By Marshall Posner, MD

Primary treatment of head and neck cancer requires multidisciplinary coordination to provide the optimal therapy.

In this current day and age, it is clear that surgery, radiation and chemotherapy, as well as chemoimmunotherapy, can have substantial impacts and competing toxicities on cancer patients. The treatment of patients with head and neck cancer is challenging, both because of the location of the tumor and the important structures necessary for maintaining life (breathing, swallowing and eating) in the head and neck, which can be easily damaged by the cancer and the treatment, and which need to be preserved both in the short term and the long term. That is why it is imperative that physicians take a multidisciplinary approach to optimally manage a combination of these treatments for the well-being of their patients.

In order to realize this goal, there is a substantial need for multidisciplinary discussions among surgeons, radiation oncologists and medical oncologists before embarking on any one of the potential treatment options for most patients with head and neck cancer – specifically, to reduce the morbidity and long-term consequences of treatment for these patients while improving survival and quality of life. We, as a team of treating physicians with different perspectives, need to coordinate and address factors and nuances that change the relative impacts of our treatments on toxicity and survival.

First, in terms of treatment, surgery is truly the mainstay of therapy for early-stage head and neck cancer, excluding nasopharyngeal cancer. The patient who is eligible for surgery should be seen and evaluated by the surgeon, radiation oncologist and medical oncologist because all three specialists may play a role in the initial curative treatment.

Surgical resection must support functional preservation and reduce the application of subsequent radiation therapy to be viable. Patients become inoperable or the value of operations ceases when they must receive a complete, aggressive course of chemoradiotherapy because of the extent of disease. Platinum is the preferred radiation sensitizer in the postoperative, definitive setting. Carboplatin, or carboplatin doublet with taxane, are alternatives to platinum in platinum ineligible patients. There is no role for cetuximab – a monoclonal antibody to EGFR – as a substitute for platinum in chemoradiotherapy.

Induction chemotherapy plus chemoradiotherapy is a reasonable treatment for organ preservation and the standard of care for nasopharyngeal cancer. Organ preservation is clearly indicated for patients with laryngeal and hypopharyngeal cancer. This approach is supported by data from randomized clinical trials. For patients with inoperable and aggressive cancers, the combination of induction chemotherapy and chemoradiotherapy is a reasonable treatment and, in some cases, induction chemotherapy can prepare the patient for surgical resection followed by chemoradiotherapy.

Immunotherapy is clearly indicated and is the first line of treatment for recurrent metastatic disease, preferably with a platinum doublet, including nasopharyngeal cancer. In cases where the recurrence is easily and surgically resectable, it could be entertained as a reasonable treatment option. But, once again, a multidisciplinary discussion should take place, and if the patient would require re-irradiation after treatment, immunotherapy is an option.

Finally, and of great importance, new data suggests that induction immunotherapy followed by surgery and subsequent pathologically determined treatment with adjuvant radiotherapy and immunotherapy will become the standard of care for treatment of patients with resectable head and neck cancer. Induction chemoimmunotherapy is likely to prove better. Trials in nasopharyngeal cancer are demonstrating this outcome. This approach may well become a standard of therapy in unresectable head and neck cancer.

It is notable that today we are finding a greater number of patients cured and living longer, such that the long-term consequences of radiation therapy are now becoming a substantial cause of morbidity and mortality in the late survivors. Efforts should be made to de-escalate radiation therapy as much as possible. This approach is particularly critical in patients with HPV-related or oropharyngeal cancer who have excellent cure rates.

Dr. Marshall Posner is a world-renowned physician scientist, clinical researcher, and head and neck oncologist with Tampa General Hospital (TGH) Cancer Institute | Cancer Center of South Florida. He is based in Palm Beach County.