Prolonged radiation time and low nadir hemoglobin during postoperative concurrent chemoradiotherapy are both poor prognostic factors with synergistic effect on locally advanced head and neck cancer patients

BACKGROUND: Anemia, a common complication of head and neck cancer treatment, is regarded as a poor prognostic factor. We evaluated the impact of low hemoglobin (Hb) levels, measured at different time points, on a consecutive cohort of patients with locally advanced squamous cell carcinoma of the head and neck (LA-SCCHN) who underwent postoperative concurrent chemoradiotherapy (CCRT). MATERIALS AND METHODS: From 2002 to 2009, 140 patients were enrolled and reviewed retrospectively. Preoperative (pre-op Hb), pre-CCRT Hb, and nadir Hb during CCRT were measured and recorded. The three Hb parameters were analyzed against several well-established pathologic risk factors and radiation-associated variables. Prognostic impacts were investigated with multivariate analysis by Cox proportional hazards model. RESULTS: On Cox regression analysis, significantly higher risk of death was associated with pre-op Hb ≦13 g/dL (hazard ratio [HR] =1.8; 95% confidence interval [CI], 1.1–3.1; P=0.023), nadir Hb ≦11 g/dL (HR =1.9; 95% CI, 1.1–3.3; P=0.020), radiation treatment time (RTT) >7 weeks (HR =1.9; 95% CI, 1.1–3.3; P=0.022), and multiple positive lymph nodes (HR =2.1; 95% CI, 1.2–3.7; P=0.010), after adjusting for primary tumor site and pathologic lymphovascular invasion. Patients with poor prognosticators including low nadir Hb ≦11 g/dL and RTT >7 weeks had a higher risk of death (HR =4.0; 95% CI =1.6–10.2; P=0.004). CONCLUSION: In the treatment setting of LA-SCCHN patients who underwent postoperative CCRT, coexistance of lower nadir Hb during CCRT and prolonged RTT resulted in reduced survival.