Last weekend (April 13-14, 2019), I was very fortunate to have had the opportunity of participating at the European Society of Medical Oncology (ESMO) Head and Neck Cancer Preceptorship Programme held at Kowloon, Hong Kong.
This program was chaired by the leading experts in the field -Dr. Anthony Chan from Hong Kong and Dr. Jean-Pascal Machiels from Belgium; which included the following speakers: Dr. Melvin Chua (Singapore), Dr. Brigette Ma (Hong Kong), Dr. Sandra Nuyts (Belgium), Dr. Christian Simon (Belgium), Dr. Joseph Wee (Singapore), And Dr. John Woo (Hong Kong).
Here are the top 10 reminders I got from the program:
- The best approach in treating head and neck cancer involves a multidisciplinary team.
With the rapidly changing advances in the management of head and neck cancers, it is always best for the patient to be offered treatment options discussed by a multidisciplinary team which includes but is not limited to: Head and Neck Surgery, Medical Oncology, Radiation Oncology, Dentistry, Speech Pathology, Rehab, Dietary, and the Nursing Team.
- Human Papilloma Virus (HPV) tumoral status is a validated positive prognostic factor for oropharyngeal cancers. However, the treatment of HPV-positive oropharyngeal cancer should still be based on the TNM staging.
Although it has been validated that early stage HPV-related tumors have a 5-year overall survival (OS) of 90%, the new staging system incorporating HPV or p16 positivity is only used for prognostication as of this time. There are currently ongoing trials aimed at treatment deintensification for this subset of patients, but treatment decisions should be based according to the TNM staging as of the moment.
- Intensity-Modulated Radiation Therapy (IMRT) is preferred when doing radiation treatment for head and neck cancers.
IMRT uses advanced technology to focus the high radiation doses on the targets and avoid irradiation of non-involved tissues. Several randomized controlled trials (RCTs) have shown that IMRT (compared to conventional RT) causes less chronic side effects such as dysphagia and xerostomia which have been proven in some studies to improve the patients’ quality of life.
- I will consider using neoadjuvant chemotherapy in carefully selected patients who need “debulking.”
Induction chemotherapy followed by radiation therapy (compared with definitive concurrent chemo-RT) for patients with hypopharyngeal and laryngeal cancers is associated with better long term survival but a lower organ preservation rate.
For head and neck cancers other than these subsites, we were reminded to use neoadjuvant chemotherapy with extreme caution (preferably in the setting of a clinical trial) as this treatment approach is considered investigational. However, it may be applied in specific cases where locally advanced tumors pose complications related to RT or in patients who need “debulking” due to local complications.
- I will consider using Epstein-Barr Virus (EBV) DNA testing in patients with Nasopharyngeal Cancer (NPCA).
In high-incidence regions such as Asia, the undifferentiated type of NPCA is prevalent and highly associated with EBV. The close association of EBV with cancer is presently being exploited to develop diagnostic tools based on detection of EBV material in tissue (EBER) or in blood (EBV DNA or antibodies). Currently, the most important application of EBV DNA in blood is to detect residual disease after treatment and recurrent disease on surveillance.
- I will use Gemcitabine – Cisplatin in treating metastatic NPCA.
A phase 3 RCT by the Sun Yat-Sen University group showed that Gemcitabine plus cisplatin (versus cisplatin with 5-Fluorouracil) prolongs progression-free survival (7 vs 5.6 months) in patients with recurrent or metastatic nasopharyngeal carcinoma. The results establish gemcitabine plus cisplatin as the standard first-line treatment option for this population.
- I will use Cetuximab with cisplatin-fluorouracil chemotherapy in non-nasopharyngeal head and neck cancer patients with recurrent, unresectable, or metastatic disease with no surgery or RT option.
The addition of Cetuximab to cisplatin-FU is the standard first line treatment, as it resulted in a 2.7 month increase in median survival and a 2.3 month prolongation of progression-free survival (PFS), thus its designation as a Category 1 recommendation by NCCN in these particular subset of patients.
When using Cetuximab, it is important to remember the following associated grade 3/4 side effects: skin toxicity, hypomagnesemia, and infusion-related reactions.
- I will not use Cetuximab as first line in NPCA patients.
Present data shows that cetuximab does not improve outcomes when added to concurrent chemoradiation with high-dose cisplatin nor does it have any advantage when replacing cisplatin in combination with radiation therapy.
- I will consider using immunotherapy as second line treatment for patients with head and neck cancers with recurrent, unresectable, or metastatic disease with no surgery or RT option.
Nivolumab and pembrolizumab are Category 1 and 2B recommendations as subsequent line treatment for Non-NPCA patients with disease progression on or after platinum therapy and previously treated NPCA patients respectively.
10. Improving the patients’ quality of life is an essential aspect of treating head and neck cancers.
Treatment of head and neck cancers involves both acute and chronic side effects (eg. xerostomia, mucositis, dermatitis, pain, dysphagia, loss of taste, osteoradionecrosis) and it is important that these are addressed.
In managing patients with metastatic head and neck cancer patients, it is important to remember that combination chemotherapy is associated with higher response rates than single-agent therapy, but has not produced better survival outcomes compared with monotherapy.
My bonus but probably the most essential reminder for clinicians taking care of cancer patients: “Always take time to nourish the soul.”
After the conference was concluded, I was very fortunate to personally thank Dr. Anthony Chan, one of the chairs of the program and definitely a leading expert of head and neck oncology. As we exchanged our goodbyes and well wishes, he randomly mentioned that he was “crossing the street to attend church service” and that “it’s very important to always take time to nourish the soul by prayers.”
Happy Easter, everyone!
*The statements here are the personal views of the author.