Читать книгу Hypopharyngeal Cancer - Группа авторов - Страница 45

From carcinogenesis, when cancers begin, until the time when, in many cases, they cause the death of the patient, cancers develop by stages over many years. This process of development, when uninterrupted by treatment, is sometimes called the “natural history” of cancer. The natural history of untreated head and neck squamous cell carcinoma has infrequently been documented in the medical literature. However, without understanding the natural history of hypopharyngeal cancer, patient counselling and clinical management are difficult. Survival results secondary to various treatment regimens must be compared with the results found in non-treated head and neck cancer patients [15]. This information is essential to provide the necessary background to evaluate and recommend various treatment options including supportive care, palliation or attempting curative treatment.

It has been known for a long time that select patients with head and neck cancer can survive longer than 5 years without treatment, although well-documented cases of this type are rare. Long-term survivals are occasionally encountered in cancer of the breast or in leukaemia and lymphoma. “Spontaneous” fluctuations in growth and regressions of cancer also may rarely occur [16]. However, spontaneous healing of histologically proven hypopharyngeal carcinoma has, to the best of our knowledge, not been reported in the literature. Therefore, it is relevant to know that without radical treatment, only a small proportion of patients with hypopharyngeal cancer will survive for more than 2 years after initial diagnosis [15, 17].

The course of untreated hypopharyngeal cancer has not been explored intensively in recent years, as curative treatment is usually offered whenever possible. Patients who do not receive any treatment have been reported to die within 6 months in a series from the Netherlands [7]. Stell [18] in 1989, reported on a personal series of 1,678 of previously untreated patients diagnosed with a squamous cell carcinoma of the head and neck. Of these, 200 patients received no treatment. They represented 12% of the squamous carcinomas patients who presented during the study period, between years 1962 and 1988. Untreatability ranged from 5% for laryngeal tumours to 25% for hypopharyngeal tumours. The median survival of the whole group was 101 days. Performance status (ECOG classification) was the only significant predictor of survival. Other host factors (age and sex) and all tumour factors (site, T, N and M stage, distant metastases, stage grouping and histological grade of the tumour) were not significantly related to prognosis [18].

In a retrospective analysis of nearly 800 Brazilian patients who elected no treatment of their head and neck cancer, during the period 1953–1990, the median observed survival was 4 months; the maximum reported survival was 4 years [15]. This study categorized the reasons for no treatment, which were advanced untreatable tumour in 75%, poor health in 6% and personal choice for 19%. Multivariate analysis identified that performance status was the only factor that predicted a more prolonged survival. Overall survival rates for hypopharyngeal carcinoma was 32% at 6 months and 12% at 12 months. No patient survived more than 3 years from initial presentation.

Hughley et al. [19] exploited the United States National Cancer Institute’s Surveillance, Epidemiology, and End Results database to identify 2,584 patients with invasive cancer of the upper aerodigestive tract diagnosed between 1983 and 2011. Patients were classified as “untreated” if they received neither surgery nor radiotherapy. Median survival was 39 months for treated patients and 4 months for untreated patients. Among those identified as untreated, 9.7% were head and neck cancer patients, but 15.6% of all 2,584 were hypopharyngeal cancer patients. This proportion (15.6%) was higher than for any other sub-site in the head and neck. On multivariate logistic regression, stage was a statistically significant predictor of untreated status, with higher stages associated with progressively higher adjusted odds of untreated status. Patients with stage IV disease were more likely to be untreated than those with stage I disease (11.9 vs. 3.8%; p < 0.0001). A more recent study from the United Kingdom confirmed the very poor prognosis of untreated hypopharyngeal cancer patients, with a median survival of < 6 months and no patients surviving for more than 11 months [20].

A recent Korean study on untreated head and neck cancer using data from a national patient sample cohort, presenting during the period 2003–2013, found that 24% of all hypopharyngeal cancer cases remained untreated, with < 20% of patients surviving > 12 months [17].