Multimodality Treatment for HNSCC

Transcript:Ezra Cohen, MD: The therapeutic goal for any patient with local regionally advanced disease is always going to be cure. That’s the first thing that we think about. We want to talk about how we can effectively cure that patient, how we can get to that point, and, of course, how we can preserve their quality of life. And what I tell patients usually is, “I want us to be sitting across from each other 6 months from when we start, and I want to tell you that the cancer is gone, and I want to hear you say that you’re swallowing and speaking normally.” It realistically takes about 1 year for complete function to return, but we get a very good indicator around 6 months, whether we’ve done a good job in terms of addressing the cancer and whether we’re going to be able to preserve normal function in that individual.

Having said that, when we think about low-risk versus intermediate- or high-risk, we do recognize that there may be some differences in our goals of therapy. For low-risk patients, we’re usually going to be thinking about a single modality, at the most maybe two modalities—that is surgery or surgery and radiation—and often, we won’t use systemic chemotherapy in a patient like that. And in low-risk patients, so stage I, stage II patients, we expect high cure rates, 80% to 90% or even more, and very good functional outcomes at the end.

For intermediate- and high-risk patients, we now know that the best course to try and cure them is going to be multimodality therapy. So, we’re talking about surgery, radiation, and chemotherapy. We know that it’s going to be a more toxic, certainly more acutely toxic, approach. Again, the goal is cure. But, we recognize that we’re going to sacrifice some function in order to achieve the cure rates that are acceptable as standard of care. And we tell patients that, of course. “We are going to embark on a very intensive treatment regimen. Our goal is to get rid of this cancer, and, we’re going to work very closely with you, especially our speech and swallow therapists, our nutritionists, our psychologists. We are going to work very closely with you on a weekly basis to try and maintain your function as good as possible.”

Robert L. Ferris, MD, PhD: Whenever we decide on treatment choices, we have to look not only at the disease and the disease stage, but also on whether the patient can tolerate intensive therapy, often the weight loss, and some of the side effects—both acute- and long-term. And older patients are not quite as robust. We’re less likely to choose cytotoxic chemotherapy in an older patient, somebody who is over 70 years of age, somebody with neurologic symptoms, side effects, or renal toxicity. These folks cannot tolerate cytotoxic chemotherapy. On the other hand, the HPV-positive patient tends to be younger, less often smoking and less often with lung, liver, and kidney disease, and they can tolerate more aggressive therapy in the locally advanced setting.

Patients with advanced head and neck cancer often have disruptions in speaking, breathing, and swallowing because the anatomy and the physiology is altered by a growing tumor in the head and neck. So, the goals of therapy are to cure it without disrupting the speaking, breathing, and swallowing, and giving long-term quality of life and function. One of the most important features in deciding on treatment for locally advanced head and neck cancer is distinguishing between the cause, whether it’s HPV-positive, in which we know the outcome will be very good, or HPV-negative, in which the survival outcomes are not as good and have not improved in some decades. Therefore, the treatment choices are driven by the HPV-positives, where we don’t want to give so much therapy because the outcome is good. And the more therapy we give, the worse the functional status. The key is to select just the right amount of therapy to cure the cancer, and it takes less to cure an HPV-positive patient because the more cancer treatment you give somebody, the worse their speaking and swallowing will be after treatment. The HPV-negative patients tend to do worse. Therefore, we choose treatment for locally advanced HPV-negative cancer that often intensifies treatments, adds different types of treatments to try to improve survival, even though we know there will be a negative impact on the quality of life and swallowing because we haven’t done as well with clinical outcome in survival.

Transcript Edited for Clarity