Head and neck cancer care has been undergoing a paradigm shift over the past decade, moving from a surgery-based approach to one that increasingly relies on chemoradiation (CRT). Few trials have directly compared the approaches, but experts agree that for some patients the two approaches can be equally efficacious. The key, they caution, is selecting the appropriate patients.
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April 2008
Historically, most patients were treated with surgery or surgery followed by radiation. However, a landmark study published in 1991 by Veterans Administration researchers showed that for some patients with stage III or IV tumors of the larynx, chemoradiation preserved the organ and resulted in the same survival as surgery followed by radiation. Based on those data, and a few trials that have followed, many physicians now offer their patients organ preservation therapy in the form of chemoradiation.
All of a sudden there appeared to be the opportunity to treat people as effectively, or more effectively, than in the past, without them being required to have the pain suffering, cosmetic deformity, and functional deformity of the surgery, said Jonas T. Johnson, MD, Professor and Chairman of the Department of Otolaryngology and Professor of Radiation Oncology at the University of Pittsburgh School of Medicine. That sounds like wonderful news, but, in fact, it is imperfect.
At least two retrospective studies have found that the five-year survival rate in laryngeal cancer has dropped over the past decade and that the use of CRT has increased over the same time period. Although such database reviews cannot show a causal link between increased use of CRT and declining survival, the observation is reason for concern, according to Christine Gourin, MD, Associate Professor and Director of the Clinical Research Program in Head and Neck Cancer at Johns Hopkins University School of Medicine in Baltimore.
My hypothesis-and others suspect the same thing-is that the decrease in survival might be because there are some patients who are receiving CRT who are not going to do well with organ preservation therapy, she said. Those are patients with gross cartilage involvement, soft tissue or skin involvement, or very extensive tumors that have a large volume. In addition, there just are no data to support the use of CRT for oral cavity tumors. Those patients benefit more from surgery with postoperative radiation to clean up microscopic residual disease.
Moreover, Dr. Gourin does not recommend CRT for patients with T4 larynx tumors and who are dependent on a feeding tube before treatment, or those whose tumor is infiltrating nerves, because that can be a sign of more aggressive disease.