Deintensification of Treatment Modalities Is Crucial to Consider in Head and Neck Cancer

Zafar Sayed, MD

The relative incidence of head and neck cancer is lower than more common cancers in the lung or breast, making National Oral, Head, and Neck Cancer Awareness Month a critical annual staple of bringing advances such as the shift toward transoral robotic surgery to the forefront, according to Zafar Sayed, MD.

“We are always thinking of areas [in which] we can deintensify treatment for our patients and achieve a cure of their cancer while still preserving function and limiting adverse effects [AEs],” said Sayed in an interview with OncLive® during National Oral, Head, and Neck Cancer Awareness Month, which is observed annually in April. “On the surgical side, one of the huge advances over the past 2 decades has been the advent of transoral robotic surgery.”

During the interview, Sayed highlighted the importance of spreading awareness about head and neck cancer, the advantages of the transoral robotic surgery approach, and the management of human papillomavirus (HPV)–related head and neck cancers.

Sayed is an assistant professor of surgery in the Department of Surgery in the Division of Otolaryngology at Yale School of Medicine in New Haven, Connecticut.

OncLive: Why is it important to spread awareness about head and neck cancer?

Sayed: Head and neck cancer tends to be one of the smaller cancers by volume, worldwide. There’s a lot of emphasis on the treatment and workup of [patients with] lung and breast cancer, and melanoma. Most folks are familiar with a lot of those [cancers], along with colon cancer, for example, with colonoscopy screening. We don’t have a lot of awareness around the common signs or symptoms. Some of these cancers tend to be relatively easy to identify in terms of the symptoms they may cause, and if we can catch them early, the treatment can allow patients to have incredible function and an incredible long-term prognosis. We want to raise public awareness that this can be an issue, and we want to let people know what signs and symptoms to look out for.

Regarding surgical approaches, how have advanced techniques, such as transoral robotic surgery changed the treatment paradigm for patients with oropharyngeal cancer?

Now we have the ability to use robotic instrumentation. This is being done in other parts of the body, but over the past 15 or [so] years, [we’ve been able to] use a robotic instrument to go through the mouth and essentially take out tumors in the tonsil area, in the base of the tongue, and around the voice box. That access cannot usually be achieved easily through traditional means. Several decades [ago], to get access to this part of the body, we would have had to split the jawbone and make a large neck incision. Of course, the recovery from that is much more extensive. Therefore, nowadays, we take most of these tumors out through the mouth.

What are the surgical advantages and disadvantages of utilizing this approach?

With transoral robotic surgery, the single biggest advantage for us is that it allows us access into really small spaces [in the mouth] while still having a tremendous degree of freedom in terms of flexibility with the instrumentation. We use robotic arms with cauterizing instruments that can move far more readily than the human wrist and are far less bulky, which allows us to fit into those tight spaces. The robot also comes with 3D stereoscopic vision, so our visualization in this part of the body is excellent. We can use angled cameras to see areas we may not have had a direct line of sight [to]. Those are the big advantages, but some of the disadvantages are that, as the surgeon, you’re relying on the robot rather than your hands to feel the tissue and the tumor. There may be something lost because of that, but generally speaking for smaller tumors and for the right patient this tends to be a great tool.

How can a multidisciplinary team help achieve optimal care for patients with head and neck cancers?

Typically, we think of head and neck cancer treatment as being a team approach, and the surgeon is certainly going to be one large component of that team. If patients undergo surgery, the surgeon is going to be involved with the immediate postoperative care. However, long term, as patients heal we’re going to have support staff that are important, including speech and language pathology, the nutrition teams, and maybe physical therapy and occupational therapy.

Some of that may be done as an outpatient after patients leave the hospital for rehabilitation purposes. We also rely heavily on radiation and medical oncologists. At Yale’s Head and Neck Program, our patients would see a radiation and medical oncologist before or after surgery to make sure we don’t need to think about additional treatment strategies after surgery, and all of that is dictated based on the final pathology report from the tumor resection.

How prevalent are HPV-related head and neck cancers, and how are they typically managed?

HPV-related cancers, typically in the head and neck, are going to affect the base of the tongue and the tonsil, and we’ve seen a rising incidence in those cancers over the past few decades. Previously, if you were to go back 30 or 40 years, we would see most of those cancers being squamous cell cancers associated with tobacco and alcohol use. Nowadays, about 75% of the cancers we see in this area are related to HPV, specifically high-risk strains of HPV in the United States. We estimate that there will be somewhere around 10,000 to 15,000 new cases of HPV-related cancer each year, and that’s a small fraction when you compare that with lung and breast cancers, but it tends to occur more often in men and tends to have some early warning signs that we want to make sure the public is aware of.

The treatments right now are typically similar [to non–HPV-related] head and neck cancers]. [This includes] surgery, potentially followed by radiation and chemotherapy, depending on the pathology report, versus radiation with or without chemotherapy given up front, without any need for surgery. Those are the 2 main treatment strategies for both HPV-related and non-HPV tumors. However, with HPV-related cancers, the prognosis tends to be much better, and we are working nationally to deintensify the treatment. Can we scale back surgery? Can we scale back the radiation dose? Can we switch around the chemotherapy agents to make it less toxic? At our Head and Neck Program, we are running clinical trials to see how we can minimize AEs from these treatment strategies.