Squamous cell carcinoma of the head and neck (SCCHN) was diagnosed in over 63,000 people in the US and was estimated to cause 13,600 deaths in 2017. While treatment can be curative in early stages, a significant proportion of patients will relapse despite curative intent treatment. If recurrence is localized to the head and neck area, surgical resection or re-irradiation can sometimes be offered.
In the recurrent or metastatic setting when local therapy is not recommended, systemic treatment with platinum-based chemotherapy regimens is the standard frontline treatment. Regimens such as 5-fluorouracil, platinum and cetuximab may afford disease control for some time and has been shown to improve overall survival compared to platinum/5-fluorouracil, but treatment is palliative. Immunotherapy drugs such as nivolumab and pembrolizumab, antibodies that block programmed death 1 (PD1), an inhibitory receptor on T-cell, are FDA approved for treatment of squamous cell carcinoma of the head and neck (SCCHN) that has recurred or metastasized after treatment with a platinum chemotherapy regimen. While these agents afford a novel class of treatment options for patient with this disease and improves overall survival compared to palliative chemotherapy, only about 15–20% of patients respond to treatment, and only a proportion experience long term disease control with therapy. Novel combination approaches are currently being explored to fill this unmet need. These include immunotherapy combinations with anti-PD1/PDL1 and agents such as IDO inhibitor epacadostat (NCT03358472, NCT03342352), anti-CD137, anti-OX40 (NCT02554812), or agents designed to stimulate innate immunity such as the intratumoral injection SD101 (NCT02521870). Combinations of immunotherapy with chemotherapy are also being explored.
Beyond treatment in the recurrent metastatic setting, evaluation of the role of anti-PD1/PD-L1 earlier in the treatment of head and neck cancer is also underway. Clinical trials of neoadjuvant treatment with pembrolizumab, nivolumab or durvalumab prior to surgery, either in the previously untreated or locally recurrent setting are recruiting patients. With the results of such data, we may see an ever-expanding role of immunotherapy for treatment of SCCHN.
At the 2018 Multidisciplinary Head and Neck Symposium, co-sponsored by ASTRO, ASCO, and AHNS, the Multidisciplinary UCLA Head and Neck Cancer Program team presented their work on how multidisciplinary approaches to treatment of head and neck cancer patients offers substantial enhancement in our ability to provide increasing quality and effectiveness of care with greater efficiency and cost-containment.
Diagnosis and treatment of cancers of the head and neck exposes patients and their immediate support systems to exceptional psychosocial distress. Distress in patients and their supports can severely impact patient quality of life, alliance with their providers, capacity to collaborate with treatment regimens, cost of treatment, and treatment outcome. While this is often recognized, programmatic efforts to address patients’ psychosocial needs with systematic Supportive Care (SC) are not widely implemented or extensively developed in multidisciplinary head and neck cancer programs. The imperative for implementation of systematic SC programs is further driven by a deep transformation unfolding in the culture of health care, exemplified in the mandate by the American College of Surgeons Commission on Cancer for implementation of patient-centered care and by changes in CMS’s reimbursement structure to include patient satisfaction as a significant parameter. Development of SC, though rich in potential benefits to patients, providers, and institutions, turns out to present complexities and challenges which can vary considerably depending on the institutional setting. The evolution of multidisciplinary approaches to treatment of head and neck cancers promises substantial enhancement in our ability to provide increasing quality and effectiveness of care with greater efficiency and cost-containment. Widespread implementation of psychosocial Supportive Care can contribute mightily to these beneficial trends.
1 Department of Hematology-Oncology, David Geffen School of Medicine at UCLA, Los Angeles, California;
2 Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California;
3 Jonsson Comprehensive Cancer Center, Ronald Reagan UCLA Medical Center, Los Angeles California;
4 UCLA Head and Neck Cancer Program, Ronald Reagan UCLA Medical Center, Los Angeles, California