A Swing of the Pendulum?

To avoid the unpredictable consequences of either surgical or nonsurgical radicalism and to embrace a new risk-based approach, we must learn more about the disease we treat.

Surprisingly, little is known about which HNSCC patients respond to chemotherapy and radiation. Whereas systemic therapy for breast cancer is given based on a panel of well-known biomarkers, including estrogen, progesterone, and HER2/neu expression, there are no such biomarkers are currently used in the treatment of head and neck cancer. The role of epidermal growth factor receptor has been explored, but at present molecular targeted therapies are just now being introduced.

As a solid tumor, the molecular heterogeneity of HNSCC has confounded the identification of clinically useful prognostic biomarkers. Since survival is equivocal regardless of a primary surgical or nonsurgical approach, treatment is often based on the desire to avoid morbidity. Patients and their physicians are essentially wagering for organ preservation, rather than basing choices on data-although, in some cases, the numbers are good.

Do all patients respond the same to radiation therapy? Do certain patients tend to develop fibrosis and others not? Which patients respond to platin-based chemotherapy? Which to taxanes? Such questions are being studied actively in several laboratories around the country but a larger and focused effort will be necessary to identify a robust panel of these biomarkers.

To achieve these goals, a multidisciplinary team is crucial. As leaders of that team, head and neck surgeons must establish the criteria for treatment selection and provide tissue for study. Most important, we must lead the clinical trials to establish this new standard of care.

References

1. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. The Department of Veterans Affairs Laryngeal Cancer Study Group. N Engl J Med 1991;324;1685-90.
   [Context Link]
2. Forastiere AA et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 2003;349:2091-8.
   [Context Link]
3. Weber RS et al. Outcome of salvage total laryngectomy following organ preservation therapy: the Radiation Therapy Oncology Group trial 91-11. Arch Otolaryngol Head Neck Surg 2003;129:44-9.
   [Context Link]
4. Temelkuran B et al. Wavelength-scalable hollow optical fibres with large photonic bandgaps for CO2 laser transmission. Nature 2002;420:650-3.
   [Context Link]
5. Hockstein NG, O’Malley BW Jr, Weinstein GS. Assessment of intraoperative safety in transoral robotic surgery. Laryngoscope 2006:116:165-8.
   [Context Link]

©2006 The Triological Society