Facility Type Predicts Treatment Regimen for HPV-Positive Oropharyngeal Squamous Cell Carcinoma

Presentation: AHNS41
Topic: Oropharynx / HPV Related Disease
Type: Oral
Date: Thursday, April 28, 2022
Session: 11:15 AM – 12:00 PM Oropharynx HPV
Authors: Monica S Trent, MD; Kelsey Roman, BS; Tjoson Tjoa, MD
Institution(s): University of California, Irvine


Introduction:

Over the past two decades, human papillomavirus-positive (HPV+) oropharyngeal cancer (OPC) has been recognized as a distinct entity affecting a younger, healthier patient population with improved oncologic outcomes using the standard radiation (RT) and chemoradiation (CRT) treatment protocols for OPC. Subsequently, there is significant interest in the de-escalation of treatment to limit functional morbidity without compromising oncologic outcomes. With the synchronous arrival of transoral robotic surgery during the past two decades, surgery has provided an alternative upfront treatment for HPV+ OPC that has been shown to have similar oncologic outcomes to RT and CRT with potentially decreased short- and long-term morbidity. However, adaptation of this treatment modality has been largely restricted to academic medical centers that have the training and resources to offer transoral robotic surgery.  This study aims to provide a retrospective analysis of the treatment trends of HPV+ OPC between academic and non-academic centers.

Methods: The National Cancer Database (NCDB) was queried and data pertaining to histologically-confirmed HPV+ OPC between the years of 2010 to 2016 were included. The American Joint Committee on Cancer (AJCC) 7th Edition staging guidelines were utilized. Multinomial logistic regression stratified by clinical stage was used to predict the odds that patients treated at academic facilities would receive RT or CRT versus surgery, while controlling for demographic factors. Statistical analysis was performed using SPSS version 27.0 with p<0.050 selected for significance threshold.

Results: 30,243 patients with HPV+ OPC were included, with 15,155 (50.1%) treated at non-academic facilities and 15,088 (49.9%) were treated at academic facilities. For patients with early stage HPV+ OPC, a total of 2,064 (66.7%) received surgery upfront, 589 (19.0%) underwent RT alone, and 443 (14.3%) received CRT. 16,273 (59.9%) patients with advanced stage cancer were treated with CRT, whereas 8,960 (33.0%) received surgery and 1,914 (7.1%) received RT alone. A significantly higher proportion of all patients, regardless of stage, were treated with surgery when comparing between academic versus non-academic facilities (p<0.001). Facility type predicted first course treatment for both early stage and advanced stage patients on multinomial logistic regression controlling for age, CD index, and clinical stage (p<0.001 in all cases). Patients treated at academic centers were less likely to receive RT compared to surgery (OR 0.57, 95% CI of 0.47-0.69 for early stage patients; OR 0.80, 95% CI of 0.73-0.89 for advanced stage) and less likely to receive CRT compared to surgery (OR 0.62, 95% CI of 0.50-0.77 for early-stage; OR 0.76, 95% CI of 0.72-0.80 for advanced stage).

Conclusion: Facility type determines treatment course for HPV+ OPC, both for early stage as well as late stage tumors. Academic hospitals are more likely to utilize surgery as primary treatment modality and patients are less likely to receive RT or CRT alone at these facilities. Although there are several factors that differentiate treatment options between academic and non-academic facilities, the highlighted differences in treatment approach point to a lack of standardized treatment regimens which prevent patients from receiving universal care independent of facility resources.