Evidence-Based Guidance for the Treatment of Head and Neck Cancers

Up-to-Date Clinical Guidelines for the Treatment of Various Head and Neck Cancer

Radiotherapy
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The use of data to drive important decisions has proven a leitmotif during the 21st century. The practice of medicine is no different and is also data dependent; ideally, treatment should be guided by evidence not by chance, intuition or mere observation. Several organizations engage in developing evidence-based clinical guidelines including the Scottish Intercollegiate Guidelines Network (SIGN).

According to the SIGN website:

“SIGN guidelines are derived from a systematic review of the scientific literature and are designed as a vehicle for accelerating the translation of new knowledge into action to meet our aim of reducing variations in practice, and improving patient-important outcomes.”

Please note that SIGN is only one organization that issues evidence-based guidelines, and there are other prominent organizations that do the same. For example, the United States Preventive Service Task Force (USPSTF) also makes suggestions based on medical evidence.

In this article, we’ll examine evidence-based clinical guidelines for the treatment of head and neck cancer according to cancer type. These treatments are based on either the recommendations of SIGN or recommendations by European Society for Medical Oncology (ESMO). Furthermore, with respect to advanced-stage cancers listed below, please note that we’re detailing treatment recommendations for early- and advanced-stage cancer that’s localized to the neck, with no distant metastases.

Overall, head and neck cancers are a diverse group of diseases, and specific treatment is based on the location of the cancer and stage. Before treatment options are considered, lymph nodes in the neck are examined for evidence of cancer, and the presence of distant metastases is ruled out.

Finally, in this article we refer to cancer staging (TNM).

For a more a comprehensive description of staging, please follow the links in this article.

Treatment of Early-Stage Oral Cancer

Here are SIGN’s evidence-based recommendations for the treatment of early-stage (Stage I and Stage II) oral cancer:

  • surgical removal (resection) of the primary tumor
  • selective neck dissection to N0 lymph nodes
  • in case several lymph nodes show evidence of cancer or the spread is more extensive, then radiation therapy is recommended

Selective neck dissection involves the preservation of more than one lymphatic groups. Select lymph node groups are removed based on predictable patterns of metastases.

Other evidence-based guidance for the treatment of early-stage oral cancer focuses on the utility of neck dissection or removal of lymphatic tissue in the neck. First, in people who have yet to receive treatment for oral cancer (treatment-naïve) with either a small or slightly larger primary tumor (T1 and T2, respectively) of squamous cell origin, elective (voluntary) neck dissection may prolong survival.

Second, neck dissection might decrease the risk of recurrence and cancer-specific death (mortality) in people with lymph nodes that show no evidence of cancer.

Treatment of Advanced-Stage Oral Cancer

According to SIGN, oral cancer that is advanced should also be removed. Furthermore, modified radical neck dissection is recommended. With modified radical neck dissection, all lymph nodes in the neck are removed and one or more lymphatic structures are preserved.

If the person with advanced oral cancer can’t be operated on (is not a surgical candidate),  chemoradiation with a cisplatin regimen and bilateral irradiation of neck (i.e., radiation therapy to both sides of the neck) is recommended.

Treatment of Early-Stage Nasopharyngeal Cancer

Here are ESMO’s recommendations for the treatment of early nasopharyngeal cancer:

  • radiation therapy alone is used to treat stage I cancer
  • concurrent chemoradiation (cisplatin and radiation therapy) could be used to treat stage II cancer
  • intensity modulated radiation therapy (IMRT) is the favored type of radiation therapy for early-stage nasopharyngeal cancer

Treatment of Advanced-Stage Nasopharyngeal Cancer

 Here are ESMO’s recommendations for the treatment of advanced nasopharyngeal cancer:

  • stage III, IVA and IVA cancers are treated with concurrent chemoradiation (cisplatin is the chemotherapy agent used)
  • IMRT is the favored mode of radiation therapy

Treatment of Early-Stage Oropharyngeal Cancer

SIGN recommends that early oropharyngeal cancer be treated with either surgery and neck dissection or external beam radiation therapy for both the tumor and lymph nodes in the neck.

Treatment of Advanced-Stage Oropharyngeal Cancer

According to SIGN, people with advanced oral cancer can be treated in one of two ways: primary surgery or organ preservation. With primary surgery, the primary tumor is removed and a modified radical neck dissection is performed. With the organ preservation approach, chemoradiation with cisplatin  is used, and lymph nodes on both sides of the neck (bilateral) are irradiated.

After either primary surgery or organ preservation, chemoradiation with cisplatin is done for patients who experience extracapsular (more extensive) spread and positive surgical margins. A positive surgical margin is present when a pathologist observes that cells at the border of the removed tissue are still cancerous.

Treatment of Early-Stage Hypopharyngeal Cancer

SIGN makes three treatment recommendations for people with early hypopharyngeal cancer. First, concurrent cisplatin chemoradiation and prophylactic radiation therapy can be used. Second, conservative surgery with bilateral selective neck dissection can be done. Third, for people who aren’t surgical candidates and are unable to undergo chemoradiation, radiation therapy alone can be used. 

Treatment of Advanced-Stage Hypopharyngeal Cancer

According to SIGN, if the tumor is resectable (i.e., can be removed), then either of two approaches can be tried: either surgery to remove the tumor or organ preservation. With organ preservation, external beam radiation therapy and concurrent chemoradiation are administered. Neck lymph nodes that are positive for cancer can be treated using neck dissection either with or without chemoradiation.

If tolerable to the patient, those with tumors that can’t be resected or removed can be treated with cisplatin chemoradiation.

Treatment of Early-Stage Glottic Cancer

According to SIGN, early glottic cancer can be treated with either conservation surgery or external beam radiation therapy. Furthermore, transoral laser surgery may be just as effective as radiation therapy

With transoral laser microsurgery, a surgeon directs the laser under the microscope thus proffering increased precision. This procedure allows the surgeon to remove only the cancerous cells from surrounding healthy tissue and is used when organ preservation is important during mouth, larynx and pharynx surgery.  Such surgery can lead to improved quality of life. For example, using transoral laser microsurgery, the surgeon can retain larynx or voice box function in those with laryngeal cancer or cancers located in the lower throat.  

Treatment of Early-Stage Supraglottic Cancer

According to SIGN, the treatment of early supraglottic cancer is similar to that of early glottis cancer, with either conservation surgery or external beam radiation therapy administered. Conservative surgery can be followed by selective neck dissection. These treatment options focus on lymph nodes between level II and level III of the neck.

Treatment of Advanced-Stage Laryngeal Cancer

According to SIGN, here is how late-stage laryngeal cancer can be treated:

  • total removal of the larynx (laryngectomy) either with or without concomitant (adjuvant) radiation therapy
  • the organ preservation approach involves the use of concurrent cisplatin chemoradiation followed by salvage surgery if needed
  • as with the organ-preservation approach, if the tumor is unresectable, the management also entails concurrent cisplatin chemoradiation followed by salvage surgery if needed
  • cancerous lymph nodes are removed by means of neck dissection either with or without chemoradiation

General Chemotherapy Recommendations

Here is some more general evidence-based guidance from SIGN regarding the treatment of head and neck cancer:

  • routine administration of  chemotherapy before radiation therapy (i.e., neoadjuvant therapy) is not recommended
  • routine administration of chemotherapy after radiation therapy (adjuvant therapy) is not recommended
  • neoadjuvant or adjuvant chemotherapy is not routinely recommended along with surgical treatment

Essentially, these chemotherapy guidelines recommend that people with oral cavity, oropharyngeal or laryngeal cancer don’t automatically receive either chemoradiation either before or after treatment with surgery or radiation therapy. In other words, radiation therapy or surgery may be sufficient treatments on their own.

Conclusion

Please understand that although many of the above recommendations are highest-grade recommendations supported by a convincing body of evidence, randomized controlled trials, meta-analysis and so forth, not all of these recommendations are of the highest grade and some are supported by less convincing evidence. Discussing the specific grades of evidence for each recommendation is outside the scope of this article.

Nevertheless, if you have questions about grades or other concerns about head and neck cancer, please discuss these concerns with your specialist physician. The treatment of head and neck cancer is complicated, and robust advice from your physician is an invaluable asset during your decision-making process.

Sources:

Head and Neck Cancer Treatment. Dynamed Plus. www.dynamed.com

NCI Dictionary of Cancer Terms. www.cancer.gov

SIGN website. http://sign.ac.uk/about/index.html

Treatment of Head and Neck Cancer: Neck Dissection. Dynamed Plus. www.dynamed.com.

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