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Nordic Cancer Rehabilisation SymposiumCopenhagen September
2010
Something about treatment of head and neck cancer
and the need for rehabilitation
Jens Overgaard Aarhus Universitetshospital
[email protected]
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>1,100 new cases in Denmark per year
prevalence 14,000 patients
Nasopharynx
Oropharynx
Laryngopharynx
Pharynx
LarynxEpiglottis
Esophagus
Thyroid gland
Nasal cavity
Oral cavity
Supraglottis
Glottis
Subglottis
Head and Neck Cancer
Salivary glands
Tumors of the
upper gastro-
intestinal and
respiratory tract
Etiology:
Tobacco
Alcohol
Infection
(EBV,HPV)
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Head and Neck Cancer
Most tumors have origin in the
mucosal epithelium (squamous
cell carcinoma)
Spread to regional neck nodes,
seldom as distant metastasis.
Loco-regional treatment (with
organ conservation).
Many vulnerable critical
structures and functions in the
area.
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Treatment of head and neck cancer is
heterogeneous (and influenced by local tradition):
Surgery alone
Radiotherapy alone
Pre- or postop-radiotherapy
Surgery combined with chemotherapy
Radiotherapy combined with chemotherapy/EFGr inhibitor
Radiotherapy combined with hypoxic modification
Radiotherapy with different dose/fractionation
All thinkable combinations of the above
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Register study 1982-1994
USA n=13.729 Canada n=5.162
Overall survival
Surgery
Radiotherapy
47%
70%
Denmark
1971 - 91
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Radical Head & Neck Surgery
Residual
tumor?
Morbidity?
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Why not try with
radiotherapy?
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Treatment delivery
Head and Neck
radiotherapy:
Conservation
of organs and
functions
- but not without
side effects
-
30 40 50 60 70 80 90
DOSE
0%
20%
40%
60%
80%
100%
PR
OB
AB
ILIT
Y
risk of
complication
tumor
control
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Primary RT of HN
Cancer
larger RT dose
Hyperfx
Neo-adjuvant Chemo-
RT
Smaller RTvolume
IMRT
Hypoxic modification
of RT
Basic
Waiting time etc.
Biological modifiers
Anti -EGFrCon-commitant Chemo-RT
Reduced RT time
Accl fx
Changed RT-Surg balance
Better diagnosis
and imaging
Dahanca 2
Dahanca 5
Dahanca 10
Dahanca 1
Dahanca 9
Dahanca 11
Dahanca 13
Dahanca 15
Dahanca 6
Dahanca 7
Dahanca study
DAHANCA.dk
Hypoxic modification
of RT
Reduced RT time
Accl fx
-
0 12 24 36 48 60
Time after treatment (months)
0
20
40
60
80
100
Lo
co
-reg
ion
al
co
ntr
ol
(%)
P=0.01
41%
52%
34%
49%
0 12 24 36 48 60
Time after treatment (months)
0
20
40
60
80
100
Dis
ease-s
pec
ific
su
rviv
al
(%)
P=0.01
62%60%
22%
35%
Death from CancerLoco-regional control
ADVANCED SUPRAGLOTTIC and PHARYNX
DAHANCA 5 (1986 - 1990) Benefit of hypoxic modification
DAHANCA 7 (1992 - 1996) Benefit of accelerated fx
DAHANCA 2 (1979 - 1985) Loss by split - course
(prolonged) treatment time
The DAHANCA strategy: progression through consecutive clinical
trials
Standard 1977
Standard 2010
DAHANCA.dk
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Acute radiation related morbidity
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Acute radiation related morbidity
Severe skin reaction Severe mucositis
It is painful, 2/3 of
pts gets morphine.
Most have eating
problems (weight loss)
-
Time (weeks)
0 2 4 6 8 10 12 14
We
igh
t (K
g)
68
70
72
74
76
78
n = 449
Weight change during radical RT (>60 Gy)
J Johansen, G Bjerg Petersen et al 2009
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Late morbidity after head and neck irradiation
Xerostomia
Dysphagia
Under- and malnutrition
Trismus
Dental problems, osteo-radionecosis
Atrophy of mucous membranes
Pain
Neurological problems, incl. visual, auditory, gustatory and
olfactory dysfunction
Hypothyroidism
Disfigurement
Laryngectomy
Secondary cancer
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Late morbidityPrevalence of grade 2-3 (n=1420)
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Observer
assessed
