Treatment of Advanced Head and Neck Cancer: What Lessons Have We Learned?

Treatment of advanced squamous cell cancers of the head and neck (HNSCC) can be a frustrating endeavor. Early diagnosis may be missed by delay on the part of patients or their physicians and dentists. Patients are often elderly and have multiple medical or social comorbidities. HNSCC is an interdisciplinary disease, with optimum management requiring the input of the medical, radiation, and surgical oncologist, as well as pathologist, dentist, speech pathologist, social worker, and a dedicated home caregiver. The necessary specialists for optimum management may not be present near the patient’s home, necessitating ad hoc clinical teams or further delay and dislocation of the patient and caregiver for an extended treatment period. Numerous phase II and phase III studies have been performed with the hope of improving survival and preserving organ function in locally advanced disease. We now know that survival is improved by radiation administered concurrent with chemotherapy, but there are added toxicities. 1 We also know that radiation with chemotherapy can result in survival that approximates the survival obtained by radical surgery followed by radiation therapy, especially if surgical salvage is performed at early signs of residual or recurrent disease. 2,3 We know less about what the optimal radiation regimen or chemotherapy regimen should be for an individual patient. Currently, standard therapy for locally advanced HNSCC could be radiation administered daily, twice daily, or in a concomitant boost regimen, with or without intensity-modulated radiation therapy, together with a platinum-based chemotherapy. When complete response is obtained, a planned neck dissection is often performed in those patients whose disease was at least N2 at presentation. If complete response is not obtained, resection of the primary and/or regional nodes is performed as is feasible. Standard care could also be surgery, followed by radiation therapy with or without concurrent chemotherapy. These modalities generally result in a 5-year survival rate of 20% to 65%, depending on stage and primary site. The choice of treatment is often dictated by the primary site, patient preferences (eg, organ preservation), and the experience of the treatment team.