- Email: [email protected]
Trends of oral and oropharyngeal cancer survival over five decades in 3267 patients treated in a single institution
Oral Oncology (2004) 40 71–76
www.elsevier.com/locate/oraloncology
Trends of oral and oropharyngeal cancer survival over five decades in 3267 patients treated in a single institution ´ L. Carvalho, Mauro K. Ikeda, Jose ´ Magrin, Luiz P. Kowalski* Andre Head and Neck Surgery and Otorhinolaringology Department Centro de Tratamento e Pesquisa, Hospital do ˆ ncer A.C.Camargo Rua Professor Antonio Prudente, 211, Sa ˜o Paulo 01509-010, Brazil Ca
Received 7 May 2003; accepted 13 June 2003
KEYWORDS Oral cancer; Oropharynx cancer; Trends; Treatment; Survival; Prognosis
Summary The objective of this study was to analyze the influence of changes in the treatment on the prognosis of patients treated over 44 years in a single institution. The 5-decade trends in treatment approach and 5-year survival of 3267 patients treated between 1953 and 1997 were analyzed. An increase was observed in primary surgical treatment and its association with radiotherapy. In the 1950s, 29.1% of the patients were treated by surgery, 54.5% by radiotherapy and 16.4% by combined treatment; in the 1990s, these proportions were 39.7, 9.7 and 50.6%, respectively (P< 0.001). There was a significant increase in the 5-year survival rates from 28.7% for patients treated in the 1950s to 43.2% in the 1990s (P <0.001). The changes in treatment approach for oral and oropharyngeal cancer over the last 5 decades, with an increase of surgical treatment and its combination with radiotherapy significantly improved the survival rates. # 2003 Elsevier Ltd. All rights reserved.
1. Introduction There are reports describing no changes in survival rates of head and neck cancer throughout the last 3 decades,1,2 however, during the same time case series had also described changes in the treatment approach of the head and neck cancer patients with significant improvements in locoregional control and survival rates.3 12 For oral cancer these changes mainly involve a shift in treatment policy in favor of primary surgical treatment, and postoperative radiotherapy for selected * Corresponding author. Tel./fax: +55-11-3341-0326. E-mail address: [email protected] (L.P. Kowalski).
cases (depending mainly on clinical stage, margins and pathological positive lymph nodes). Our institution as many others have been following these changes.13,14 In fact, the characteristics of the patients during the same period had also changed, concerning the clinical stage at presentation and the distribution of tumor sites. Moreover the main changes in treatment, based on a higher indication of surgical procedures instead of radiotherapy alone, were possible due to the evolution of the medical care regarding patient care (introduction of the intensive care unit), anesthesia (technique, monitorization and drugs) and surgical procedures (specially reconstrutive techniques). On the other side, the radiotherapy
1368-8375/$ - see front matter # 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S1368-8375(03)00138-6
72 technique and equipment had an overwhelming improvement.9, 15 The objective of this study is to evaluate the changes in the treatment approach that occurred in the Centro de Tratamento e Pesquisa Hospital do Cancer A.C.Camargo, Sao Paulo, Brazil, during the last 44 years concerning oral cavity and oropharynx cancer patients, and analyze the association of these changes with patient’s prognosis.
2. Patients and methods Patients were identified by screening from the Head and Neck Surgery Department Database of the Centro de Tratamento e Pesquisa Hospital do Cancer A.C.Camargo in Sao Paulo, Brazil, that includes patients treated in the institution from 1953 to 1997. A total of 6281 were identified, but 2896 were excluded because one or more of the following inclusion criteria: oral and oropharyngeal tumors (excluding lip cancers), histologically classified as squamous cell carcinoma, previously untreated and admitted for treatment in the institution. For this study, 3385 patients were selected. The clinical, pathological and therapeutic information were reviewed from the medical charts and cases were restaged based upon the clinical staging system proposed by the UICC criteria published in 1997.16 Clinical stage (CS) was then grouped into early stage disease (CS I and II) or advanced stage disease (CS III and IV). Patients were also grouped according to the decade of admission at the institution. Three types of treatment approaches were considered for analysis: surgery alone, radiotherapy alone and combined treatment (surgery plus radiotherapy). Among all patients, 118 cases (3.5%) were submitted to chemotherapy alone. These cases were excluded from the analysis. The trends in patients characteristics concerning clinical stage and tumor site, treatment approach and 5-year overall survival were compared within the 5 decades.
2.1. Statistical analysis For statistical analysis was used the computer program SPSS for Windows.17 Descriptive analysis was performed to show the distribution of the population and the statistical comparisons using the Chi-square test. Overall survival time was calculated as the period between the date of treatment beginning and date of last observation. Patients were uncensored for any cause of death, patients alive in the last observation were considered censored in that date for the survival
A.L. Carvalho et al. analysis. Survival analysis were performed using the Kaplan—Meier method and the log-rank test. Cox’s regression analysis was used to calculate multivariate hazard ratios of death. Statistical significance was determined for P-value < 0.05.
3. Results This series include 3267 patients treated over 44 years. They were 2781 males (85.1%) and 2790 were caucasians (85.4%). Median age was 57 years (mean, 56.6 years). The tumor was sited in the oral cavity in 2492 cases (76.3%) and in the oropharynx in 775 cases (23.7%). Clinical stages (CS) were: CS I, 178 cases (5.4%); CS II, 455 (13.9%); CS III, 705 (21.6%); CS IV, 1902 (58.2%) and in 27 cases (0.8%) this information was not available. Among all patients, 378 (11.6%) were treated in the 1950s; 666 (20.4%), in the 1960s; 842 (25.8%), in the 1970s; 918 (26.1%), in the 1980s and 463 (14.2%), in the 1990s. According to the treatment performed, 957 patients (29.3%) underwent surgery alone; 1551 (47.5%), radiotherapy alone and 759 (23.7%) combined treatment (surgery plus radiotherapy). The proportion of gender (male/female) and age distribution were maintained along the period. However, there was a significant difference according to the decade of admission and the distribution of cases regarding their clinical stage and site of the tumor. In the early decades (1950s, 1960s and 1970s), there was a higher number of oral cavity cancer patients than in the later decades (1980s and 1990s) (P < 0.001) (Table 1). Besides, in the early decades the number of advanced cases was higher than in the later (P < 0.001) (Table 2). We observed also that the treatment approach changed with the increase of cases treated by surgery based approach (alone or combined with radiotherapy). These changes were significantly different even when the distribution of the treatment approach by each decade was stratified by clinical stage (Figs. 1 and 2). There was a significant increase in the 5-year overall survival rates from 28.7% for patients treated in the 1950s to 43.2% for those treated in the 1990s (P < 0.001). For initial tumors (CS I and II), the improvement in their prognosis along this time, were from a 5-year overall survival rate of 53.4% in the 1950s to 77.3% in the 1990s (P=0.011). Among the patients with advanced tumors (CS III and IV), we observed a rate of 24% in the 1950s and 32% in the 1990s (P=0.062) (Table 3). However, the Cox’s regression analysis showed that the decade of patient’s admission remains as an independent factor associated with
Trends of oral and oropharyngeal cancer survival over five decades
73
Table 1 Distribution of the cases according to the decade of admission in the hospital and the site of the tumor Period of admission (number of cases)
Decade Decade Decade Decade Decade
1950 1960 1970 1980 1990
Oral cavity
(378) (666) (842) (918) (463)
Oropharynx
P-value
N
(%)
N
(%)
301 556 659 666 310
(79.6) (83.5) (78.3) (72.5) (67.0)
77 110 183 252 153
(20.4) (16.5) (21.7) (27.5) (33.0)
< 0.001
Table 2 Distribution of the cases according to the decade of admission in the hospital and the clinical stage at diagnosisa Period of admission (number of cases)
Decade Decade Decade Decade Decade a
1950 1960 1970 1980 1990
(377) (663) (839) (913) (448)
Clinical stages I and II
Clinical stages III and IV
N
(%)
N
(%)
57 13 143 180 119
(15.1) (20.2) (17.0) (19.7) (26.6)
320 529 696 733 344
(84.9) (79.8) (83.0) (80.3) (73.4)
P-value
< 0.001
In 27 cases (0.8%) the information about clinical stage were not available.
Figure 1 Distribution of the cases along the decades according to the treatment approach (for clinical stage I and II).
74
A.L. Carvalho et al.
Figure 2 Distribution of the cases along the decades according to the treatment approach (for clinical stage III and IV).
Table 3 Five-year survival rates (%) according to the decade of admission in the hospital and the clinical stage at diagnosisa
All patients CS I and II CS III and IV
Decade 1950
Decade 1960
Decade 1970
Decade 1980
Decade 1990
P-value
28.7 53.4 23.9
29.6 54.0 23.3
26.4 52.4 21.4
32.5 56.2 26.4
43.2 77.3 32.2
< 0.001 0.011 0.062
CS, clinical stage. a In 27 cases (0.8%) the information about clinical stage were not available.
Table 4 Cox’s regression model for the risk of death Variables
Categories
Hazard ratio
95% CI
Decade
1950s 1960s 1970s 1980s 1990s Male Female < 65 years 565 years Early (I and II) Advanced (III and IV) Oral cavity Oropharynx
1.0 0.95 1.02 0.98 0.71 1.0 0.61 1.0 1.17 1.0 2.11 1.0 1.22
Ref. 0.8—1.1 0.9—1.2 0.9—1.1 0.6—0.9 Ref. 0.5—0.7 Ref. 1.1—1.3 Ref. 1.9—2.4 Ref. 1.1—1.3
Gender Age Clinical stage Site
Trends of oral and oropharyngeal cancer survival over five decades the survival, when the model was adjusted for age, gender, clinical stage and tumor site (P < 0.001) (Table 4).
4. Discussion At first sight, the fact we observed better survival in the latter decade could be attributed to the influence of the differences in the tumor site and the clinical stage at presentation of the patients along the decades or other patient’s characteristics, mainly comorbidities. And also to improvements in hospital facilities, intensive care units, anesthetic equipment and drugs and others medical progresses. However, in the Cox’s regression, adjusted for age, gender, clinical stage and tumor site, the decade of admission remains as an independent predictor of better survival (1990s), but this findings did not remain when the treatment approach was added to the model (data not shown), what means that the difference in the survival rates for the 1990s is due to the changes in the treatment approach rather than to changes in the patient’s performance status or other characteristics. Although many studies discussing changes in treatment approach were associated with improvement in locoregional control and survival rates,3 12 some studies that discussed the trend in survival along the time did not show improvement in survival rates.1,2 However, these hospital cancer registry analyzed in the same group, lip, oral cavity and pharynx (including nasopharynx, oropharynx and hypopharynx) tumors and did not take in account possible changes in the incidence of these tumors along the time, changes in clinical stage and changes in treatment approach and the other one was described before the 1990s.1,2 This series reflects the shift in treatment approach that have occurred in our institution over the last 44 years, during the same period significant changes on treatment approach for oral and oropharyngeal cancer patients have been described.3 12 Following these trends, the treatment approach in our institution had changed. It is important to notice that most of these changes were only possible due to the medical advances during this period, which includes the more accurate staging of the patient, based on computed tomography and magnetic nuclear resonance; better description of the pathological findings allowing a better option for adjuvant treatment approach; surgical techniques, mainly in reconstructive surgery, allowing more extensive resections; techniques and equipment of radiotherapy; better
75
patient clinical and multiprofessional care, including the anesthetic advances, intensive care units, control of comorbidities, and the increase in the life expectancy for the general population. Therefore, these advances are supposed to be followed by an increase in survival rates, which was observed in this series, mainly in patients treated in the latter decade. However, we must take into account that not only the survival rates of the patients improved but, patients treated during the 1990s (the decade that reflects the main changes in the treatment approach) had the best survival rates ever, even when the model was adjusted for age, gender, clinical stage and tumor site (P < 0.001). These observations allow us to conclude that the changes in the treatment approach for oral and oropharyngeal cancer patients in the institution were positively related with the increase of the survival rates of these patients.
Acknowledgements This work was supported in part by a grant from Fundac¸a ˜o de Amparo a ` Pesquisa do Estado de Sa ˜o Paulo, FAPESP (CEPID, Grant # 98/14335-2). References 1. Greenle RT, Murray T, Bolden S, Wingo PA. Cancer Statistics. CA Cancer J Clin 2000;50:7—33. 2. Stell PM, McCormick MS. Cancer of the head and neck: are we doing any better? Lancet 1985;2(8464):1127. 3. Fein DA, Mendenhall WM, Parsons JT, et al. Carcinoma of the oral tongue: a comparison of results and complications of treatment with radiothrapy and/or surgery. Head Neck 1994;16:358—365. 4. Kramer S, Gelger RD, Snow JB, et al. Combined radiation therapy and surgery in the management of advanced head and neck cancer: final report of study 73-03 of the Radiation Therapy Oncology Group. Head Neck 1987;10:19—30. 5. Hicks WL, North JH, Loree TR, et al. Surgery as a single modality therapy for squamous cell carcinoma of the oral tongue. Am J Otolaryngol 1998;19:24—28. 6. Dixit S, Vyas RK, Toparani RB, et al. Surgery versus surgery and postoperative radiotherapy in squamous cell carcinoma of the buccal mucosa: a comparative study. Ann Surg Oncol 1998;5:502—510. 7. Mishra RC, Singh DN, Mishra TK. Post-operative radiotherapy in carcinoma of buccal mucosa, a prospective randomized trial. Eur J Surg Oncol 1996;22:502—504. 8. Shah JP, Lydiatt W. Treatment of cancer of the head and neck. CA Cancer J Clin 1995;45:352—368. 9. Vikram B. Adjuvant Therapy in Head and Neck Cancer. CA Cancer J Clin 1998;48:199—209. 10. Rao DN, Shroff PD, Chattopadhyay G, Dinshaw KA. Survival analysis of 5595 head and neck cancers—results of conventional treatment in a high-risk population. Br J Cancer 1998;77:1514—1518. 11. Calais F, Alfonsi M, Bardet E, et al. Randomized trial of radiation therapy versus concomitant chemotherapy and
76 radiation therapy of advanced-stage oropharynx carcinoma. J Nat Cancer Inst 1999:2081—2086. 12. Robertson AG, Soutar DS, Paul J, et al. Early closure of a randomized trial: surgery and postoperative radiotherpay versus radiotherapy in the management of intra-oral tumours. Clin Oncol 1998;10:155—160. 13. Magrin J, Kowalski LP, Sabo ´ia M, Sabo ´ia RP. Major glossectomy: end results of 106 cases. Oral Oncol, Eur J Cancer B 1996;32B:407—412. 14. Kowalski LP, Magrin J, Sabo ´ia M, et al. Squamous cell car-
A.L. Carvalho et al. cinoma of the tongue: a review of 629 patients treated at a single institution. South Am J Cancer 1997:245—254. 15. Goepfert H. Squamous cell carcinoma of the head and neck: past progress and future promise. CA Cancer J Clin 1998; 48:195—198. 16. Sobin LH, Wittekind CH, editors. UICC TNM—classification of malignant tumors 5th ed. New York: John Wiley & Sons; 1997. 17. SPSS. Statistical package for social science, statistical data analysis for Windows. Chicago (IL, USA): SPSS; 1999.
www.elsevier.com/locate/oraloncology
Trends of oral and oropharyngeal cancer survival over five decades in 3267 patients treated in a single institution ´ L. Carvalho, Mauro K. Ikeda, Jose ´ Magrin, Luiz P. Kowalski* Andre Head and Neck Surgery and Otorhinolaringology Department Centro de Tratamento e Pesquisa, Hospital do ˆ ncer A.C.Camargo Rua Professor Antonio Prudente, 211, Sa ˜o Paulo 01509-010, Brazil Ca
Received 7 May 2003; accepted 13 June 2003
KEYWORDS Oral cancer; Oropharynx cancer; Trends; Treatment; Survival; Prognosis
Summary The objective of this study was to analyze the influence of changes in the treatment on the prognosis of patients treated over 44 years in a single institution. The 5-decade trends in treatment approach and 5-year survival of 3267 patients treated between 1953 and 1997 were analyzed. An increase was observed in primary surgical treatment and its association with radiotherapy. In the 1950s, 29.1% of the patients were treated by surgery, 54.5% by radiotherapy and 16.4% by combined treatment; in the 1990s, these proportions were 39.7, 9.7 and 50.6%, respectively (P< 0.001). There was a significant increase in the 5-year survival rates from 28.7% for patients treated in the 1950s to 43.2% in the 1990s (P <0.001). The changes in treatment approach for oral and oropharyngeal cancer over the last 5 decades, with an increase of surgical treatment and its combination with radiotherapy significantly improved the survival rates. # 2003 Elsevier Ltd. All rights reserved.
1. Introduction There are reports describing no changes in survival rates of head and neck cancer throughout the last 3 decades,1,2 however, during the same time case series had also described changes in the treatment approach of the head and neck cancer patients with significant improvements in locoregional control and survival rates.3 12 For oral cancer these changes mainly involve a shift in treatment policy in favor of primary surgical treatment, and postoperative radiotherapy for selected * Corresponding author. Tel./fax: +55-11-3341-0326. E-mail address: [email protected] (L.P. Kowalski).
cases (depending mainly on clinical stage, margins and pathological positive lymph nodes). Our institution as many others have been following these changes.13,14 In fact, the characteristics of the patients during the same period had also changed, concerning the clinical stage at presentation and the distribution of tumor sites. Moreover the main changes in treatment, based on a higher indication of surgical procedures instead of radiotherapy alone, were possible due to the evolution of the medical care regarding patient care (introduction of the intensive care unit), anesthesia (technique, monitorization and drugs) and surgical procedures (specially reconstrutive techniques). On the other side, the radiotherapy
1368-8375/$ - see front matter # 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S1368-8375(03)00138-6
72 technique and equipment had an overwhelming improvement.9, 15 The objective of this study is to evaluate the changes in the treatment approach that occurred in the Centro de Tratamento e Pesquisa Hospital do Cancer A.C.Camargo, Sao Paulo, Brazil, during the last 44 years concerning oral cavity and oropharynx cancer patients, and analyze the association of these changes with patient’s prognosis.
2. Patients and methods Patients were identified by screening from the Head and Neck Surgery Department Database of the Centro de Tratamento e Pesquisa Hospital do Cancer A.C.Camargo in Sao Paulo, Brazil, that includes patients treated in the institution from 1953 to 1997. A total of 6281 were identified, but 2896 were excluded because one or more of the following inclusion criteria: oral and oropharyngeal tumors (excluding lip cancers), histologically classified as squamous cell carcinoma, previously untreated and admitted for treatment in the institution. For this study, 3385 patients were selected. The clinical, pathological and therapeutic information were reviewed from the medical charts and cases were restaged based upon the clinical staging system proposed by the UICC criteria published in 1997.16 Clinical stage (CS) was then grouped into early stage disease (CS I and II) or advanced stage disease (CS III and IV). Patients were also grouped according to the decade of admission at the institution. Three types of treatment approaches were considered for analysis: surgery alone, radiotherapy alone and combined treatment (surgery plus radiotherapy). Among all patients, 118 cases (3.5%) were submitted to chemotherapy alone. These cases were excluded from the analysis. The trends in patients characteristics concerning clinical stage and tumor site, treatment approach and 5-year overall survival were compared within the 5 decades.
2.1. Statistical analysis For statistical analysis was used the computer program SPSS for Windows.17 Descriptive analysis was performed to show the distribution of the population and the statistical comparisons using the Chi-square test. Overall survival time was calculated as the period between the date of treatment beginning and date of last observation. Patients were uncensored for any cause of death, patients alive in the last observation were considered censored in that date for the survival
A.L. Carvalho et al. analysis. Survival analysis were performed using the Kaplan—Meier method and the log-rank test. Cox’s regression analysis was used to calculate multivariate hazard ratios of death. Statistical significance was determined for P-value < 0.05.
3. Results This series include 3267 patients treated over 44 years. They were 2781 males (85.1%) and 2790 were caucasians (85.4%). Median age was 57 years (mean, 56.6 years). The tumor was sited in the oral cavity in 2492 cases (76.3%) and in the oropharynx in 775 cases (23.7%). Clinical stages (CS) were: CS I, 178 cases (5.4%); CS II, 455 (13.9%); CS III, 705 (21.6%); CS IV, 1902 (58.2%) and in 27 cases (0.8%) this information was not available. Among all patients, 378 (11.6%) were treated in the 1950s; 666 (20.4%), in the 1960s; 842 (25.8%), in the 1970s; 918 (26.1%), in the 1980s and 463 (14.2%), in the 1990s. According to the treatment performed, 957 patients (29.3%) underwent surgery alone; 1551 (47.5%), radiotherapy alone and 759 (23.7%) combined treatment (surgery plus radiotherapy). The proportion of gender (male/female) and age distribution were maintained along the period. However, there was a significant difference according to the decade of admission and the distribution of cases regarding their clinical stage and site of the tumor. In the early decades (1950s, 1960s and 1970s), there was a higher number of oral cavity cancer patients than in the later decades (1980s and 1990s) (P < 0.001) (Table 1). Besides, in the early decades the number of advanced cases was higher than in the later (P < 0.001) (Table 2). We observed also that the treatment approach changed with the increase of cases treated by surgery based approach (alone or combined with radiotherapy). These changes were significantly different even when the distribution of the treatment approach by each decade was stratified by clinical stage (Figs. 1 and 2). There was a significant increase in the 5-year overall survival rates from 28.7% for patients treated in the 1950s to 43.2% for those treated in the 1990s (P < 0.001). For initial tumors (CS I and II), the improvement in their prognosis along this time, were from a 5-year overall survival rate of 53.4% in the 1950s to 77.3% in the 1990s (P=0.011). Among the patients with advanced tumors (CS III and IV), we observed a rate of 24% in the 1950s and 32% in the 1990s (P=0.062) (Table 3). However, the Cox’s regression analysis showed that the decade of patient’s admission remains as an independent factor associated with
Trends of oral and oropharyngeal cancer survival over five decades
73
Table 1 Distribution of the cases according to the decade of admission in the hospital and the site of the tumor Period of admission (number of cases)
Decade Decade Decade Decade Decade
1950 1960 1970 1980 1990
Oral cavity
(378) (666) (842) (918) (463)
Oropharynx
P-value
N
(%)
N
(%)
301 556 659 666 310
(79.6) (83.5) (78.3) (72.5) (67.0)
77 110 183 252 153
(20.4) (16.5) (21.7) (27.5) (33.0)
< 0.001
Table 2 Distribution of the cases according to the decade of admission in the hospital and the clinical stage at diagnosisa Period of admission (number of cases)
Decade Decade Decade Decade Decade a
1950 1960 1970 1980 1990
(377) (663) (839) (913) (448)
Clinical stages I and II
Clinical stages III and IV
N
(%)
N
(%)
57 13 143 180 119
(15.1) (20.2) (17.0) (19.7) (26.6)
320 529 696 733 344
(84.9) (79.8) (83.0) (80.3) (73.4)
P-value
< 0.001
In 27 cases (0.8%) the information about clinical stage were not available.
Figure 1 Distribution of the cases along the decades according to the treatment approach (for clinical stage I and II).
74
A.L. Carvalho et al.
Figure 2 Distribution of the cases along the decades according to the treatment approach (for clinical stage III and IV).
Table 3 Five-year survival rates (%) according to the decade of admission in the hospital and the clinical stage at diagnosisa
All patients CS I and II CS III and IV
Decade 1950
Decade 1960
Decade 1970
Decade 1980
Decade 1990
P-value
28.7 53.4 23.9
29.6 54.0 23.3
26.4 52.4 21.4
32.5 56.2 26.4
43.2 77.3 32.2
< 0.001 0.011 0.062
CS, clinical stage. a In 27 cases (0.8%) the information about clinical stage were not available.
Table 4 Cox’s regression model for the risk of death Variables
Categories
Hazard ratio
95% CI
Decade
1950s 1960s 1970s 1980s 1990s Male Female < 65 years 565 years Early (I and II) Advanced (III and IV) Oral cavity Oropharynx
1.0 0.95 1.02 0.98 0.71 1.0 0.61 1.0 1.17 1.0 2.11 1.0 1.22
Ref. 0.8—1.1 0.9—1.2 0.9—1.1 0.6—0.9 Ref. 0.5—0.7 Ref. 1.1—1.3 Ref. 1.9—2.4 Ref. 1.1—1.3
Gender Age Clinical stage Site
Trends of oral and oropharyngeal cancer survival over five decades the survival, when the model was adjusted for age, gender, clinical stage and tumor site (P < 0.001) (Table 4).
4. Discussion At first sight, the fact we observed better survival in the latter decade could be attributed to the influence of the differences in the tumor site and the clinical stage at presentation of the patients along the decades or other patient’s characteristics, mainly comorbidities. And also to improvements in hospital facilities, intensive care units, anesthetic equipment and drugs and others medical progresses. However, in the Cox’s regression, adjusted for age, gender, clinical stage and tumor site, the decade of admission remains as an independent predictor of better survival (1990s), but this findings did not remain when the treatment approach was added to the model (data not shown), what means that the difference in the survival rates for the 1990s is due to the changes in the treatment approach rather than to changes in the patient’s performance status or other characteristics. Although many studies discussing changes in treatment approach were associated with improvement in locoregional control and survival rates,3 12 some studies that discussed the trend in survival along the time did not show improvement in survival rates.1,2 However, these hospital cancer registry analyzed in the same group, lip, oral cavity and pharynx (including nasopharynx, oropharynx and hypopharynx) tumors and did not take in account possible changes in the incidence of these tumors along the time, changes in clinical stage and changes in treatment approach and the other one was described before the 1990s.1,2 This series reflects the shift in treatment approach that have occurred in our institution over the last 44 years, during the same period significant changes on treatment approach for oral and oropharyngeal cancer patients have been described.3 12 Following these trends, the treatment approach in our institution had changed. It is important to notice that most of these changes were only possible due to the medical advances during this period, which includes the more accurate staging of the patient, based on computed tomography and magnetic nuclear resonance; better description of the pathological findings allowing a better option for adjuvant treatment approach; surgical techniques, mainly in reconstructive surgery, allowing more extensive resections; techniques and equipment of radiotherapy; better
75
patient clinical and multiprofessional care, including the anesthetic advances, intensive care units, control of comorbidities, and the increase in the life expectancy for the general population. Therefore, these advances are supposed to be followed by an increase in survival rates, which was observed in this series, mainly in patients treated in the latter decade. However, we must take into account that not only the survival rates of the patients improved but, patients treated during the 1990s (the decade that reflects the main changes in the treatment approach) had the best survival rates ever, even when the model was adjusted for age, gender, clinical stage and tumor site (P < 0.001). These observations allow us to conclude that the changes in the treatment approach for oral and oropharyngeal cancer patients in the institution were positively related with the increase of the survival rates of these patients.
Acknowledgements This work was supported in part by a grant from Fundac¸a ˜o de Amparo a ` Pesquisa do Estado de Sa ˜o Paulo, FAPESP (CEPID, Grant # 98/14335-2). References 1. Greenle RT, Murray T, Bolden S, Wingo PA. Cancer Statistics. CA Cancer J Clin 2000;50:7—33. 2. Stell PM, McCormick MS. Cancer of the head and neck: are we doing any better? Lancet 1985;2(8464):1127. 3. Fein DA, Mendenhall WM, Parsons JT, et al. Carcinoma of the oral tongue: a comparison of results and complications of treatment with radiothrapy and/or surgery. Head Neck 1994;16:358—365. 4. Kramer S, Gelger RD, Snow JB, et al. Combined radiation therapy and surgery in the management of advanced head and neck cancer: final report of study 73-03 of the Radiation Therapy Oncology Group. Head Neck 1987;10:19—30. 5. Hicks WL, North JH, Loree TR, et al. Surgery as a single modality therapy for squamous cell carcinoma of the oral tongue. Am J Otolaryngol 1998;19:24—28. 6. Dixit S, Vyas RK, Toparani RB, et al. Surgery versus surgery and postoperative radiotherapy in squamous cell carcinoma of the buccal mucosa: a comparative study. Ann Surg Oncol 1998;5:502—510. 7. Mishra RC, Singh DN, Mishra TK. Post-operative radiotherapy in carcinoma of buccal mucosa, a prospective randomized trial. Eur J Surg Oncol 1996;22:502—504. 8. Shah JP, Lydiatt W. Treatment of cancer of the head and neck. CA Cancer J Clin 1995;45:352—368. 9. Vikram B. Adjuvant Therapy in Head and Neck Cancer. CA Cancer J Clin 1998;48:199—209. 10. Rao DN, Shroff PD, Chattopadhyay G, Dinshaw KA. Survival analysis of 5595 head and neck cancers—results of conventional treatment in a high-risk population. Br J Cancer 1998;77:1514—1518. 11. Calais F, Alfonsi M, Bardet E, et al. Randomized trial of radiation therapy versus concomitant chemotherapy and
76 radiation therapy of advanced-stage oropharynx carcinoma. J Nat Cancer Inst 1999:2081—2086. 12. Robertson AG, Soutar DS, Paul J, et al. Early closure of a randomized trial: surgery and postoperative radiotherpay versus radiotherapy in the management of intra-oral tumours. Clin Oncol 1998;10:155—160. 13. Magrin J, Kowalski LP, Sabo ´ia M, Sabo ´ia RP. Major glossectomy: end results of 106 cases. Oral Oncol, Eur J Cancer B 1996;32B:407—412. 14. Kowalski LP, Magrin J, Sabo ´ia M, et al. Squamous cell car-
A.L. Carvalho et al. cinoma of the tongue: a review of 629 patients treated at a single institution. South Am J Cancer 1997:245—254. 15. Goepfert H. Squamous cell carcinoma of the head and neck: past progress and future promise. CA Cancer J Clin 1998; 48:195—198. 16. Sobin LH, Wittekind CH, editors. UICC TNM—classification of malignant tumors 5th ed. New York: John Wiley & Sons; 1997. 17. SPSS. Statistical package for social science, statistical data analysis for Windows. Chicago (IL, USA): SPSS; 1999.