Assessment of Predictive Scoring System for 90-Day Mortality Among Patients With Locally Advanced Head and Neck Squamous Cell Carcinoma Who Have Completed Concurrent Chemoradiotherapy

Kuan-Chou Lin,Alexander T. H. Wu,Kevin Sheng-Po Yuan,Szu-Yuan Wu,Tsung-Ming Chen

doi:10.1001/jamanetworkopen.2019.20671

Kuan-Chou Lin, Alexander T. H. Wu + Show 3 more

Open Access

https://doi.org/10.1001/jamanetworkopen.2019.20671

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Abstract

There is currently no system to predict 90-day morality among patients with locally advanced head and neck squamous cell carcinoma (HNSCC) after the completion of concurrent chemoradiotherapy (CCRT). To validate the accuracy of a predictive scoring system for 90-day mortality among patients with locally advanced HNSCC who have completed CCRT. This prognostic study included 16 029 patients with HNSCC who completed CCRT between January 2006 and December 2015. Data were extracted from the Taiwan Cancer Registry Database. A risk scoring system was developed based on significant risk factors and corresponding risk coefficients. Data analysis was conducted from June 2018 to February 2019. Mortality within 90 days of completion of definitive CCRT. The 90-day mortality rate after completion of CCRT and the accuracy of the scoring system, based on a comparison of mortality rates between training and test data sets. Among 16 029 patients with locally advanced HNSCC, 1068 (6.66%; 1016 [95.1%] men; mean [SD] age, 55.11 [11.45] years) died before reaching the 90-day threshold, and 14 961 (93.4%; 14 080 [94.1%] men; mean [SD] age, 52.07 [9.99] years) survived. Multivariable analysis revealed that being aged 50 years or older (adjusted hazard ratio [aHR], 1.263; 95% CI, 1.104-1.445; P < .001), being aged 70 years or older (aHR, 2.183; 95% CI, 1.801-2.645; P < .001), having pneumonia (aHR, 1.946; 95% CI, 1.636-2.314; P < .001), having sepsis (aHR, 3.005; 95% CI, 2.503-3.607; P < .001), having hemiplegia (aHR, 1.430; 95% CI, 1.085-1.884; P = .01), having moderate or severe renal disease (aHR, 2.054; 95% CI, 1.643-2.568; P < .001), having leukemia (aHR, 4.541; 95% CI, 1.132-8.207; P = .03), and having non-HNSCC metastatic solid cancers (aHR, 1.457; 95% CI, 1.292-1.644; P < .001) were significant risk factors for 90-day mortality. Risk scores were categorized as very low risk (score of 0), low risk (score 1-3), moderate risk (score 4-6), and high risk (score ≥7), with 90-day mortality rates of 3.37%, 5.00% to 10.98%, 16.15% to 29.13%, and 33.93% to 37.50%, respectively. Mortality rates for patients with the same risk score in the training and test data sets were similar (score of 0, 3.27% vs 3.66%; score of 6, 27.42% vs 25.00%). In this prognostic study, a 90-day mortality scoring system accurately predicted 90-day mortality among patients with locally advanced HNSCC who completed CCRT.

Highlights

In Taiwan, the annual incidence of head and neck squamous cell carcinoma (HNSCC) is approximately 7800 cases, and HNSCC is the sixth leading cause of cancer death in the country.[1,2,3,4] Radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) treatment for HNSCC can cause severe treatmentrelated toxic effects
Multivariable analysis revealed that being aged 50 years or older, being aged 70 years or older, having pneumonia, having sepsis, having hemiplegia, having moderate or severe renal disease, having leukemia, and having non-HNSCC metastatic solid cancers were significant risk factors for 90-day mortality
This study was approved by the institutional review board of Taipei Medical University; informed consent was waived because the data were from the publicly available National Health Insurance Research Database (NHIRD)

Summary

Introduction

In Taiwan, the annual incidence of head and neck squamous cell carcinoma (HNSCC) is approximately 7800 cases, and HNSCC is the sixth leading cause of cancer death in the country.[1,2,3,4] Radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) treatment for HNSCC can cause severe treatmentrelated toxic effects. The 90-day mortality rate after completion of RT is a proposed measure for improving cancer outcomes and reducing avoidable treatment-related toxic effects.[5,6,7] In the United Kingdom, the 90-day mortality rate among patients with HNSCC after completion of RT (3.6% per the Data Audit for Head and Neck Oncology8) has been proposed as the reference to indicate treatment suitability, reduce treatment-related mortality, and improve cancer outcomes.[7] the Scottish Cancer Taskforce recommended that the 90-day mortality of patients with HNSCC after treatment be considered a guideline for ensuring the quality of care and appropriate curative treatment administration.[9] Other studies on different cancer sites have reported 90-day mortality rates of 1.7% and 4.8% after radical RT.[10,11] only a few reports have documented the 90-day post-CCRT mortality rate specific to HNSCC, with a reported post-CCRT early mortality rate (ie, not specific to a 90-day threshold) of 5.4% to 18.3%.12-14 In these studies, patient parameters that contributed to early mortality after RT included older age, male sex, low socioeconomic status, elevated white blood cell count, vascular comorbidities, poor performance status, low body mass index, and low peripheral blood total lymphocyte count. These factors were associated with increased treatment-related mortality.[7,8,9,10,11,12,13,14]

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