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New Guidelines for Head & Neck Cancer Reirradiation

Recurrent and second primary head-and-neck squamous cell carcinomas (HNSCC) arising within or close to previously irradiated areas are a significant clinical challenge. Salvage surgical resection is the standard of care, but reirradiation is the only potentially curative treatment when surgery is not an option. Reirradiation is more challenging than initial treatment because of the side effects of prior therapy and concerns about the risks of high cumulative radiation doses to normal structures. Multi-institutional trials and large single institutional experiences have demonstrated that aggressive reirradiation, most often with chemotherapy, is feasible and provides durable locoregional control in some patients. An Expert Consensus on Reirradiation In the August 1, 2011 International Journal of Radiation Oncology * Biology * Physics, the American College of Radiology (ACR) published appropriateness criteria for recurrent head and neck cancer after prior definitive radiation. The ACR expert panel recommended that patient evaluation and reirradiation for HNSCC be performed at a tertiary care center with a head and neck oncology team that is equipped with the resources and experience to manage the complexities and toxicities of retreatment. Evaluation of Patients with Head & Neck Cancer Patient evaluation is important in assuring only appropriate patients are offered reirradiation. Evaluation should include careful restaging imaging, a detailed history and assessment of life expectancy, access to the prior radiotherapy details, and evaluation of: Comorbidities. Performance status. Speech and swallowing function. Sequelae of previous treatment (eg, fibrosis, carotid stenosis, osteoradionecrosis, or other severe toxicity). The ACR recommends that patients with a reasonable performance status who do not have severe soft tissue or bone toxicities from prior therapy and do not have distant...

Treatment Trends in Laryngeal Cancer

Of the 13,000 Americans diagnosed with laryngeal cancer in 2010, 3,660 were projected to die from the disease. Traditionally, early-stage disease has been treated using radiation therapy (RT) or surgical resection with comparably successful outcomes. While total laryngectomy was the treatment of choice for advanced disease prior to 1991, publication of the VA Laryngeal Cancer Study that year displayed the usefulness of chemoradiation as a treatment option. Chemoradiation allowed 62% of patients to preserve their larynx with no significant differences from surgery in overall survival. In a 2003 comparison of RT alone, chemotherapy followed by RT, and concurrent chemoradiation for advanced laryngeal cancer, the validity of chemoradiation as a treatment option for these patients was solidified. Reevaluating Laryngeal Cancer Treatments In a study published in the October 2011 Archives of Otolaryngology- Head & Neck Surgery, my colleagues and I sought to compare 4-year survival trends of surgical and nonsurgical treatment for patients with laryngeal cancer. Using the National Cancer Database we analyzed, more than 131,000 patients who were diagnosed from 1985 to 2007. For those with early-stage cancer, 4-year survival rates were 79% for surgery and 71% for RT. In patients with advanced disease, survival rates were 51% for total laryngectomy, 48% for chemoradiation, and 38% for RT. These findings contrast those of clinical trials from the late 1990s, which demonstrated equivalent survival rates for the aforementioned treatment options. These survival differences are likely explained by the use of “real world” data, in which patient inclusion criteria aren’t nearly as strict. In addition, completion of therapy regimens is not observed. Factors Influencing Treatment Choice For early-stage laryngeal cancer in...
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