Advances in Oropharyngeal Cancer Care

With the rising epidemic of human papillomavirus (HPV), there has been an increase in the incidence of oropharyngeal squamous cell carcinoma (OPSCC) in the Western world, with approximately 16,000 cases of HPV-associated OPSCC diagnosed in the United States every year. Compared to patients with HPV-negative disease, HPV-positive OPSCC patients have better oncologic outcomes and improved survival.

Despite these findings, advanced HPV-positive disease often requires intensified multimodality treatment with high-dose radiation leading to increased risk of serious sequelae such as mucositis, trismus, xerostomia, dysphagia, and osteoradionecrosis of the jaw. As a result, there has been a heightened interest in treatment de-intensification for HPV-related OPSCC to reduce treatment-related morbidity and improve patients’ quality of life.

How the Treatment Works

Head and neck surgeons and medical oncologists at The George Washington University Hospital have developed a novel treatment protocol for patients with HPV-associated OPSCC. Oropharyngeal cancer patients at GW Hospital who are candidates for this procedure receive three cycles (one every two weeks) of two chemotherapeutic agents to diminish the tumor size. Following these three cycles, they undergo trans-oral robotic surgery with the Da Vinci surgical robot.

“We are the only institution in the United States that has been doing this neoadjuvant protocol for HPV-related oropharyngeal cancer,” says Punam Thakkar, MD, assistant professor of otolaryngology/head and neck surgery at the George Washington University School of Medicine and Health Sciences. “Our data shows that the majority of our patients have a complete response to neoadjuvant chemotherapy and transoral surgery, and therefore can avoid radiation therapy.”

“Our forward-looking treatment options are creating better functional outcomes and a better quality of life for patients,” says Arjun Joshi, MD, FACS, FRCSC, director of head and neck oncology and professor of surgery at GW Hospital. “Like most hospitals, our program is centered on excellence in terms of oncologic outcomes, but we have a singular emphasis on preservation of form and function for the patient.”

“The introduction of trans-oral robotic surgery has been a real game changer,” says Joseph Goodman, MD, FACS, associate professor of surgery and associate program director, otolaryngology residency, GW Hospital. “Surgical sites once inaccessible by minimally invasive procedures are not only accessible, but the success rate is high. The bulk of our patients have demonstrated good outcomes,” Dr. Goodman says. “They’re still alive. They haven’t had a higher rate of recurrence. And there weren’t any unexpected complications.”

Low-Dose Radiation

Skipping radiation isn’t just easier for patients in the short term, it also provides a better backup treatment option should the cancer recur. “We like keeping the radiation on the back burner in case of recurrence because it is rarely given more than once,” Dr. Goodman says. However, if the cancer has spread into nearby lymph nodes, low-dose radiation may be recommended. GW Hospital uses advanced radiation therapy planning and intensity modulated radiation therapy (IMRT) for maximum protection of the salivary glands.

Patients who are not candidates for the neoadjuvant protocol, such as those with recurrent tumors or other advanced staged head and neck cancers, may need to undergo more extensive surgery with reconstruction. Dr. Joshi, Dr. Goodman and Dr. Thakkar are all trained in both ablative and microvascular reconstructive surgery and take a team approach to ensure optimal oncologic and functional outcomes.

“We work together to ensure that patients can continue to eat, swallow and communicate as well as they did prior to their surgical procedures,” Dr. Thakkar says. Patients receive lymphedema therapy, speech and swallow therapy, and physical therapy at GW Hospital throughout their treatment course.

Clinical Trials

There are several clinical trials underway, with more upcoming. One ongoing trial, a multicenter study called KEYNOTE-689, involves treatment with pembrolizumab for patients with resectable, locally advanced head and neck squamous cell carcinoma. Other ongoing trials involve immunotherapy.

“In addition to these trials, we have a great partnership with the NIH,” Dr. Thakkar says. “Having that partnership has given us another way to treat patients in novel ways that are proving to be very beneficial.”

Individual results may vary. There are risks associated with any surgical procedure. Talk with your doctor about these risks to find out if robotic-assisted surgery is right for you.