Northeast Florida Medicine
Vol. 66, No. 1 2015
35
Otolaryngology
Update on the Management of Head and Neck Cancer
Introduction
Cancer of the head and neck is not a single disease, but
rather a heterogeneous group of cancers that affect various
anatomic sub-sites, producing a different form of disability
depending on the region involved. These sub-sites include
salivary glands, nasal cavity and paranasal sinuses, lip, oral
cavity, oropharynx, larynx and hypopharynx, thyroid,
skin, ear and temporal bone. Fortunately, these cancers
are relatively rare, representing approximately 3.2 percent
of all cancers. The economic impact of head and neck
cancer is significant at $3.6 billion annually. According
to the National Cancer Institute (NCI), the incidence of
head and neck cancer has decreased over the past several
decades, but the decline levelled off in 2003; despite this,
overall mortality rate has continued to decline. The NCI
estimates that there were 55,070 new cases of head and
neck cancer in 2013, and there were an estimated 12,000
head and neck cancer deaths.
1
Men have a higher incidence of head and neck cancer
than women.
2
Tobacco and alcohol consumption play
an important etiologic role, particularly in cancer of
the larynx and hypopharynx. Human Papilloma Virus
(HPV) has been associated with an increase in incidence
Abstract:
The past decade has seen remarkable progress in the
evaluation and treatment of cancers affecting the head and neck
region. The discovery of the association of the Human Papilloma
Virus (HPV) with some head and neck cancers has changed the
demographics of the disease, and our approach to it. Innovations
have occurred across a broad multi-disciplinary front. New
diagnostic methods have emerged that take advantage of recent
discoveries in tumor genetic markers. Significant advances in have
also taken place in the fields of surgery, radiation oncology, and
medical oncology and are described.
of cancers located in the tonsil and base of tongue. While
HPV associated tumors have only relatively recently been
described, viral associated head and neck cancer is not
a new discovery. Nasopharyngeal carcinoma has long
been associated with the Epstein-Barr Virus. Other risk
factors include betel nut chewing, periodontal disease
and chronic trauma for oral carcinoma, and radiation
exposure for thyroid cancer and sarcomas of the head
and neck. Other head and neck cancers (e.g., sinonasal
carcinomas) have been traced to occupational exposure
including chromium, wood dust and various solvents. Fire
breathing has been linked to high rates of oral carcinoma.
For decades, the standard treatment for head and neck
cancer was surgery, often associated with a range of cosmetic
and functional deficits. This frequently required complex
reconstruction of the surgical defect using local, regional
or microvascular free tissue flaps. Radiation therapy came
into play as an adjuvant treatment in advanced stage tu-
mors (III or IV) in the 1970s and 1980s. In the 1990s,
chemotherapy was combined with radiation therapy and
emerged as first line therapy for a number of tumor sites
with survival rates equivalent to surgery, but offering the
possibility of organ preservation.
3
Severe toxicities, in-
cluding xerostomia, mucositis, dysphagia, and even death
were seen with some of these treatment protocols, fueling
the search for approaches that maximized cure rates while
minimizing treatment side-effects. This article discusses
some of the more significant discoveries of the past decade.
HPV
First reports of the association of the Human Papillo-
ma Virus (HPV) and oropharyngeal carcinoma began to
surface in 1983.
4
HPV-related tumors appeared to be a
different sort of cancer than that typically associated with
heavy tobacco and alcohol usage. Subtyping of the HPV
virus revealed that p16 and p18 were the most commonly
associated subtypes of the virus, with rates of 90 percent
and five percent respectively. Additionally, Patients with
HPV-associated tumors had improved survival, and
HPV-associated tumors appeared (at least in vitro) to be
more sensitive to radiation.
5
By John D. Casler, MD, FACS
Address Correspondence to:
John D. Casler, MD, FACS
4500 San Pablo Road
Jacksonville, FL 32224
