Cancers of the head and neck are associated with those that arise in the mouth, nose, throat, larynx, sinuses, and salivary glands.
In the past, most of these tumors were associated with exposure to cigarettes and alcohol.
More recently, human papilloma virus (HPV) has become an important cause of oropharyngeal cancers. The American Cancer Society estimates that 51,540 people will get oral cavity or oropharyngeal cancers in the United States in 2018. These are more than twice as common in men as in women.
Depending upon the location within the oropharynx, the cancers may be treated with surgery, radiation, or combined modality approaches.
Most patients present with a sore in the mouth or tongue, or palpable lymph node in the neck.
At the time of diagnosis, the patients are staged with MRI, CT scan, and in some circumstances PET/CT. The final stage determines the treatment with combined modality radiation and chemotherapy widely used.
It is now recognized that the human papilloma virus (HPV) is associated with a somewhat better prognosis and patients can receive dose-limited exposures, to provide equal outcome with lower toxicity.
Patients who present with non-HPV cancers or with recurrent cancers are often treated with chemotherapeutic agents.
The most widely used treatment for these patients is platinum-based.
Combinations of Cisplatin with 5-FU are widely used, but the taxanes, VINCA alkaloids, antimetabolites, signal transduction inhibitors that target the epidermal growth factor receptors, and more recently immune therapies are proving highly effective in some patients.
We have pioneered the use of Cisplatin plus Gemcitabine in this disease and have found this is a more widely used combination.
Similar to Cisplatin plus 5-FU, Cisplatin plus Gemcitabine plays upon DNA damage and repair and can provide an effective regimen for many patients, even in those previously treated with 5-FU.
Among the most exciting areas of investigation are immune therapeutics, the use of PD-L1 and PD-1 checkpoint inhibitors have provided objective responses in between 15 and 20% of patients and some can prove durable. The signal transduction inhibitors that are directed toward the epidermal growth factor family are also useful.
Oral therapies such as Tarceva and Afatinib are utilized, as well as the monoclonal antibodies Cetuximab and Panitumumab.
Based upon the broad expression of epidermal growth factor receptors in these tumors, these drugs can prove effective and have been used alone and in combination with chemotherapy and radiation.
The most common form of head and neck cancer is known as squamous cell carcinoma.
However, there are other histological subtypes that include the minor salivary glands known as adenocarcinomas. Neuroendocrine tumors can arise in the oropharynx, as can lymphomas.
Each patient's treatment is dependent on the type of tumor, its location, whether it is amenable to surgery, its HPV status, and the patient's performance status.
Many patients, even some with advanced disease, can be cured with combined modalities and patients should seek expert opinions when the diagnosis of head and neck cancer is entertained.
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