Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
Corporal Michael Crescenz VA Medical Center, Philadelphia.
JAMA Otolaryngol Head Neck Surg. 2022 Aug 1;148(8):740-747. doi: 10.1001/jamaoto.2022.1327.
Cardiovascular events are an important cause of morbidity in patients with oropharyngeal squamous cell carcinoma (OPSCC). Radiation and chemotherapy have been associated with increased risk of stroke; up-front surgery allows the opportunity for (chemo)radiotherapy de-escalation.
To evaluate whether up-front surgery was associated with decreased stroke risk compared to nonsurgical treatment for OPSCC.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study was conducted at the US Veterans Health Administration and examined US veterans diagnosed with nonmetastatic OPSCC from 2000 to 2020. Data cutoff was September 17, 2021, and data analysis was performed from October 2021 to February 2022.
Up-front surgical treatment or definitive (chemo)radiotherapy as captured in cancer registry.
Cumulative incidence of stroke, accounting for death as a competing risk; and association between up-front surgery and stroke risk. After generating propensity scores for the probability of receiving surgical treatment and using inverse probability weighting (IPW) to construct balanced pseudo-populations, Cox regression was used to estimate a cause-specific hazard ratio (csHR) of stroke associated with surgical vs nonsurgical treatment.
Of 10 436 patients, median (IQR) age was 61 (56-67) years; 10 329 (99%) were male; 1319 (13%) were Black, and 7823 (75%) were White; 2717 received up-front surgery, and 7719 received nonsurgical therapy with definitive (chemo)radiotherapy. The 10-year cumulative incidence of stroke was 12.5% (95% CI, 11.8%-13.3%) and death was 57.3% (95% CI, 56.2%-58.4%). Surgical patients who also received (chemo)radiotherapy had shorter radiation and chemotherapy courses than nonsurgical patients. After propensity score and IPW, the csHR of stroke for surgical treatment was 0.77 (95% CI, 0.66-0.91). This association was consistent across subgroups defined by age and baseline cardiovascular risk factors.
In this cohort study, up-front surgical treatment was associated with a 23% reduced risk of stroke compared with definitive (chemo)radiotherapy. These findings present an important additional risk-benefit consideration to factor into treatment decisions and patient counseling and should motivate future studies to examine cardiovascular events in this high-risk population.
心血管事件是口咽鳞状细胞癌（OPSCC）患者发病和致残的一个重要原因。放疗和化疗与中风风险增加有关；而术前手术则为（放）化疗强度降低提供了机会。
评估与非手术治疗相比，术前手术是否与 OPSCC 患者的中风风险降低相关。
设计、地点和参与者：本队列研究在美国退伍军人健康管理局进行，纳入了 2000 年至 2020 年期间被诊断为非转移性 OPSCC 的美国退伍军人。数据截止日期为 2021 年 9 月 17 日，数据分析于 2021 年 10 月至 2022 年 2 月进行。
癌症登记处记录的初始手术治疗或明确的（放）化疗。
中风的累积发生率，将死亡作为竞争风险；以及手术与中风风险之间的关联。在生成接受手术治疗的概率倾向评分并使用逆概率加权（IPW）构建平衡的拟人群后，使用 Cox 回归估计手术与非手术治疗相关的中风的特定原因风险比（csHR）。
在 10436 名患者中，中位（IQR）年龄为 61（56-67）岁；10329 名（99%）为男性；1319 名（13%）为黑人，7823 名（75%）为白人；2717 名患者接受了初始手术，7719 名患者接受了明确的（放）化疗的非手术治疗。10 年中风累积发生率为 12.5%（95%CI，11.8%-13.3%），死亡为 57.3%（95%CI，56.2%-58.4%）。接受（放）化疗的手术患者的放疗和化疗疗程比非手术患者更短。经过倾向评分和 IPW 后，手术治疗的中风 csHR 为 0.77（95%CI，0.66-0.91）。这种关联在根据年龄和基线心血管危险因素定义的亚组中是一致的。
在这项队列研究中，与明确的（放）化疗相比，初始手术治疗与中风风险降低 23%相关。这些发现为治疗决策和患者咨询提供了一个重要的额外风险效益考虑因素，应促使未来的研究在这一高风险人群中检查心血管事件。
