Cancer of the hypopharynx is a complex disease associated with morbid treatment and poor survival. The introduction of non-surgical organ preserving treatment protocols in the late 1990’s has led to a paradigm shift in the management of head and neck cancer. However, it is unclear if this has translated into better outcomes for this patient group. In order to evaluate the introduction of radical chemoradiotherapy, we examined outcomes in patients diagnosed with squamous cell carcinoma (SCC) of the hypopharynx over a thirty-year period, thus spanning the move towards organ-preservation therapy.
Methods: A 30-year retrospective case series analysis of 305 patients with cancer of the hypopharynx at a single tertiary referral hospital was conducted to identify treatment choices and surgical and oncologic outcomes prior to and during the epoch of organ preservation. A detailed analysis of outcomes is presented.
Results: Between 1983-2017 305 patients were diagnosed with SCC of the hypopharynx. The primary treatment of choice in 186 consecutive patients between 1983 and 2000 was: 61/186 (33%) radiotherapy (RT): 74/186 (40%) surgery +/- adjuvant RT: 37/186 (20%) palliative: 14/186 (7%) other. Between 2001 and 2017, the treatment of choice in 119 consecutive patients was: 18/119 (15%) chemoradiotherapy (CRT); 34/119 (29%) radiotherapy (RT); 50/119 (42%) surgery +/- adjuvant RT or CRT; 18/119 (15%) palliative. Between 1983-2000 5-year overall survival for patients treated with primary surgery with or without adjuvant treatment was 27.4%. In the same period 5-year survival for patients treated non-surgically was 14.4%. Between 2001-2017 5-year overall survival for patients treated with primary surgery with or without adjuvant treatment was 20.6%. In the same period 5-year survival for patients treated non-surgically was 31.6%.
Conclusions: In the period 2000-2017 relative to 1983-1999 the incidence of hypopharynx cancer in our population has reduced by around 1/3. The reasons for this are likely multifactorial and may include changing demographics and a decline in smoking rates. The introduction of primary chemo-radiotherapy has brought about a rise in the proportion of patients treated non-surgically. The concomitant increase in survival in this group (14.4% cf 20.6%) is consistent with the evidence of the additional benefit chemotherapy brings. Five-year overall survival in patients undergoing primary surgery in the era of organ preservation has decreased (27.4% cf. 20.6%). This may be in part due to surgery being reserved for those presenting with more advanced disease.
The crude laryngectomy free survival rate following CRT or RT was 89%. Of those undergoing salvage surgery, the median disease relapse time was 7.2 months (range 4.7-103.4 months). Despite this confidence intervals suggest that overall survival has remained depressingly unchanged in more than 30 years.