Abstract
Should advanced age be a contraindication to the surgical management of head and neck cancer patients? A retrospective chart review was performed of patients aged ≥80 years treated surgically for a head and neck malignancy during the period 1996–2011 in a tertiary care cancer centre. The average follow-up was 32 months. Fifty-three patients were identified (mean age 85 years). Cardiovascular disease was the most prevalent co-morbidity (43%). Forty-five patients (85%) had oral cavity/oropharynx squamous cell carcinoma. Surgeries performed included 40 neck dissections and 12 microvascular free flaps. The average length of hospital stay (LOS) was 6.4 days. An increased LOS was significant in patients requiring free flap reconstruction ( P < 0.01). There were no perioperative deaths or free flap failures. The most common postoperative complications were cardiovascular ( n = 8), infection ( n = 10), and delirium ( n = 6). Thirty-four patients were discharged directly home. Free flap reconstruction did not adversely affect discharge disposition ( P > 0.05). More than 75% of patients did not report any major limitations to their activities of daily living. Major head and neck surgical procedures can be tolerated by patients of advanced age using careful patient selection. Age alone should not be a primary factor in the management of head and neck cancer patients.
In the USA, head and neck malignancies account for approximately 3% of all malignancies (the majority are squamous cell carcinoma), with an estimated 53,000 new cases diagnosed annually. Of cases diagnosed, up to 25% will occur in the elderly population, often involving patients with concomitant medical co-morbidities.
A matter of great debate is what truly constitutes an elderly patient or ‘old age’. Most industrialized developed countries set the age of retirement at between 60 and 65 years, but even this is changing. The National Institute of Aging uses three categories to define elderly patients: ages 65–74 years as ‘young old’, 75–84 years as ‘older old’, and greater than 85 years as ‘oldest old’. According to the most recent estimates, the number of persons aged over 80 years in the USA is expected to increase from 9.3 million to 19.5 million by the year 2030 (US Census Bureau). This will translate into an ageing population requiring treatment for head and neck malignancies.
There are few reports in the scientific literature regarding the outcomes in the management of elderly patients (especially those of very advanced age) undergoing head and neck cancer treatment. Historically this population was considered to be at high risk of complications with aggressive surgical therapy, often unnecessarily condemning the patient to medical palliation and poor quality of life. The more recent literature suggests that this cohort of patients is being undertreated and can tolerate treatment just as well as younger patient groups.
The purpose of this study was to evaluate the outcomes of patients of advanced age (≥80 years) who have undergone surgical treatment for head and neck malignancies.
Patients and methods
A retrospective chart review of the oral and maxillofacial oncology database was done to identify all patients aged ≥80 years who had been treated surgically for a head and neck malignancy between January 1996 and December 2011. All patients had been evaluated preoperatively by their primary care physician or consultant medical specialist. Patient medical co-morbidities had been medically optimized prior to undergoing any surgical procedure.
Data analysed included age, pathology, medical co-morbidities, surgical procedure, perioperative course, postoperative hospital disposition, and outpatient follow-up. Postoperative medical and surgical morbidity and mortality (death within 30 days of surgery) were also evaluated. Applicable data were analysed using Microsoft Excel 14.3.9 software and SAS 9.1.3 (SAS Institute, Cary, NC, USA). P -values of <0.05 were accepted as an indication that the differences did not arise by chance. This study was approved by the institutional review board for ethical human research.
Results
A total of 110 patients aged ≥80 years with a head and neck malignancy were identified. Fifty-seven patients did not undergo surgery, of whom only 11 were deemed medically unfit for surgical therapy ( Table 1 ). Fifty-three patients underwent surgical treatment. One of these patients had been treated for osteoradionecrosis (ORN); this patient had an obvious history of malignancy and underwent composite resection and a free flap for management of the ORN. Based on the extensive surgery and previous history, this patient was included in the study.
| Reason against surgery | Number of patients |
|---|---|
| Patient refusal | 20 |
| Medically compromised | 11 |
| Oropharyngeal primary | 7 |
| Unresectable disease | 6 |
| Treatment at another medical centre | 4 |
| Non-surgical disease | 3 |
| Distant metastasis | 2 |
| Unknown reason | 4 |
The tumour histopathology and clinical characteristics of the patients included in the study are given in Tables 2 and 3 , respectively.
| Pathological diagnosis | Number of patients |
|---|---|
| Squamous cell carcinoma | 45 |
| Merkel cell | 1 |
| Basal cell carcinoma | 1 |
| Anaplastic lymphoma | 1 |
| Mucoepidermoid carcinoma | 1 |
| Polymorphous low grade adenocarcinoma | 1 |
| Carcinoma-in situ/dysplasia | 2 |
| Osteoradionecrosis | 1 |
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