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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