Squamous cell carcinoma of the head and neck treated with irradiation: Management of the neck

This chapter reviews the clinical trials of definitive, not palliative, treatment for patients with advanced squamous cell head and neck cancer. The chapter focuses on squamous cell cancers of the oral cavity, oropharynx, larynx, and hypopharynx where surgery was felt to be a poor therapeutic choice based on the disease extent. Clinical trials for these patients have focused on either altered radiation therapy fractionation schedules or combinations of radiation therapy and chemotherapy. While many phase II, single-arm clinical experiences have been reported, the heterogeneity of patients studied precludes anything but a feasibility or toxicity analysis of this work. Meaningful conclusions can only be drawn from randomized phase III trials. Efforts to improve upon the disappointing consequences of radiation therapy have included altered radiation therapy fractionation schedules and the use of systemic chemotherapy in conjunction with radiation. Altered radiation fractionation schedules can be characterized as either accelerated fractionation or hyperfractionation. Hyperfractionated schedules have been associated with some increase in acute toxicity, but they have also demonstrated promising survival benefits. Accelerated fractionation schedules, however, have been more toxic, and a survival benefit has not been demonstrated consistently. Much of the success of recent multimodality treatments has come from an improvement in the ability to manage these toxicities.