Cancer Today • Spring 2016

Expertise Essential for Cancers of the Head and Neck Region
Multidisciplinary Approach for Oropharynx Cancer

Over the past couple of decades, while the incidence of most head and neck cancers has been falling, oropharynx cancer in the U.S. has reached epidemic rates, with a 225 percent increase between 1988 and 2004 and continued increases to date. But the oropharynx cancer that’s so widespread today is different from the classic oropharynx malignancy seen in people who smoked or drank heavily. Now the most prevalent form — currently three out of four cases — is human papillomavirus-positive (HPV+) oropharynx squamous cell carcinoma (OPSCC).  

Both men and women can get HPV-positive oropharynx cancers, though more males in their 50s, 60s or 70s are seen. Most do not have a history of smoking or alcohol abuse, and there is sometimes an association with having had multiple sexual partners. Patients were likely infected many years ago with HPV through sexual activity. The virus can remain latent for decades and then, for some people, eventually lead to HPV+ cancer of the oropharynx, which includes the tonsils and base of the tongue.

“Unfortunately there’s no screening test like the pap smear for HPV-positive oropharynx cancer,” explained Lukasz Czerwonka, MD, head and neck cancer surgeon. “With HPVinfection of the oropharynx, the initial tumor is often too tiny to see, so the cancer isn’t caught until it’s metastasized.”

Here are some facts about this disease:
• HPV-positive oropharynx cancer is so widespread that it is predicted to outnumber cervical cancer from HPV by the year 2020.
• Patients with HPV-positive OPSCC — even those who present with more advanced disease — experience significantly better outcomes than patients with HPV-negative OPSCC.
• The cure rate for HPV-related oral cancer is close to 90 percent.
• Once diagnosed, optimal results are obtained through multidisciplinary care by evaluating and combining surgery, radiation and chemotherapy, which are tailored to the tumor stage and the patient’s functional status.

A thriving robotic program
Surgery is often the first line of treatment for oropharynx disease, and at Stony Brook, 90 percent or more of HPV+ OPSCC surgeries are trans-oral robotic-assisted procedures. These can allow complete and more precise removal of tumors with fewer side effects, possibly fewer or no adjuvant therapies, and shorter or no hospital stays. If the tumor is too large to be resected completely with robotic-assisted surgery, sometimes a minimally invasive technique that combines robotic-assisted and conventional surgery may be used.

Robotic-assisted procedures give the surgeons access to areas they normally can’t reach without major trauma. For example, to visualize the base of the tongue and resect a tumor, a surgeon using a conventional open technique has to split the lip and mandible, which then need to be repaired with major surgery. Using a robotic-assisted approach, the surgeon can reach the tumor, visualize it under very high magnification and resect it with very close margins. 

For patients whose cancers are not resectable by robotic-assisted surgery, conventional open surgeries with free-flap reconstructions are used.

“Robotic-assisted surgery has really revolutionized the treatment of oropharynx carcinoma. Tumors that used to be very debilitating to remove can now be resected almost entirely between the teeth, often with no external incisions and less trauma to other structures.”
– Ghassan Samara, MD

Team Leader, Head and Neck, and Thyroid Oncology Management Team

State-of-the-art diagnostics
Most patients present at an advanced stage, when lymph node metastasis are visible. To help identify the site of the primary disease, PET/CT is used, often followed by a separate MRI to provide guidance for surgery. Endoscopies are also employed to locate the primary tumor, and ultrasound studies can locate cancer in the lymph nodes.

Technologically advanced treatment modalities
Because HPV-positive oropharynx disease responds so well to treatment, patients are offered many viable treatment options instead of or in addition to surgery.  

Radiation. Radiotherapy is geared to cure early-stage oropharyngeal cancers, and it is most effective when the tumor burden is smaller. Advanced technology is used to customize the treatment based on the patient’s functional status and general condition, as well as HPV or other tumor parameters. Radiation is delivered with curative intent, either alone or with chemotherapy, before surgery to shrink tumors or after surgery to kill any remaining cancer cells. The types of radiation used most often for oropharynx malignancy include external-beam radiation therapy, 3D conformal radiation therapy, intensity modulated radiation therapy and stereotactic radiosurgery.
Chemotherapy. Chemotherapy is also used for early oropharynx disease and can be used as an alternative to surgery, usually with radiotherapy as well, or as adjuvant therapy along with radiation. Neoadjuvant chemotherapy, sometimes with radiation, can be used to help shrink larger tumors or unresectable tumors. Frequently employed chemotherapy drugs include cisplatin, carboplatin, 5-fl uorouracil, paclitaxel and docetaxel. In addition, newer targeting agents such as cetuximab and others are also used.  
Combined modality treatment. Stony Brook’s team determines the most suitable treatment based on a patient’s need and in most cases highly recommends combined modality treatment to ensure the best functional outcome and cancer cure. In many oropharyngeal cancers, chemoradiation is administered concomitantly. This approach is also applicable for those who are not surgical candidates or whose tumors are large.

On the frontline for early detection
Primary care physicians — and dentists — are well positioned to spot early signs of oropharynx malignancy, which often manifests as a unilateral neck mass, and refer patients for evaluation and treatment. Practitioners are also encouraged to recommend that all girls and boys ages 11 and up start the HPV vaccination series to help prevent HPV-caused cancers in the future.

For the full issue: Cancer Today • Spring 2016