Elsevier

The Surgeon

Volume 14, Issue 4, August 2016, Pages 180-183
The Surgeon

Matter for Debate
Is treatment de-escalation a reality in HPV related oropharyngeal cancer?

https://doi.org/10.1016/j.surge.2016.04.002Get rights and content

Abstract

The incidence of HPV related oropharyngeal squamous cell carcinoma (OPSCC) is rapidly increasing. It is now well recognised as a distinct clinical and biologic entity, compared to traditional OPSCC. The majority of these patients have an excellent prognosis due to the chemo-radiosensitive nature of these tumours. The de-escalation of current treatment regimens have therefore been proposed in an attempt to reduce the long term treatment related morbidity of this much younger patient cohort. Several of the more pertinent points regarding safe de-escalation strategies are considered within this manuscript.

Introduction

HPV related oropharyngeal squamous cell carcinoma (OPSCC) has demonstrated a rapid increase in incidence over the past decade, leading some to describe this as an epidemic.1, 2 A recent systematic review clearly demonstrated that prior to 2000 the incidence of HPV related OPSCC was in the region of 40.5% and has escalated to 72.2% after 2005, with rates as high as 93% described in some series.3, 4 Furthermore it has become evident that HPV related OPSCC is a distinct clinical and molecular entity compared to traditional OPSCC.5 This is reflected by the superior treatment response, prognosis and survival rates observed in virally induced OPSCC, with HPV status now considered the strongest prognostic factor in Head and Neck oncology.6, 7, 8 It can therefore be presumed that HPV related OPSCC is chemo-radiosensitive, which has sparked the debate regarding de-escalation of treatment for patients with confirmed HPV related OPSCC.5 This is primarily due to the morbidity and toxicity associated with current chemo-radiotherapy treatment regimens which include carotid stenosis, gastric tube dependence, osteoradionecrosis and xerostomia to name but a few.7 There are however a multitude of factors that need to be considered prior to the implementation of de-escalation in general practice. Some of the more pertinent points will be discussed in this manuscript.

Section snippets

Methods and materials

In order to identify current literature relating to the discussion topic a focussed Pubmed literature search was performed. The following keywords were utilised: HPV, treatment, Oropharyngeal SCC, de-escalation and de-intensification. The “view similar” feature was also utilised to broaden the literature search and to identify all relevant manuscripts. The identified manuscripts were used to discuss issues surrounding patient selection for de-escalation trials, current de-escalation strategies

What represents true HPV related disease?

At present treatment de-escalation is only considered within the confines of clinical trials, of which there are several underway. Patient selection criteria for these trials are a key consideration to ensure that the potential positive outcomes of these patients aren't compromised. Initial independent studies and subsequent meta-analyses have clearly demonstrated that virally induced OPSCC have far superior 5 year survival rates (75–80% vs. 45–50%) and a significantly improved response to

Conclusion

Treatment de-escalation should not be considered for any HPV related OPSCC patients at present, however it is certainly a reality in the very near future. The accurate identification of HPV related disease along with risk stratification based on not only smoking history but other prognosticators will become the foundation of future trials and ultimately de-escalation regimens in general practice. The results of several phase 3 trials are eagerly awaited and the initial data of ECOG 1308 is very

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