Expert Sheds Light on Investigative Surgical Approaches in Head and Neck Cancer

Benjamin L. Judson, MD

Amid the increasing variety of treatments available for patients with head and neck cancer, surgical oncologists are also exploring more minimally invasive approaches to lower associated adverse events and, overall, improve patient outcomes.

“If we could incorporate surgery, either endoscopic laser surgery or transoral robotic surgery, in order to minimize or reduce the treatments that might have side effects, that is going to be beneficial,” states Benjamin L. Judson, MD.

OncLive: Can you please discuss the case study you were involved in?

What are the benefits of having a multidisciplinary team?

How do you determine if a patient should receive surgery over other forms of treatment?

In an interview at the 2017 OncLive State of the Science Summit on Head and Neck Cancers, Judson, an associate professor of surgery at Yale School of Medicine, highlights the importance of a multidisciplinary team and shares insight on some of the advancements related to surgery for patients with head and neck cancer.Judson: We presented a few cases of head and neck cancer. Our panel consisted of a surgeon, a radiation oncologist, and a medical oncologist. Just as we would when we take care of patients, we discussed the patients in a multidisciplinary fashion. We covered some of the issues by discussing them from different perspectives.Head and neck cancer is one of those diseases where the treatments are multidisciplinary. For some patients, the most beneficial treatment might involve surgery, whereas for others it does not. Similarly, some patients are going to benefit from radiation or chemotherapy instead of surgery. Having each of those perspectives present while discussing a case is important in terms of coming up with a treatment that will be beneficial for an individual.In many cases, the evidence makes it straightforward as to what the best treatment option is, whether it be surgery followed by radiation or whether it’s radiation therapy only. There are always specific factors for each patient that might make receiving 1 form of treatment more difficult or riskier than others.

What are some of the most prominent recent advancements that have been made?

Some patients might not be able to get radiation because of a disease that they have or because of prior treatments, when radiation would normally be the standard of treatment for that patient. Similarly, with chemotherapy, some are unable to receive it because of a medical condition that they have. In terms of surgery, some might not be healthy enough to undergo surgery, which makes it important to discuss the specifics of individual cases.In head and neck cancers, there are a few major changes that are happening. Even in my short 15 years, there has been this rise of human papillomavirus (HPV)-associated cancers. It’s distinct from the disease that we have taken care of before.

What impact has minimally invasive surgery had on the patient population?

What challenges would you like to see tackled regarding surgery for patients with head and neck cancer?

Are there any ongoing trials that you’re particularly excited to see the results of?

Additionally, there has been surgical advances in terms of different ways to provide minimally invasive surgery for patients. Currently, people are unsure what the best treatments are. There are clinical trials underway and, hopefully, in a few years we will begin to know more about what the best treatment is based on evidence—but we are not there yet.In my opinion, the impact of minimally invasive surgery is based on whether you can use it judiciously and balance it with the other treatments that are available. For patients with whom the prognosis is already excellent, we are trying to minimize the treatment and the treatment side effects. If we could incorporate surgery, either endoscopic laser surgery or transoral robotic surgery, in order to minimize or reduce the treatments that might have side effects, that is going to be beneficial. One really needs to be thoughtful about if surgery is going to fit in with the other treatments that are needed.In terms of minimally invasive surgery in head and neck tumors there are 2 areas where there is going to be changes in the years ahead. One change is involving technologically. There are new developments coming down the pipeline that will affect what we can do with surgery and how it’s done. In my opinion, what is more important is starting to get back data from trials that will allow us to make evidence-based decisions and recommendations about how to use this tool.ECOG-3311 is an open trial that we’re hopefully getting close to seeing data. In that trial patients with HPV-positive disease are going to receive minimally invasive surgery and, if their pathology report is low risk, they go into the observation arm. If the report is high-risk they get the standard treatment, which is chemotherapy and radiation. If they demonstrate an intermediate-risk stage, the patients will be randomized to either standard radiation or lower-dose radiation.

Why do you think surgical based trials have not been as prevalent in this field?

In all of the arms, there are multiple quality-of-life functional outcome measures, which is a great advancement to have. Surgery is frequently used in the treatment of head and neck cancer, it’s important and unique to have a trial like this that involves surgery because there have not been many surgery-based trials in the past.One of the rationales behind ECOG-3311 was that patients with HPV-positive disease have a much better prognosis. The trial in many ways is aimed to determine if we could give a less intensive treatment to minimize the side effects while maintaining the same cure rate.

We found that HPV-negative cancers, meaning the critical smoking- and drinking-related cancers, have a much worse prognosis than previously thought. The response rates are quite low. At the same time of the ECOG-3311 trial, there was another ECOG Group trial that was aimed at the HPV-negative cancers.

In that trial, the design was for patients to be randomized to either transoral minimally invasive surgery or chemoradiation therapy. We opened that trial at Yale Cancer Center and I tried to enroll patients, but no one would do it. Patients don’t want to be randomized to surgery versus a non-surgery arm. They have biases as to what they think is the best treatment and they don’t want to give up making that decision.

What advice can you give to doctors who are looking to enroll patients in their clinical trials?

That does point to difficulty with surgical-based trials. Patients tend not to want to get randomized or give up that decision about whether to have surgery or not.It’s important to have the trials open and it sounds simple; however, it takes a lot of work to get a trial to the point of accrual. Being at a center where you have multiple people who are opening trials is helpful.

Is there anything else you would like to add?

It is important to develop collaboration amongst the team. If you have a patient who you think is a great candidate for a trial run by a member of your team, you can recommend that patient to that trial. Likewise, if they have a patient who they think will fit well with that trial, they will do the same.In many ways, having multidisciplinary aspects of care for head and neck cancer is critical. It helps determines what the best treatment is for an individual. By presenting a patient to a multidisciplinary team and hearing the perspective from the medical oncologists and the radiation oncologists, it improves our patients care. Particularly, if you have a complicated patient with head and neck cancer, they will see the benefits of having the feedback of a multidisciplinary team.