Yonago Acta medica 2015;58:9–13

Original Article

Treatment Outcomes of Head and Neck Squamous Cell Carcinoma in the Elderly:
A Retrospective Study over 7 Years (2003–2009)
Yuji Hasegawa, Takahiro Fukuhara, Kazunori Fujiwara, Eiji Takeuchi and Hiroya Kitano
Division of Otolaryngology, Head and Neck Surgery, Department of Medicine of Sensory and Motor Organs, School of Medicine,
Tottori University Faculty of Medicine, Yonago, 683-8504, Japanand that 20% of HNSCC patients are aged 75 and older.1
We thus have more and more opportunities to conduct
treatment decisions in elderly patients. However, thevariety of such treatments is restricted in the elderly due
to physical issues such as decreased organ function andincreased prevalence of underlying diseases, as well as
psychological and societal problems such as impaired
cognition, tendency to accept death and the nearly absolute necessity of societal and financial supports. A separate issue is that no studies have clarified the threshold
age defining “elderly.” A number of previous articles
have used cutoff ages of 70 or 75 years.2–7
In Japan, individuals aged 65 and older are referred
to as “elderly.” The ratio of elderly people to the total
population in Japan was 25.1% in April 2014, while theproportion of individuals aged 75 years and older was
12.3%.8 Both ratios are increasing. The same census
found that in Tottori Prefecture (the location of our
hospital), the ratio of elderly people to the total prefectural population was 28.2% and the ratio of those aged
75 years and older was 15.6%. Thus the population of
Tottori Prefecture is aging more rapidly than Japan as awhole.
This study compared the treatment outcomes of
elderly patients aged 65 and older seen at our hospitalfor HNSCC. We classified the patients into 2 groups:
the young-old group, aged 65−74, and the old-old group,
aged 75 and older.

ABSTRACT
Background Head and neck squamous cell carcinoma(HNSCC) is increasing in prevalence as society ages
worldwide. However, there are no established treatment
protocols for elderly patients, and the threshold for defining “elderly” is undetermined. In this study, we categorized elderly patients (65 years and older) with HNSCC
into 2 groups: “young-old,” from 65 to 74 years old, and“old-old,” 75 years and older, and compared their treatment outcomes.
Methods The subjects were 182 patients aged 65
years and older who visited our hospital for HNSCC
from 2003 to 2009. We categorized them into 2 groups,
young-old (65−74 years) and old-old (75 years and older),and compared the male-female ratio, ratio with underlying diseases, primary tumor sites, disease stage, applied
treatments and curative rate. Additionally, for the curative treatment category in both groups, we comparedrecurrence rate, relationship between recurrence rate anduse of concomitant chemotherapy, the 5-year relapsefree survival and the 5-year cause-specific survival.
Results The ratio of patients with underlying diseases
in the old-old group was significantly higher than in theyoung-old group, but there was no significant differencein curative rate between the 2 (old-old, 81.9%; youngold, 82.7%). The 5-year, cause-specific survival in curative treatment category was significantly lower in theold-old (66.1%) group than the young-old (94.1%) group.
Conclusion Elderly patients of all ages should positively receive curative treatment. We suppose that concomitant chemotherapy is not acceptable in elderly
patients. The 5-CSS of the curative treatment category
in the old-old patients was significantly lower than in theyoung-old patients.

MATERIALS AND METHODSThis study analyzed 182 patients aged 65 and older who
visited our hospital for HNSCC from 2003 to 2009.
First, we divided the patients into 2 groups based on thepatients’ ages at their initial visits: the young-old group,
aged 65 to 74 years, and the old-old group, aged 75 years
and older.
We compared the male-female ratio, ratio of patientswith underlying diseases, primary tumor sites, diseasestage, applied treatments and curative rate. Underlying

Key words

elderly patients; head and neck squamouscell carcinoma; outcome
Globally, the population is rapidly aging and consequently the prevalence of patients with head and necksquamous cell carcinoma (HNSCC) is increasing. HNSCC is not a rare disease among elderly patients, as aprevious study reported that the number of patients with
HNSCC is increasing among patients aged 50 and older,

Corresponding author: Yuji Hasegawa
blood423@live.jp
Received 2014 December 8
Accepted 2014 December 18
Abbreviations: CSS, cause-specific survival; RFS, relapse-freesurvival; HNSCC, head and neck squamous cell carcinoma

9Y. Hasegawa et al.
Table 2. Primary tumor site

Table 1. Male-female ratio and the percentage of patients with underlying diseases

Male:female ratio
Patients with underlying diseases
Number (%)

GroupYoung-old[n = 110]

Old-old[n = 72]

92:18(5.1:1)55:17(3.2:1)64 (58.2%)

55 (76.2%)

LarynxOral cavity
Hypopharynx
OthersOld-old[n = 72]

Early (I–II)
Advanced (III–IV)

51 (46.4%)
59 (53.6%)

32 (44.4%)
40 (55.6%)

43 (39.1%)
18 (16.4%)
35 (31.8%)
14 (12.7%)

30 (41.7%)
17 (23.6%)
11 (15.3%)
14 (19.4%)

category, in which no treatment was conducted due topatient refusal. We also examined the relationship between the frequency of underlying diseases and the curative rate.
Next, we investigated the recurrence rate, prevalenceof concomitant chemotherapy use, relationship between
recurrence rate and use of concomitant chemotherapy,
the 5-year relapse-free survival (RFS) and the 5-year
cause-specific survival (CSS) in the curative treatment
category in each group.
The study was approved by the Ethics Committee of
Tottori University Faculty of Medicine (approval number
2594).
When comparing the 2 groups, we used the chisquared and Fisher’s exact test. We calculated the 5-year
RFS and CSS using the Kaplan-Meier method, and detected the significant differences between groups using
the log-rank test. A P value smaller then 0.05 was considered statistically significant.
RESULTS
Male-female ratio and ratio of patients with underlying diseases

Table 1 shows the male-female ratio and the ratio of
patients with underlying diseases. The young-old group
comprised 110 patients with a mean age of 69.5 years(65–74 years) and a male-female ratio of 5.1 (92 male, 18
female). The old-old group comprised 72 patients with amean age of 80.0 years (75–93 years) and a male-female
ratio of 3.2 (55 male, 17 female). The percentage of paTable 4. Applied treatments

Table 3. Disease stageStage

Old-old[n = 72]

Others: epipharynx, oropharynx, acoustic organ, paranasal sinus
and salivary gland.

diseases were defined as conditions that could affect tumor treatment, such as cardiovascular disease, diabetes,
cerebrovascular disease, respiratory disease, hepatic disease, kidney disease and psychiatric disorders. Patientswith at least one of these disease types were considered
to have an underlying disease.
Primary tumor sites were classified as larynx, oralcavity, hypopharynx, or others (epipharynx, oropharynx, acoustic organ, paranasal sinus and salivary gland),while tumor stage was classified as either early tumor(Stage I or II) or advanced tumor (Stage III or IV), according to the fifth edition of the Union for International
Cancer Control classification of malignant tumors.
In our protocol, curative treatments were categorized
as radiotherapy alone, surgery alone, or the combinationof surgery and radiotherapy. Concomitant chemotherapy
for curative treatments was classified as 4 patterns: neoadjuvant chemotherapy before surgery; neoadjuvant concurrent chemoradiotherapy before surgery; adjuvant concurrent chemoradiotherapy after surgery; and concurrent
chemoradiotherapy alone. Chemotherapy dosages weredecreased in patients aged 70 years or older or in those
whose creatinine clearance was lower than 50 mL/min.
Further, chemotherapy was not conducted in patients
whose creatinine clearance was lower than 30 mL/min.
For both the young-old and old-old groups, we investigated the prevalence of patients in each of the following three categories: curative treatment category, inwhich patients received curative treatment and achieved
locoregional control; palliative treatment category, inwhich patients received palliative treatment because they
had distant metastasis at their initial visit or could not
tolerate further curative treatments, or in which distantmetastasis developed during treatment; and no-treatment

Group
Young-old[n = 110]Group
Young-old[n = 110]

10Treatment

Group
Young-old[n = 110]

Old-old[n = 72]

Radical treatment
Radiotherapy
Surgery
Surgery + radiotherapy
Palliative treatment
No treatment

91 (82.7%)2535
31
14 (12.7%)
5 (4.5%)59 (81.9%)1828
13
8 (11.1%)
5 (6.9%)

Outcomes of HNSCC in the elderly
Table 5. Relationship between the existence of underlying disease and cure rate
Underlying
diseaseGroup
Young-old [n = 110]
Curative rate P value

Table 6. Number of recurrent patients

Old-old [n = 72]
Curative rate P value

Positive
50/64 (78.6%) 		
44/55 (80.0%)		
0.132		0.355Negative
41/46 (89.1%) 		
15/17 (88.2%)

Recurrent patientsGroup
Young-old[n = 91]

Old-old[n = 59]

P value

Number (%)

18 (19.8%)

19 (32.2%)

0.084

Relationship between underlying disease and curative rate

Table 5 shows the curative rates in patients with or without underlying diseases. In both groups, curative treatments were possible in a higher percentage of patients
without underlying diseases than in those who had suchconditions: in the young-old group, 89.1% versus 78.1%,
and in the old-old group, 88.2% versus 80.0%. In eachgroup, the curative rate of patients without underlying
diseases was slightly higher but not significantly so.

tients with underlying diseases was significantly higher
in the old-old group (76.4%, 55 of 72 patients) than in
the young-old group (58.2%, 64 of 110 patients) (P =0.012).
Primary tumor sites and disease stage

As shown in Table 2, the primary tumor sites in theyoung-old group (110 patients) were: larynx (43 patients,
39.1%), hypopharynx (35 patients, 31.8%), oral cavity(18 patients, 16.4%) and others (14 patients, 12.7%). In
the old-old group (72 patients) the sites were: larynx(30 patients, 41.7%), hypopharynx (11 patients, 15.3%),
oral cavity (17 patients, 23.6%) and others (14 patients,
19.4%). Table 3 shows that in the young-old group, 51
patients (46.4%) were early stage (I or II) and 59 patients(53.6%) were advanced stage (III or IV). In the old-old
group, 32 patients (44.4%) were early stage and 40 patients (55.6%) were advanced stage.

Frequency of recurrence

Table 6 shows the number of patients who developed recurrence in the curative treatment category. Recurrence
occurred in 18 of 91 patients (19.8%) in the young-old
group and 19 of 59 patients (32.3%) in the old-old group.
The recurrence rate was higher in the old-old group than
the young-old group, but the difference was not significant.

Applied treatments

Relationship between use of concomitant chemotherapy and recurrence rates

Table 4 shows the details of the applied treatments ineach category. The curative treatment category comprised 91 of 110 patients (82.7%) in the young-old groupand 59 of 72 patients (81.9%) in the old-old group. The
palliative treatment category comprised 14 of 110 patients (12.7%) in the young-old group and 8 of 72 patients(11.1%) in the old-old group. The no treatment categorycomprised 5 of 110 patients (4.5%) in the young-old and
5 of 72 patients (6.9%) in the old-old group.

The percentage of the curative treatment category inwhich concomitant chemotherapy was performed wassignificantly higher in the young-old group than in theold-old group: 58.2% (53 of 91 patients) versus 40.7% (24of 59 patients), respectively (P = 0.035). In both groups,
the recurrence rates were higher when concomitantchemotherapy was used than when it was not, but notsignificantly so: in the young-old group, 26.4% (14 of 53
patients) versus 10.5% (4 of 38 patients), and in the old-

(%)
100
90
80
70
60
50
40
30
20
10
0
0

CSS
Young-Old: 76.4%
Old-Old: 61.3%

1

2

3

4

*

Survival

Survival

RFS

5 (yr)

(%)
100
90
80
70
60
50
40
30
20
10
0
0

Young-Old: 94.1%**
Old-Old: 66.1%

1

2

3

4

5 (yr)

Follow-up period

Follow-up period

Fig. 1. In the curative treatment category, the difference between
the 5-year RFS of the young-old group (76.4%) and old-old
group (61.3%) was significant (*P = 0.027). RFS, relapse-freesurvival.

Fig. 2. In the curative treatment category, the difference between
the 5-year CSS of the young-old group (94.1%) and old-old group(66.1%) was significant (**P = 0.0016). CSS, cause-specific survival.

11

Y. Hasegawa et al.

lying diseases did not affect treatment completion,11 andanother found that there was no correlation between theexistence of underlying disease and either co-morbidity
or complications in elderly patients.12 As reported insome studies,2, 3, 6, 13 treatment choices in elderly patientswith HNSCC should not be based on patients’ ages. We
suppose that both young-old and old-old patients canachieve nearly equivalent curative rates as a result of curative treatments.
In our study, the use of concomitant chemotherapy
did not diminish the recurrence rate in either group,
although the recurrence rate tended to be higher inthe old-old group than the young-old group. Previous
studies reported that reducing chemotherapy dosages
undermined the effectiveness of treatments 14 and thatthe concomitant use of chemotherapy did not suppress
local tumor recurrence or distant metastasis.15 We suppose that concomitant chemotherapy is not acceptablein elderly patients, since chemotherapy doses must be
reduced in most of them.
It was reported that the survival rate was lower
or almost equivalent in an elderly group compared toa younger group.9 In our study, the 5-year RFS of thecurative treatment category in the young-old group was
76.4%, which was significantly higher than the 61.3% in
the old-old group. Further the 5-year CSS of the curative
treatment category in the young-old group was 94.1%,
which was significantly higher than the 66.1% in the oldold group.
In conclusion, elderly patients of all ages should
absolutely receive curative treatment. We believe thatconcomitant chemotherapy is not acceptable in elderly
patients. The 5-CSS of the curative treatment category
in the old-old patients was significantly lower than in theyoung-old patients.

old group, 33.3% (8 of 24 patients) versus 31.4% (11 of
35 patients), respectively.
Survival rate (5-year RFS and CSS)As shown in Fig. 1, the 5-year RFS of the curative treatment category in the young-old group (91 patients) was
76.4%, while that in the old-old group (59 patients) was
61.3%, a significant difference (P = 0.027). As shown in
Fig. 2, the 5-year CSS of the curative treatment category
in the young-old group (91 patients) was 94.1%, whilethat in the old-old group (59 patients) was 66.1%, a significant difference (P = 0.0016).
DISCUSSION
The treatment decision was dedicated to elderly patients
because of their physical or social circumstances. In
our study, we investigated the outcomes of treatment for
HNSCC in elderly patients.
Prior studies reported that increased patient age wasassociated with a significantly higher ratio of females tomales,2, 9 and our results showed a similar trend. In addition, the prevalence of larynx and oral cavity tumors
was found to be higher in older patients while that of hypopharynx tumors was lower,2, 9, 10 which mirrored our
findings.
Regarding the ratio of early- to advanced-stage tumors, various results have been reported. For example,
one study found that in patients aged 75 years and older,this ratio did not differ greatly between elderly andyoung adult patients.2 Another study reported that elderly patients had more early-stage tumors than younger
patients.4 In our study, advanced-stage tumors wereobserved slightly more often than early-stage tumors inboth groups.
Derks et al. reported that in 3 patients groups divided by age (ages 45−60, 70−79 and 80 years and older),the percentages of patients who received curative treatment were 89%, 75% and 36%, respectively.3 Huang etal.4 reported that patients under 75 years old and those
75 years and older received curative treatment in 93%
and 79% of patients, respectively. As shown in thesereports, older patients were less likely to be candidates
for curative treatments. In our study, the percentages ofpatients in the curative treatment category were 82.7% in
the young-old group and 81.9% in the old-old group.
The percentages of patients with underlying diseases
were 58.2% in the young-old group and 76.2% in theold-old group. However, there were no significant correlations between the existence of underlying disease
and the curative rate, and curative treatments can often
be conducted despite the presence of these conditions.
One previous study reported that the presence of under-

The authors declare no conflict of interest.
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