This article is more than 5 years old. Information may no longer be current.
As head and neck cancer treatments have improved, have they become unacceptably toxic?
Click Here to Manage Email Alerts
Improved survival came with a cost
I don’t think we have the answer to this question. Over the past two decades we developed very aggressive combined modality therapy to try to improve survival; we were successful, but our success was at a cost. It would have been nice if we had concurrently investigated the biopsychosocial impact of aggressive treatment on our patients and their families; however, that didn’t happen. Unfortunately, we lost valuable opportunities to learn about the treatments that are currently being used as standard of care for head and neck cancer patients.
|
|
We now recognize that aggressive combined modality therapy has not only had a profound and lasting physiologic effect on patients, but also a dramatic psychosocial impact. Investigators are therefore going back and attempting to define the biopsychosocial costs of treatment and how to minimize those costs through supportive care. Supportive care aims at improving quality of life, functional outcome, and symptom burden. An aggressive supportive care program is vital for any clinician who commits to treating and caring for patients with head and neck cancer. It behooves us as investigators to provide clinicians with evidence-based approaches to preventing, treating and palliating the numerous supportive care issues faced by patients with head and neck cancer.
I got started down my path in supportive care about 10 years ago. At that time, you could bang your head against the wall insisting that we attend to these issues without garnering any attention. That has changed. I don’t think there is a head and neck conference you can attend today that doesn’t have supportive care as an integral part of the agenda. Furthermore, there isn’t a researcher doing a randomized phase-3 trial who isn’t asking, “How can I incorporate some of these outcome measures into my trial?” That was not the case 10 years ago.
We’re moving in the right direction but we’re not moving as fast as we could. There are a number of barriers to good supportive care research. One important barrier is the lack of researchers. We need to foster supportive care research as a career for surgeons and medical and radiation oncologists who are interested in the area. Furthermore, funding must be available so that talented investigators can support themselves through research dollars. Without this support, the handful of people interested in supportive care will continue to struggle and may flee the field.
It is important that as we move our treatment regimens forward, we keep both acute and late biopsychosocial effects in mind. We must understand the ramifications of our treatments, not only on survival but also on the patient’s quality of life, functionality and symptom burden. Optimally, we would like to cure our patients and leave them with as normal an existence after their treatment as possible. That is a worthy goal. It needs to be an accepted goal. I think we’re getting there.
Barbara A. Murphy, MD, is Director of the Head and Neck Research Program and the Cancer Supportive Care Program at Vanderbilt-Ingram Cancer Center.
It depends on the patient’s goals
The goal and more recent philosophy in treating head and neck cancer is to first of all improve and certainly not compromise the ability to cure, and secondly, to have an organ-preserving approach. That requires more aggressive use of chemotherapy and radiation therapy, which leads to more acute and chronic long-term side effects — but it is an approach that ultimately results in improved prognosis with these organ-sparing therapies where the larynx, tongue or orbit is preserved because there’s no need for additional surgery.
|
|
The next step is to have more specific and targeted types of therapy and not treat all tumors the same way. Hopefully, this targeted therapy would be more specifically aimed at the tumor with increased preservation of normal tissue and, hopefully, less long-term adverse effects of the treatment.
Much is dependent upon the lifestyle and subjective quality of life of the patient. Head and neck cancer is very different from other types of cancer because often the treatment or the surgery involves compromise in voice, swallowing, vision, and the ability to phonate and articulate. If the patient is invested in maintaining quality of life by sparing the involved organ, then the more aggressive therapy really must be pursued. That’s the only way to avoid surgical sacrifice of these organs. At this point, we must assume that there will be increased long-term effects, but curing the tumor and preserving quality of life is the ultimate goal.
Certainly, what each individual patient maintains as his quality of life must be considered before embarking on any aggressive therapy. It comes down to defining the best results of cure, tempered by what’s most important to the patient’s future function.
Mark S. Persky, MD, is Chair of the Department of Otolaryngology at Beth Israel Medical Center and a HemOnc Today Editorial Board member.