1. Age as a prognostic factor for head and neck squamous cell carcinoma: should older patients be treated differently? Udi Cinamon 1, Michael P. Hier 2, Martin J. Black 2 1 - Department of Otolaryngology, Head & Neck Surgery, Wolfson Medical Center, Holon, Israel 2 - Department of Otolaryngology, Head & Neck Surgery, Jewish General Hospital, McGill University, Montreal Special thanks to CISEPO (Canada International Scientific Exchange Program)

2. Old age: Jim Barry

3. Children should not be treated as small adults !!! Should elderly patients be treated differently?

4. Introduction:  Improved medical care  New surgical techniques, i.e., reconstructive surgery  Progress in the field of anesthesia Enable a more aggressive treatment to patients with HNSCC.HOWEVER Feasibility = appropriateness?

5. Epidemiology:

6. 2.7 2003 CanadaMaleFemaleCanadaMaleFemale Age groupPersons (thousands)% of total of each group Total31,629.715,661.715,967.9100.0 0–40–41,714.3877.3837.05.45.65.2 5–95–91,949.7998.6951.16.26.46.0 10 – 142,117.61,084.81,032.96.76.96.5 15 – 192,120.51,088.81,031.86.77.06.5 20 – 242,188.51,119.01,069.56.97.16.7 25 – 292,118.11,074.01,044.26.76.96.5 30 – 342,228.71,124.81,103.97.07.26.9 35 – 392,481.21,247.41,233.87.88.07.7 40 – 442,719.31,364.31,355.08.68.78.5 45 – 492,515.71,251.61,264.28.0 7.9 50 – 542,176.51,078.81,097.76.9 55 – 591,842.5913.9928.55.8 60 – 641,396.8684.8712.04.4 4.5 65 – 691,147.9552.2595.73.63.53.7 70 – 741,039.1484.2554.93.33.13.5 75 – 79839.4358.8480.72.33.0 80 – 84583.7221.6362.01.81.42.3 85 – 89297.097.2199.70.90.61.3 90 and over153.139.8113.30.50.30.7 Note: Population as of July 1. Source: Statistics Canada, CANSIM II, table 051-0001.051-0001 Last modified: 2003-11-06.

7. 2.7 2003 CanadaMaleFemaleCanadaMaleFemale Age groupPersons (thousands)% of total of each group Total31,629.715,661.715,967.9100.0 0–40–41,714.3877.3837.05.45.65.2 5–95–91,949.7998.6951.16.26.46.0 10 – 142,117.61,084.81,032.96.76.96.5 15 – 192,120.51,088.81,031.86.77.06.5 20 – 242,188.51,119.01,069.56.97.16.7 25 – 292,118.11,074.01,044.26.76.96.5 30 – 342,228.71,124.81,103.97.07.26.9 35 – 392,481.21,247.41,233.87.88.07.7 40 – 442,719.31,364.31,355.08.68.78.5 45 – 492,515.71,251.61,264.28.0 7.9 50 – 542,176.51,078.81,097.76.9 55 – 591,842.5913.9928.55.8 60 – 641,396.8684.8712.04.4 4.5 65 – 691,147.9552.2595.73.63.53.7 70 – 741,039.1484.2554.93.33.13.5 75 – 79839.4358.8480.72.33.0 80 – 84583.7221.6362.01.81.42.3 85 – 89297.097.2199.70.90.61.3 90 and over153.139.8113.30.50.30.7 Note: Population as of July 1. Source: Statistics Canada, CANSIM II, table 051-0001.051-0001 Last modified: 2003-11-06.

8. Age Incidence Mortality 75

9. In Israel / Canada the average age: 75-♂ / 82-♀ Living in an aging society: We may expect to treat more seniors with HNSCC

10. Objective:  To explore the issue of proper treatment in an aging society.  To address the question: feasibility = appropriateness?

11. Methods:  A retrospective study of the treatment outcome for patients that were primarily treated on our service 1990-1999.  Patients ≥ 75 years with HNSCC of the oral cavity, pharynx and larynx.

12. Results:  40 Pts  75-99 years (average, 82.2)  26♂ and 14♀

13. Distribution of patients according to stage and primary site of tumor.

14. Co-morbidity Co-morbidity Pre – treatment medical evaluation according to the ASA Classification of Physical Status system.

15. Treatment modalities and staging.

16. Major complications for 36 Pts treated for cure  Post operative mortality - 2  Cessation of radiotherapy - 1  Free flap complication - 1  Hospital stay > 6 weeks - 3

17. Treatment outcome and survival data: 4 Pts - Stage IV received palliative radiotherapy. Dead of disease after 4 months (2-6 mon.). 2 Pts that were treated with a curative intention: Postoperative mortality 34 Pts that were treated with a curative intention:  11 - Recurrence  2 - Metastasis Survival of the 34 Pts. was 4.7 years (3 mon.–11y).

18. Treatment outcome and survival data: Stage I: 15 Pts: Average follow up - 6 years. 3 Pts had a recurrence and treated. None died from cancer related causes. Stage II: 3 Pts: one died after 2 years with no evidence of disease. Second patient recurred after one year, treated, and is alive 4 years after with NED. The third recurred locally after 9 months, for which he was treated surgically. He had a fatal myocardial infarction a week after his operation. Stage III: 5 Pts: One had a jejunum free flap and died of post-operative complications. Two are alive with NED after 6 years, another died after 4 years with NED, the fourth had a recurrence after 5 years and died soon after from an un-related cause. Stage IV: 13 Pts: five were dead of disease within 3-15 months, two with distant metastasis. One patient recurred had a fatal MI a week after been treated surgically. One died 9 months after treatment having an acute MI. Two died with NED after 4 and 6 years. One patient was free of disease for 10 years and died from lung cancer. Three patients are living with NED after 5, 6, and 7 years, the latter had a recurrence after one year that was treated surgically.

19. Discussion: An intention to cure HNSCC necessitates a vigorous treatment which by itself may jeopardize the patient. Investigation of the association between age and treatment-outcome reveals conflicting opinions.

20. Main outcome of studies:  Koch et al.(1995), McGuirt & Davis (1995): Older Pts have more complications.  Clayman et al. (1998): same complication rate and almost the same recurrence & mets rate.

21. Main outcome of studies:  Shaari et al. (1998,1999), Blackwell et al.(2002), studies of surgical+free flap outcome: Seniors have more medical complications and almost the same flap/surgical complication rate.  Sarini et al. (2001); 273 Pts≥75y. Decision making according to age: older→less aggressive treat; more XRT/ less surgery Almost the same results as younger Pts.

22. Main outcome of studies: Hirano & Mori (1998): The treatment outcome of 37 patients that were eligible for curative treatment but preferred palliative treatment was significantly worse compared to those treated for cure.

23. Summary: Decision making: Age was not an exclusion factor from receiving curative treatment. Pts. medically eligible → for curative treatment. The survival of Pts. treated for cure was 4.7 years, while the life expectancy of the general population (of 82 y old) is about the same (6.3 y). Conclusion: Seniors having HNSCC do benefit from curative treatment. Therefore, exclusion from receiving such treatment should be based, as for younger subjects, on a careful individual basis.

24. Thank You