Sarcopenia and Treatment Toxicity in Older Adults Undergoing Chemoradiation for Head and Neck Cancer: Identifying Factors to Predict Frailty

Purpose/Objective(s)

Geriatric tools and objective measures may identify vulnerabilities to inform potential side effects or adjust treatment choices in cancer patients eligible for definitive therapy. Early identification may allow for immediate intervention or enhanced oversight during treatment by the oncologist or a geriatrician. This study was performed to identify treatment related toxicities in older adults undergoing concurrent chemoradiotherapy for head and neck cancer and whether nutritional and skeletal muscle measures may be additional measures of frailty.

Materials/Methods

Definitive and post-operative patients undergoing concurrent chemoradiotherapy for locally advanced (AJCC 7^th edition Stage III-IVB) head and neck cancer at an academic medical center between 2011 and 2016 were reviewed. Imaging analysis was performed to identify sarcopenia, defined as a decrease in skeletal muscle, using the cross-sectional area at the axial slice of the C3 vertebral body. Patients were dichotomized by the age at diagnosis into younger (<70 years old, 221 patients) and older age groups (≥70 years old, 51 patients).

Results

A total 272 patients were included with most primary tumors in the oropharynx (64.7%), 137 (77.8%) were p16-positive. 79% were treated with definitive chemoradiation (21% post-operatively) with a majority former or current smokers (70.2%). Older patients had expected higher ≥2 ECOG performance status pre-treatment (19.6% versus 8.6%, p=0.02), remaining clinical and demographic characteristics were well balanced (p>0.05). Sarcopenia was more common in older patients (86.7%) compared to younger patients (51.7%, p<0.01) despite having similar BMIs <30 kg/m2 (74.5% vs 66.1%, p=0.25). Older patients were significantly more likely to experience chemotherapy toxicity than younger patients (54.9% versus 32.3%, p<0.01). On multivariate analysis age (p<0.01), current smoking status (p<0.01), and sarcopenia (p<0.01) remained as significant predictors for missed chemotherapy cycles or discontinuation. Older patients were more likely to require ≥5-day radiation breaks than younger patients (27.5% versus 8.6%, p<0.01). On multivariate analysis, age (p<0.01), low albumin status (p=0.03), and sarcopenia (p=0.04) were identified as predictors of prolonged radiation treatment breaks.

Conclusion

Older age and sarcopenia were identified as independent pretreatment characteristics for chemotherapy toxicity and prolonged radiation breaks, where sarcopenia was present in most elderly patients. Sarcopenia may be used as an additional marker for frailty compared to traditional performance status scales in older individuals and may identify patients needing intensive supportive care during treatment.