Early Death in T3-T4 Head and Neck Cancer: NCDB Comparison of Surgical vs. Non-Surgical Approaches

Surgeries for T3-T4 head and neck squamous cell carcinoma (HNSCC) are often complex and high-risk with the potential for early death, which is both clinically devastating and a negative quality indicator for health systems. This study aims to compare surgical and non-surgical approaches in an aggressive subset of HNSCC for early death.

This is a retrospective analysis of the National Cancer Database (NCDB) v2018 for advanced T3-T4 HNSCC patients from 2004 to 2018. Univariate and multivariate logistic regression analyses were performed with the primary goal of comparing 30-day mortality in patients undergoing primary surgery (PS) versus radiation with or without chemotherapy (CRT). Subgroup analysis between treatment groups was performed with respect to HPV status.

A total of 79 677 advanced head and neck cancer patients with a mean (SD) age of 62.5 (12.0) years, predominantly male (74.0%), were included in the analysis. Patients with T3-T4 HNSCC undergoing upfront surgery had an early death rate of 1.1%, compared to 4.7% for CRT (p < 0.001). This translated to significantly lower odds of early death with PS compared to CRT (OR = 0.25, 95% CI 0.22-0.28), adjusting for age, comorbidity index, stage III or IV, subsite, insurance status, and grade. Subset analysis showed survival benefits of PS irrespective of HPV status. Age ≥ 65 years, T4 tumors, higher Charlson Comorbidity Index (CCI), and uninsured status were consistently associated with increased mortality risk.

This study suggests that an upfront surgical approach is associated with decreased early death compared to non-surgical treatment for HNSCC. HPV-based subgroup analysis has shown a more focused predictor of early death. Cancer treatment paradigms should account for the observation of these findings for advanced HNSCC.