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Original Investigation
October 17, 2019

Assessing Care Value for Older Patients Receiving Radiotherapy With or Without Cisplatin or Cetuximab for Locoregionally Advanced Head and Neck Cancer

Author Affiliations
  • 1Stanford University School of Medicine, Stanford, California
  • 2Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
  • 3Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California
JAMA Otolaryngol Head Neck Surg. 2019;145(12):1160-1167. doi:10.1001/jamaoto.2019.2381
Key Points

Question  What is the value of cetuximab chemoradiotherapy compared with radiotherapy alone for older patients with locoregionally advanced head and neck cancer?

Findings  In this cohort study of 1091 older patients with stages III to IVB head and neck cancer, radiotherapy with cetuximab treatment was not associated with improved survival compared with radiotherapy alone, but radiotherapy with cisplatin was associated with improved survival. Cetuximab use was associated with higher Medicare spending but not with higher rates of inpatient admission compared with radiotherapy alone, unlike radiotherapy with cisplatin.

Meaning  Despite performing better on some Medicare quality metrics, cetuximab appears to be of low value for older patients with advanced disease; composite metrics should be used in the future to assess care quality within the context of outcomes and treatment cost.

Abstract

Importance  Clinicians frequently use radiotherapy with cetuximab over radiotherapy only or radiotherapy with cisplatin because of a perceived survival and tolerability advantage, but scant data are available to support this perception.

Objective  To measure the 3 aspects of value (quality, outcomes, and cost) in older patients receiving radiotherapy only, radiotherapy with cisplatin, or radiotherapy with cetuximab for locoregionally advanced head and neck cancer.

Design, Setting, and Participants  For this cohort study, patient records were obtained from the Surveillance, Epidemiology, and End Results Program (SEER)–Medicare outcomes and claims database from January 1, 2004, to December 31, 2014. Participants were 65 years or older; received a diagnosis between 2006 and 2013 of stages III to IVB head and neck cancer; had only 1 cancer on record; and did not undergo surgical intervention. Data analysis was conducted from February 5, 2018, to March 27, 2019.

Exposures  Patients were divided into exposure arms on the basis of their first-line therapy or identified chemoradiotherapy and radiotherapy regimen.

Main Outcomes and Measures  Overall survival was analyzed by propensity score matching Cox proportional hazards regression models, quality by measuring 90-day emergency department (ED) visit and inpatient admission rates, and costs by assessing 90-day total Medicare spending.

Results  The overall cohort included 1091 patients, of whom 815 (74.7%) were male; the mean (SD) age was 73.9 (6.6) years. Patients receiving radiotherapy with cisplatin had higher overall survival compared with those receiving radiotherapy only (adjusted hazard ratio [HR], 0.64; 95% CI, 0.47-0.87). This finding was not seen in patients receiving radiotherapy with cetuximab (adjusted HR, 0.95; 95% CI, 0.75-1.20), compared with the radiotherapy only group, and it persisted after stratifying patients by age. The ED visit (adjusted incidence rate ratio [IRR], 1.72; 95% CI, 1.30-2.30) and inpatient admission (adjusted IRR, 1.48; 95% CI, 1.12-1.98) rates in the 90 days after treatment start were higher in patients receiving radiotherapy with cisplatin compared with those treated with radiotherapy only. Patients receiving radiotherapy with cetuximab had a higher rate of ED visits (adjusted IRR, 1.38; 95% CI, 1.05-1.82) compared with those in the radiotherapy only group. The 90-day after-treatment spending for patients receiving radiotherapy with cetuximab was $48 620 (95% CI, $46 466-$50 775) compared with $33 009 (95% CI, $31 499-$34 519) for radiotherapy with cisplatin and $27 622 (95% CI, $25 118-$30 126) for radiotherapy only.

Conclusions and Relevance  In this cohort study, no survival difference, a higher rate of ED visits but not of inpatient admissions, and higher spending were observed in patients receiving radiotherapy with cetuximab compared with patients receiving radiotherapy only. The findings suggest that radiotherapy alone should be maintained as a treatment arm in evaluation of novel therapeutics for locoregionally advanced head and neck cancer in older and sicker patients.

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