Changing the Surgical Treatment Paradigm in Recurrent Head and Neck Cancer

Though advances in radiation technology are helping improve outcomes in primary and, more recently, in recurrent head and neck cancer (HNC), surgery still proves necessary in most cases.

“For patients with recurrent head and neck cancer who’ve had prior radiation, the only curative treatment that we know is surgery,” says Brian Burkey, MD, Head of the Section of Head and Neck Surgery and Oncology at Cleveland Clinic’s Head and Neck Institute.

Dr. Burkey says the surgical team works closely with other disciplines to coordinate patient care. He sees this commitment to a multidisciplinary team approach in treating HNC as one of the strengths of Cleveland Clinic’s program. Once surgery is completed, he has confidence in the next steps in the process.

For example, dental reconstruction is done in-house. “So I don’t have to send somebody three towns away or three states away to get a good consult. I can send them three doors away,” he says.

Factors that influence recurrence in HNC

A major focus for the team is identifying cancers as early as possible and helping patients quit smoking, because those are two key factors in HNC recurrence.

• Tumor size — “The recurrence rate may be as low as 2 or 3 percent in cases of small, early-stage tumors, particularly in HPV-associated disease, and above 50 percent in large, late-stage tumors in heavy smokers,” says Dr. Burkey. “We’re involved in an annual head and neck screening program that’s part of an international initiative to try to pick up new cancers early.”

• Discontinuation of smoking — Patients who continue to smoke double the chances that their cancer will come back. “Getting people to quit smoking is a major part of reducing recurrences. A smoking cessation program is part of our standard protocol in initial cancer therapy for these patients,” he says.

Challenges in the treatment of recurrent disease

Surgery to treat recurrent HNC is more challenging because tissue in the area has been affected by previous treatment.

“It is much more difficult to operate after prior radiation therapy because the tissues are scarred and tissue planes are distorted,” says Dr. Burkey. “The second thing is that those tissues don’t heal well, because the microvasculature is injured, decreasing the blood flow to radiated areas.”

Surgical treatment almost doubles the chance of eliminating recurrent cancer after radiation therapy, compared with second treatment using radiation alone. So surgeons have developed techniques to introduce healthy tissues from other parts of the body to reconstruct the operated area and aid healing.

“We bring in tissue that’s not been previously irradiated,” Dr. Burkey says. “We do this in a variety of ways — sometimes we use regional flaps by bringing pectoralis muscle and skin up to the neck. Or we use a microvascular free tissue transfer, in which tissue comes from a distant part of the body, such as the lower leg.

“This is not a new treatment. We’ve been training people how to do it for the last 25-30 years, and we are very good at it — our success rates are 98 percent,” he says. “But people outside of an academic medical center really are not doing that kind of work, so where a patient goes for treatment really matters.”

Minimizing long-term impact of treatment

“From a surgical perspective, the use of robots and lasers trans-orally for advanced HNC in recent years further improves the functional outcomes of our patients and we’re getting better at it,” says Dr. Burkey.

The team at the Head and Neck Institute is also focused on how to minimize treatment for those head and neck cancers with high cure rates, such as HPV-positive HNC, which tends to occur in younger, healthier patients.

Several clinical trials under the leadership of Cleveland Clinic medical oncologist David Adelstein, MD, Co-Chairman of the National Cancer Institute Head and Neck Cancer Steering Committee, aim to address this challenge. “The goal is to use less toxic medication, do less invasive surgery, and reduce the amount of radiation to improve the quality of life,” says Dr. Adelstein.

For other patients, however, aggressive treatment is critical from the start, so screening is a key factor in determining treatment.

“We’re trying to figure out how to predict which patients aren’t going to do as well and try to intensify their treatment up front,” says Cleveland Clinic radiation oncologist Shlomo Koyfman, MD.

Teamwork among disciplines and continued education

The multidisciplinary approach is crucial to developing the right treatment plans for patients and then assessing those treatments and their outcomes to better guide future decisions.

“In a weekly tumor board, we review nearly all of our cases, with medical oncology, surgery, radiation oncology, and pathology at every meeting. You need all of that input to properly manage this complicated disease,” says Dr. Koyfman.

“Head and neck cancer is, to me, a prototype of a disease that requires multidisciplinary care,” says Dr. Burkey. “You can’t do it by yourself. Within our own group, we have a speech therapist who helps with speech and voice training and a dental team so that our dental consults and reconstructions are all done in-house.

“We also conduct several continuing medical education events every year,” he says. “We have an educational course annually that focuses on a particular site in HNC, and we have the whole team together — pathology, dentistry, nursing, social work, medical oncologists, radiation oncologists and surgeons — they all take part in it.”.