Susceptibility to Adverse Respiratory Outcomes
Patients with HNSCC are at high risk for poor respiratory outcomes due
to underlying respiratory comorbidities. Kawakita et al. performed the
first population-based analysis designed to compare the incidence of
respiratory disease in HNSCC patients compared to the general
population. In a study of 1901 head and neck cancer patients within the
Utah Cancer Registry matched to 7796 noncancer patients, the authors
discovered that risks of respiratory infection (HR 1.63), COPD and
bronchiectasis (HR 2.65), and aspiration pneumonitis (HR 6.21) were
higher among head and neck cancer survivors, even after adjusting for
baseline smoking status.6 Interestingly, this
increased risk persisted more than 5 years after diagnosis
(Table 1 ).6 Specifically, risks of COPD and
aspiration pneumonitis were more than 3-times higher among this
population. Moreover, the authors demonstrated that triple modality
therapy was the strongest risk factor for aspiration pneumonia. Age at
diagnosis, baseline body mass index, sex, smoking status, treatment
modality, primary tumor site, and stage were also identified as
significant risk factors for adverse respiratory outcomes.
The risk of severe pulmonary complications remains elevated in both the
immediate and long-term perioperative period. In a review of 3932
patients from a national database who underwent head and neck surgical
procedures, postoperative pneumonia was the most common medical
complication (3.26%) and was associated with a mortality rate of 10.9%
(OR for mortality, 4.4).39 Buitelaar et al. showed
comparable outcomes in a retrospective series of 469 patients undergoing
primary major head and neck ablation with cardiovascular (12%) and
respiratory (11%) complications being the most frequent. Significant
risk factors for pulmonary complications included preexisting pulmonary
disease, prior myocardial infarction, and ASA grade.40The incidence of new respiratory comorbidities including pneumonia,
asthma, and COPD has been found to be highest within the first 6 to 12
months following treatment and remains nearly two-fold higher compared
to non-cancer patients. Similar findings were reported by Baxi et al.
who demonstrated that mortality from COPD, pneumonia, and influenza
continued to rise among HNSCC survivors who had lived at least 3 years
after diagnosis (Table 1).3
These findings highlight several key considerations. First, early
dysphagia intervention programs may be useful in mitigating the adverse
functional impacts of surgery and radiation-induced fibrosis and prevent
aspiration pneumonitis.41 Second, adherence to smoking
cessation is critical to reducing the risk of recurrence, second primary
malignancies, and comorbid respiratory diseases.42Finally, in general, frequent disease surveillance and multidisciplinary
care should remain central to the treatment and prevention of adverse
pulmonary outcomes among higher risk HNSCC survivors.