Treatment preferences in human papillomavirus-associated oropharyngeal cancer

Current status and future perspectives of oral HPV testing in the diagnosis and monitoring of oropharyngeal cancer. A review

HPV16 status in oropharyngeal cancer (OPC) is an important prognostic factor. Its determination, based on immunistochemical analysis of p16 oncoprotein requires an invasive biopsy. Thus, alternative methods are being sought. Determining oral HPV16 status appears to be a promising alternative. However, it is not used routinely. This prompted us to perform a systematic literature review enabling us to evaluate the diagnostic and predictive ability of this approach. Thirty-four relevant studies were finally selected. For determination of HPV status in OPC, the calculated average sensitivity and specificity for oral sampling was 74% and 91%, respectively, with p16 tumour tissue marker being the gold standard. The method appears to be valuable in monitoring treatment response as well as the biological activity of the tumour, enabling early detection of persistent or relapsing carcinoma sufficiently long before its clinical and/or radiological manifestation. It can also contribute to identification of the primary tumour in cases of metastases of unknown origin. Last but not least, the screening HPV oral testing would help to identify individuals with persistent HPV oral infection who are at increased risk of development of OPC.

Head and neck cancer treatment outcome priorities: A multi-perspective concept mapping study

With the increasing focus on patient-centred care, this study sought to understand priorities considered by patients and healthcare providers from their experience with head and neck cancer treatment, and to compare how patients' priorities compare to healthcare providers' priorities. Group concept mapping was used to actively identify priorities from participants (patients and healthcare providers) in two phases. In phase one, participants brainstormed statements reflecting considerations related to their experience with head and neck cancer treatment. In phase two, statements were sorted based on their similarity in theme and rated in terms of their priority. Multidimensional scaling and cluster analysis were performed to produce multidimensional maps to visualize the findings. Two-hundred fifty statements were generated by participants in the brainstorming phase, finalized to 94 statements that were included in phase two. From the sorting activity, a two-dimensional map with stress value of 0.2213 was generated, and eight clusters were created to encompass all statements. Timely care, education, and person-centred care were the highest rated priorities for patients and healthcare providers. Overall, there was a strong correlation between patient and healthcare providers' ratings (r = 0.80). Our findings support the complexity of the treatment planning process in head and neck cancer, evident by the complex maps and highly interconnected statements related to the experience of treatment. Implications for improving the quality of care delivered and care experience of head and cancer are discussed.

Risk Stratification for Oropharyngeal Squamous Cell Carcinoma Using Texture Analysis on CT - A Step Beyond HPV Status

Background and Purpose: Human papillomavirus-associated oropharyngeal squamous cell carcinoma (OPSCC) is increasingly prevalent. Despite the overall more favorable outcome, the observed heterogeneous treatment response within this patient group highlights the need for additional means to prognosticate and guide clinical decision-making. Promising prediction models using radiomics from primary OPSCC have been derived. However, no model/s using metastatic lymphadenopathy exist to allow prognostication in those instances when the primary tumor is not seen. The aim of our study was to evaluate whether radiomics using metastatic lymphadenopathy allows for the development of a useful risk assessment model comparable to the primary tumor and whether additional knowledge of the HPV status further improves its prognostic efficacy. Materials and Methods: 80 consecutive patients diagnosed with stage III-IV OPSCC between February 2009 and October 2015, known human papillomavirus status, and pre-treatment CT images were retrospectively identified. Manual segmentation of primary tumor and metastatic lymphadenopathy was performed and the extracted texture features were used to develop multivariate assessment models to prognosticate treatment response. Results: Texture analysis of either the primary or metastatic lymphadenopathy from pre-treatment enhanced CT images can be used to develop models for the stratification of treatment outcomes in OPSCC patients. AUCs range from .78 to .85 for the various OPSCC groups tested, indicating high predictive capability of the models. Conclusions: This preliminary study can form the basis multi-centre trial that may help optimize treatment and improve quality of life in patients with OPSCC in the era of personalized medicine.

Differences in Functional and Survival Outcomes Between Patients Receiving Primary Surgery vs Chemoradiation Therapy for Treatment of T1-T2 Oropharyngeal Squamous Cell Carcinoma

Importance

Due to lack of data from high-powered randomized clinical trials, the differences in functional and survival outcomes for patients with oropharyngeal squamous cell carcinoma (OPSCC) undergoing primary transoral robotic surgery (TORS) vs primary radiation therapy and/or chemoradiation therapy (RT/CRT) are unclear.

Objectives

To compare 5-year functional (dysphagia, tracheostomy dependence, and gastrostomy tube dependence) and survivorship outcomes in patients with T1-T2 OPSCC receiving primary TORS vs RT/CRT.

Design, Setting, and Population

This national multicenter cohort study used data from a global health network (TriNetX) to identify differences in functional and survival outcomes among patients with OPSCC who underwent primary TORS or RT/CRT in 2002 to 2022. After propensity matching, 726 patients with OPSCC met inclusion criteria. In the TORS group, 363 (50%) patients had undergone primary surgery, and in the RT/CRT group, 363 (50%) patients had received primary RT/CRT. Data analyses were performed from December 2022 to January 2023 using the TriNetX platform.

Exposure

Primary surgery with TORS or primary treatment with radiation therapy and/or chemoradiation therapy.

Main Outcomes and Measures

Propensity score matching was used to balance the 2 groups. Functional outcomes were measured at 6 months, 1 year, 3 years, 5 years, and more than 5 years posttreatment and included dysphagia, gastrostomy tube dependence, and tracheostomy dependence according to standard medical codes. Five-year overall survivorship was compared between patients undergoing primary TORS vs RT/CRT.

Results

Propensity score matching allowed a study sample with 2 cohorts comprising statistically similar parameters with 363 (50%) patients in each. Patients in the TORS cohort had a mean (SD) age of 68.5 (9.9) vs 68.8 (9.7) years in RT/CRT cohort; 86% and 88% were White individuals, respectively; 79% of patients were men in both cohorts. Primary TORS was associated with clinically meaningful increased risk of dysphagia at 6 months (OR, 1.37; 95% CI, 1.01-1.84) and 1 year posttreatment (OR, 1.71; 95% CI, 1.22-2.39) compared with primary RT/CRT. Patients receiving surgery were less likely to be gastrostomy tube dependent at 6 months (OR, 0.46; 95% CI, 0.21-1.00) and 5 years posttreatment (risk difference, -0.05; 95% CI, -0.07 to -0.02). Differences in overall rates of tracheostomy dependence (OR, 0.97; 95% CI, 0.51-1.82) between groups were not clinically meaningful. Patients with OPSCC, unmatched for cancer stage or human papillomavirus status, who received RT/CRT had worse 5-year overall survival than those who underwent primary surgery (70.2% vs 58.4%; hazard ratio, 0.56; 95% CI, 0.40-0.79).

Conclusions and Relevance

This national multicenter cohort study of patients undergoing primary TORS vs primary RT/CRT for T1-T2 OPSCC found that primary TORS was associated with a clinically meaningful increased risk of short-term dysphagia. Patients treated with primary RT/CRT had an increased risk of short- and long-term gastrostomy tube dependence and worse 5-year overall survival than those who underwent surgery.

Interpretable radiomics method for predicting human papillomavirus status in oropharyngeal cancer using Bayesian networks

OBJECTIVES

To develop a simple interpretable Bayesian Network (BN) to classify HPV status in patients with oropharyngeal cancer.

METHODS

Two hundred forty-six patients, 216 of whom were HPV positive, were used in this study. We extracted 851 radiomics markers from patients' contrast-enhanced Computed Tomography (CT) images. Mens eX Machina (MXM) approach selected two most relevant predictors: sphericity and max2DDiameterRow. The area under the curve (AUC) demonstrated BN model performance in 30% of the data reserved for testing. A Support Vector Machine (SVM) based method was also implemented for comparison purposes.

RESULTS

The Mens eX Machina (MXM) approach selected two most relevant predictors: sphericity and max2DDiameterRow. Areas under the Curves (AUC) were found 0.78 and 0.72 on the training and test data, respectively. When using support vector machine (SVM) and 25 features, the AUC was found 0.83 on the test data.

CONCLUSIONS

The straightforward structure and power of interpretability of our BN model will help clinicians make treatment decisions and enable the non-invasive detection of HPV status from contrast-enhanced CT images. Higher accuracy can be obtained using more complex structures at the expense of lower interpretability.

ADVANCES IN KNOWLEDGE

Radiomics is being studied lately as a simple imaging data based HPV status detection technique which can be an alternative to laboratory approaches. However, it generally lacks interpretability. This work demonstrated the feasibility of using Bayesian networks based radiomics for predicting HPV positivity in an interpretable way.

Trends in Swallowing Outcomes Following Deintensified Treatment in Selected p16+ Oropharyngeal Carcinoma

Objective

Identify trends in swallowing outcomes in p16+ oropharyngeal squamous cell carcinoma following neoadjuvant chemotherapy+surgery (NAC+S) versus neoadjuvant chemotherapy+surgery+radiation (NAC+S+R).

Study Design

Cohort study.

Setting

Single academic institution.

Methods

Swallowing outcome was measured using a validated questionnaire, MD Anderson Dysphagia Inventory (MDADI). MDADI scores were compared between NAC+S and NAC+S+R groups in short-term (<1 year), middle-term (1-3 years), and long-term (>3 years). Clinical factors associated with MDADI scores were explored using a linear mixed model. Statistical significance was established at p < .05.

Results

Sixty-seven patients met the inclusion criteria and were divided into 2 groups: NAC+S (57 [85.1%]) and NAC+S+R (10 [14.9%]). All patients had improved MDADI scores in the middle-term compared to short-term (NAC+S: score increase = 3.43, p = .002; NAC+S+R: score increase = 11.18, p = .044), long-term compared to short-term (NAC+S: score increase = 6.97, p < .001; NAC+S+R: score increase = 20.35, p < .001), and long-term compared to middle-term (NAC+S: score increase = 3.54, p = .043; NAC+S+R: score increase = 9.18, p = .026). NAC+S patients had better MDADI scores than NAC+S+R patients at short-term (83.80 vs 71.26, p = .001). There was no significant difference in swallowing function in the middle-term or long-term.

Conclusion

Regardless of treatment type, swallowing will likely be improved in the middle-term and long-term compared to the short-term. Patients treated with NAC+S+R will have worse short-term swallowing function. However, in the middle-term and long-term, there is no significant difference in swallowing function between patients treated with NAC+S and NAC+S+R.

Development of a web-based, patient-centered decision aid for oropharyngeal cancer treatment

OBJECTIVES

Many patients diagnosed with oropharyngeal squamous cell carcinoma (OPSCC) have the option of radiation- or surgery-based therapy, and would benefit from a treatment decision aid (DA) to make decisions congruent with their personal values. Our objective was to develop a patient-centered DA for patients with OPSCC that is comprehensible, usable, acceptable, and well-designed.

MATERIALS AND METHODS

Decisional needs from a pilot study of OPSCC survivors and treating physicians were used to inform a web-based prototype DA. A multidisciplinary steering group developed and iteratively revised the DA. Feasibility testing was conducted in two cycles to assess perspectives of stakeholders (medical, radiation and surgical oncologists, patient education experts, and OPSCC survivors). Survey data and open-ended responses were used to evaluate and refine the DA.

RESULTS

16 physicians, 4 patient education experts, and 6 survivors of OPSCC evaluated a web-based DA prototype in two cycles of testing. Participant feedback was used to revise the DA content and design between cycles. The majority of participants across both cycles indicated that the DA was comprehensible (97%), usable (86%), acceptable (78%), and well-designed (93%). Approximately three quarters of respondents indicated that they would use or share the DA in clinical practice.

CONCLUSION

We developed the first patient-centered treatment decision aid (DA) designed for patients with OPSCC, to our knowledge. The DA was perceived favorably by stakeholders, with more than three quarters of respondents indicating they would use it in clinical practice. This tool may improve clinical practice as an adjunct to shared decision-making for OPSCC.

Comparison of Survival of Patients With T1 -2 cN0 Oropharyngeal Cancer Treated With or Without Elective Neck Dissection

OBJECTIVES/HYPOTHESIS

This study aimed to examine the prognostic value of elective neck dissection (END) in T_1-2 clinical negative cervical lymph node (cN₀ ) oropharyngeal cancer (OPC) patients.

STUDY DESIGN

An observational retrospective study.

METHODS

This retrospective study included 845 patients diagnosed with T_1-2 cN₀ OPC during 2010-2015 from Surveillance, Epidemiology, and End Results database. Univariable and multivariable Cox regression models were used to evaluate the prognostic roles of END. Furthermore, propensity score matching was used to balance the covariates between the END and observation (OBS) groups, and subgroup analyses were conducted in the matched cohorts. The primary endpoint was overall survival (OS).

RESULTS

Our study showed that END was an independent prognostic factor associated with a better 3-year OS compared with OBS in human papillomavirus (HPV)-positive cohort (adjusted hazard ratio [HR], 0.464; 95% confidence interval [CI], 0.235-0.916; P = .027). However, we found no prognostic value of END in HPV-negative cohort (adjusted HR, 0.837; 95% CI, 0.535-1.310; P = .435). In the subgroup analyses, we found that younger patients (≤65 years old) and patients with nontonsillar tumors in HPV-positive cohort were more likely to benefit from END, while patients with tonsillar tumors in HPV-negative cohort may benefit from END.

CONCLUSIONS

We found that patients with HPV-positive T_1-2 cN₀ OPC could benefit from END in terms of OS, especially younger patients and those with nontonsillar tumors. Patients with HPV-negative T_1-2 cN₀ OPC could not benefit from END in terms of OS, while those with tonsillar tumors may benefit from END.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Risk of Pathologic Extranodal Extension and Other Adverse Features After Transoral Robotic Surgery in Patients With HPV-Positive Oropharynx Cancer

Importance

Understanding patient-specific risk of adverse histopathologic findings after primary surgery for human papillomavirus (HPV)-positive oropharynx squamous cell carcinoma (OPSCC) may help guide patient consultations.

Objective

To determine the likelihood of adverse histopathologic features that may indicate adjuvant radiotherapy or chemoradiotherapy after primary surgery for HPV-positive OPSCC according to 2021 National Comprehensive Cancer Network guidelines.

Design, Setting, and Participants

This retrospective cohort study was performed at a single academic tertiary care center. Of 258 patients who underwent transoral robotic surgery (TORS) from March 1, 2012, to March 1, 2021, 136 consecutive, treatment-naive patients with HPV-positive OPSCC without obvious clinical extranodal extension (ENE) who underwent definitive TORS and neck dissection were included in the analysis. Indications for surgical treatment included non-deeply infiltrative oropharynx tumors, minimal soft palate involvement, and low suspicion for pathologic ENE.

Exposures

Primary site TORS with neck dissection.

Main Outcomes and Measures

The primary outcomes were the adverse histopathologic features of pathologic ENE and positive surgical margins (PSM) that are indications for possible adjuvant chemoradiotherapy. Outcomes were compared among varying American Joint Committee on Cancer 7th edition (AJCC-7) T and N categories and patient clinical characteristics.

Results

Of the 136 patients included in the analysis (113 men [83.1%]; median age, 63 [interquartile range, 55-70] years), 109 (80.1%) had at least 1 indication for possible adjuvant radiotherapy. Twenty-seven patients (19.9%) had pathologic ENE and 10 (7.3%) had PSM. Thirty-four patients (25.0%) had pathologic ENE and/or PSM, whereas 3 (2.2%) had both. Age, smoking history, history of alcohol consumption, and clinical T category were not associated with pathologic ENE, PSM, lymphovascular invasion, perineural invasion, or pN2 category or greater. The proportion of pathologic ENE varied by clinical N category: 0 of 16 for cN0, 8 of 48 (16.7%) for cN1, 3 of 23 (13.0%) for cN2a, and 16 of 45 (35.6%) for cN2b. Compared with patients with cN1-cN2a disease, patients with cN2b disease had higher odds of pathologic ENE (odds ratio, 3.01; 95% CI, 1.14-8.10). Clinical and pathologic N category were concordant in 77 patients (56.6%), whereas 42 (30.9%) were upstaged and 17 (12.5%) were downstaged.

Conclusions and Relevance

In this cohort study, approximately one-quarter of carefully selected patients with HPV-positive OPSCC without obvious clinical ENE undergoing primary surgery had pathologic ENE and/or PSM. Patients with AJCC-7 cT0-cT2 cN0-cN2b disease, especially cN0-cN2a, without signs of clinical ENE may represent appropriate candidates for primary surgery when avoidance of adjuvant chemotherapy and/or reduction of adjuvant radiotherapy dose/extent are the goals.

Impact of Treatment Parameters on Racial Survival Differences in Oropharyngeal Cancer: National Cancer Database Study

OBJECTIVE

To investigate how differences in treatment parameters account for survival differences between races of patients with oropharyngeal squamous cell carcinoma (OPSCC).

STUDY DESIGN

Retrospective cohort study.

SETTING

National Cancer Database.

METHODS

Data of patients with OPSCC undergoing radiation therapy (RT) or concurrent chemoradiation therapy as primary treatment were obtained from the National Cancer Database from 2004 to 2016. We analyzed 4 treatment-related time intervals to determine their impact on survival between races when controlling for human papilloma virus (HPV) status. Cox proportional hazards models, stepwise logistic regressions, covariate adjustments, and propensity score matching were performed.

RESULTS

A total of 3152 patients were identified (2877 White, 275 Black). In HPV- cases, Black patients with prolonged radiation duration had a significantly worse overall survival as compared with White patients (hazard ratio, 1.77; 95% CI, 1.03-3.05; P = .039). In a logistic regression model, the only covariate that was significantly associated with prolonged RT was facility type. When further adjusted for facility type, the survival difference between Black and White patients with HPV- status and prolonged RT times was no longer significant (hazard ratio, 1.55; 95% CI, 0.90-2.69; P = .116).

CONCLUSIONS

There is a significant disparity in overall survival between Black and White patients with HPV- OPSCC when RT duration is prolonged. Clinicians should be aware of the negative impact of prolonged RT, especially in Black patients, so that they can attempt to decrease treatment-related time intervals. Facility type was also found to affect the outcomes of patients with OPSCC, and efforts should be made to improve patient access to well-equipped, high-volume facilities.

Predicting Adverse Histopathology and Need for Postsurgical Adjuvant Therapy for Human Papilloma Virus-Associated Oropharynx Carcinoma

OBJECTIVE

For human papillomavirus-associated oropharynx carcinoma treated with definitive surgery, we aimed to find predictors of adverse histopathology indicating the possible need for adjuvant therapy.

STUDY DESIGN

Retrospective review.

SETTING

National Cancer Database.

METHODS

We analyzed 2347 eligible patients from 2010 to 2015. We evaluated (1) the ability of clinical nodal staging and extranodal extension designation per the AJCC, seventh edition (American Joint Committee on Cancer), to predict histopathology and (2) the likelihoods for adverse postsurgery histopathology by common clinical stages.

RESULTS

Clinical nodal staging predicted pathologic nodal staging 65% of the time, with 24% (569/2347) being upstaged and 11% (251/2347) being downstaged. In patients with cN+ disease, clinical extranodal extension distinction had the following accuracy for pathologic extranodal extension: positive predictive value, 81% (88/109); negative predictive value, 73.1% (505/691); sensitivity, 32.1% (88/274); and specificity, 96.0% (505/526). Patients with cT1-2, N0-N2c, without clinical extranodal extension had the following proportions of pN2+ without pathologic extranodal extension (indicating consideration for adjuvant radiation): cN0, 11%; cN1, 31%; cN2a, 67% (8% downstaged); cN2b, 66% (6% downstaged); and cN2c, 35% (17% downstaged). From this group, patients had the following proportions of pathologic extranodal extension (indicating consideration for adjuvant chemoradiation): cN0, 6%; cN1, 20%; cN2a, 27%; cN2b, 28%; and cN2c, 48%.

CONCLUSION

For human papillomavirus-associated oropharynx carcinoma, nodal clinical staging per the American Joint Committee on Cancer, seventh edition, predicts pathologic stage about two-thirds of the time, leading to up- and downstaging. Clinical extranodal extension assessment has low sensitivity and moderate predictive capability. With careful selection, definitive surgery can allow patients to often avoid adjuvant chemotherapy and sometimes avoid adjuvant radiation.

Treatment decision-making among patients with oropharyngeal squamous cell cancer: A qualitative study

Oropharyngeal squamous cell cancer (OPSCC) is now the most common site of head and neck squamous cell cancer. Despite the focus on treatment deintensification in clinical trials, little is known about the preferences, experiences and needs of patients with OPSCC when deciding between surgery and radiation therapy as primary treatment with curative intent. In this qualitative study, pre-treatment and post-treatment oropharyngeal cancer patients were recruited to take part in one-on-one interviews (n = 11 pre-treatment) and focus group discussions (n = 15 post-treatment) about treatment decision-making. Recordings were transcribed and assessed for emergent themes using framework analysis. From the one-on-one interviews and focus group discussions with OPSCC patients, fourteen themes were identified. Participants expressed alarm at diagnosis, decisional conflict, and a variety of roles in decision-making (physician-controlled, shared, and autonomous). Decisions were driven by the perceived recommendation of the treatment team, a desire for physical (surgical) tumor removal, fear of adverse effects of treatment, and patient-specific values. Although participants felt well-informed by their treating physicians, they identified a need for additional patient-centered information. Participants were critical of the poor quality of information available on the internet, and acknowledged the advantage of hearing the experiences of post-treatment patients. The experiences identified herein may be used to guide patient-centered communication during patient counseling and to inform interventions designed to support patients' needs at diagnosis, ultimately helping to implement high-quality, patient-centered care.

Pretreatment DWI with Histogram Analysis of the ADC in Predicting the Outcome of Advanced Oropharyngeal Cancer with Known Human Papillomavirus Status Treated with Chemoradiation

BACKGROUND AND PURPOSE

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) has increased in the period from the 1970s to 2004, due to increase of infection with human papilloma virus (HPV). This study aimed to examine the role of histogram analysis of the ADC in treatment response and survival prediction of patients with oropharyngeal squamous cell carcinoma and known human papillomavirus status.

MATERIALS AND METHODS

This was a retrospective single-center study. Following inclusion and exclusion criteria, data for 59 patients affected by T2-T4 (according to the 8th edition of the AJCC Cancer Staging Manual) oropharyngeal squamous cell carcinoma were retrieved. Twenty-eight had human papillomavirus-positive oropharyngeal squamous cell carcinoma, while 31 had human papillomavirus-negative oropharyngeal squamous cell carcinoma. All patients underwent a pretreatment MR imaging. Histogram analysis of ADC maps obtained by DWI (b = 0-1000 mm/s²) was performed on the central section of all of tumors. The minimum follow-up period was 2 years. Histogram ADC parameters were associated with progression-free survival and overall survival. Univariable and multivariable Cox models were applied to the data; P values were corrected using the Benjamini-Hochberg method.

RESULTS

At univariable analysis, both human papillomavirus status and mean ADC were associated with progression-free survival (hazard ratio = 0.267, P < .05, and hazard ratio  = 1.0028, P ≤ .05, respectively), while only human papillomavirus status was associated with overall survival (hazard ratio  = 0.213, P ≤ .05) before correction. At multivariable analysis, no parameter was included (in fact, human papillomavirus status lost significance after correction). If we separated the patients into 2 subgroups according to human papillomavirus status, ADC entropy was associated with overall survival in the human papillomavirus-negative group (hazard ratio  = 4.846, P = .01).

CONCLUSIONS

ADC and human papillomavirus status are related to progression-free survival in patients treated with chemoradiation for advanced oropharyngeal squamous cell carcinoma; however, this association seems to result from the strong association between ADC and human papillomavirus status.

Special Issue about Head and Neck Cancers: HPV Positive Cancers

The oropharynx has become the leading primary site for Human Papilloma Virus (HPV)-associated head and neck cancer. HPV positive oropharyngeal squamous cell carcinoma (HPV+ OSCC) has emerged as an epidemic not easily recognized by many physicians, resulting in delays in diagnosis and management. HPV+ OSCC traditionally refers to younger, healthier patients with high economic status and high-risk sexual behavior and is related to improved prognosis. De-intensification strategies are being evaluated in ongoing clinical trials and if validated, might help spare severe morbidity associated with current cisplatin-based chemoradiotherapy, which is the standard of care for all patients with locally advanced head and neck cancer. On the other hand, whether HPV status represents an important prognostic factor for non-oropharyngeal sites remains to be elucidated.

Current role of primary surgical treatment in patients with head and neck squamous cell carcinoma

PURPOSE OF REVIEW

The objective of this review article is to discuss the current role of surgery as the primary treatment modality in patients with head and neck squamous cell carcinoma (HNSCC).

RECENT FINDINGS

HNSCC represents one of the cancer locations where the primary treatment modality is the most under discussion. Indeed, the respective roles of primary surgical resection followed, as necessary, by adjuvant radiotherapy or definitive chemoradiotherapy remain controversial. The results of organ preservation trials and the drastic rise in the incidence of human papillomavirus-induced oropharyngeal tumors, which are known to be highly radiosensitive, have led to an increasing use of chemoradiation-based therapies in HNSCC patients. However, no chemoradiation-based protocol has shown better oncologic outcomes than radical primary surgery. Moreover, development of minimally invasive surgical techniques, such as transoral robotic surgery, and advances in head and neck microvascular reconstruction have considerably improved the clinical outcomes of the patients and have led to a reconsideration of the role of primary surgery in HNSCC patients.

SUMMARY

Surgery should be the primary treatment modality for most resectable oral cavity cancers and for T4a laryngeal/hypopharyngeal cancers. Primary surgery could also be the preferred modality of treatment for most early (T1-T2, N0) laryngeal and hypo/oropharyngeal carcinomas when this strategy offers an opportunity to reserve radiotherapy for a potential recurrence or second primary tumor. Primary surgery should also be considered in patients with locally advanced human papillomavirus-negative oropharyngeal carcinoma.

Strategies for communicating oral and oropharyngeal cancer diagnosis: why talk about it?

OBJECTIVE

This review aimed to explore the paradigms of disclosing a cancer diagnosis with a focus on oral and oropharyngeal cancer and patient-related considerations.

STUDY DESIGN

A search of MEDLINE, Embase, and Scopus was conducted using the following keywords: oral cancer; mouth lesions; oncology; breaking bad news; truth disclosure; and communication skills training. English and Spanish language studies published through October 2019 were included.

RESULTS

The way bad news is conveyed to patients with cancer may affect their comprehension of information, emotional distress, treatment adherence, and health outcomes. Models of communication that are focused on patients' preferences may result in better treatment outcomes. Available protocols, such as SPIKES and ABCDE, have useful recommendations for health care professionals communicating an oral cancer diagnosis. However, it is important to be attentive to the particular information needs of patients.

CONCLUSIONS

When communicating a cancer diagnosis, providers should employ validated methods of information delivery and support for oncology patients. Further studies are needed to evaluate the experiences and preferences of patients with oral cancer during these communications.

Imaging biomarkers in upper gastrointestinal cancers

In parallel with the increasingly widespread availability of high performance imaging platforms and recent progresses in pathobiological characterisation and treatment of gastrointestinal malignancies, imaging biomarkers have become a major research topic due to their potential to provide additional quantitative information to conventional imaging modalities that can improve accuracy at staging and follow-up, predict outcome, and guide treatment planning in an individualised manner. The aim of this review is to briefly examine the status of current knowledge about imaging biomarkers in the field of upper gastrointestinal cancers, highlighting their potential applications and future perspectives in patient management from diagnosis onwards.

Priorities, concerns, and regret among patients with head and neck cancer

BACKGROUND

In the era of deintensification, little data are available regarding patients' treatment preferences. The current study evaluated treatment-related priorities, concerns, and regret among patients with head and neck squamous cell cancer (HNSCC).

METHODS

A total of 150 patients with HNSCC ranked the importance of 10 nononcologic treatment goals relative to the oncologic goals of cure and survival. The level of concern regarding 11 issues and decision regret was recorded. Median rank was reported overall, and factors associated with odds of rank as a top 3 priority were modeled using logistic regression.

RESULTS

Among the treatment effects analyzed, the odds of being a top 3 priority was especially high for cure (odds, 9.17; 95% confidence interval [95% CI], 5.05-16.63), followed by survival and swallow (odds, 1.26 [95% CI, 0.88-1.80] and odds, 0.85 [95% CI, 0.59-1.21], respectively). Prioritization of cure, survival, and swallow was similar based on human papillomavirus (HPV) tumor status. By increasing decade of age, older participants were found to be significantly less likely than younger individuals to prioritize survival (odds ratio, 0.72; 95% CI, 0.52-1.00). Concerns regarding mortality (P = .04) and transmission of HPV to the patient's spouse (P = .03) were more frequent among participants with HPV-associated HNSCC. Regret increased with additional treatment modalities (P = .02).

CONCLUSIONS

Patients with HNSCC overwhelming prioritize cure, followed by survival and swallow. The decreased prioritization of survival by older age supports further examination of treatment preference by age. The precedence of oncologic over nononcologic priorities among patients regardless of HPV tumor status supports the conservative adoption of deintensification regimens until the interplay between competing oncologic and nononcologic treatment goals is better understood.