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Head and Neck Cancer

Dr Amanda Salisbury

Consultant Clinical Oncologist

Oxford University Hospitals NHS Trust

Head and Neck Cancer

• History

• The challenge of Head and Neck Cancer

• 7 steps to improved outcomes

Discovery of Xrays

Roentgen Mrs Roentgen

8th November 1895

Roentgen Mrs Roentgen

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X-ray therapy began within months of Roentgen’s discovery

Health -Vigor - Vitality Within Reach of All

“Applying the Radium”

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London Scalp RT - kV 125 – 250 kV

125 – 250 kV

Cobalt Machine 1-2 MV

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Linear accelerator 6 – 15 MV

and superficial electrons Linear accelerator

Suit of Armor made for

Grand Master Alof de

Wignacourt

1601-1622

Malta

Power and

Quality

Control

Quality Control

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Timeline of Cancer Chemotherapy

DeVita V T , and Chu E Cancer Res 2008;68:8643-8653

©2008 by American Association for Cancer Research

Timeline of Cancer Chemotherapy

21st century:

Small molecule inhibitors

Monoclonal antibodies

Immune modulation – Nivolumab for H&N cancer 2018

Non-surgical treatment

Radiotherapy

• 1895 Discovery of X-rays

• kilovoltage photons

• megavoltage photons and

electrons

• solid sources for

brachytherapy

• IMRT, highly conformal

RT

• Protons

Chemotherapy

• 1st WW - mustard gas

caused lymphopenia

• 2nd WW - nitrogen

mustard in HD patient

• 1965 5-FU

• 1970s Cisplatin

• 1990s taxanes

• 2000s biologcals

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Head and Neck Cancer Locoregional Spread to Lymphnodes

Head and Neck Cancer

• Most patients, most of the time, have disease confined to the primary site and neck. If they relapse it will tend to be here rather than elsewhere in the body

• Speech, swallowing, eating and drinking, appearance and airway may all be affected.

• Traditionally patients are older, with other medical problems and some are socially isolated

• Now there are younger patients with HPV related oropharynx cancer, with complex needs related to working life and children

‘Clinically Silent’ Sites

Nasopharynx

Piriform fossa

Tongue base

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Special Challenges

PEG feeding

Risk of Bleeding/Carotid blowout

Airway worries

Hearing and sight

Social isolation – speech, appearance,

Loss of usual support network

Patient Journey

• Diagnosis and staging

• Early disease – surgery or radiotherapy

• Advanced disease – surgery and/or radiotherapy

• Advanced disease in fit patient – surgery and/or

concomitant chemo-radiotherapy

• Local recurrence – salvage treatment

• Recurrence / distant relapse – palliative treatment

and best supportive care

The sort of treatment which seems to

require… But often looks like this…

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But also looks like this… Challenging treatment plan

7 steps to improved outcomes

in Head and Neck Cancer

Prevention

Treatment

Rehabilitation

7 steps to improved outcomes

• Vaccinate against HPV high risk strains

Proportion of Australian born women diagnosed as having genital warts

at first visit, by age group, 2004-11

BMJ 2013

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7 steps to improved outcomes

• Smoking reduction

– Continue decline in incidence

– Better outcomes for patients on treatment

– Avoid nicotine itself

7 steps to improved outcomes

• Surgical developments – robotic surgery

7 steps to improved outcomes

• RT developments

Radiotherapy Goals

• Treat the tumour

• Avoid treating normal tissue

• In Head and cancer this is often complicated

• Radiotherapy beams come in straight lines

but can be shaped to vary the dose –

conformal planning

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Radiotherapy targeting

“Direct Field”

“Wedged Pair”

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Five Field Plan – large laterals

• Left lateral

• Right lateral

• Left posterior neck

• Right posterior neck

• Low anterior neck

IMRT Plans

IMRT in the Head and Neck IMRT in the Head and Neck

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7 steps to improved outcomes

• Risk stratification

– Of the tumour

– Of the individual

7 steps to improved outcomes

• Risk stratification – genetic profiling of tumours and individuals

MS Lawrence et al. Nature 517, 576-582 (2015) doi:10.1038/nature14129

Integrated analysis of genomic alterations.

And individual RT sensitivity

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And individual RT sensitivity 7 steps to improved outcomes

• Systemic agents – for radiosensitisation

7 steps to improved outcomes

• Systemic agents

– For radiosensitisation

– To reduce risk of systemic relapse

– For palliative management

7 steps to improved outcomes

• Systemic agents

– For radiosensitisation

– To reduce risk of systemic relapse

– For palliative management

• Immunotherapy with Nivolumab N Engl J Med 2016; 375:1856-1867 Ferris et al

Nivolumab for Recurrent Squamous-Cell Carcinoma of the Head and Neck

NICE approved for within 6 months of Platinum based chemotherapy

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7 steps to improved outcomes

• Psychological needs – explaining and engaging

7 steps to improved outcomes

• Psychological needs –understanding the HPV story

7 steps to improved outcomes

• Psychological needs – depression and fear of recurrence

– Identify

– Tackle as part of rehabilitation following treatment

7 steps to improved outcomes

• Vaccinate against HPV high risk strains

• Smoking reduction

• Surgical developments – robotic surgery

• RT developments – IGRT, protons

• Risk stratification – genetic profiling of tumours and individuals

• Systemic agents – immune checkpoint

• Psychological needs – depression, fear of recurrence, understanding the HPV story

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Effects of Disease and Treatment

“C” Because Cowards Get Cancer Too”

John Diamond