Some Head and Neck Cancers Have Poorer Outcomes with Community Care

According to new research from the Johns Hopkins Kimmel Cancer Center and its Head and Neck Cancer Center, care for patients with human papillomavirus (HPV)-related squamous cell cancers of the oropharynx (an area in the back of the throat) is shifting toward community cancer centers, but patients treated in this setting may be less likely to survive. The study, which was published on January 3 in the Journal of the National Cancer Institute, raises concerns regarding the quality of care provided to patients with this kind of head and neck cancers outside of academic medical facilities. Patients treated at community cancer centers were less likely to obtain recommended treatments such as surgery and more likely to receive radiation as a main treatment. As a result, their outcomes suffered.

“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 Carole Fakhry, M.D., M.P.H., director of the Johns Hopkins Head and Neck Cancer Center and senior study author.

The oropharynx is made up of structures in the back of the throat, such as the tongue base, tonsils, and soft palate. HPV, the most common sexually transmitted infection in the United States, causes HPV-related cancers there. Each year, around 15,000 new cases of oropharyngeal cancer are diagnosed in the United States, with the vast majority of these cases being HPV-positive.

Fakhry and her colleagues examined data from the United States National Cancer Database from over 20,000 patients with HPV-related oropharyngeal squamous cell malignancies identified and treated between 2010 and 2019. They discovered that the majority of patients — almost two-thirds — continue to get care at academic cancer institutions. The proportion of people receiving care in community cancer centers, on the other hand, increased from 24% in 2010 to 36% in 2019. If current trends continue, community cancer centers might treat 50% of all patients with these uncommon malignancies by 2030.

Growing confidence among clinicians at community cancer centers in treating these tumors, according to Fakhry, may explain this rise. However, the quality of care and survival rates in community cancer centers remain behind those of patients treated at academic cancer centers. Nonsurgical radiation-based therapy, for example, is becoming more popular as patients transition to community-based care. During the research period, the proportion of patients undergoing nonsurgical treatment grew from 62% to 74%.

In recent years, survival rates have begun to differ between patients treated at community centers and those treated at academic centers. Survival rates for the two types of centers were comparable between 2010 and 2013. However, between 2014 and 2017, over 87% of patients treated at academic cancer centers survived, compared to approximately 81% at community cancer centers, according to the study.

According to Fakhry, these patterns have significant consequences for future care quality. “Academic center volume is critical for training the next generation of physicians.” Furthermore, 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,” says lead study author Danielle Trakimas, M.D., an 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 adds to the notion that higher-volume treatment centers outperform lower-volume clinics. Academic centers that specialize in rare head and neck malignancies are more likely to offer transoral robotic surgery and may be better positioned to provide multidisciplinary team care and wrap-around services, which improves patient outcomes, according to Fakhry.

“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 said.

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