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A Prospective Evaluation of Dysphagia After Transoral Robotic Surgery for Squamous Cell Carcinoma of the Oropharynx
Volume 94 Number 4 2016 Author Disclosure: N.P. Joshi: None. A. Juloori: None. M.C. Ward: None. H. Qu: None. J.F. Greskovich: None. E. Murray: None. J. Potter: None. A. Dorfmeyer: None. P. Xia: Honoraria; Philips. S. Koyfman: None.
114 A Prospective Evaluation of Dysphagia After Transoral Robotic Surgery for Squamous Cell Carcinoma of the Oropharynx W.G. Albergotti, R.L. Ferris, U. Duvvuri, S. Kim, T. Wasserman, J. Jordan, and K. Anthony; University of Pittsburgh Medical Center, Pittsburgh, PA Purpose/Objective(s): Transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC) has been associated with improved long-term dysphagia quality of life as compared to chemoradiation. Nevertheless, dysphagia is common in the perioperative period and has been inadequately characterized. Our primary objective in this study is to characterize short-term swallowing outcomes after TORS for OPSCC in a prospective manner in an attempt to improve postoperative outcomes. Materials/Methods: Patients undergoing TORS for OPSCC were prospectively enrolled into this study between the dates of June 20, 2014 and July 31, 2015. Patients were evaluated by a speech-language pathologist postoperatively for diet recommendations and swallow strengthening exercises. The Eating Assessment Tool 10 (EAT-10), a 10-item validated questionnaire measuring swallowing quality of life, was administered on postoperative day (POD) 1, POD 7, and POD 30. A score >3 is considered to be indicative of swallowing dysfunction. Medical records were queried for demographics, clinical history, staging, intraoperative factors, and postoperative course. Patients were excluded for a history of previous TORS or radiation to the oropharynx, repeat TORS within 1 month after enrollment, TORS for nonmalignancy, a procedure on a nonoropharyngeal aerodigestive subsite, a contraindication to swallowing evaluation, or incomplete data. Statistical analysis was performed using a paired t test to compare EAT-10 scores between POD 1 and POD 7 and POD 30. Results: Fifty-nine patients met initial inclusion criteria. Twenty-four patients were excluded (8 for nonoropharyngeal procedures, 5 for contraindications to swallowing evaluation, 7 for repeat TORS within 1 month, and 4 for incomplete data), leaving 35 patients (26 males, 9 females) for analysis. The mean age was 58.8 (range 43-74) years. Four of the 35 patients (11.4%) reported preoperative dysphagia. Twenty of the 35 patients (57.1%) underwent tongue base resection, with the remainder undergoing radical tonsillectomy. T stages were Tx (3), T1 (18), T2 (13), T3 (1), all HPV+. All patients were started on an oral diet by POD 1 without instrumental testing. The mean EAT-10 score (0-40) on POD 1 was 21.5 (range 0-37), on POD 7 was 27.7 (range 14-45), and on POD 30 was 11.9 (range 1-33). EAT-10 scores were significantly worse at POD 7 (PZ.003) and significantly better on POD 30 (P<.001) as compared with initial evaluation. However, at 1 month, only 5 of 34 patients (14.3%) had normal EAT-10 scores. Mean weights (lbs) decreased significantly over the month (207.6 vs 198.8, P<.001). Conclusion: Most patients who undergo TORS experience dysphagia for at least the first month after surgery. Patients can be counseled that dysphagia will worsen by postoperative day 7 and then improve, but it likely will not resolve by 1 month. Swallowing evaluation and therapy should be considered routine in this cohort of patients. Author Disclosure: W.G. Albergotti: None. R.L. Ferris: None. U. Duvvuri: None. S. Kim: None. T. Wasserman: None. J. Jordan: None. K. Anthony: None.
115 The Influence of Diabetes Mellitus and Metformin on Distant Metastases in Oropharyngeal Cancer: A Multicenter Study Z.S. Zumsteg,1 B.M. Beadle,2 D.E. Spratt,3 A. Rivera,4 H.D. Skinner,2 J. Osborne,5 A.S. Garden,2 and N. Lee4; 1Cedars-Sinai Medical Center, Los Angeles, CA, 2The University of Texas MD Anderson Cancer Center, Houston, TX, 3University of Michigan, Ann Arbor, MI, 4Memorial Sloan
Posters
877
Kettering Cancer Center, New York, NY, 5Memorial Sloan-Kettering Cancer Center, New York, NY Purpose/Objective(s): Locoregional control in oropharyngeal cancer (OPC) following concomitant chemoradiation (CRT) has improved to unprecedented rates in the modern era. This is largely attributable to the increasing prevalence of human papillomavirus (HPV)-positive OPC, a malignancy with increased sensitivity to both radiation therapy (RT) and chemotherapy when compared to HPV-negative OPC. As a result, distant metastases are increasing, driving survival outcomes for OPC. Given that both diabetes mellitus and metformin use have been purported to affect clinical cancer outcomes, including metastases, we aimed to determine the impact of these factors in a large population of OPC patients treated in the modern era. Materials/Methods: The records of 1745 patients with OPC cancer treated at 2 large cancer centers with definitive RT from 1998 to 2011 were retrospectively reviewed. Outcomes assessed included local failure-free survival (LFFS), regional failure-free survival (RFFS), distant metastasisfree survival (DMFS), and overall survival (OS). Results: Median follow-up was 4.3 years. A total of 184 patients had diabetes at time of diagnosis, including 102 patients taking metformin. Chemotherapy was administered to 77%, 86%, and 82%, of nondiabetic patients, diabetic patients taking metformin, and diabetic patients not taking metformin, respectively (PZ.063). There was no significant difference between these groups in terms of tumor stage (PZ.18), nodal stage (PZ.18), or HPV status (PZ.56), although HPV data was available for only 23% of the cohort. In comparison to patients without diabetes, diabetic patients not using metformin had worse 5-year DMFS (89.6% vs 78.7%, PZ.011) and OS (83.0% vs 70.7%, PZ.048). By contrast, diabetic metformin users had no significant difference in 5-year DMFS (90.1%) or OS (89.6%) in comparison to nondiabetic patients. On multivariate analysis with diabetic patients not using metformin as a reference, nondiabetic patients (hazard ratio [HR] Z 0.54, 95% confidence interval [CI] 0.320.93, PZ.03) and diabetic metformin users (HRZ0.46, 95% CI 0.20-1.04, PZ.06) had improved DMFS after adjusting for age, stage, smoking, and chemotherapy use, although this did not reach statistical significance for diabetic metformin users. Five-year LFFS and RFFS was 93% to 95% in all groups, with no significant difference with respect to diabetes status or metformin use. Conclusion: Diabetic OPC patients not using metformin had significantly higher rates of distant metastases than nondiabetic patients even after adjusting for confounding variables, whereas diabetics using metformin had similar rates of distant metastases to nondiabetics. Further prospective investigation is warranted to validate metformin’s benefit in OPC. Author Disclosure: Z.S. Zumsteg: None. B.M. Beadle: None. D.E. Spratt: None. A. Rivera: None. H.D. Skinner: None. J. Osborne: None. A.S. Garden: None. N. Lee: None.
116 Response-Adapted Volume De-escalation (RAVD) in Locally Advanced Head and Neck Cancer: Toxicity and Quality of Life Analyses J.M. Melotek,1 V.M. Villaflor,1 T.G. Karrison,1 R.J. Brisson,1 E.A. Blair,1 L. Portugal,1 K.M. Stenson,2 J.A. de Souza,1 E. Cohen,3 A. Langerman,1 M.T. Spiotto,1 T.Y. Seiwert,1 E.E. Vokes,1 and D.J. Haraf1; 1University of Chicago, Chicago, IL, 2Rush University, Chicago, IL, 3University of California San Diego, La Jolla, CA Purpose/Objective(s): Efforts to reduce treatment toxicity in locally advanced head and neck squamous cell carcinoma (LA-HNSCC) have focused on radiation therapy (RT) dose de-escalation in select populations. We report here the toxicity and quality of life (QOL) outcomes from a phase 1/randomized phase 2 trial using response to induction chemotherapy (IC) as a decision tool to guide the extent of RT volume reduction in a nonselected population of patients (pts) with LA-HNSCC. Materials/Methods: Pts with measurable LA-HNSCC received 2 cycles of IC (cisplatin, paclitaxel, cetuximab everolimus). Pts with “good” response (GR), defined as 50% reduction in the sum of gross tumor
114 A Prospective Evaluation of Dysphagia After Transoral Robotic Surgery for Squamous Cell Carcinoma of the Oropharynx W.G. Albergotti, R.L. Ferris, U. Duvvuri, S. Kim, T. Wasserman, J. Jordan, and K. Anthony; University of Pittsburgh Medical Center, Pittsburgh, PA Purpose/Objective(s): Transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC) has been associated with improved long-term dysphagia quality of life as compared to chemoradiation. Nevertheless, dysphagia is common in the perioperative period and has been inadequately characterized. Our primary objective in this study is to characterize short-term swallowing outcomes after TORS for OPSCC in a prospective manner in an attempt to improve postoperative outcomes. Materials/Methods: Patients undergoing TORS for OPSCC were prospectively enrolled into this study between the dates of June 20, 2014 and July 31, 2015. Patients were evaluated by a speech-language pathologist postoperatively for diet recommendations and swallow strengthening exercises. The Eating Assessment Tool 10 (EAT-10), a 10-item validated questionnaire measuring swallowing quality of life, was administered on postoperative day (POD) 1, POD 7, and POD 30. A score >3 is considered to be indicative of swallowing dysfunction. Medical records were queried for demographics, clinical history, staging, intraoperative factors, and postoperative course. Patients were excluded for a history of previous TORS or radiation to the oropharynx, repeat TORS within 1 month after enrollment, TORS for nonmalignancy, a procedure on a nonoropharyngeal aerodigestive subsite, a contraindication to swallowing evaluation, or incomplete data. Statistical analysis was performed using a paired t test to compare EAT-10 scores between POD 1 and POD 7 and POD 30. Results: Fifty-nine patients met initial inclusion criteria. Twenty-four patients were excluded (8 for nonoropharyngeal procedures, 5 for contraindications to swallowing evaluation, 7 for repeat TORS within 1 month, and 4 for incomplete data), leaving 35 patients (26 males, 9 females) for analysis. The mean age was 58.8 (range 43-74) years. Four of the 35 patients (11.4%) reported preoperative dysphagia. Twenty of the 35 patients (57.1%) underwent tongue base resection, with the remainder undergoing radical tonsillectomy. T stages were Tx (3), T1 (18), T2 (13), T3 (1), all HPV+. All patients were started on an oral diet by POD 1 without instrumental testing. The mean EAT-10 score (0-40) on POD 1 was 21.5 (range 0-37), on POD 7 was 27.7 (range 14-45), and on POD 30 was 11.9 (range 1-33). EAT-10 scores were significantly worse at POD 7 (PZ.003) and significantly better on POD 30 (P<.001) as compared with initial evaluation. However, at 1 month, only 5 of 34 patients (14.3%) had normal EAT-10 scores. Mean weights (lbs) decreased significantly over the month (207.6 vs 198.8, P<.001). Conclusion: Most patients who undergo TORS experience dysphagia for at least the first month after surgery. Patients can be counseled that dysphagia will worsen by postoperative day 7 and then improve, but it likely will not resolve by 1 month. Swallowing evaluation and therapy should be considered routine in this cohort of patients. Author Disclosure: W.G. Albergotti: None. R.L. Ferris: None. U. Duvvuri: None. S. Kim: None. T. Wasserman: None. J. Jordan: None. K. Anthony: None.
115 The Influence of Diabetes Mellitus and Metformin on Distant Metastases in Oropharyngeal Cancer: A Multicenter Study Z.S. Zumsteg,1 B.M. Beadle,2 D.E. Spratt,3 A. Rivera,4 H.D. Skinner,2 J. Osborne,5 A.S. Garden,2 and N. Lee4; 1Cedars-Sinai Medical Center, Los Angeles, CA, 2The University of Texas MD Anderson Cancer Center, Houston, TX, 3University of Michigan, Ann Arbor, MI, 4Memorial Sloan
Posters
877
Kettering Cancer Center, New York, NY, 5Memorial Sloan-Kettering Cancer Center, New York, NY Purpose/Objective(s): Locoregional control in oropharyngeal cancer (OPC) following concomitant chemoradiation (CRT) has improved to unprecedented rates in the modern era. This is largely attributable to the increasing prevalence of human papillomavirus (HPV)-positive OPC, a malignancy with increased sensitivity to both radiation therapy (RT) and chemotherapy when compared to HPV-negative OPC. As a result, distant metastases are increasing, driving survival outcomes for OPC. Given that both diabetes mellitus and metformin use have been purported to affect clinical cancer outcomes, including metastases, we aimed to determine the impact of these factors in a large population of OPC patients treated in the modern era. Materials/Methods: The records of 1745 patients with OPC cancer treated at 2 large cancer centers with definitive RT from 1998 to 2011 were retrospectively reviewed. Outcomes assessed included local failure-free survival (LFFS), regional failure-free survival (RFFS), distant metastasisfree survival (DMFS), and overall survival (OS). Results: Median follow-up was 4.3 years. A total of 184 patients had diabetes at time of diagnosis, including 102 patients taking metformin. Chemotherapy was administered to 77%, 86%, and 82%, of nondiabetic patients, diabetic patients taking metformin, and diabetic patients not taking metformin, respectively (PZ.063). There was no significant difference between these groups in terms of tumor stage (PZ.18), nodal stage (PZ.18), or HPV status (PZ.56), although HPV data was available for only 23% of the cohort. In comparison to patients without diabetes, diabetic patients not using metformin had worse 5-year DMFS (89.6% vs 78.7%, PZ.011) and OS (83.0% vs 70.7%, PZ.048). By contrast, diabetic metformin users had no significant difference in 5-year DMFS (90.1%) or OS (89.6%) in comparison to nondiabetic patients. On multivariate analysis with diabetic patients not using metformin as a reference, nondiabetic patients (hazard ratio [HR] Z 0.54, 95% confidence interval [CI] 0.320.93, PZ.03) and diabetic metformin users (HRZ0.46, 95% CI 0.20-1.04, PZ.06) had improved DMFS after adjusting for age, stage, smoking, and chemotherapy use, although this did not reach statistical significance for diabetic metformin users. Five-year LFFS and RFFS was 93% to 95% in all groups, with no significant difference with respect to diabetes status or metformin use. Conclusion: Diabetic OPC patients not using metformin had significantly higher rates of distant metastases than nondiabetic patients even after adjusting for confounding variables, whereas diabetics using metformin had similar rates of distant metastases to nondiabetics. Further prospective investigation is warranted to validate metformin’s benefit in OPC. Author Disclosure: Z.S. Zumsteg: None. B.M. Beadle: None. D.E. Spratt: None. A. Rivera: None. H.D. Skinner: None. J. Osborne: None. A.S. Garden: None. N. Lee: None.
116 Response-Adapted Volume De-escalation (RAVD) in Locally Advanced Head and Neck Cancer: Toxicity and Quality of Life Analyses J.M. Melotek,1 V.M. Villaflor,1 T.G. Karrison,1 R.J. Brisson,1 E.A. Blair,1 L. Portugal,1 K.M. Stenson,2 J.A. de Souza,1 E. Cohen,3 A. Langerman,1 M.T. Spiotto,1 T.Y. Seiwert,1 E.E. Vokes,1 and D.J. Haraf1; 1University of Chicago, Chicago, IL, 2Rush University, Chicago, IL, 3University of California San Diego, La Jolla, CA Purpose/Objective(s): Efforts to reduce treatment toxicity in locally advanced head and neck squamous cell carcinoma (LA-HNSCC) have focused on radiation therapy (RT) dose de-escalation in select populations. We report here the toxicity and quality of life (QOL) outcomes from a phase 1/randomized phase 2 trial using response to induction chemotherapy (IC) as a decision tool to guide the extent of RT volume reduction in a nonselected population of patients (pts) with LA-HNSCC. Materials/Methods: Pts with measurable LA-HNSCC received 2 cycles of IC (cisplatin, paclitaxel, cetuximab everolimus). Pts with “good” response (GR), defined as 50% reduction in the sum of gross tumor