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Challenging the odds
Caught early, head and neck cancers can often be cured with surgery and radiation. The relatively small number that metastasize are difficult to cure. A large intermediate group of cancers are known as "locally advanced"—they have spread beyond the original site to lymph nodes or other tissues, but not spread elsewhere in the body.
Left to right: Robert Haddad, MD, Rosemary Costello, RN, BSN, and Marshall Posner, MD, of the Head and Neck Oncology Program confer about a film showing a large tumor.
For locally advanced cancers Stage III cancers, three-year survival has been about 50—75 percent in most centers, while those with Stage IV disease have less than 50 percent odds. Posner, Haddad, Tishler, Charles Norris, MD, (surgical director of the head and neck program) and other DFCI colleagues are pushing the envelope for still better results.
Their best shot currently is a four-month regimen termed "sequential therapy." Initially, patients receive "induction chemotherapy" with potent medications given by infusion daily (except for weekends) over nine weeks. Often this therapy alone shrinks the tumor, with subsequent treatment aimed at destroying remaining cancer cells that could cause a recurrence.
The next phase, "chemoradiotherapy," is the most punishing for the patient, but the most crucial for long-term survival. Tishler oversees radiation treatment with DFCI's new Linear Accelerator, which can deliver Intensity Modulated Radiotherapy (IMRT), aiming thousands of powerful, narrow beams on the tumor while sparing nearby normal tissues. Patients receive daily radiation for four weeks, then twice-daily doses to finish out the fifth and sixth weeks. Concurrently, chemotherapy is administered once a week for the first four weeks. Following the four-month regimen, some patients undergo limited surgery to remove hundreds of neck lymph nodes and prevent recurrences from migrating tumor cells.
The head and neck cancer researchers are running several clinical trials to test cutting-edge treatment. This past September, Posner and his colleagues received $2.5 million from Aventis, the company that makes the drug Taxotere, to fund a trial whose results could change the standard way that head and neck cancers are treated. Posner, Haddad, and Tishler plan to enroll 75 patients at Dana-Farber (330 patients will take part nationally) to compare sequential therapy with a standard, aggressive chemoradiotherapy regimen. In the sequential therapy arm, patients will receive an initial dose of chemotherapy, followed by chemo-radiotherapy; the other patients will get chemoradiotherapy alone. In another trial, some patients will take a drug called amifostine that may reduce the severity of radiation side effects.
Even with today's targeted radiation beams, injury to normal tissues is unavoidable. In addition to fatigue, patients may face blistered skin on their necks, pain and swelling of the throat that interferes with swallowing, and persistent dry mouth and throat due to radiation damage to the salivary glands. Because their throats are so swollen, patients usually have a feeding tube placed in their stomach to combat the weight loss that is common. They also require physical therapy to retrain their muscles to swallow after the tube is removed.
- Next: Getting through it
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