(talking about HPV-associated Oropharyngeal Cancer)
Expanding on the content of this letter…
To deintensify treatment for patients with human papillomavirus virus–associated oropharyngeal squamous cell carcinoma (HPV-OPSCC) is one of the hot topics in head and neck cancer. But, the imperative lies not merely in deintensifying but rather in averting overtreatment.
Why?
HPV-OPSCC presents as a distinct biological entity, diverging from traditional oropharyngeal cancer associated with tobacco and alcohol usage. Despite this divergence, historical treatment paradigms have been applied uniformly to both subtypes. Consequently, numerous HPV-OPSCC patients have endured unnecessary treatment intensities.
Most of the long term sequelae of head and neck cancer survivors, impacting their quality of quality of life, are treatment-related. The consequence of overtreatment is that patients live with side-effects they should not be experiencing. As until the arrival of Transoral Robotic Surgery (TORS) most of the patients with oropharyngeal cancer were treated with chemoradiation, most of this side effects are related to this treatments: xerostomia (radiation), dysphagia (chemoradiation), neurotoxicity (platinum-based chemotherapy schemes) …
The greatest de-escalation step was moving from TNM 7th edition to TNM 8th edition. Most of HPV-OPSCC cases were down-staged one, two or even three stages (from stage IV to stage I). The reason for this was adjusting its prognosis (which is what TNM classification was made for), but obviously, it had a direct consequence in the intensity of the treatments (of should have had). Compare:
(Released Fall 2016, Valid since Jan 2018)
So, the publication of a scientific study on HPV-OPSCC based on TNM7 now (year 2024) is simply not acceptable.
How can we avoid over-treatment? Some lines of research:
– If surgery with minimum morbidity is feasible, choose surgery. This is the only treatment option available nowadays that can aspire to a complete absence of sequelae.
-Do not fear high-volume nodal disease. Functional neck dissection is usually feasible and it is likely there will be no indications for adjuvant treatment.
– There is evidence supporting performing less surgery on the neck: we do not perform elective (cN0) neck dissections for HPV-OPSCC and as a direct consequence we rarely perform bilateral neck dissections (even for tumors in the base of the tongue).
– Question the indications for adjuvant treatment. They are mostly based on historical series of non- HPV-OPSCC. There are many themes of discussion here. For example, extranodal disease (remember that this does not apply for HPV-OPSCC).
– When choosing radiation therapy as primary treatment, remember the tumor stage. Many patients with stage I or II HPV-OPSCC are still receiving chemorradiation instead of a single modality treatment with radiation.
– Numerous trials reducing the dose or the field of radiation are already going on.
– There is no strong evidence in the medical literature to support using conventional chemotherapy in HPV-OPSCC.
Standards are evolving rapidly, making it crucial to stay up-dated.
J Granell. April 14, 2024
Head and Neck Robotic Surgery 