Head & Neck Cancer

The article presented by Bhayani, Holsinger, and Lai thoroughly evaluates the emergence of transoral robotic surgery (TORS) as a technique in the field of otolaryngology. Transoral approaches to the upper aerodigestive tract, whether for diagnostic or therapeutic purposes, represent core tenets of the discipline and formed one of the bases for the inception of the specialty. Innovations and refinements in optics and materials have steadily increased the view, reach, and, consequently the effectiveness of the endoscopic surgeon with each passing decade. In the past thirty years, the introduction of the laser has further enhanced the capabilities of the surgeon, augmenting treatment options beyond open tumor resection and chemoradiation. The introduction of the daVinci robot is an incremental step in the development of techniques that have been evolving over the past one hundred and twenty years.

The evolution of surgical oncologic technology has moved toward reducing patient morbidity without compromising oncologic resection. In head and neck surgery, organ-preserving techniques have paved the way for the development of transoral techniques that remove tumors of the upper aerodigestive tract without external incisions and potentially spare the patient adjuvant treatment. The introduction of transoral robotic surgery (TORS) improves upon current transoral techniques to the oropharynx and supraglottis. This review will report on the evolution of robotic-assisted surgery: We will cover its applications in head and neck surgery by examining early oncologic and functional outcomes, training of surgeons, costs, and future directions.

Head and neck squamous cell carcinoma (HNSCC) represents a heterogeneous group of malignancies caused by the traditional risk factors of tobacco, alcohol, and poor oral hygiene, as well as more recently identified roles of human papillomavirus (HPV) and Epstein-Barr virus (EBV).[1-3] We commend Kim and colleagues on their comprehensive review of the epidemiology of HNSCC. There has been a clear change in the epidemiology of HNSCC which has further accentuated differences in etiology, survival, and demographics among HNSCC patients. We will discuss several important nuances of this changing epidemiology, including the role of tobacco, race, sexual behavior, and gender, as well as HNSCC in nonsmokers and nondrinkers.

As outlined by Leslie Kim and colleagues in this issue of ONCOLOGY,[1] almost 650,000 new cases of head and neck cancer are identified and approximately 350,000 individuals die from this disease worldwide each year. Most cancers of the head and neck are squamous cell carcinomas and originate from one of five major sites: oral cavity, oropharynx, nasopharynx, hypopharynx, and larynx. Traditionally, tobacco smoking and alcohol consumption have been considered to be the main risk factors for head and neck squamous cell carcinoma (HNSCC) and, thus far, most prevention strategies and public health messages have focused on these two factors. However, as described in the review by Kim et al., there is increasing evidence that, independent of tobacco and alcohol exposure, oral human papillomavirus (HPV) infection is a major risk factor for a specific subset of HNSCCs. We agree with the authors that this is an important public health concern, especially given the increasing prevalence of HPV infection in the US and Western Europe and our limited knowledge about the natural history of oral HPV infection. Here we summarize the role of HPV in HNSCC and discuss clinical implications.

Characterizing the epidemiology of head and neck cancers is challenging and has received limited attention in the medical literature. Traditionally, 80%–90% of head and neck squamous cell carcinomas (HNSCCs) have been attributed to tobacco and alcohol use, but with growing public awareness and tobacco control efforts over the past few decades, there has been a downward trend in smoking prevalence in the US. There is also emerging evidence that human papillomavirus (HPV) is responsible for inconsistencies in HNSCC trends, with oncogenic HPV DNA found in approximately half of oropharyngeal cancers and in a high proportion of oropharyngeal cancers in nonsmokers and nondrinkers. The risk to HNSCC epidemiology is that whatever gains continue to be made in tobacco control may become lost in the increasing numbers of oropharyngeal cancers due to HPV. The purpose of this review is to explore the changing epidemiology of HNSCC, focusing on how it has been shaped by health policy and advocacy interventions and how it will continue to have public health implications in the future, particularly in considering preventive strategies against HPV. Given that the majority of HNSCCs are the result of exposure to preventable public health risks, more focus should be given to this area.

Radiation oncologist Jonathan J. Beitler, MD, MBA, offers the radiation oncology perspective on the array of treatment combinations in this complex disease.

Induction chemotherapy has led to improved survival and organ preservation. Combining induction therapy with other treatment modalities is critical for treating this complex disease and attaining optimal outcomes.

A medical oncologist, a radiation oncologist, and a surgeon share pearls and pitfalls in their specialized approaches to managing recurrent disease.

PET paired with a variety of radiotracers offers insights into the metabolic, DNA, and protein pathways.

Removing an oropharyngeal tumor through the open mouth using robotic instruments now has FDA approval, and its safety is well documented. Comparative evidence of its effectiveness is beginning to trickle in.

HOLLYWOOD, FLA.-Two speakers at the 2009 Palm Beach Cancer Symposium agreed that surgery will always play a role in the treatment of squamous-cell head and neck cancers. The question at issue: Is surgery losing ground to chemoradiotherapy as the primary treatment for head and neck cancer?

Quitting smoking during radiation treatment for lung and head and neck cancer significantly enhances treatment efficacy, yet many patients will not give up the habit even though the benefits are very obvious.

Oncologists who treat head and neck cancer face a double-edged sword-life-saving procedures often leave patients disfigured or unable to speak. For Waun Ki Hong, MD, it simply wasn’t enough to offer a cure that was saddled with too many severe consequence

Epidermal growth factor receptor (EGFR) inhibitors have emerged as important drugs in cancer therapy, providing a proven survival advantage for some patients with non–small-cell lung cancer, colorectal cancer, head and neck cancer, and pancreas cancer.

About 500,000 head and neck carcinomas are diagnosed worldwide annually. This accounts for approximately 8% of all newly diagnosed cases of cancer, ranking head and neck carcinoma the sixth most common.[1] In the United States, 47,560 new head and neck carcinomas are expected to be diagnosed in 2008,[2] and this disease accounts for 5% of all newly diagnosed cases of cancer. Approximately 90% to 95% are squamous cell carcinomas of the head and neck (SCCHNs).

In the past, locoregionally advanced head and neck cancer routinely was treated by surgery followed by adjuvant radiation therapy, unless the disease was too extensive to be resected and treatment defaulted to radiation therapy alone.

Bruce Culliney and colleagues have provided a thorough and well written summary of the literature regarding multimodality treatment of patients with locoregionally advanced or unresectable head and neck malignancies. In particular, they offer a detailed outline of recent insights into radiation dosing and fractionation and their optimal use in the combined-modality setting.

In the following sections, we will first review the radiotherapy techniques that have been investigated. We will then review the progressive advances achieved with the addition of chemotherapeutic strategies to RT in an attempt to achieve better outcomes.

BOSTON-A gene therapy agent that delivers a normal p53 gene to the tumor significantly increased survival by 4.5 months in end-stage head and neck cancer patients with p53-favorable tumor profiles, compared to those with unfavorable profiles.

Data published in the New England Journal of Medicine show that oral capecitabine (Xeloda) and oxaliplatin (Eloxatin) in combination with epirubicin (Ellence) is a comparable alternative to infused fluorouracil (5-FU) and cisplatin with epirubicin in patients with previously untreated, advanced esophagogastric cancer.

A 51-year-old man presented to the Dermatology Section at the University of Chicago Medical Center in August 2007 with a pruritic, papulopustular eruption on the face. He had been started 4 weeks ago on induction chemotherapy with paclitaxel, carboplatin, and cetuximab (Erbitux) for hypopharyngeal squamous cell carcinoma (T2N3M0). He denied any prior history of acne or rosacea.

10 notable developments and events in cancer research and care

Wedding high technology to recent advances in understanding the molecular biology of oral squamous cell carcinoma

FDA has approved Sanofi-Aventis' Taxotere (docetaxel) for use in combination with cisplatin and fluorouracil (TPF) for the induction treatment of patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN)

Barrett's esophagus represents replacement of normal distal esophageal squamous epithelium with specialized columnar epithelium containing goblet cells. Typically arising in the setting of chronic gastroesophageal reflux disease, the presence of Barrett's esophagus carries a 50- to 100-fold increased risk of developing esophageal cancer. Risk factors include male sex, smoking history, obesity, Caucasian ethnicity, age > 50 and > 5-year history of reflux symptoms. Aggressive medical or surgical antireflux therapy may ameliorate symptoms, but have not yet been proven to affect the risk of developing esophageal adenocarcinoma in randomized trials. Although dysplasia is an imperfect biomarker for the development of subsequent malignancy, random sampling of esophageal tissue for dysplasia remains the clinical standard. There have been no studies to establish that endoscopic screening/surveillance programs decrease the rates of death from cancer. Fit patients with Barrett's esophagus and high-grade dysplasia should undergo esophagectomy to prevent the risk of developing esophageal adenocarcinoma. For non–operative candidates, endoscopic ablative approaches may represent a reasonable therapeutic alternative.