Clinical Pearls & Morning Reports
Published January 1, 2020
Despite advances in diagnosis and treatment, recurrent or metastatic disease (or both) develops in more than 65% of patients with squamous-cell cancer of the head and neck. Read the Review Article here.
Q: What percentage of patients with squamous-cell cancer of the head and neck present with stage I or II disease?
A: Approximately 30 to 40% of patients present with stage I or II disease, which is curable with surgery alone or definitive radiotherapy alone. Surgery alone and radiotherapy alone can provide similar oncologic control and improved long-term survival rates in almost 70 to 90% of patients with early-stage disease. The choice of treatment depends on anatomical accessibility, with efforts to minimize morbidity and preserve function.
Q: What is the prognosis associated with locally advanced squamous-cell cancer of the head and neck?
A: More than 60 of patients with squamous-cell cancer of the head and neck present with stage III or IV disease, which is characterized by large tumors with marked local invasion, evidence of metastases to regional nodes, or both. Locally advanced disease carries a high risk of local recurrence (15 to 40%) and distant metastasis, with a poor prognosis (5-year overall survival, <50%).
A: High-dose cisplatin (100 mg per square meter of body-surface area, administered intravenously every 21 days for three cycles), given concurrently with radiotherapy as part of a definitive chemoradiotherapy regimen, is the standard of care, with established survival benefits for patients with good performance status; however, because of the substantial short- and long-term toxic effects associated with cisplatin, its use is predominately reserved for nonelderly patients who have no major coexisting conditions. For less fit patients or patients in whom high-dose cisplatin is associated with unacceptable adverse effects, alternative systemic therapies have not yet been elucidated but are being investigated.
A: Cases of HPV-associated oropharyngeal cancer, induced primarily by HPV type 16, are increasing, predominantly among younger people in North America and northern Europe, reflecting a latency of 10 to 30 years after oral-sex exposure. The fraction of head and neck cancers diagnosed as HPV-positive oropharyngeal cancers in the United States rose from 16.3% in the 1980s to more than 72.7% in the 2000s as a result of increased awareness, identification of the association between HPV and cancers of the head and neck, and enhanced diagnostic evaluation for HPV. The effectiveness of prophylactic HPV vaccination is less well defined for oropharyngeal cancer than for anogenital and cervical cancers. Nevertheless, a decreased incidence is expected but may not be evident until after 2060. The prognosis is more favorable for patients with HPV-positive oropharyngeal cancer, who tend to have better responses to chemotherapy and radiotherapy and are generally more fit, with fewer coexisting conditions, than patients with HPV-negative disease, who are often compromised physiologically by chronic tobacco and alcohol use.