- decodeMR Team
HNSCC - One of the consequences of smoking - Q&A session with an Expert.
(Focus - Australia)
The high prevalence of HNSCC (Head and neck squamous cell carcinoma) in Southeast Asia and Australia is associated with the consumption of specific carcinogen-containing products (areca nut, betel leaf, tobacco, etc.) in contrast to the high rates of HPV infection being the contributor in the West. In this head and neck cancer awareness month, we bring you our discussion with Dr. Divyanshu Dua, a renowned medical oncologist from Australia, who shared his thoughts on the role of neoadjuvant immunotherapy and other emerging trends related to Head and Neck cancer.
Dr. Divyanshu Dua is currently serving as a Consultant at Canberra Hospital, Australia.
For head and neck cancer, neoadjuvant immunotherapy helps with the complete pathological response rates, making a big difference for cancer patients.
How has the emergence of immune-checkpoint inhibitors impacted the treatment landscape of recurrent and metastatic (R/M) head and neck squamous cell carcinoma?
Dr. Divyanshu: It has made a big difference. Initially, we didn't have more options; in the last 20 years, we only had chemotherapy, cetuximab, and the EGFR monoclonal antibodies. Apart from these two drugs, we never had anything else, so we used chemotherapy with a very low response rate. To have something less toxic and which gives better results is quite important. Head and neck cancer patients who have had surgeries and radiotherapy previously know that they have many comorbidities. So, something that will be less painful does make a big difference for them.
A recently published review article states that "we are observing a paradigm shift from induction chemotherapy to neoadjuvant immunotherapy for head and neck cancer."  Could you please elaborate more on this?
Dr. Divyanshu: This is not just for head and neck cancer but for all types of cancer. Anything that can shrink the cancer cells smaller or makes us give less amount of radiotherapy or less amount of treatment with better cure rates is always good. Similarly, for head and neck cancer, neoadjuvant immunotherapy helps with the complete pathological response rates, making a big difference for cancer patients.
As you have mentioned, neoadjuvant immunotherapy plays a significant role in improving response rates in head and neck cancer and other cancers. Do you think this strategy translates to any overall survival benefits?
Dr. Divyanshu: Yes, but neoadjuvant takes a long time. I think in the next few years, we might get this data. But yes, it will definitely make a difference in the overall survival benefit. Currently, the data is not yet out.
We understand that there is an increasing trend of HPV-positive oropharyngeal cancer.  According to you, what can be done for the early detection of these cases?
Dr. Divyanshu: We need to be aware of cancer; GPs should be more familiar to find out about head and neck cancer. More focus should be on education, trying to target those people who are at high risk, like smokers. These are the people that we need to target for early identification.
Who is at a high risk of developing head and neck cancer?
Dr. Divyanshu: Long-term smokers and somebody who's got pre-malignant changes are always at a higher risk of developing cancer.
HPV Vaccination will target only the HPV-associated head and neck cancer, and it will not target the whole head and neck cancer population. We can estimate that the severity of head and neck cancer will be less in a specific subset of people where HPV infection is less. So, once the HPV infection rate goes down, the incidence of HPV-associated head and neck cancer will eventually be less. Yes, in the long term, it will make a difference.
Is there an active HPV vaccination program in Australia?
Dr. Divyanshu: Yes, but that is for the school-going people, for someone who is at a high risk of developing genital cancer. This might make a big difference in the next five to ten years. At this point, this takes a long time to make a difference in the overall survival.
Can you let me know which group of people HPV vaccination is currently available?
Dr. Divyanshu: Currently, no data says it is targeting head and neck cancer. But HPV vaccination is available for girls at high risk of developing cervical cancer.
How do you think HPV vaccination will be effective in preventing the HNSCC?
Dr. Divyanshu: It will target only the HPV-associated head and neck cancer, and it will not target the whole head and neck cancer population. We can estimate that the severity of head and neck cancer will be less in a specific subset of people where HPV infection is less. So, once the HPV infection rate goes down, the incidence of HPV-associated head and neck cancer will eventually be less. Yes, in the long term, it will make a difference.
Are there any specific unmet needs with the treatment and management pathway of HNSCC in Australia?
Dr. Divyanshu: The survival of these people is still low. Hence, a lot of work has to be done on metastatic recurrent head and neck cancer.
There is an evolving understanding that lower respiratory tract infections increase the mortality rate in HNSCC patients. How do you think the COVID-19 pandemic has impacted the treatment and management of head and neck cancer in Australia?
Dr. Divyanshu: These people are already at a high risk of aspiration, and their swallowing is not the best. Also, they are at high risk of developing a chest infection and lung infection. Additionally, if these patients get COVID, then their mortality rate increases. The scenario during the pandemic was not easy. People faced lots of interruptions and challenges in accessing the services. Also, the intubation was challenging because of the risk of ventilators, and hence they had poor treatment outcomes when they got cold along with their cancer.
What measures did your institute/hospital take to overcome challenges due to the COVID pandemic?
Dr. Divyanshu: We continued seeing the patients and doing our best via telehealth or any other way. We tried to do our best during the pandemic, but we have our limitations. We've tried to continue the service, and treatment, including radiotherapy, chemotherapy, and immunotherapy. So, we made sure to have a minimum interruption in accessing the treatment.
Before we conclude, what is your takeaway message for HNSCC patients and caregivers?
Dr. Divyanshu: We are on the right path, but there's a lot more work to be done in head and neck cancers. We are not there yet.
Thank you very much for your insights.