Undergoing head and neck cancer surgery: A grounded theory

Surgery is the treatment of choice in most head and neck cancers. Very often, the surgery is radical with high impact on the psychosocial, functional and aesthetic fields. The aim of this study is to gain a deeper understanding of the patient's, clinician's and key informant's point of view when surgery is proposed, to improve the quality of pathways in terms of patients’ practical, psychological and relational needs. We followed a Grounded Theory approach with semi‐structured interviews. Seventeen participants (six patients, nine healthcare professionals and two volunteers) were interviewed immediately before surgery. The study generated a process of “persuading the patient of an obligation” as the core category. The other principal categories that emerged highlighted the patients’ doubts and fears regarding the surgery consequences and, in parallel, strategies employed by the healthcare professionals to rebut hindering issues impeding surgery. In particular, healthcare professionals involved patients in an affiliation process through simplified communication to sustain the choice of surgery; the family plays a supportive role in this process. The interplay between the organisational process and patients’ experience results in “I will let you convince me” at the end of the decision‐making process, where the main aim was to save and be saved.     

How patients adjust psychologically to the experience of head and neck cancer: A grounded theory

Numerous physical and psychological challenges are recognised as consequences of head and neck cancer and its treatment, but little is known about how patients adjust psychologically to these experiences. This study aimed to develop a theoretical understanding of the processes patients engage in when adjusting to head and neck cancer. Twelve patients participated in semi‐structured interviews conducted individually and transcribed verbatim. Data were analysed using grounded theory methodology. Analysis generated a core category of “modifying my relationship to the changes cancer brings,” which encompassed 11 processes patients engaged in throughout their adjustment: “survive mode,” “instrumental support from others,” “making a choice,” “developing own understanding,” “acceptance,” “talking with others,” “making changes,” “redefining or regaining normality,” “managing emotions/distressing thoughts,” “putting things into perspective” and “barriers to progress.” Contrasting findings are discussed, and a model of psychological adjustment to head and neck cancer is proposed. The study found that patients engage in a series of processes throughout adjustment to head and neck cancer, which broadly map on to the cancer treatment trajectory, though these processes did not appear to be specific to head and neck cancer. The proposed model may be used as a framework to guide psychological interventions.     

Personalizing cancer care: updates on head and neck cancer

With an emphasis on personalizing cancer care, the American Society of Clinical Oncology 45th Annual Meeting was held from 29 May to 2 June in Orlando (FL, USA). Several abstracts were presented that will significantly impact the management of squamous cell carcinoma of the head and neck both currently and in the near future, especially with respect to patient selection for specific therapies, prognostic biomarkers and novel agents.     

Surgical treatment in head and neck cancer

Three topics currently important in head and neck surgery are voice-conserving surgical treatment of laryngeal cancer, the role of modified radical neck dissection in the treatment of cervical metastases, and reconstruction and rehabilitation of the head and neck cancer patient. The laser has become an accepted modality for the treatment of early vocal cord cancer and has local control rates comparable to other treatment methods. Partial laryngectomy can conserve voice and yield excellent local control rates. The modified radical neck dissection has been shown to yield rates of local recurrence no greater than radical neck dissection for N0 and N1 neck disease associated with laryngeal cancer. Vocal rehabilitation following total laryngectomy has been revolutionized by the tracheoesophageal puncture procedure. Most patients can be expected to acquire voice using tracheoesophageal puncture following total laryngectomy. Free flaps have improved the functional results of many major head and neck surgical procedures and offer the possibility of better results in the future. However, more conventional reconstructive techniques, including local flaps, continue to have a role in head and neck surgery.     

Prevalence of obstructive sleep apnoea following head and neck cancer treatment: a cross-sectional study

The obstructive sleep apnoea-hypopnoea syndrome (OSAHS) is a sleep-related breathing disorder characterised by repetitive pharyngeal collapse. OSAHS is associated with a reduced quality of life. A high OSAHS prevalence has been reported in patients treated for head and neck cancer (HNC). The aim of the present study was to identify the prevalence of OSAHS within a Dutch population of patients treated for HNC. Consecutive HNC patients with a follow-up of 6 months to 5 years after treatment of an oral or oropharynx carcinoma were eligible for inclusion. Two questionnaires were used to assess the presence of OSAHS-related complaints. Subsequently, polysomnography was used in patients with OSAHS-related complaints to confirm the diagnosis of OSAHS. Four out of 33 included patients were diagnosed with OSAHS, yielding a prevalence of 12%. Since recognition and treatment of OSAHS might play an important role in improving quality of life of HNC patients, we suggest screening all patients with an oral or oropharynx carcinoma for the presence of OSAHS-related complaints prior to and following HNC treatment.     

Ifosfamide in the treatment of head and neck cancer

Ifosfamide (IFO) has demonstrated activity in recurrent/metastatic squamous cell head and neck carcinoma with an overall response rate of 24-26%. Better results are reported for chemotherapy-naive patients; in heavily pretreated cases results are poor and toxicity unacceptable. Cisplatin-IFO combination in stage III-IV is probably more active than IFO alone (ORR = 60-72 vs. 50%) but is indicated in patients who desire aggressive treatment and are physically able to tolerate the drugs. The carboplatin-IFO scheme is better tolerated than the cisplatin-IFO regimen with superimposable clinical results (ORR = 69%; CR = 15%). Carboplatin-taxol-IFO is one of the most active regimens in recurrent (ORR = 59%; CR = 17%) and in locally advanced (ORR = 81%; CR = 31%) head and neck cancer. Its role in the multidisciplinary treatment of advanced head and neck cancer is under investigation. In recurrent/metastatic undifferentiated nasopharygeal carcinoma, IFO combinations have proven to be effective as first- and second-line treatment.     

Cetuximab in the treatment of head and neck cancer

Approaches to the treatment of locally advanced and recurrent and/or metastatic squamous cell carcinoma of the head and neck (SCCHN) have been limited by their toxicity. Effective, better tolerated approaches are urgently required. Cetuximab is an immunoglobulin G(1) monoclonal antibody that specifically targets the epidermal growth factor receptor (EGFR), which is commonly expressed in a number of solid tumors, including SCCHN, where it is associated with poor prognosis. Cetuximab is approved in 56 countries for use in the treatment of EGFR-expressing metastatic colorectal cancer that has progressed on irinotecan-containing therapy and has recently received approval in Europe and the USA for use in the treatment of SCCHN. A randomized Phase III study has demonstrated that cetuximab plus radiotherapy can significantly improve locoregional control and prolong overall survival compared with radiotherapy alone. Cetuximab has also been confirmed to be effective as monotherapy in recurrent and/or metastatic SCCHN that has progressed on platinum-containing therapy. Clinical studies have demonstrated that cetuximab is well tolerated and does not significantly increase the side effects associated with radiotherapy or chemotherapy. This article presents the rationale for EGFR inhibition in the management of head and neck cancers, and the preclinical and clinical evidence for the use of cetuximab in the treatment of SCCHN.     

Taxanes in the treatment of head and neck cancer

PURPOSE OF REVIEW: This review presents new data on the role of paclitaxel and docetaxel in the management of squamous cell carcinoma of the head and neck. Recently both agents have been tested in squamous cell carcinoma of the head and neck in combination with other chemotherapeutic agents, targeted drugs, and radiotherapy in in-vitro experiments and in the clinic as first-line treatment of patients with metastatic/recurrent and locally advanced squamous cell carcinoma of the head and neck. RECENT FINDINGS: The combination of taxanes with standard or accelerated radiotherapy is feasible and induction chemotherapy followed by chemoradiation is active and feasible without excessive toxicity in patients with locally advanced squamous cell carcinoma of the head and neck. The use of low-dose fractionated radiotherapy shows promising in-vitro and clinical results and is further explored. SUMMARY: Both docetaxel and paclitaxel can be combined with chemotherapeutic agents and radiotherapy, but phase III studies are needed to prove the superiority of these approaches compared to standard treatment. The final results of the combination study of cisplatin and 5-fluorouracil with or without docetaxel may change the standard chemotherapeutic regimen for induction chemotherapy in patients with locally advanced squamous cell carcinoma of the head and neck.     

Brachytherapy in the treatment of head and neck cancer

Brachytherapy is a therapeutic modality that may provide a significant improvement in the therapeutic ratio when appropriately applied, and hence, is an appealing treatment strategy for the head and neck. For several tumor sites in the head and neck, the use of a brachytherapy implant has been demonstrated to be effective and is optimally provided within a multidisciplinary team setting. This enables meticulous attention to technical and treatment-related factors that have been demonstrated to influence the therapeutic ratio for low-dose-rate implants. Recent technologic advances have enabled the study of promising high-dose-rate and pulsed-dose-rate afterloading brachytherapy techniques, in an attempt to expand the role of brachytherapy in the head and neck. These techniques minimize radiation exposure hazards while offering the physical and biologic advantages of brachytherapy. Issues pertinent to members of the brachytherapy team providing multidisciplinary care of the implanted head and neck patient are discussed.     

Cetuximab in the treatment of head and neck cancer

Approaches to the treatment of locally advanced and recurrent and/or metastatic squamous cell carcinoma of the head and neck (SCCHN) have been limited by their toxicity. Effective, better tolerated approaches are urgently required. Cetuximab is an immunoglobulin G₁ monoclonal antibody that specifically targets the epidermal growth factor receptor (EGFR), which is commonly expressed in a number of solid tumors, including SCCHN, where it is associated with poor prognosis. Cetuximab is approved in 56 countries for use in the treatment of EGFR-expressing metastatic colorectal cancer that has progressed on irinotecan-containing therapy and has recently received approval in Europe and the USA for use in the treatment of SCCHN. A randomized Phase III study has demonstrated that cetuximab plus radiotherapy can significantly improve locoregional control and prolong overall survival compared with radiotherapy alone. Cetuximab has also been confirmed to be effective as monotherapy in recurrent and/or metastatic SCCHN that has progressed on platinum-containing therapy. Clinical studies have demonstrated that cetuximab is well tolerated and does not significantly increase the side effects associated with radiotherapy or chemotherapy. This article presents the rationale for EGFR inhibition in the management of head and neck cancers, and the preclinical and clinical evidence for the use of cetuximab in the treatment of SCCHN.     

5-氟尿嘧啶在头颈部肿瘤病人体内的群体药动学研究

目的:二氢嘧啶脱氢酶（DPD）缺乏是导致5-FU毒性的主要原因。我们根据病人DPD状态调节5-FU的使用剂量,减少了毒副作用而没有影响疗效。当前的工作目标是确定5-FU药动学的合变量并为它建立一个新的模型。方法:本研究纳入22个头颈部肿瘤患者,根据DPD状态调节5-FU的剂量,利用NONMEM V5计算群体和个体的药动学参数。结果:在本组病人中,5-FU的药动学被描述为线性的、利用一级条件评估法和混合误差模型构成的一室模型。影响5-FU清除的主要合变量首先是体表面积。DPD状态对5-FU清除的影响出现在64%的病人中。DPD状态比年龄、性别等经常与5-FU毒性相关的合变量更能影响5-FU的清除。结论:在基于DPD的5-FU剂量调整战略的病人中,预先确定DPD不足的病人已被初筛并调整剂量,从而影响了5-FU的药动学。当DPD的问题被预先处理后,体表面积成为调节5-FU剂量的相关合变量。     

Altered fractionation in the treatment of head and neck cancer

Several altered fractionation schemes have evolved to exploit different aspects of head and neck cancer growth kinetics and normal tissue repair. Hyperfractionation schedules exploit the differential repair abilities of tumor and normal tissue, whereas accelerated fractionation regimens minimize the time of tumor repopulation. Significant clinical data have accumulated that indicate an improvement between 15% and 20% in locoregional control from altered fractionation. Preliminary analysis of a randomized Radiation Therapy Oncology Group trial testing four fractionation schemes confirms the benefit of one altered fractionation approach. Several promising concurrent chemoradiation treatments involving altered fractionation have been reported. Future trials will determine whether the addition of chemotherapy to altered fractionation schemes is warranted in light of the factor of added toxicity.     

Gemcitabine in the treatment of advanced head and neck cancer

AimsSeveral new chemotherapy agents show varying degrees of activity in head and neck cancer. One of them is gemcitabine, which is a new nucleoside analogue with an innovative cytostatic mode of action. Gemcitabine has demonstrated a broad spectrum anti-tumoural effect and a favourable toxicity profile. These attributes prompted us to introduce gemcitabine into the treatment of head-and-neck tumours.Materials and methodsTen heavily pre-treated patients with recurrent and incurable squamous-cell carcinoma of the head and neck (SCCHN) were treated with Gem. The initial cycle consisted of six administrations of the drug (1250 mg/m² once weekly intravenously over 30 min) followed by a week without cytotoxic treatment. All following cycles were composed of two infusions once weekly (d1, 8), followed by a week of rest.ResultsToxic effects, length of survival and tumour response was assessable in eight patients owing to one suicide and loss of one patient for follow-up. One complete remission, two partial remissions and three ‘no change’ situations (stable disease) were observed, yielding a response rate of 37.5%. Median survival was 8 months (range 3–12). The incidence of haematological toxicity was low, with grade 3–4 neutropenia in less than 10%. Flu-like symptoms were reported by one-third of patients.ConclusionsIn this small phase-II study, gemcitabine demonstrated a high anti-tumoural activity in SCCHN, with a favourable toxicity profile. Gemcitabine seems to be a promising new drug without severe burden even for patients who are refractory to other cytostatic drugs. Within recent years, the activity and tolerability of gemcitabine was documented in several phase I and phase II trials, especially in combination with cisplatin, and paclitaxel resp, carboplatin/paclitaxel, cisplatin/ifosfamide, and 5-fluorouracil/paclitaxel. The results of these trials will be outlined in the discussion.     

Alcohol and head and neck cancer risk in a prospective study

We investigated the relation between head and neck cancer risk and alcohol consumption in the NIH-AARP Diet and Health Study. During 2,203,500 person-years of follow-up, 611 men and 183 women developed head and neck cancer. With moderate drinking (up to one alcoholic drink per day) as the referent group, non-drinkers showed an increased risk of head and neck cancer (men: hazard ratio (HR) 1.68, 95% confidence interval (95% CI) 1.37-2.06; women: 1.46, 1.02-2.08). Among male and female alcohol drinkers, we observed a significant dose-response relationship between alcohol consumption and risk. The HR for consuming >3 drinks per day was significantly higher in women (2.52, 1.46-4.35) than in men (1.48, 1.15-1.90; P for interaction=0.0036). The incidence rates per 100 000 person-years for those who consumed >3 drinks per day were similar in men (77.6) and women (75.3). The higher HRs observed in women resulted from lower incidence rates in the referent group: women (14.7), men (34.4). In summary, drinking >3 alcoholic beverages per day was associated with increased risk in men and women, but consumption of up to one drink per day may be associated with reduced risk relative to non-drinking.     

Concurrent palliative care in the surgical management of head and neck cancer

Head and neck cancer affects vital functions of speech, swallowing, breathing, and appearance. Overall survival remains poor and symptom burden is high for both patients with incurable disease at the end of life and for long-term survivors. Early and concurrent palliative care helps guide treatment decision making and support quality of life during and after treatment. Both narrative competence and directive counsel can affect the concordance of patient goals and tolerance of treatment and outcomes.