Over the last 20 years, head and neck cancer treatment moved away from aggressive treatments for all patients to a more personalized approach — improving both outcomes and quality of life for patients with the disease.
Head and neck cancer treatment looks vastly different than it did decades ago, as now doctors are now offering more individualized care that not only may reduce a patient’s need for aggressive treatment or surgery, but also offers the chance to mitigate or better treat side effects.
In honor of CURE®’s 20th anniversary, we spoke with Dr. Warren C. Swegal, a head and neck surgical oncologist at Allegheny Health Network in Pittsburgh, about how the field has changed.
CURE: What are some of the most exciting advancements in the treatment of head and neck cancer, and how has the field changed over the last 20 years?
Swegal: One of the main things in head and neck cancer has been a focus on de-escalation or a reduction in the amount of care needed to treat head and neck cancer. A lot of that has come from years of practice, data and research from many institutions that showed that some cancers need aggressive treatment; they need high-dose radiation, high-dose chemotherapy and aggressive surgery. But there are some cancers of the head and neck where aggressive surgery is not needed, we could lower the dose of radiation or even avoid chemotherapy in total.
And that has come with the recognition of subtypes of cancer. Not all cancer is created equal. Specifically for the head and neck, we think of (human papillomavirus; HPV)-driven cancer, (cancer that's caused by the HPV virus) that (is) mostly found in the back of the tongue and tonsils. Those cancers tend to respond very well to treatment, so we realize we don't need to give these patients seven weeks of radiation or do aggressive surgery. We can be a little more focused and have the same, if not better outcomes, better survival, better treatment with (fewer) side effects.
How has the option of treatment de-escalation changed the quality of life for patients undergoing treatment for head and neck cancer?
I do want to state that we do need to be cognizant that while for a lot of cancers, we can de-escalate care (and provide) more focused care, there are other types of cancer that we still do need to be aggressive with.
That being said, it has been kind of a shift in mentality from treating cancer to now also then treating the patient after the cancer, this idea of survivorship, that a lot of patients will survive their cancer. (There is) a mentality that we not only need to cure them of the cancer but also try to prevent long-term side effects.
Things like lower doses of radiation can help reduce problems with swallowing, changing the types of chemo or being more focused now with immunotherapy, all with an effort to try to limit some of those side effects.
From a surgery standpoint, the introduction of transoral robotic surgery to be able to do surgery on the back of the tongue, the tonsil area of the throat all through the mouth, as opposed to having to do big, aggressive surgery and cut open the jawbone to get back there (may improve quality of life).
Those are all ways that have come about in the last 20 or so years that have helped significantly reduce those side effects.
What are some of the long-term side effects that may result from head and neck cancer treatment?
Traditionally, most of the complications from head and neck cancer treatments include things like problems swallowing, stiff neck, swelling and lymphedema. As treatment has improved, they've changed to other things like change in taste and dry mouth. The side effect definitely varies depending on the treatment.
With this focus on survivorship, we've realized that as a head and neck surgeon, I'm not going to be able to treat all of the side effects on my own, so bringing in supportive care partners like a speech language pathologist, the dental team or physical therapy managers (for) lymphedema (can help). Providing a multidisciplinary team care approach is one step to help reduce, as well as treat, some of those side effects.
From a swallowing standpoint, getting them in to see the speech and swallowing therapist even before they have any treatment, to hopefully help prevent problems swallowing after treatment (can be beneficial). For dry mouth, there are multiple topical and medication solutions as well. That's an area of active research to try to build back some of that saliva flow.
Why is it important for patients to discuss side effects with their care team?
A lot of patients get in the tunnel vision of, “It's cancer, we're focused on cancer and that's all. Damn the rest.”
But we need patients to know (that) even if we cure the cancer, if your quality of life is extremely poor, that is something we can help with. There's no need to suffer if we have a good solution for it. We want our patients to have excellent quality of life after treatment, and we have ways to improve it. So if patients have problems sleeping, if they have anxiety, these are all things we know come with treatment. We want our patients to talk to us about those things and not just focus on the cancer aspect; we have to treat the patient as a whole in that manner.
This interview has been edited for clarity and conciseness
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