Treatment choices in head and neck cancer

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Published: 29 Mar 2017
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Dr Gouri Pantvaidya - Tata Memorial Centre, Mumbai, India

Dr Pantvaidya speaks with ecancer at EBMCI 2017 about treating head and neck cancer, with oral cancers in India driven by tobacco and areca nut chewing.

She summarises the staging of primary lesions and distant metastases, and the subsequent courses of treatment including surgery, brachytherapy and chemotherapy where suitable.

Dr Pantvaidya describes surgery becoming uncommon for treating laryngeal cancer, opting for chemo-radiation instead, and considers the option of palliative care as a component in treating widespread cancers.

She also introduces trials of metronomic chemotherapy, which has been associated with control of tumour angiogenesis.

Oral cancer and tobacco chewing is also discussed by Dr Chaturvedi here.

Oral cancer is pretty much one of the most common cancers here in males; it has just been taken over by lung cancer as the first cancer but it is the second most common cancer in males here. The reason we have a lot of oral cancer is we have a habit of a lot of tobacco chewing. This is something that is very characteristic of the South Asian population here and not only do we chew tobacco, we use tobacco with areca nut which is a nut that is taken, it’s called supari, and the combination of this is known to have higher chances of having oral cancer. So we do a lot of that; everyone chews tobacco so unfortunately our burden of oral cancer is very high.

What is the most common site for oral cancer occurrence?

We would say the gingivobuccal complex, that’s the buccal mucosa and the retromolar trigone and the alveolus is the commonest site but tongue cancers are now coming up. We are having younger patients having tongue cancers that is a little bit of a change, we didn’t have as much of tongue cancers but we have tongue cancers now and I don’t know whether that could be related with an increased incidence of smoking now that is also prevalent in the country.

How do you stage patients?

We use the AJCC TNM staging so we would like to get the T, N and M of every patient. After we perform a biopsy to confirm that it is a cancer we would use a modality of imaging, depending on where the subsite of the tumour is. So largely if you have gingivobuccal cancers we would use a CT scan to image both the oral cavity as well as the neck; if you have a tongue cancer then we would prefer to use an MRI for these patients which would also image the neck. With regard to imaging for distant metastases we would restrict the use of imaging for distant metastases in patients who have locally advanced tumours; we wouldn’t do it for early cancers. In these patients who have large neck node metastases or an extensive oral cancer we would either choose a CT scan of the thorax or a PET CT.

How do you treat early stage cancers?

If you look at early stage cancers, and we’re going to have to talk about the oral cavity separate from the neck, if you talk of early stage cancers then in a large proportion we would treat these patients with surgery, with or without reconstruction depending on the excision, how much we excise. But also we are able to provide very high quality, high dose rate brachytherapy to our patients for cancers which are like lip cancers, anteriorly placed small superficial lesions we are able to provide them with a high dose rate brachytherapy schedule with or without external beam radiation.

For the neck, management of the neck, we have just published our paper in the New England Journal of Medicine, it was a randomised controlled trial and we would provide neck dissections for all patients with early oral cancer.

Do you follow up with radiation therapy?

It would depend on the histopathology. So the indication in early cancers for radiation therapy is if you have any node positive patients on your staging neck dissection or if you have a thickness of tumour that’s more than 1cm, which from next year when the eighth edition of the AJCC comes up would anyway go on to a T3 tumour.

How would you treat the cases in later stages?

Let’s go to locally advanced cancers. Now, in these cancers the primary treatment would be surgery. So we would provide surgery followed by… We have a lot of patients with extensive lesions; we are lucky to have a state of the art microvascular reconstruction team and we can provide these patients with excellent reconstruction with regard to soft tissue reconstruction, bony reconstruction, nerve grafts, all of the above will be done. So depending upon the excision of the tumour these patients would receive surgery with a neck dissection, with a reconstruction, and would be followed by, in all probability, adjuvant chemo-radiation depending upon the histopathology.

How would you categorise cancers of the larynx?

Larynx cancer is not very common, not as common as oral cancers in India. We are very happy to treat laryngeal cancers, they do very well. So compared to oral cancer if you find a laryngeal cancer we are very happy to treat laryngeal cancers. In the early stages we would try and choose patients to decide whether we would like to do a laser resection or assess giving the patient radiation therapy. That is discussed with each patient since the control rates are more or less similar in early laryngeal cancers. For the slightly locally advanced cancers we would most definitely practise organ preservation with the use of concurrent chemo-radiation, again platinum based with radiation therapy. For the most advanced cancers we would then go ahead with surgery. So surgery is becoming, if I can say, almost obsolete in laryngeal cancers with good control rates with chemo-radiation.

How do you treat the other head and neck cancers?

We have a lot of issues in these patients because to try to give curative therapy in this group of patients is very difficult with the logistics that we face because we have patients coming all over the country. So in this group of patients we decide between giving complete dose concurrent chemo-radiation versus a palliative radiation versus palliative chemotherapy, depending on two things. One is what is the extent of the primary tumour; if it’s very non-resectable, multiple neck nodes, we probably wouldn’t give high dose chemo-radiation to this patient, they would go to the more palliative. However, if the patient has a good general condition and the extent of tumour is not much then we would probably treat these patients with concurrent chemo-radiation.

What do you hope to see at the Tata Memorial Hospital in the coming years?

We have now started performing robotic surgery, transoral robotic surgery. We have an excise system and we are now trying to stratify patients with p16 positivity to decide whether we should… Though this is not something that we do regularly, we discuss with the patient and we decide whether this patient goes for chemo-radiation or the patient goes for robotic surgery. So we have started with transoral robotic surgery for all oropharyngeal cancers which are resectable by the robotic surgery. So we will be doing very well, we’ve already done a good bit of cases and that’s one of the things that we would be doing.

Then the many other cases, we are looking at a very novel type of treatment that is called maintenance chemotherapy in patients with oral cancer. This is something that has not been investigated too much. So we have what is called metronomic chemotherapy; these are oral agents which we use and we are running two or three large phase III randomised trials here and a number of patients are on these trials. We’re trying to look at giving this metronomic chemotherapy in the perioperative period as well as maintenance post-chemo-radiation. I think in the next three or four years we would get the results of this; the initial results that we see shows us that there is very less toxicity of these agents taken even over an eighteen month period. We are finding good control rates but, of course, we will have to wait for the results of that study.