By David Douglas
NEW YORK (Reuters Health) - 12/3/2019
Patients with cutaneous squamous-cell cancer of the head and neck who have disease recurrence after definitive treatment with surgery and postoperative radiotherapy have poor survival, according to a retrospective study.
"The findings underscore the importance of intensifying upfront treatment to prevent recurrence for high-risk patients, given the low rate of successful salvage," Dr. Bindu V. Manyam of the Cleveland Clinic, Ohio, told Reuters Health by email.
In a paper online February 28 in JAMA Dermatology, Dr. Manyam and colleagues note that following definitive treatment, immunocompetent patients show significantly better locoregional recurrence-free survival and progression-free survival compared with patients who are immunosuppressed.
To investigate what influence immune status might have on outcome following recurrence, the researchers examined data on 205 patients who underwent surgical resection and postoperative radiotherapy for primary or recurrent stage I to IV disease between 1995 and 2014.
Seventy-two patients developed recurrence. Of these, 40 were immunosuppressed and the remaining 32 were immunocompetent. In both groups locoregional occurrence was the most common first pattern of failure.
After any recurrence, one-year overall survival was 43.2% and median survival was 8.4 months. Median survival did not differ significantly between immunosuppressed and immunocompetent patients (8.0 vs. 12.9 months).
In the 45 patients with available salvage data, the nine who underwent surgical salvage showed significantly better survival than those who had palliative radiotherapy, hospice care or other treatment (26.1 vs. 4.7 months).
The ability to undergo salvage surgery, say the researchers, "may have selected patients who had either less extensive initial treatment or more limited recurrence with correspondingly more favorable outcomes."
"The low rate of successful salvage," they conclude, "underscores the importance of intensifying upfront treatment to prevent recurrence."
Additionally, said Dr. Manyam, "our findings provide an important baseline for clinical outcomes after post radiation recurrence and can help inform clinical trial design in high-risk populations. Most importantly, it highlights the need for more effective treatment regimens in this space."
Dermatologist Dr. Jerry D. Brewer of the Mayo Clinic, in Rochester, Minnesota, told Reuters Health by email, "This study highlights the importance of treating squamous-cell carcinoma promptly, aggressively, and definitively the first time, regardless of immunosuppressed state."
"Once a cutaneous squamous-cell carcinoma recurs," added Dr. Brewer, who was not involved in the study, "it can be very hard to get control over, and this study does a wonderful job of highlighting the increased mortality associated with the scenario of a recurrent squamous-cell carcinoma that has already been treated with surgery and radiation."
Dr. Brewer concluded that "we as a medical community should consider ways to be more aggressive with these squamous-cell carcinomas that require post-operative radiation from the get go, whether more aggressive surgical measures, more adjuvant therapeutic options or otherwise. The bottom line is the time to treat a squamous-cell carcinoma aggressively that may have the potential of misbehaving, is the first time it is treated."
JAMA Dermatol 2019.