Care for patients with human papillomavirus (HPV)-related squamous cell cancers of the oropharynx (an area in back of the throat) is shifting toward community cancer centers, but patients treated in this setting may be less likely to survive, according to new research by investigators from the Johns Hopkins Kimmel Cancer Center and its Head and Neck Cancer Center.
The study, published Jan. 3 in the Journal of the National Cancer Institute, raises concerns about the quality of care that patients with this type of head and neck cancer receive outside of academic medical centers. Patients treated at community cancer centers were less likely to receive care such as surgery recommended by national guidelines, and more likely to receive radiation as a primary treatment. Their outcomes suffered as a result.
"The site of care determines patient outcomes and may influence the therapy landscape and survival for these rare head and neck cancer patients in the future," says senior study author Carole Fakhry, M.D., M.P.H., director of the Johns Hopkins Head and Neck Cancer Center.
The oropharynx consists of structures in the back of the throat, including the base of the tongue, tonsils and soft palate. HPV-related tumors there are caused by HPV, the most common sexually transmitted infection in the U.S. There are about 15,000 new cases of oropharyngeal cancer in the U.S. each year, the vast majority of which are HPV-positive.
Fakhry and her colleagues analyzed U.S. National Cancer Database data from more than 20,000 patients with HPV-related oropharyngeal squamous cell cancers who were diagnosed and underwent treatment between 2010 and 2019. They found that most patients — about two-thirds — continue to receive care at academic cancer centers. However, the proportion receiving care in community cancer centers grew from 24% in 2010 to 36% in 2019. If these trends continue, as many as half of all patients with these rare cancers will be treated at community cancer centers by 2030.
Growing comfort by clinicians at community cancer centers in treating these cancers may explain this trend, Fakhry says. However, the quality of care patients receive in community cancer centers, and their survival rates, are lagging behind those of patients treated at academic cancer centers. For example, as more patients shift to community-based care, they are receiving nonsurgical radiation-based therapy. The number of patients receiving nonsurgical treatment increased from 62% to 74% during the study period.
Survival among patients treated at community centers versus academic centers has also started to diverge in recent years. Between 2010 and 2013, the survival rates for the two types of centers were similar. However, between 2014 and 2017, about 87% of patients treated at academic cancer centers survived, compared with about 81% at community cancer centers, the research found.
These trends have important implications for future care quality, Fakhry says. "Volume at academic centers is important to train the next generation of physicians. Additionally, if radiation is the primary modality of the future in community centers, there may be a greater need for radiation oncologists and the multidisciplinary team, which is critical to the guideline-directed care of these patients," adds Danielle Trakimas, M.D., lead study author and otolaryngology resident at The Johns Hopkins Hospital. "If patients with these head and neck cancers are less likely to be treated at academic centers, we need to better understand the determinants of differences in survival outcomes."
The study also bolsters evidence that higher-volume treatment centers have better outcomes than lower-volume ones. Academic centers specializing in treating rare head and neck cancers are more likely to offer transoral robotic surgery, and may be better equipped to provide multidisciplinary team care and wrap-around services, improving patient outcomes, Fakhry says.
"It raises the question of whether we should focus care for HPV-related oropharyngeal squamous cell carcinomas at high-volume academic centers to optimize care," she says.
Additional study co-authors were Wojtek Mydlarz, Leila Mady, Wayne Koch, Harry Quon and Nyall London Jr. of Johns Hopkins.
The study was supported by the National Institutes of Health (grant #T32DC000027-32).
