Department of Radiation Oncology, Stanford University, Stanford, California.
Palo Alto Veterans Affairs Health Care System, Palo Alto, California.
JAMA Otolaryngol Head Neck Surg. 2018 Apr 1;144(4):349-359. doi: 10.1001/jamaoto.2017.3406.
Shortening the time from surgery to the start of radiation (TS-RT) is a consideration for physicians and patients. Although the National Comprehensive Cancer Network recommends radiation to start within 6 weeks, a survival benefit with this metric remains controversial.
To determine the association of delayed TS-RT with overall survival (OS) using a large cancer registry.
DESIGN, SETTING, AND PARTICIPANTS: In this observational cohort study, 25 216 patients with nonmetastatic stages III to IV head and neck cancer were identified from the National Cancer Database (NCDB).
Patients received definitive surgery followed by adjuvant radiation therapy, with an interval duration defined as TS-RT.
Overall survival as a function of TS-RT and the effect of clinicopathologic risk factors and accelerated fractionation.
We identified 25 216 patients with nonmetastatic squamous cell carcinoma of the head and neck. There were 18 968 (75%) men and 6248 (25%) women and the mean (SD) age of the cohort was 59 (10.9) years. Of the 25 216 patients, 9765 (39%) had a 42-days or less TS-RT and 4735 (19%) had a 43- to 49-day TS-RT. Median OS was 10.5 years (95% CI, 10.0-11.1 years) for patients with a 42-days or less TS-RT, 8.2 years (95% CI, 7.4-8.6 years; absolute difference, -2.4 years, 95% CI, -1.5 to -3.2 years) for patients with a 43- to 49-day TS-RT, and 6.5 years (95% CI, 6.1-6.8 years; absolute difference, -4.1 years, 95% CI, -3.4 to -4.7 years) for those with a 50-days or more TS-RT. Multivariable analysis found that compared with a 42-days or less TS-RT, there was not a significant increase in mortality with a 43- to 49-day TS-RT (HR, 0.98; 95% CI, 0.93-1.04), although there was for a TS-RT of 50 days or more (HR, 1.07; 95% CI, 1.02-1.12). A significant interaction was identified between TS-RT and disease site. Subgroup effect modeling found that a delayed TS-RT of 7 days resulted in significantly worse OS for patients with tonsil tumors (HR, 1.22; 95% CI, 1.05-1.43) though not other tumor subtypes. Accelerated fractionation of 5.2 fractions or more per week was associated with improved survival (HR, 0.93; 95% CI, 0.87-0.99) compared with standard fractionation.
Delayed TS-RT of 50 days or more was associated with worse overall survival. The multidisciplinary care team should focus on shortening TS-RT to improve survival. Unavoidable delays may be an indication for accelerated fractionation or other dose intensification strategies.
缩短手术到开始放疗的时间（TS-RT）是医生和患者需要考虑的问题。尽管国家综合癌症网络建议在 6 周内开始放疗，但这种指标与生存获益仍存在争议。
利用大型癌症数据库确定 TS-RT 延迟与总生存期（OS）的相关性。
设计、地点和参与者：在这项观察性队列研究中，从国家癌症数据库（NCDB）中确定了 25216 例非转移性 III 期至 IV 期头颈部癌症患者。
患者接受根治性手术，随后接受辅助放疗，间隔时间定义为 TS-RT。
作为 TS-RT 的函数的总生存期，以及临床病理危险因素和加速分割的影响。
我们确定了 25216 例非转移性头颈部鳞状细胞癌患者。其中 18968 例（75%）为男性，6248 例（25%）为女性，队列的平均（SD）年龄为 59（10.9）岁。在 25216 例患者中，9765 例（39%）的 TS-RT 为 42 天或更短，4735 例（19%）的 TS-RT 为 43-49 天。42 天或更短 TS-RT 的患者中位 OS 为 10.5 年（95%CI，10.0-11.1 年），43-49 天 TS-RT 的患者为 8.2 年（95%CI，7.4-8.6 年；绝对差值，-2.4 年，95%CI，-1.5 至-3.2 年），50 天或更长 TS-RT 的患者为 6.5 年（95%CI，6.1-6.8 年；绝对差值，-4.1 年，95%CI，-3.4 至-4.7 年）。多变量分析发现，与 42 天或更短的 TS-RT 相比，43-49 天的 TS-RT 并没有显著增加死亡率（HR，0.98；95%CI，0.93-1.04），尽管 50 天或更长的 TS-RT 有（HR，1.07；95%CI，1.02-1.12）。发现 TS-RT 和疾病部位之间存在显著的交互作用。亚组效果模型发现，对于扁桃体肿瘤患者，TS-RT 延迟 7 天会导致 OS 显著恶化（HR，1.22；95%CI，1.05-1.43），尽管其他肿瘤亚型并非如此。与标准分割相比，每周 5.2 次或更多次的加速分割与生存改善相关（HR，0.93；95%CI，0.87-0.99）。
TS-RT 延迟 50 天或更长时间与总体生存较差相关。多学科护理团队应专注于缩短 TS-RT 以提高生存率。不可避免的延迟可能是加速分割或其他剂量强化策略的指征。
