feature
Nasopharyngeal cancer in Newfoundland
and Labrador: 7-year experience
Dawn Armstrong MD; Erin Powell MD; Melanie Seal MD; Stewart Rorke MD; Kara Laing MD;
Pradip Ganguly MD; Craig Pochini MD; Farah McCrate MSc; Joy McCarthy MD
Abstract
Purpose: Nasopharyngeal cancer (NPC) is a rare malignancy
in Newfoundland and Labrador (NL), and little is known
about risk factors and preferred treatment in this unique
patient population. The purpose of this study is to review
outcomes of NPC patients in NL and determine if these
outcomes are associated with stage at diagnosis and/or
treatment given.
Methods: This retrospective chart review includes all patients
seen at the Dr. H. Bliss Murphy Cancer Centre from 2002
to 2009 who were diagnosed with Stage I–IV NPC.
Patients received either radiation alone or concurrent
chemoradiation. Information collected included patient
demographics, treatment received, recurrence and survival
outcomes. Outcomes were then compared based on stage
and treatment (concurrent chemoradiation vs radiation alone).
Results: Out of 37 patients identified using the provincial
tumour registry, 32 cases met our criteria. Sixteen patients
(50.0%) presented as Stage IV. Local recurrence was docu-
mented in 10 patients (31.3%), and metastatic disease was
Dawn Armstrong, MD is an Internal Medicine Resident at
Memorial University, Newfoundland. Email: dawn.armstrong@mun.ca;
Erin Powell, MD, FRCPC is a Clinical Assistant Professor in
Medical Oncology at Memorial University; Melanie Seal, MD,
FRCPC is an Assistant Professor of Medical Oncology at Memorial
University; Stewart Rorke, MD, FRCPC is a Clinical Assistant
Professor in Medical Oncology at Memorial University; Kara Laing,
MD, FRCPC is an Associate Professor of Medical Oncology at
Memorial University; Pradip Ganguly, MD, FFRCSI is a Clinical
Associate Professor of Radiation Oncology at Memorial University;
Craig Pochini, MD, FRCPC is a Clinical Assistant Professor of
Radiation Oncology at Memorial University; Farah McCrate,
MSc, PhD candidate at Memorial University, contributed to the
statistical analysis for this article; Joy McCarthy, MD, FRCPC is a
Clinical Assistant Professor in Medical Oncology at Memorial University.
©2011 Parkhurst, publisher of Oncology Exchange. All rights reserved.
e-4 oe VOL. 10, No. 2, may 2011
also seen in 10 patients. Twenty-two patients (68.8%) were
disease-free 12 months after diagnosis, half of these pre-
senting with Stage IV at diagnosis. As of September 2010,
20 patients (62.5%) were alive.
Median disease-free survival (DFS) and overall survival
(OS) were greatest in Stage II patients, at a median of 39
and 50 months, respectively. Finally, when comparing OS
by treatment, patients who had chemoradiation did better
than those with radiation alone (42 vs 21 months).
Conclusion: Our findings show that the majority of patients
with NPC in NL present at an advanced stage, and as expected,
outcomes are worse for more advanced stages at presentation.
In our cohort, no significant difference in OS was seen
between patients treated with radiation only vs those treated
with chemoradiation. However, Stage III and IV patients
had longer OS with the addition of chemotherapy to radiation
treatment. Future studies should target differences in sub-
populations based on World Health Organization (WHO)
type, ethnicity, Epstein-Barr virus (EBV) status and other
risk factors for NPC.
keywords
Nasopharyngeal cancer, Newfoundland and Labrador
Introduction
Nasopharyngeal cancer (NPC) is a rare and understudied
form of cancer. In Canada, there were only 228 new
reported cases in 2005, making it a mere 0.3% of total new
cancer cases.1 Similarly, in the US2 and UK,3 NPC accounts
for only about 1 out of every 1000 diagnosed cancers.
Interestingly, in Asia, rates of NPC are estimated as high
as 21 in 1000 men, pointing to an undetermined interplay
of both environmental and genetic factors.4,5 Because of its
low incidence, little is known about the risk factors for
developing NPC in North America.6
NPC is also characterized by its poor prognosis. Like many
other cancers, prognosis is related to stage at diagnosis,
with worse prognosis at higher stages.7 NPC is divided into
4 stages using the American Joint Committee on Cancer
(AJCC) designated staging by TNM classification. Because of
its anatomic location and often vague presenting symptoms,
most NPC cases are diagnosed at Stages III and IV.
Standard treatment for NPC includes high-dose external
beam radiation therapy, with the addition of cisplatin-based
 feature
chemotherapy in later-stage and/or node-positive disease. Methods
Surgery can also be an option for nonresponding disease or We conducted this retrospective chart review in accordance
locoregional recurrence, according to the BC Cancer Agency with the Memorial University of Newfoundland Human
(BCCA) Protocol, 20098 and National Cancer Institute, 2009.9 Investigation Committee ethical research guidelines. A total
However, there is a paucity of randomized controlled clinical of 37 patients with Stage I–IV NPC who received either
data relating to treatment of NPC, and optimal regimens radiation alone or chemoradiation between 2002 and 2009
differ somewhat among major centres and are often based were identified from the Newfoundland and Labrador (NL)
on centre-specific data. This study will add to the limited
outcomes data available for NPC.
Table 3. Patient outcomes
Local recurrence
Table 1. Patient characteristics (n=32)
Stage I 1
Gender
Stage II 1
Male 22 (68.8%)
Stage III 4
Female 10 (31.3%)
Stage IV 4
Median age at diagnosis
Total 10 (31.3%)
56 years (range 18–78)
Metastasis
Smoking history
Stage I 1
Yes 23 (71.9%)
Stage II 0
No 9 (28.1%)
Stage III 4
History of alcohol use
Stage IV 5
Yes 25 (78.1%)
Total 10 (31.3%)
No 5 (15.6%)
Number still living*
Unknown 2 (6.3%)
Stage I 1
Stage II 7
Table 2. Tumour characteristics Stage III 3
Stage IV 9
WHO histologic type
Total 20 (62.5%)
I (squamous cell carcinoma) 25 (78.1%)
Median DFS*
II (nonkeratinizing carcinoma) 0 (0%)
Stage I 24.5 months (range 7–42)
III (undifferentiated carcinoma) 7 (21.9%)
Stage II 39.0 months (range 15–70)
Primary tumour (T) classification
Stage III 14.0 months (range 3–74)
T1 10 (31.3%)
Stage IV 13.0 months (range 2–48)
T2 9 (28.1%)
12 month DFS*
T3 2 (6.3%)
Stage I 1
T4 12 (37.5%)
Stage II 7
Regional lymph node (N) classification
Stage III 4
N0 8 (25.0%)
Stage IV 10
N1 6 (18.8%)
Total 22 (68.8%)
N2 13 (46.9%)
Median OS by AJCC Stage*
N3 5 (15.6%)
Stage I 34.5 months (range 27–42)
AJCC Stage
Stage II 50.0 months (range 15–72)
I 2 (6.3%)
Stage III 14.0 months (range 3–74)
II 7 (21.9%)
Stage IV 25.0 months (range 2–48)
III 7 (21.9%)
AJCC=American Joint Committee on Cancer
IV 16 (50.0%)
DFS=disease-free survival OS=overall survival
AJCC=American Joint Committee on Cancer WHO=World Health Organization *as of September 2010

©2011 Parkhurst, publisher of Oncology Exchange. All rights reserved.

oe VOL. 10, No. 2, may 2011 e-5
 feature
Cancer Registry at the Dr. H. Bliss Murphy Cancer Centre
(HBMCC). Staging was based on the AJCC Cancer Staging Table 5. Overall survival (months), by treatment
Manual, 7th Ed,10 and treatment was decided by our centre’s and stage at time of diagnosis
multidisciplinary team based on staging, pathologic features, Radiation Only Chemoradiation
medical comorbidities and patient preference.
Stage I 42 27
Two patients were excluded because their final diagnosis
did not meet the World Health Organization (WHO) defi- Stage II 72, 50, 15 (median=50.0) 70, 36, 54, 39 (median=46.5)
nition of NPC:11 one case was diagnosed as a nasopharyngeal Stage III 14, 3, 11, 45 (median=12.5) 74, 53, 10 (median=53.0)
chondroid cordoma, and another as a diffuse large non-
Stage IV 16, 5, 2, 48, 45, 49, 11, 26, 10, 7 32, 16, 31, 45, 50, 50
Hodgkin B-cell lymphoma. Three charts were not available
(median=13.5) (median=38.5)
for review; therefore, a total of 32 charts were reviewed.
Information collected from each patient’s chart and used All stages 21.0 42.0
in our analysis included: date of birth, age at diagnosis, sex,
birth place, occupation, smoking history, alcohol use, stage,
TNM diagnosis, date symptoms began, date of diagnosis,
date of biopsy, dates first seen by otolaryngologist, Medical Figure 1. Overall survival across all stages
Oncology and Radiation Oncology, date of first radiation for radiation alone vs chemoradiation
dose, dose of radiation, length of radiation treatment (days),
chemotherapy given post radiation (Y/N), dose reduction
of chemotherapy (Y/N), living at the time of chart review
(Y/N), date of death, metastases (Y/N), method of finding
metastases and local recurrence (Y/N).
All information was put into a standardized spreadsheet
and organized according to stage, treatment and outcome.
Outcome was separated into 12-month DFS, defined as the
percentage of patients who had no evidence of either local
recurrence or metastatic disease after 12 months from
diagnosis, and OS, defined as time (months) from date of
diagnosis to date of death from any cause.
Twelve-month disease-free survival (DFS) and overall
survival (OS) were recorded as simple calculations of the
median. To analyze OS stratified by treatment regime
(radiation vs chemoradiation), a Kaplan-Meier survival
curve was constructed, and a log-rank test was carried out Stage IV at diagnosis (Table 2).
to compare survival curves. Local recurrence was documented in 10 (31.3%) patients,
8 of whom were Stage III or IV at time of diagnosis.
Results Metastatic disease was also documented in 10 (31.3%) of the
Of the 32 patients included in this study, 22 (68.8%) were male, charts reviewed, with 9 of these patients being Stage III or
resulting in a male-to-female ratio of 2.2:1. The median age IV at diagnosis. A total of 22 (68.8%) patients were disease-
of patients at diagnosis was 56 years. Nearly two-thirds (23 free 12 months after diagnosis; 10 of these patients pre-
or 71.9%) reported having a smoking history, and 78.1% sented as Stage IV at diagnosis. As of September 2010,
claimed to be current consumers of alcohol (Table 1). 20 patients (62.5%) were alive. Median OS across all stages
Dividing the patients by histologic type, the vast majority was 34.3 months, with the shortest survival (14 months)
(25 or 78.1%) were WHO type I (squamous cell carcinoma). seen in Stage III patients (Tables 3 and 4).
Using the TNM classification system, 50.0% of patients were Comparing treatment regimens, 14 patients (43.8%)
received radiation therapy and 18 (56.3%)
received cisplatin-based chemotherapy in con-
Table 4. Patient outcomes, by stage at time of diagnosis junction with radiation. Treatments
Number of Local Metastasis 12-month Number OS
did not appear to differ according to stage,
patients recurrence DFS living (months) as all stages included patients treated with
radiation-only as well as patients treated with
Stage I 2 1 1 1 1 43.5
chemo­radiation.
Stage II 7 1 0 7 7 50.0 Patients in the chemoradiation group lived
Stage III 7 4 4 4 3 14.0 longer compared to the radiation only group
(21 vs 42 months; Table 5). When comparing
Stage IV 16 4 5 10 9 25.0
treatment regimens across all stages, there was
All stages 32 10 (31.3%) 10 (31.3%) 22 (68.8%) 20 (62.5%) 34.3 no significant difference in the Kaplan-Meier
DFS=disease-free survival OS=overall survival survival curves (p=0.3533; Figure 1).
However, when the results were stratified by

©2011 Parkhurst, publisher of Oncology Exchange. All rights reserved.

e-6 oe VOL. 10, No. 2, may 2011

stage at diagnosis, it appears that in earlier stages (I and II),
the radiation only groups survived longer, while in later stages
(III and IV), OS was longer in the chemoradiation group.
Discussion
The objective of this retrospective review was to document
outcomes of NPC patients in NL and to draw a hypothesis
on the best treatment options. In terms of epidemiology
and patient characteristics, it was clear that our population
was similar to other NPC populations in the literature. The
majority of patients were men in their late 50s with a history
of smoking and alcohol use who were diagnosed with WHO
type I NPC.12 This enabled us to draw conclusions on the
wider population of NPC patients. Also like the wider pop-
ulation, we had a large number of individuals presenting at
later stages (Stages III and IV). There have been hypotheses
regarding the reasons for late presentation, including vague
symptoms, physical location in the skull and ease of metas-
tasis to cervical lymph nodes. Regardless of the cause, our
study further demonstrates that earlier diagnosis is crucial,
since later stage at presentation leads to a greater likelihood
of metastasis and lower OS.
Of interest is the marked difference in OS when adding
chemotherapy to the treatment regimen for Stages III and IV
patients. This is in concordance with a number of landmark
studies that show statistically significant OS benefits in both
Stage III and Stage IV patients with cisplatin-based chemo-
radiation compared to radiotherapy alone.13,14 It should also
be noted that a large number of patients did not complete
the full intended dose of chemoradiation, due to side effects
and/or advanced stage of disease. In fact, as a group, these
patients received two-thirds of the intended chemotherapy
during radiation; of those who were dose-reduced, all were
Stage III or Stage IV.
Since this was a retrospective chart review, our study had
the limitations of availability of medical records, possible
selection bias and lack of randomization. Further, with our
small sample size, any results could only serve to generate
hypotheses. Given the rarity of NPC, however, information
compiled from small chart reviews such as this will be neces-
sary to provide the foundation for larger prospective studies.
Although we did not specifically look at a subgroup analysis
of the Labrador Innu and Inuit population, this chart review
did contain patients from this ethnicity. Native populations
in Canada have comparable rates of NPC to those found in
parts of Asia. In Nunavut, cancer of the nasopharynx
accounted for 5.6% of reported cancers between 1992 and
2001, and the rate of NPC was 14.6/100,000 for men and
women combined.15 Further, it appears that of these Nunavut
patients, all were Inuit. It is thought that Epstein-Barr virus
(EBV) may play a role in this population.16 Consequently,
EBV testing may be beneficial in our local population in NL.
Our study adds to the mounting literature pointing to a
high rate of metastasis and local recurrence in patients with
advanced NPC. Treatment changes, such as possible new
chemotherapeutic agents and different delivery schedules,17
need to be considered. The use of targeted therapies such as
epidermal growth factor receptor (EGFR) inhibitors to treat
NPC is currently being investigated. Early studies have shown
©2011 Parkhurst, publisher of Oncology Exchange. All rights reserved.
feature
that EGFR inhibitors, when combined with conventional
chemotherapies, may offer improved outcomes.18 Unfortu-
nately, the data regarding efficacy of EGFR inhibitors in the
metastatic setting seem to be limited.19 Additionally, although
studies have shown EBV latent membrane protein 1 (LMP1)
to impact EGFR expression,20 the direct effects of this inter-
action and how it affects the sensitivity of EBV-containing
NPC cells to EGFR inhibitors need further study.
Conclusions
Our retrospective review found that the majority of patients
with NPC in NL present at an advanced stage. As expected,
outcomes are worse for more advanced stages at presentation.
This study also suggests that chemoradiation has the advan-
tage of prolonging OS, especially in later-stage disease.
Further prospective study will be required to clearly define
optimal treatment.
Disclosure
The authors report no conflict of interest relevant to this article.
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