Looking at the patient as a whole in head and neck cancer
Prof Jatin Shah - Memorial Sloan Kettering Cancer Center, New York, USA
The topic of my keynote address was on successes and realities of non-surgical treatment of head and neck cancer. We all know that the introduction of radiation therapy and chemotherapy as a component of multidisciplinary treatment of head and neck cancer entered into the arena some 25 years ago. The other reports from this type of multimodal treatment with chemo and radiation, they are outstanding results in terms of preservation of the organ, for example larynx, the voice box. We could preserve the larynx in up to 60-80% of patients receiving such treatment who would have otherwise required a laryngectomy which is a crippling and disabling event in the life of a patient, life-changing event.
The time has now come to do a reality check – what do we gain, when I use the word we, what does the patient gain and what does the patient pay in terms of longevity, function and the quality of life. Like the famous saying, all that glitters is not gold. So the early experience was very good but we have now come to realise that the sequela and the long-term side effects of chemo and radiation are prohibitive. Some of these patients will never swallow, will require maintaining nutrition through a tube in the stomach; some of them do not have a sufficient airway and they require a tracheostomy lifelong. Admittedly they are a small number of patients but for those the non-surgical option was not a good one.
The patients who fail chemo and radiation therapy need salvage surgery and salvage surgery is possible in perhaps half of the patients who fail. In those in whom we perform successful salvage surgery the curability is only 20-25%. So the glory of preservation of an organ must be weighed against the losses of life, long-term sequela of treatment, quality of life and quality of function of the preserved organ. That was the focus of my keynote lecture.
Are these guidelines written down somewhere?
There are a number of articles in the literature addressing this issue and I’m not sure whether the keynote lecture I gave is going to be published or not. The long-term sequela of treatment has been looked at very critically in numerous journals, even the primary investigators of the clinical trials are to say for one she herself has published on the long-term sequela and outcomes. In fact, in the very long term we have a poorer survival rate compared to those who had primary surgery. So I think in all there is a lot of reality check we need to do to address the issue of non-surgical management. The exciting news is there are newer drugs coming along the way, immune modulators, gene therapy, targeted treatments addressing specific genetic mutations. These are all currently pie in the sky but very promising avenues to look for newer agents, hopefully they will do better than the cytotoxic agents we have used over the course of the past 20-30 years.
What’s the take-home message?
It is difficult to crystallise reality in one capsule but suffice it to say that we need to be discretionary at the outset in selecting the right type of tumour and the right type of patient for the appropriate management, be it surgery, be it a non-surgical treatment with chemoradiation. And whether the tumour may be suitable for a particular treatment plan but the patient may not be. A patient’s physical status, patient’s ability to tolerate treatment, patient’s vocation and all of these issues need to be addressed in selecting a particular type of treatment that you would embark upon initially. Therefore discretion in early and accurate diagnosis and assessment of the applicability and tolerability of treatment that you offer.
How do you think this might be achieved?
How we do that is educate, educate and educate. Educate physicians, young trainees, educate practitioners in the community, educate the public at large about awareness of the disease and the consequences of getting that disease and its treatment. To increase their awareness last year at the World Congress in New York organised by the International Federation of Head and Neck Societies, we proclaimed July 27th to be called the World Head and Neck Cancer Day. Michael Douglas, who gave the opening ceremony address, supported that and proclaimed that he supports July 27th as the World Head and Neck Cancer Day. The first one will be in three weeks, this year, where throughout the world people will be observing the day conducting programmes of awareness, education, free screening, early diagnosis, support groups and training sessions for young trainees throughout the world. Currently this programme is supported by 53 national societies from over 50 countries in the world and more are accumulating every day. Any information people need to know can be obtained at www.ifhnos.org.
