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Treatment Approaches in Head and Neck Cancer

Insights From: Ezra Cohen, MD, UC San Diego Moores Cancer Center; Robert L. Ferris, MD, PhD, FACS, University of Pittsburgh Cancer Institute; Jared Weiss, MD, University of North Carolina School of Medicine
Published: Wednesday, Apr 27, 2016


Transcript:

Jared Weiss, MD:
In personalizing care to the patient, we need to consider the anatomic site, the stage, and the comorbidities of the patient. So, for example, an oral cavity cancer is usually best treated with surgery. The healthy jaw and teeth don’t tolerate radiation very well, and the site is obviously very surgically accessible. In contrast, with tumors of the larynx, you’re worried about speech, and often avoiding a laryngectomy by using radiation can better do that for the patient, typically, than a surgical approach. In contrast, when you get into the oral pharynx, that’s where really some of our most vibrant conversations come in, trying to individualize care to the patient. An evenhanded multidisciplinary conversation about the merits of surgery versus radiation can be very helpful. The particular variables involved in that conversation are expected voice function at completion of therapy and expected swallowing function at completion of therapy. There’s no substitute for frank conversation between the radiation oncologist and the surgeon in personalizing that care.

Ezra Cohen, MD: The guidelines for treatment of head-and-neck cancer, and mostly it’s around squamous cell carcinomas, are available through a few sources. Probably the most commonly used is the NCCN, and those guidelines are developed through peer groups and meetings reviewing the data. They’re very easy-to-use guidelines—which I think makes them very accessible and commonly used—separating the disease into its different settings, such as early stage, locally advanced, recurrent metastatic, and even providing lines of therapy along the way. The NCCN also deals with surveillance of patients after they’re treated. So, these guidelines become quite helpful and, as much as possible, they’re evidence-based. And when they’re not, the guidelines tell you that we’re making a statement that doesn’t have a lot of evidence behind it.

But they’re not the only guidelines. ASTRO has issued guidelines on specific topics around head and neck. For instance, several years ago, they issued a guideline around the use of induction chemotherapy and radiation planning. ASCO has issued some guidelines that can be applicable to head and neck cancer. ASTRO is soon to publish guidelines on the treatment of oral pharynx cancers. This will be a more comprehensive guideline around the therapy: how to use chemotherapy, how to use surgery, and how to use radiation therapy. Those should be scheduled to come out sometime later this year. And then the American Cancer Society is also coming out with guidelines around head and neck cancer survivorship. These are guidelines that are geared primarily for primary care physicians, but having participated in authoring these guidelines, they would certainly be applicable to oncologists as well. And I think they’ll be quite helpful, because one of the things we realize with head and neck cancer is that many patients are cured of this disease, and this is especially true for HPV-positive cancers that have a better prognosis. So, we’re left with, believe it or not, about almost half a million patients in this country that have survived head and neck cancer and the long-term side effects of not only the disease, but the treatment. And those ACS Guidelines will hopefully help physicians deal with many of the issues that these patients face.

Whenever we see a patient with squamous cell carcinoma of the head and neck, I think it’s imperative for us to first ask, is the patient in front of us curable? Can we treat them with curative intent? And the reality is that 90% of the patients with squamous cell carcinoma of the head and neck will present with either local or local regional disease. And so, in theory, 90% of our patients should at least be approached initially with that in mind. Some of those patients will decide to not have a curative option for several reasons, either patient-related comorbidities or the extent of the tumor. But at the very least, we need to think about that. Now, as we begin to do the work-up, some patients will discover that they have metastatic disease, and that puts them into a different scenario. Then, there are some other factors that begin to come into play when we decide about therapy. One of them is age, and related to age is comorbidity.

So, what we’ve come to realize is that, unfortunately, older patients don’t appear to do as well with therapy for locally advanced disease, with curative intent therapy. And, in fact, meta-analyses have even looked at the outcome of younger patients versus older patients, and older patients don’t seem to benefit as much from certain interventions; most notably, the addition of chemotherapy to radiation. But if you look at the data very closely, really the reasons behind that are that older patients die of other causes. So, it’s not so much the cancer-specific mortality that we worry about in these patients—of course we do worry about it, and that’s paramount—but we also have to keep in mind that there’s associated illnesses that come with age, comorbidities that come with age that we also need to manage. Because those patients are at much greater risk for non-cancer-related mortality. When we look at fit elderly patients—and we’re seeing many more of these in our clinics as society in general becomes healthier—the treatment approach to them appears to be the same, should be the same, as what we apply to younger patients. The data that we have in younger patients is valid for the fit elderly ones.

Robert Ferris, MD, PhD, FACS: The goals of treatment, particularly when we separate patients out by locally advanced or resectable versus locally advanced unresectable, we usually prioritize cure as number one. There is a subset of far-advanced tumors where the surgery, for instance, may be debilitating or disfiguring, or may cause the removal of an organ such as the voice box or the tongue that a patient wouldn’t want to live without and wouldn’t want to live with that sort of a surgical approach. So, usually, when we can do a surgical therapy without destroying the function of an organ, then we retain that as a strong option in the treatments we offer the patient. Interestingly, one can remove a relatively small portion of the tongue or different portions of the voice box and still have good speaking, breathing, and swallowing. So, we usually feel like the best way to assess those prognostic features that we talked about pathologically is to remove the cancer and, at the same time, remove lymph nodes on that side of the neck. A surgical approach up front has the goal of cure, particularly if you document a low rate of spread to the neck. Sometimes, we don’t even need postoperative radiation therapy. As long as that can be done functionally, then that’s often a preferred approach.

For bigger tumors, we’re likely to need both surgery and radiation therapy, and so the goals are still cure. But we recognize that function is going to become more important in that regard. Not only because of the size of the tumor and the tissue removed, but because the treatments themselves and the addition of radiation therapy will affect function also. And yet, we still prioritize cure because this is a curative population. When a tumor is so-called unresectable, that is usually because of the structures it invades. But very occasionally it is because the patient simply refuses to have the procedure, and we shouldn’t muddy up the unresectables with patient preference. But, we would say that an unresectable patient is usually treated with definitive radiotherapy in an attempt to cure. The chance to cure is much lower if that patient is in an unresectable category. We’d certainly add chemotherapy to radiation if the patient could tolerate it. Perhaps up to 20% or 30% of patients are intolerant of chemotherapy due to kidney dysfunction, or neuropathy, or other side effects that may limit our ability to utilize those modalities, the intensification with chemotherapy.

Transcript Edited for Clarity
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Transcript:

Jared Weiss, MD:
In personalizing care to the patient, we need to consider the anatomic site, the stage, and the comorbidities of the patient. So, for example, an oral cavity cancer is usually best treated with surgery. The healthy jaw and teeth don’t tolerate radiation very well, and the site is obviously very surgically accessible. In contrast, with tumors of the larynx, you’re worried about speech, and often avoiding a laryngectomy by using radiation can better do that for the patient, typically, than a surgical approach. In contrast, when you get into the oral pharynx, that’s where really some of our most vibrant conversations come in, trying to individualize care to the patient. An evenhanded multidisciplinary conversation about the merits of surgery versus radiation can be very helpful. The particular variables involved in that conversation are expected voice function at completion of therapy and expected swallowing function at completion of therapy. There’s no substitute for frank conversation between the radiation oncologist and the surgeon in personalizing that care.

Ezra Cohen, MD: The guidelines for treatment of head-and-neck cancer, and mostly it’s around squamous cell carcinomas, are available through a few sources. Probably the most commonly used is the NCCN, and those guidelines are developed through peer groups and meetings reviewing the data. They’re very easy-to-use guidelines—which I think makes them very accessible and commonly used—separating the disease into its different settings, such as early stage, locally advanced, recurrent metastatic, and even providing lines of therapy along the way. The NCCN also deals with surveillance of patients after they’re treated. So, these guidelines become quite helpful and, as much as possible, they’re evidence-based. And when they’re not, the guidelines tell you that we’re making a statement that doesn’t have a lot of evidence behind it.

But they’re not the only guidelines. ASTRO has issued guidelines on specific topics around head and neck. For instance, several years ago, they issued a guideline around the use of induction chemotherapy and radiation planning. ASCO has issued some guidelines that can be applicable to head and neck cancer. ASTRO is soon to publish guidelines on the treatment of oral pharynx cancers. This will be a more comprehensive guideline around the therapy: how to use chemotherapy, how to use surgery, and how to use radiation therapy. Those should be scheduled to come out sometime later this year. And then the American Cancer Society is also coming out with guidelines around head and neck cancer survivorship. These are guidelines that are geared primarily for primary care physicians, but having participated in authoring these guidelines, they would certainly be applicable to oncologists as well. And I think they’ll be quite helpful, because one of the things we realize with head and neck cancer is that many patients are cured of this disease, and this is especially true for HPV-positive cancers that have a better prognosis. So, we’re left with, believe it or not, about almost half a million patients in this country that have survived head and neck cancer and the long-term side effects of not only the disease, but the treatment. And those ACS Guidelines will hopefully help physicians deal with many of the issues that these patients face.

Whenever we see a patient with squamous cell carcinoma of the head and neck, I think it’s imperative for us to first ask, is the patient in front of us curable? Can we treat them with curative intent? And the reality is that 90% of the patients with squamous cell carcinoma of the head and neck will present with either local or local regional disease. And so, in theory, 90% of our patients should at least be approached initially with that in mind. Some of those patients will decide to not have a curative option for several reasons, either patient-related comorbidities or the extent of the tumor. But at the very least, we need to think about that. Now, as we begin to do the work-up, some patients will discover that they have metastatic disease, and that puts them into a different scenario. Then, there are some other factors that begin to come into play when we decide about therapy. One of them is age, and related to age is comorbidity.

So, what we’ve come to realize is that, unfortunately, older patients don’t appear to do as well with therapy for locally advanced disease, with curative intent therapy. And, in fact, meta-analyses have even looked at the outcome of younger patients versus older patients, and older patients don’t seem to benefit as much from certain interventions; most notably, the addition of chemotherapy to radiation. But if you look at the data very closely, really the reasons behind that are that older patients die of other causes. So, it’s not so much the cancer-specific mortality that we worry about in these patients—of course we do worry about it, and that’s paramount—but we also have to keep in mind that there’s associated illnesses that come with age, comorbidities that come with age that we also need to manage. Because those patients are at much greater risk for non-cancer-related mortality. When we look at fit elderly patients—and we’re seeing many more of these in our clinics as society in general becomes healthier—the treatment approach to them appears to be the same, should be the same, as what we apply to younger patients. The data that we have in younger patients is valid for the fit elderly ones.

Robert Ferris, MD, PhD, FACS: The goals of treatment, particularly when we separate patients out by locally advanced or resectable versus locally advanced unresectable, we usually prioritize cure as number one. There is a subset of far-advanced tumors where the surgery, for instance, may be debilitating or disfiguring, or may cause the removal of an organ such as the voice box or the tongue that a patient wouldn’t want to live without and wouldn’t want to live with that sort of a surgical approach. So, usually, when we can do a surgical therapy without destroying the function of an organ, then we retain that as a strong option in the treatments we offer the patient. Interestingly, one can remove a relatively small portion of the tongue or different portions of the voice box and still have good speaking, breathing, and swallowing. So, we usually feel like the best way to assess those prognostic features that we talked about pathologically is to remove the cancer and, at the same time, remove lymph nodes on that side of the neck. A surgical approach up front has the goal of cure, particularly if you document a low rate of spread to the neck. Sometimes, we don’t even need postoperative radiation therapy. As long as that can be done functionally, then that’s often a preferred approach.

For bigger tumors, we’re likely to need both surgery and radiation therapy, and so the goals are still cure. But we recognize that function is going to become more important in that regard. Not only because of the size of the tumor and the tissue removed, but because the treatments themselves and the addition of radiation therapy will affect function also. And yet, we still prioritize cure because this is a curative population. When a tumor is so-called unresectable, that is usually because of the structures it invades. But very occasionally it is because the patient simply refuses to have the procedure, and we shouldn’t muddy up the unresectables with patient preference. But, we would say that an unresectable patient is usually treated with definitive radiotherapy in an attempt to cure. The chance to cure is much lower if that patient is in an unresectable category. We’d certainly add chemotherapy to radiation if the patient could tolerate it. Perhaps up to 20% or 30% of patients are intolerant of chemotherapy due to kidney dysfunction, or neuropathy, or other side effects that may limit our ability to utilize those modalities, the intensification with chemotherapy.

Transcript Edited for Clarity
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