoglobin 7/19 (37%) failures Normal hemoglobin 8/59 (14%) failures P = 0.042
17 RPCI Study #1 Interruption > 1 week 6/13 (46%) failures Interruption < 1 week 9/65 (14%) failures P = 0.015
18 RPCI Study #1 : Summary More loco regional failures in H&N with Low hemoglobin Not easily / realistically correctable Treatment interruptions Easily Correctable! but will it matter?
19 Outline TREATMENT TIME Historical Data RPCI Experience pt 1 3 4% per day over 50 RPCI Experience pt 2 Preventing treatment prolongation works TOBACCO It is bad for you Bad during RT Quitting prior to RT makes a BIG difference
20 Head and Neck
21 RPCI Study # patients Mostly male Oropharynx, larynx most common Treatment Chemotherapy AND IMRT Avoid treatment interruptions # patients % Total 62 Median age (range) Sex 59 (38-82) Male 51 82% Female 11 18% Tumor Site Oropharynx 37 66% Larynx 14 25% Hypopharynx 5 9% Oral Cavity 0 0%
22 Treatment Time at RPCI Median RT duration (days) (n = 78) 51 (39 83) (n = 62) 46 (38 67) Local Control 81 vs 95%, P=0.01 Duration < 56 days % Duration > 56 days %
23 Optimal Treatment Time Start on a Monday! Sun Mo Tu We Th Fr Sat Treatment time = 47 days Sun Mo Tu We Th Fr Sat Treatment time = 49 days Up to 6 fx/week if needed
24 IMRT Prescription Total dose 70 Gy 2 Gy per fraction 35 treatments. Treatment time 35 fractions (35 days) 6 weekends (12 days) Total time 47 days RPCI Study #2 Sun Mo Tu We Th Fr Sat
25 Outline TREATMENT TIME Historical Data RPCI Experience pt 1 3 4% per day over 50 RPCI Experience pt 2 Preventing treatment prolongation works TOBACCO It is bad for you Bad during RT Quitting prior to RT makes a BIG difference
26 RTOG 0129 Post Hoc Analysis Retrospective Analysis Randomized Trial Stage III and IV Oropharyngeal cancer Accelerated fractionation vs Standard fractionation patients 323 patients had HPV status known. Ang KK, New England Journal of Medicine. 2010; 363, 24-35
27 RTOG 0129 Post Hoc Analysis Ang KK, New England Journal of Medicine. 2010; 363, 24-35
28 RTOG 0129 Post Hoc Analysis Ang KK, New England Journal of Medicine. 2010; 363, 24-35
29 Outline TREATMENT TIME Historical Data RPCI Experience pt 1 3 4% per day over 50 RPCI Experience pt 2 Preventing treatment prolongation works TOBACCO It is bad for you Bad during RT Quitting prior to RT makes a BIG difference
30 Effect of Smoking on H&N Ca Retrospective Study patients All H&N disease sites All stages Follow up time approximately 3 years. Fortin et al. Int. J. Radiation Oncology Biol. Phys., Vol. 74, No. 4, pp , 2009
31 Effect of Smoking on H&N Ca Fortin et al. Int. J. Radiation Oncology Biol. Phys., Vol. 74, No. 4, pp , 2009
32 Effect of Smoking on H&N Ca Fortin et al. Int. J. Radiation Oncology Biol. Phys., Vol. 74, No. 4, pp , 2009
33 Smoking During RT Bad Outcome Chen. Int Jn Radiat Oncol Biol Phys Retrospective Study, case matched ( ) 202 patients Former smoker anyone who quit anytime prior to RT Squamous cell cancer of Oral cavity Pharynx (Naso, Oro, Hypo ) Larynx Median follow up 49 months
34 Smoking During RT Bad Outcome Overall Survival Chen et al. Int. J. Radiation Oncology Biol. Phys., Vol. 79, No. 2, pp , 2011
35 Smoking During RT Bad Outcome Loco-regional Control Chen et al. Int. J. Radiation Oncology Biol. Phys., Vol. 79, No. 2, pp , 2011
36 Smoking + RT = bad idea. Fortin (2009) 5 yr LRC Former Active 80% 67% 5 yr OS Former 55% Active 50% Chen (2011) 69% 58% 55% 23% Int Jn of Rad Onc Biol Phys
37 Outline TREATMENT TIME Historical Data RPCI Experience pt 1 3 4% per day over 50 RPCI Experience pt 2 Preventing treatment prolongation works TOBACCO It is bad for you Bad during RT Quitting prior to RT makes a BIG difference
38 120 pts
39 HPV+ Never/Former p<0.01 HPV+ Active smoker HPV- Never/Former p<0.28 HPV- Active smoker 90% OS in those who quit 30 days prior to starting RT.
40 Outline TREATMENT TIME Historical Data RPCI Experience pt 1 3 4% per day over 50 RPCI Experience pt 2 Preventing treatment prolongation works TOBACCO It is bad for you Bad during RT Quitting prior to RT makes a BIG difference
41 CASE 53 y/o man T2N2cM0 Base of Tongue Cancer 40 pack years HPV positive Smokes 1.5 ppd Seen November 10 Because of work, wants to start on a wednesday Can t be changed
42 Smokes 1.5 ppd Seen November 10 CASE Smoking Cessation TX 6 fx/wk wknd/bid to cmplete in 47d Because of work, wants to start on a wednesday Start on a Monday
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