Preventive measures and immunology in head and neck cancer
Dr Fernando Cotait Maluf - Oncologia Clínica do Centro Oncológico Antônio Ermírio de Moraes, Sao Paulo, Brazil
Head and neck cancer is a very common disease worldwide, particularly in developing countries like Brazil. It’s related to a lot of risk factors, particularly in our country to tobacco and drinking abuse. Unfortunately in Brazil more than 70% of patients with head and neck cancer are diagnosed with locally advanced or metastatic disease. The organ preservation strategies for patients with locally advanced disease have evolved considerably during the past two decades. The conjunction of better radiation therapy schedules with chemotherapy concomitantly and maybe neoadjuvantly, as well as with immunotherapies such as cetuximab has been associated with high organ preservation rates, not only anatomic preservation but functionally larynx preservation. So I think that’s one of the areas that has most been developed compared with other cancers as well.
Aside from that the immunotherapy has been shown to be a very promising strategy with preliminary data of the anti-PD1 medications that has been studied initially on patients with recurrent or metastatic disease after failing to cisplatin based therapy with response rates of around 25%, compared with 10% at most for other drugs, has been shown to be a very promising class of agents. So expect that phase III trials in metastatic disease first line as well as patients who fail cisplatin based therapy will show that these drugs are not just promising but a reality and are going to help patients with advanced disease.
So I would say that my guess, my feeling, is that immunotherapy is going to be elected the fourth arm of treatment in head and neck cancer in conjunction with radiation therapy, surgery, as well as cytotoxic chemotherapy.
What trends have you noticed in terms of lifestyle factors?
In Brazil most of the cancers, the head and neck cancers, are associated with tobacco as well as alcohol use. We are aware that in some countries like the US and some countries in Europe HPV related cancers, and oropharynx cancer in particular, are growing in a very fast way although the incidence is growing in these countries. In Brazil we don’t know if this is our reality, we don’t think we have enough data in our country that supports that HPV is playing a critical role as a cause of oropharynx cancer and less frequently oral cavity as well as larynx cancer. But future studies in our country will try to establish this association as it has already been established in the US and Europe. Despite that our government needs to provoke some campaigns to inhibit the tobacco as well as alcohol use because in our country, unfortunately, both habits are very frequent, particularly in our male population.
Is the HPV vaccine available in Brazil?
In Brazil HPV vaccine is approved for girls between the ages of 7 to 10, 12 years old, not for men. That’s a very posing interesting question is how is the impact of vaccination of boys, not only girls, to prevent other HPV cancers like penile cancer, like oropharynx cancer and less frequently larynx and oral cavity cancer. So I think that’s a very intriguing question that needs to be answered by prospective and randomised trials.
Can you tell us more about the benefits of a multidisciplinary approach?
There are some studies that have asked the question what’s the role of a multidisciplinary approach, not only as assisting the patient but also as discussing a case. Most of the studies have shown at least a third to 50% of the cases when you take from your outpatient clinic to the discussion meeting the management will change and most of the time it’s for good, not for bad. So our philosophy in our centre at Beneficência Portuguesa is that every single new patient that we saw in outpatient clinic, we bring the case to our multidisciplinary team and share the whole information with our colleagues because we feel that we may change our decision in about a third to 50% of the cases and we will have patient management regarding the best treatment approach.
What is the take-home message?
I would say that for head and neck cancer patients that have experienced a lot of advances with organ preservation but not that much with recurrent metastatic disease which the prognosis is dismal is that immunotherapy may help a lot of patients and probably is going to be a new weapon regarding the backbone for these patients with incurable disease and may be a very potent weapon and efficacious as well for patients with locally advanced disease.