- The human papilloma virus has been identified as the etiologic agent in the majority of patients with squamous cell carcinoma of the oropharynx (tonsil and base of tongue) in North America and northern Europe.
- Unlike tobacco-induced squamous cell cancer, which represents most cases of disease at other head and neck subsites, HPV-mediated OPC is increasing in frequency.
- These cancers tend to occur in a younger, healthier population with less tobacco exposure.
- Furthermore, the prognosis of HPV-mediated cancer is significantly better than that of the tobacco induced malignancies.
- Historically, single modality surgery or radiation have been appropriate and highly effective treatment options for patients with stage I-II head and neck cancer.
- Transoral surgical approaches and intensity modulated radiation have been rapidly incorporated into treatment standards and have proven very successful in limiting morbidity.
- For more advanced disease, recent multimodality treatment standards used for oropharynx squamous cell cancer have generally employed concurrent cisplatin-based chemoradiotherapy, administered either definitely, or as a post-operative adjuvant. These treatments are rigorous and produce considerable acute and late toxicity.
- In 2008 the National Cancer Institute concluded that “treatment de-intensification” was a reasonable investigational strategy to pursue in the HPV-mediated cancers with the best prognosis, with the goal of reducing short and long-term toxicity without compromising outcomes.
- De-escalation of treatment intensity for p16+ OPC patients can reduce long-term toxicity without compromising survival is a hypothesis that requires appropriate testing.
- Despite the identification of good-prognosis patient subsets, the promising early results of treatment de-intensified regimens, and the fact that many formerly advanced stage p16+ cancers are now considered to have early stage disease, current treatment recommendations have not changed.
- The standard of care for the definitive non-operative management of cisplatin-eligible patients with advanced disease is concurrent chemoradiation with high-dose cisplatin given every three weeks. For patients undergoing initial surgical resection, adjuvant chemoradiation with concurrent high-dose cisplatin given every three weeks is recommended for those patients with positive margins and/or extranodal tumor extension.
- De-intensification of treatment for patients with p16+ oropharynx cancer should only be undertaken in a clinical trial.