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Multidisciplinary Care Critical in Head and Neck Cancer

Angelica Welch

The treatment of patients with head and neck cancer is complex, requiring a multifaceted approach including surgical and systemic therapy and supportive care, according to Assuntina G. Sacco, MD.

“In addition to cure, we need to be looking at functional outcomes, and without appropriate supportive services both cure, as well as functional outcomes, are impacted,” said Sacco. “It is critical to have the relevant players at the table to optimize our patients' outcomes.”

At the 2017 OncLive® State of the Science SummitTM on Head and Neck Squamous Cell Carcinoma, Sacco, a medical oncologist and assistant clinical professor at Moores Cancer Center, University of California, San Diego discussed the available treatment options for locally advanced disease. In an interview during the meeting, Sacco emphasized the importance of multidisciplinary care for these patients.

OncLive: Can you provide an overview of your presentation?

Sacco: My talk was about treatment options for locally advanced head and neck cancer. In respect to concurrent chemoradiation, I discussed the importance of giving high-dose cisplatin as opposed to weekly cisplatin, as there were data presented from Tata Memorial Hospital that demonstrated that the higher dose was superior to the weekly dose with respect to local-regional control. There was also a trend toward improved disease-free survival and overall survival; however, the study was simply not powered to detect that.

I also touched on induction chemotherapy and how the trials to date have not shown a survival benefit. Therefore, the use of induction therapy should be limited to select situations, such as a patient who has an unavoidable delay in treatment or has such locally advanced disease that they might have an impending issue that cannot otherwise be adequately treated with surgery. 

Then, I touched on HPV and how the standard of care is the same irrespective of HPV status at this time. There have been many trials that have been completed looking to de-escalate or risk-stratify treatment based on HPV status. However, until we have the results of those trials, we should not be changing our treatment paradigm outside the context of a clinical trial. 

I discussed how the timing of treatment initiation, as well as package time, are important with respect to outcomes. And, I briefly touched on how receiving treatment at high-volume centers does improve outcomes. Finally, I reviewed the clinical trials that we have active at Moores Cancer Center; there are quite a few that are mostly incorporating the use of immunotherapy. 

Additionally, I stressed the importance of a multidisciplinary team, as complex management of head and neck cancer requires supportive care, as well as the usual providers, such as physicians. Then, I talked about care pathway models. Care pathway models are essentially a roadmap to help standardize how we treat our patients, and provide early integration of supportive care services. That will be extremely useful in optimizing survival outcomes, but also functional outcome, patient experience, and satisfaction. 

What are some trials that are currently ongoing at Moores Cancer Center?

For patients with locally advanced disease who are going to get chemoradiation, we have 2 trials. One of them is involving the addition of immunotherapy, specifically pembrolizumab (Keytruda), as both a lead-in phase, given concurrently throughout chemotherapy and radiation, and then as an adjuvant treatment. That study was designed by Sanford Health; Dr Kathryn A. Gold is the principle investigator at our institution. 

The second trial is a Pfizer-sponsored trial called JAVELIN. This is for patients with high-risk head and neck cancer, and it involved high-dose cisplatin with radiation. They may also receive placebo or a PD-L1 inhibitor, specifically avelumab (Bavencio), which is given as a lead in concurrent throughout chemoradiation, and then in a maintenance phase that goes on for up to 1 year. 

What is imperative for community oncologists to know regarding multidisciplinary care in head and neck cancer?

Multidisciplinary care is more important now than ever with respect to the management of head and neck cancer. No physician can do it alone—we need to have collaboration, not only among physician providers, such as your surgeon, radiation oncologist, and medical oncologist, but our speech language therapists are super important and need to be seeing these patients regularly. We also need to have dietitians involved, that helps to minimize weight loss, and reduce the potential for a feeding tube. If a patient does need a feeding tube, having a dietitian and a speech pathologist involved can potentially expedite the removal of feeding tubes, as well as improving swallowing mechanisms.

I cannot stress the importance of a multidisciplinary team enough, simply because our patients go through a lot with respect to treatment and toxicity. They need intensive support throughout the care continuum, so not only during treatment, but even in the months of recovery that follow.
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