|Year : 2017 | Volume
| Issue : 2 | Page : 351-355
Overall treatment duration with multimodality treatment approach and outcome results in oral cavity carcinoma: A study from an institute from central India
Vandana Jain1, Digpal Dharkar2, Hamsa Nandini3, Shailendra M Jain4
1 Department of Radiation Oncology, Indian Institute of Head and Neck Oncology, Indore Cancer Foundation, Indore, Madhya Pradesh, India
2 Department of Oncosurgery, Indian Institute of Head and Neck Oncology, Indore Cancer Foundation, Indore, Madhya Pradesh, India
3 Malabar Cancer Centre, Thalassery, Kerala, India
4 Department of Microbiology, Rural Medical College, Loni Bk, Maharashtra, India
|Date of Web Publication||23-Jun-2017|
Department of Radiotherapy and Oncology, Rural Medical College and Hospital, Pravara Institute of Medical Sciences DU., Loni Bk., Tal: Rahata, Ahmednagar - 413 736, Maharashtra
Source of Support: None, Conflict of Interest: None
Objective of the Study: To see the different age groups, gender, sites, disease stage, treatment outcome of various oral cavity sites carcinoma by combined modalities and the overall treatment duration.
Materials and Methods: A total of 212 oral cavity carcinoma patients (169 males and 43 females) with complete records (from September 2009 to December 2012) were analyzed for age, sex, histopathology, associated medical illnesses, various subsites with disease stage, various treatment modalities with the duration and follow-up records for disease control as well as disease failure at local, nodal, local + nodal, and distant metastasis.
Results: The most common site in oral cavity cancer was buccal mucosa 81 (38.20%). 149 (69%) patients reported were in advanced Stages III and IV of the disease. The majority of patients 149 (70.28%) were given chemotherapy + radiotherapy postoperatively (S-CRT group). The mean follow-up for all patients was 41 months (range = 21–59 months). In terms of overall disease control and metastases-free survival, the best results were (80%) for Stage I in all oral cavity sites. Irrespective of disease stage best results (59.57%) were in alveolar ridge subsite of oral cavity carcinoma.
Conclusion: Challenges are still lie ahead in treating head and neck carcinoma, as in spite of using multimodality treatment approach and biological and molecular research, the overall survival percentage has not changed much. In India as oral cavity carcinoma is in increasing trend in younger individuals massive health promotion and awareness programs targeting the risk population along with financial support for those already affected are required.
Keywords: Head and neck carcinoma, multimodality treatment, oral cavity carcinoma, overall treatment duration, treatment outcome
|How to cite this article:|
Jain V, Dharkar D, Nandini H, Jain SM. Overall treatment duration with multimodality treatment approach and outcome results in oral cavity carcinoma: A study from an institute from central India. J Can Res Ther 2017;13:351-5
|How to cite this URL:|
Jain V, Dharkar D, Nandini H, Jain SM. Overall treatment duration with multimodality treatment approach and outcome results in oral cavity carcinoma: A study from an institute from central India. J Can Res Ther [serial online] 2017 [cited 2022 Sep 25];13:351-5. Available from: https://www.cancerjournal.net/text.asp?2017/13/2/351/180613
| > Introduction|| |
Head and neck cancers are the sixth most common malignancy and are the major cause of cancer morbidity and mortality worldwide. In India and South East Asia, oral cancer incidence accounts for 40% of all the malignancies. India has the dubious distinction of harboring world's highest number (nearly 20%) of oral cancers. Each year, approximately 1 million people in India are diagnosed with oral cancers. One-third of all male cancers in India originate in the oral cavity. Cancer of the buccal mucosa (BM) and alveolar ridge together called the gingivobuccal complex cancer (Indian oral cancer) is the most commonly affected oral subsite in India. About 60–70% of these patients report in Stage III/IV or advanced stages of the disease. Metastases to regional lymph nodes are the single most important prognostic factor in predicting local and distant failure as well as survival. The nodal metastases reduce the survival by 50%. Radiotherapy (RT) alone has long been the standard nonsurgical therapy for locally advanced head and neck carcinoma, but locoregional failure was the predominant recurrence pattern. In oral cavity carcinoma uncontrolled local and/or regional disease leads to higher morbidity and mortality. Treatment of advanced stage oral cavity carcinoma has classically involved surgical resection with postoperatively adjuvant RT (S-RT)., Despite this dual modality treatment outcome has remained same., Adjuvant concurrent chemo-RT postoperatively for advanced stage disease as a more effective treatment option was established in two landmark trials (radiation therapy oncology group 9501 and the European Organization for Research and Treatment of Cancer 22,931 trials)., To achieve good disease control combination of various treatment modalities such as chemotherapy (CT) and surgery to RT is preferred.
Combined treatment modality approach is preferred as per patient disease stage, performance status, other associated illnesses, and patient's convenience. At our institute, most of the patients were first evaluated for operability, and RT ± CT treatment is planned postoperatively. Inoperable oral cavity carcinoma patients were given neoadjuvant CT (NACT) and then again reviewed for operability. This retrospective study is performed to assess the outcome of various oral cavity sites carcinoma by combined modalities and the overall treatment duration.
| > Materials and Methods|| |
This retrospective study was performed on all oral cavity carcinoma patients reported at the Institute from September 2009 to December 2012 for their management. Data collection were done from file records to see for age, gender, various sites, stage, histopathology, various treatment modalities used in combination, overall treatment duration, and follow-up records for disease control as well as disease failure at local, nodal, local + nodal sites, and distant metastasis.
Maximum patients in head and neck carcinoma were from the oral cavity. All oral cavity carcinoma patients were grouped in four groups: Oral tongue, BM, alveolar ridge, and other sites (lip, floor of mouth, retromolar trigone, and hard palate).
Staging of the tumor was done as per the American Joint Committee on Cancer guidelines, (staging manual 2009) clinically supported with relevant radiological investigations. In postoperative cases, pathological staging was considered. All these oral cavity cancer patients were referred postoperatively for RT/RT + CT. There were few inoperable patients, and they were given 2–3 cycles of NACT (paclitaxel + cisplatin) and again seen for operability. If operable planned for surgery then postoperatively planned for RT + CT. Those that were inoperable even after three cycles of NACT were planned for CT + RT. Surgery is planned as per the site, stage of the disease, and patient general condition as well as patient willingness for surgery. The various surgical procedures performed included wide local excision of the soft tissue and bony components, selective, modified or radical neck dissection, and flap reconstruction. RT treatment was given by conventional two-dimensional planning on cobalt 60 tele-therapy unit by shrinking field technique. Total dose given was 60 Gy in postoperated and 66 Gy in unoperated patients over 6–7 weeks duration (200 cGy/fraction). Injection Cisplatin 30 mg/m 2 was given weekly over 6–7 weeks as CT for concurrent CT + RT treatment. Treatment duration was calculated from the day 1 (RT or surgery or NACT or CT + RT) to the last day of treatment in all the study group patients who completed their treatment. Usually, postoperative adjuvant RT or RT + CT was started after 21–40 days of surgery. This usually takes 6–7 weeks (42–49 days). Overall treatment time (OTT) taken was from 71 to 90 days if all three treatment modalities were used. Only in NACT treatment duration was prolonged for 6–8 weeks. If only CT + RT used then the treatment duration was 45–49 days. OTT is grouped into three groups namely 50, 51–90, and >90 days.
Disease control is analyzed in terms of disease-free survival till last follow-up and disease failure in term of local, nodal, local + nodal, and distant metastasis. Duration is counted after last treatment day. On clinical suspicion disease, failure was confirmed by supporting radiological investigations and histopathology. Disease failure was recorded as failure within 6 months, 6 months to 1 year, 1–2 years, 2–3 years, 3–4 years, 4–5 years, and more than 5 years. Last follow-up record was considered up to May 2015.
| > Results|| |
A total of 940 patients were treated at the institute from September 2009 to December 2012. Of which 416 (44.25%) were of head and neck carcinoma. Of 416 head and neck carcinoma patients, 269 were of oral cavity 213 and 56 were males and females, respectively.
Of 269 oral cavity carcinoma patients, 212 were analyzed for this study. Fifty-seven patients were excluded from the study as 33 patients defaulted their treatment (mostly due to advanced stages of disease), some lost for follow-up (21), two expired during treatment, and three patients record was incomplete.
Of 212 study group patients, 169 (87.06%) were males, and 43 (12.94%) were females. The most common histopathology reported was squamous cell carcinoma 207 patients and only five with adenocarcinoma. Associated medical problems were hypertension, diabetes, pulmonary tuberculosis, and bronchial asthma as per records are shown in [Table 1].
The most common site in oral cavity carcinoma was BM 81 patients (38.20%) followed by oral tongue 68 (32.07%), alveolar ridge 47 (22.14%), and other sites 16 (7.54%). Details of this are shown in [Table 2].
Most of the patients were from 40 to 60 years of age group. The youngest patient was of 23 years male and the oldest was 86-year-old male. Various oral cavity cancer sites in different age groups are shown in [Table 3]. Only 15 (7.07%) patients were reported in Stage I, 48 (22.64%) were in Stage II, and remaining 149 patients were in advanced Stages III and IV of the disease which accounts for more than 69% of the patients. Details of this are shown in [Table 3].
Details of various treatment modalities used and overall treatment duration are shown in [Table 4] and [Table 5]. Only 17 patients were given CT + RT treatment of which three exceeded their treatment duration by 1 week (OTT-56 days). Nineteen early stage patients were given only RT treatment postoperatively. Twenty-seven advanced stages patients were given 2–3 cycles of CT (NACT) followed by surgery and CT + RT postoperatively. Overall treatment duration of 12 patients was prolonged due to late reporting postoperatively for RT and CT treatment.
The mean follow-up for all patients was 41 months (range = 21–59 months).
Overall disease control for various treatment groups is not separately analyzed as most of the patients were in S-CRT group (83%).
Disease- and metastases-free survival analysis at various oral cavity carcinoma subsites were done from the last date of treatment to the last follow-up by Kaplan–Meier survival analysis (by Med Cal-version 15.10.0). This is shown in [Figure 1] and [Table 6]. Best results (80%) were for Stage I in all oral cavity sites. Irrespective of stage best results (59.57%) were in alveolar ridge subsite of oral cavity carcinoma.
|Figure 1: Kaplan–Meier plot showing disease-free survival curve of various oral cavity sites patients|
Click here to view
Disease failure at local sites was highest in 1st year of completion of treatment. Lowest disease failure is observed in early stage disease (Stages I and II) and at alveolar ridge subsite of oral cavity carcinoma. Details of this are shown in [Table 7].
| > Discussion|| |
This study was a retrospective and hospital record-based study and only histopathologically confirmed patients of oral carcinoma were considered. Male preponderance with oral cancer in this study indicates males were more often involve themselves with various addictions which is a known risk factor for oral cavity carcinoma.
With the advancement in various surgical procedures and good anesthesia, support surgery remains the main-stay of treatment for oral cavity carcinoma even in advanced stages.,,, Despite advances in surgical and reconstructive techniques, complete clearance of infratemporal fossa and masticator space which are the frequently involved anatomical sites in oral carcinoma, is extensive and extremely morbid., Induction CT/NACT in unresectable/locally advanced head and neck carcinoma has encouraging results in TAX232 and TAX234 trials.,
Standard fractionation RT with concurrent cisplatin was shown to provide superior locoregional and overall survival in head and neck carcinoma over RT alone by the American intergroup trial published by Adelstein et al.,
Our results are slightly at lower side if compared with other similar studies. Probable reasons for this are multifactorial such as poor patient compliance for the treatment, nutritional factors, and continuation of some, or the other addictions. Treatment-related factors such as radiation dose, CT drug dose, and more radical surgeries will help in improving results to some extent, but at the same time will increase more treatment-related morbidity and more defaulters.
In this study, disease failure at nodal and nodal + local is very less as compare to local failure. This shows that the treatment in combined modality approach (surgery for neck node dissection, including neck nodes in radiation field, and concurrent CT with radiation) controls nodal metastases better. At the same time, high local failure needs more attention at local site.
Our institute being charitable institute, most of the patients reported were from lower middle or lower socioeconomic group. RT or RT plus CT treatment takes minimum 50 days' time plus the time for various investigations to confirm the diagnosis and staging of disease. More than 65% of patients were below 50 years of age, and they were the only or main earning member of the family. Adding other treatment modalities such as surgery and NACT to this will further prolong the treatment by 3–8 weeks. On the flip side, multimodality treatment increases the OTT. Constant family and financial support for the longer duration of treatment with combined modality is of great concern as most of these individuals are the earning member of the family.
| > Conclusion|| |
Challenges are still ahead in treating head and neck carcinoma as in spite of using multimodality treatment approach and biological and molecular research, the overall survival percentage has not changed much. In India, oral cavity carcinoma is in increasing trend in younger individuals due to various addictions, poor diet, poor oral hygiene, and carelessness toward various oral pathologies. Massive health promotion and awareness programs targeting the risk population along with financial support for those already affected are required.
We would like to thank Mr. Prakash Rawat, Mrs. Rekha Jatav, and Mr. Deepak Rawat for providing technical support for taking out hospital records from medical record section of the institute.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]
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