Multidisciplinary Approach to Head and Neck Cancers May Improve Outcomes

A multidisciplinary approach, whereby clinicians from different specialties collaborate and interact as a team, has become increasingly important in the treatment of head and neck cancer (HNC) in order to provide effective, timely, and evidence-based management of these complex and heterogeneous tumors.^1,2

Members of the multidisciplinary team may vary per institution, depending on available resources and clinicians, but a team typically includes head and neck surgeons, radiation and medical oncologists, specialists in medical imaging, nurses, and social workers.¹One of the benefits of a multidisciplinary approach to HNC is that allows for patients to be offered an increasing array of treatment options from a team of specialists who keep abreast of the latest developments within their respective fields.¹

“I consider [the multidisciplinary team] an absolute necessity to manage patients with head and neck cancer. These tumors affect vital areas of anatomy. Speech, swallowing, communication—all of those are affected,” said Everett E. Vokes, MD, Giant of Cancer Care for Head and Neck Cancer, John E. Ultmann Professor, chair, department of medicine, and physician-in-chief at the University of Chicago. “The fact is that these days, we can treat many patients with voice-preserving approaches that were pioneered many years ago, and are [now] standard of care at our institution for virtually all anatomic sites.”

Vokes added that such approaches “should always be considered for patients with oropharyngeal disease, larynx cancer, and certainly nasopharynx cancer.” His HNC multidisciplinary team consists of surgeons, radiation oncologists, medical oncologists, pathologists (particularly for some of the rarer histologies and human papilloma virus [HPV]-related disease), a dental/oral surgeon team, radiologists, and nurses.

“The surgeon is frequently first,” Vokes said, “to stage the patient, to carefully evaluate the location, and sometimes to do some treatment. Similarly, for patients who have early-stage disease, there has to be a discussion about…surgery [versus] radiation.” He noted that, for advanced-stage disease, chemoradiation (chemotherapy in combination with radiotherapy), possibly with surgical salvage, or sometimes surgery first followed by chemo radiotherapy, are options that can be considered. Given the range of possible interventions, he stressed that consultation with the multidisciplinary team is especially important. “There’s no way to do this without sitting down, looking at the scans together, and talking about what everybody thinks is going on with the patient.”

Surgery is one of the most critical components of HNC treatment, and advances in surgical techniques now allow for a greater number of treatment options.¹Radiation oncologists and medical oncologists on the team also collaborate to provide the latest nonsurgical treatment modalities for HNC, including image-guided and intensity-modulated radiotherapies and chemoradiation.

In the context of multidisciplinary team care, use of these therapies can be optimized to allow for more conservative surgeries and improved survival, with better preservation of functional status by sparing damage to normal tissues and other critical structures.^1,3While surgery remains the mainstay of treatment for many patients, those with poor performance status, advanced age, or comorbidities may be treated with radiation therapy or chemoradiation.^3,4

Reconstructive surgery specialists are also important members of the team, to provide the latest options for restoring form and function to patients and to introduce the team to other cutting-edge technologies, such as tissue engineering, that may be used to generate replacements for mucosal tissue.¹

Because patients with HNC will frequently present with advanced-stage tumors (stage 3 and 4), initial staging is an integral part of treatment planning, and effective follow-up for recurrence and metastasis is also important for these patients.^1,5Advanced techniques, such as combined positron emission tomography/computed tomography (PET/CT), have become widely used for initial staging and screening for metastatic disease, and experienced radiologists who are familiar with the latest techniques in imaging are an essential part of the HNC multidisciplinary team.^3,5

Molecular diagnostics is a burgeoning area of interest in the management of HNC. In the near future, the pathology team and/or specialists in molecular biology will likely be consulted to assess and report to the team the presence or absence of key mutations and/or gene rearrangements that have recently been identified through large-scale initiatives, such as The Cancer Genome Atlas (TCGA). Whole genome sequencing of >300 squamous cell carcinoma specimens in TCGA has recently identified mutations in genes involved in squamous epithelial differentiation, as well as established oncogenes and tumor suppressor genes, as potentially important drivers of oncogenesis in HNC.⁶These will add to previously identified molecular targets in HNC, including the epidermal growth factor receptor (EGFR) and HPV-driven pathways.³Molecular information will also become increasingly important to the team as targeted therapies aimed at a specific mutations or genetic alterations become available and are shown to confer survival benefit for specific types of HNCs.

Although limited data are available, some evidence suggests that multidisciplinary care can improve outcomes in HNC. Friedland and colleagues compared outcomes and survival between HNC patients managed with or without a multidisciplinary team (MDT) in a retrospective 12-year analysis.²The investigators found that, when analyzed individually, there was no difference in survival between the MDT (n = 395) and non-MDT (n=331) groups for patients with stage 1, 2, or 3 disease; however, a significant benefit in 5-year survival was noted for patients with stage 4 disease who were managed by the MDT (hazard ratio [HR] = 0.69;P= .004).

Clinical Pearls

• Evidence suggests that multidisciplinary care can improve outcomes in HNC.
• Surgery is one of the most critical components of HNC treatment, and advances in surgical techniques allow for a greater number of treatment options.¹Radiation and medical oncologists also collaborate to provide nonsurgical treatment modalities for HNC.
• In the near future, the pathology team and/or specialists in molecular biology may be consulted to assess and report the presence or absence of key mutations and/or gene rearrangements that have recently been identified.
• With advances in technology, smaller community hospitals and areas with limited medical resources to create telemedicine multidisciplinary teams.

There were also some notable differences in treatment modalities, with MDT patients having a greater use of synchronous chemotherapy (P<.001) and non-MDT patients having a greater use of radiotherapy only (P<.001).²Important sources of bias in the study were that MDT patients were younger (&asymp;2 yrs) and were more likely to have advanced disease, which could have impacted the findings.

A multidisciplinary approach has been found to be important when using chemoradiation for patients with advanced-stage HNCs. In a retrospective, single-center study of patients with squamous cell carcinoma and stage 3 or 4 disease (N = 17), female gender, single marital status, and stage 4 disease were found to be predictors for increased use of adjunctive nursing and social services, whereas distance from the center, as expected, was a negative predictor for use of these services.⁷Recognizing these treatment utilization patterns is an important step to guide resource allocation for the team and to help better assess the needs of HNC patients.⁷

Lastly, whereas large hospitals and established cancer centers clearly have the most available resources to generate multidisciplinary teams for HNC and other cancers, with advances in technology, there may also be options for smaller community hospitals and areas with limited medical resources to create telemedicine multidisciplinary teams.¹Using video conferencing approaches, all relevant information pertaining to a case can be presented; one study found that among 80 HNC patients who could be evaluated using both teleoncology and in-person approaches, 91% had the same TNM classification and treatment plan, suggesting that telemedicine can safely be used to manage HNC patients.⁸The availability of such approaches and the increasing use and appreciation of MDTs in general will continue to improve care and quality of life for patients with HNC.

References

1. Varkey P, Liu YT, Tan NC. Multidisciplinary treatment of head and neck cancer.Semin Plast Surg. 2010;24(3):331-334.
2. Friedland PL, Bozic B, Dewar J, Kuan R, Meyer C, Phillips M. Impact of multidisciplinary team management in head and neck cancer patients.Br J Cancer. 2011;104(8):1246-1248.
3. Machiels JP, Lambrecht M, Hanin FX, et al. Advances in the management of squamous cell carcinoma of the head and neck.F1000Prime Rep. 2014;6:44.
4. Perri F, Muto P, Aversa C, et al. Integrated therapeutic approaches in head and neck cancer: the importance of multidisciplinary team management.Anticancer Agents Med Chem. 2013;13(6):834-843.
5. Tantiwongkosi B, Yu F, Kanard A, Miller FR. Role of (18)F-FDG PET/CT in pre and post treatment evaluation in head and neck carcinoma.World J Radiol. 2014;6(5):177-191.
6. Mountzios G, Rampias T, Psyrri A. The mutational spectrum of squamous-cell carcinoma of the head and neck: targetable genetic events and clinical impact [published online ahead of print 2014 April 8].Ann Oncol. pii:mdu143.
7. Junn JC, Kim IA, Zahurak ML, et al. Multidisciplinary service utilization pattern by advanced head and neck cancer patients: a single institution study.Int J Otolaryngol. 2012;2012:628578.
8. Stalfors J, Edstr&ouml;m S, Bj&ouml;rk-Eriksson T, Mercke C, Nyman J, Westin T. Accuracy of tele-oncology compared with face-to-face consultation in head and neck cancer case conferences.J Telemed Telecare. 2001;7(6):338-343.