ECC 2015

Watchful waiting versus neck dissection in patients with head and neck cancers

Prof Hisham Mehanna - University of Birmingham, Birmingham, UK

Hisham, it’s very nice to talk with you. You’re actually from Birmingham, you have experience from other parts of the world as well but you’re talking here about oropharyngeal cancer. The big divider in that disease is HPV, which you’ve been investigating. What did you do?

We were looking at a study looking at watchful waiting versus neck dissection for those patients with oropharyngeal cancer and other types of head and neck cancer who had big nodal disease. As part of that study we wanted to see how they differed in terms of their quality of life and their functional outcomes when it came to the HPV status of the tumour.

How did you go about making this investigation?

It was a randomised controlled trial looking at 560 patients and half of them got randomised to a neck dissection and half of them got randomised to a PET CT scan after their chemoradiotherapy. They only got a neck dissection if they were positive on the PET CT scan. We found that actually the watchful waiting system was as good as the neck dissection but saved 80% of patients having a neck dissection so it was a really significant finding and it was also very cost-effective in the long term.

And whether people had HPV association or not had an implication for acute or long-term quality of life, didn’t it?

That’s right. As part of that study we then looked at their HPV status and whether they were HPV positive or not and then looked at their quality of life over the course of the study. What we found was that the patients who had HPV started with a much better quality of life, much less symptoms, but during the acute phase of the treatment, during the treatment period, their quality of life dropped considerably, far more in magnitude than the HPV negative patients. So during that treatment period their quality of life really dropped quite significantly and therefore they’re more likely to need support during that period of time. Now, after treatment the quality of life of both sets of patients started improving again and by two years their quality of life had gone back to where they were before treatment in both sets. But because the HPV positive patients had higher quality of life they’d gone back to having a higher quality of life than the HPV negative patients. So what we’re saying is that in the long-term HPV negative patients may require more support because their quality of life is lower.

So what’s the impact on how cancer doctors should be approaching their patients with head and neck cancer and how they should be individualising therapy and withholding therapy in many cases?

Absolutely. So for this study that we presented here in Vienna the impact or the implications are that for… know the status of HPV, the HPV status for your patient, because if they are HPV positive then they may definitely require more support during treatment, during that acute phase of treatment. But also if they are HPV negative they may require support in the long term. Being aware of those and instituting those types of support will be important. We especially found that both groups have long-term problems with swallowing and long-term problems with saliva production and that actually the HPV positive patients had even bigger problems there. Therefore, interventions to support them with their swallowing, speech and language interventions, would be a good thing to keep in mind and also interventions to improve their saliva will help as well.

So what’s the short, bottom line message for clinicians?

Know the HPV status of your patients because that’s going to affect where you institute maximum support for those patients.

And how easily can you not treat them with dissection, for instance?

That is definitely something that one should consider. In fact we are saying that should now be the standard of care if patients… but that has nothing to do with their HPV status. If they have advanced nodal disease and they are head and neck cancer patients and they’re going to get chemoradiotherapy then one should wait three months after the chemoradiotherapy to do the PET CT scan and then decide on that basis whether they need a neck dissection or not. The era of doing what we called a planned neck dissection in everybody should now be over.

But the HPV association status is important in helping you plan the ongoing care of your patients?

Exactly. Definitely.

Thank you very much Hisham.

You’re very welcome.