Current and Novel Approaches to the Treatment of Head and Neck Cancer
Susannah Motl, PharmD
Cancer is the second-leading cause of death in the United States with 1 of every 4 deaths attributable to cancer.1 However, when mortality rates are considered on the basis of age, starting in 2001, cancer began to surpass heart disease as the leading cause of death for persons younger than 85 years.1 Because of the high incidence, morbidity, and mortality rates associated with cancer, understanding its pathophysiology, recognizing its signs and symptoms, and staying abreast of emerging therapeutic innovations in cancer care are paramount for pharmacists, both professionally and personally.
Head and neck cancer (HNCA) is defined as cancer of the oral cavity, tongue, mouth, pharynx, and/or larynx. Approximately 40 000 cases of HNCA occur annually in the United States, and approximately 25% of patients with HNCA die each year. HNCA is the eighth most common cancer in US men1; its annual incidence in men is approximately 27 000 cases compared to 12 000 cases in women.1
Although oncology surgeons and radiotherapists have historically managed the care of patients with HNCA, recent evidence has suggested that the use of chemotherapy substantially improves overall survival rates. Therefore, in the last decade, medical oncologists have played an increasingly important role in the management of these patients. For this reason, multimodality management of patients with HNCA by head and neck surgeons, radiotherapists, medical oncologists, primary care physicians, dentists, occupational therapists, and pharmacists is necessary.
Healthcare professionals, including pharmacists, who have familiarized themselves with these tumors often can recognize their signs and symptoms early in the course of the disease and promptly refer patients to facilitate an early diagnosis. This role is particularly important because the establishment of an HNCA diagnosis at an early stage substantially improves the odds that treatment will be curative. In addition, pharmacists play a key role in the multidisciplinary HNCA treatment team by helping to manage side effects of the disease and its treatment, such as speech impairment, dysphagia, malnutrition, mucositis, and pain.
This issue of the University of Tennessee Advanced Studies in Pharmacy provides complete coverage of a satellite continuing education symposium, which was held in conjunction with the 40th Annual American Society of Health-System Pharmacists' Midyear Clinical Meeting in Las Vegas, Nev, on December 5, 2005. The goal of this program was to promote a better appreciation of how pharmacists can play an active role in the multidisciplinary treatment of HNCA. The objectives of this symposium were to examine the epidemiology, pathology, and molecular biology of HNCA; to understand the multimodal approach to HNCA treatment; to describe emerging strategies for the treatment of HNCA, particularly the potential role of antibody therapy; and to establish how a hospital pharmacist can minimize treatment and disease-induced side effects through the proper coordination of supportive care.
The symposium began with an overview of the epidemiology, risk factors, diagnosis, staging, and treatment of HNCA presented by Barry R. Goldspiel, PharmD, BCPS, BCOP, FASHP. During his presentation, Dr Goldspiel explained that surgery and radiotherapy are the main treatments for early stages of HNCA and can cure local disease in approximately 80% of cases.1 He also noted that substantial research has established that epidermal growth factor receptor (EGFR) and vascular endothelial growth factor (VEGF) are overexpressed in HNCA. In addition, EGFR and VEGF levels can serve as prognostic indicators, in addition to indicators of potential response to radiotherapy in HNCA. According to Dr Goldspiel, therapy targeted at EGFR and VEGF represents a rational strategy for increasing 5-year survival rates in advanced HNCA, which have improved little since 1976.
Next, Patrick J. Medina, PharmD, BCOP, provided an overview of the role of chemotherapy in HNCA with special focus on traditional cytotoxic agents and targeted agents, such as the EGFR inhibitor cetuximab. Dr Medina noted that traditional chemotherapeutic agents, particularly cisplatin, in combination with radiotherapy, are increasingly being used for all stages of HNCA to improve locoregional control and organ preservation and to reduce the formation of distant metastases. Dr Medina also reviewed emerging clinical data that demonstrate the value of EGFR inhibitors—alone and in combination with traditional therapies—in treating HNCA.
In the next presentation, Rowena N. Schwartz, PharmD, BCOP, discussed the use of surgery and radiation therapy for HNCA. She also discussed related quality-of-life issues, such as pain and nutrition, in which pharmacists can play a key role in enhancing the quality of patient care. During her presentation, Dr Schwartz reviewed the many nonpharmacologic and pharmacologic interventions available for treating radiotherapy-induced mucositis and related mouth soreness. In addition, Dr Schwartz stressed that HNCA pain is a mixed-pain syndrome that does not simply require opiate therapy but instead requires aggressive management that changes as the disease progresses. She also reviewed study findings that demonstrated that early dietary counseling during the course of HNCA treatment can substantially increase caloric intake.2 Finally, the symposium moderator, Susannah Motl, PharmD, presented a case study highlighting the emerging options for the treatment of stage IVA HNCA and mucositis that commonly results as a side effect of HNCA radiotherapy.
1. Jemal A, Murray T, Ward E, et al. Cancer statistics, 2005. CA Cancer J Clin. 2005;55:10-30.
2. Ravasco P, Monteiro-Grillo I, Marques Vidal P, Camilo ME. Impact of nutrition on outcome: a prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head Neck. 2005;27:659-668.
*Assistant Professor, Department of Pharmacy, University of Tennessee College of Pharmacy, Memphis, Tennessee.
Address correspondence to: Susannah Motl, PharmD, Assistant Professor, Department of Pharmacy, University of Tennessee College of Pharmacy, 875 Monroe Avenue, Suite 112, Memphis, TN 38111. E-mail: email@example.com.