He said that transoral surgery can be an advantage for more than just small tumors. The technique allows surgeons to remove the primary cancer in pieces so that it can be mapped and its margins more carefully monitored, with less normal tissue removed.
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April 2017Patients with HPV-positive oropharyngeal tumors, who traditionally have undergone radiation therapy after surgery, may not need it, he said. In one study of 69 patients who underwent transoral microsurgery alone, a third had an indication for radiotherapy but declined it, and only three of those patients had local recurrences (Arch Otolaryngol Head Neck Surg. 2009;135:1225–1230). “This speaks to our ability to effectively clear margins,” Dr. Hinni added. “De-intensification, in my mind, is adjusting the dose, adjusting the volume, or perhaps eliminating it altogether.”
A radiation oncologist at his center has finished Phase 2 of a study on patients with intermediate or low risk who, when they qualified for radiation, received just 30 Gy over the course of two weeks. Among 70 patients, there had been no local recurrences for more than two years. “Now, a larger study is following,” Dr. Hinni said. “This has the potential to be a game-changer.”
He added that limiting therapy, when possible, is even more attractive considering that surgery alone is a quarter of the cost of non-surgical treatment.
Prevalence
Marilene Wang, MD, professor of head and neck surgery at the University of California, Los Angeles School of Medicine, said that while it remains true that HPV-positive head and neck squamous cell carcinoma is associated with a higher number of sex partners, there’s no cause for shame or stigmatization. “It’s a very common infection, and many patients with this disease do not actually have a high-risk sexual history; more than half have fewer than five lifetime oral sex partners,” she said.
When a diagnosis of an HPV-related cancer is discovered, it’s important for physicians to let couples know that 80% of the population have been exposed to HPV and 7% have an active HPV infection. They should know that it’s not necessarily a sign of promiscuity, Dr. Wang said.
Patients and their partners should also know that exposure doesn’t mean you’ll develop cancer and that their sexual lives should continue; that they could consider protection with new partners; and that the rate of HPV infection among partners is actually the same as it is in the general population.
Caring for Survivors
Bruce Campbell, MD, chief of the division of head and neck oncology and a professor of otolaryngology and communication sciences at the Medical College of Wisconsin in Madison, said that with the prognosis of HPV cancer survivors so favorable, handling long-term issues will be critical in the future. “We are going to see many of these patients for years. This will be especially true for our younger colleagues and current residents,” he said. “This may be a pretty significant part of your practice.”