Oct. 13, 2022
The head and neck cancer team at Mayo Clinic Comprehensive Cancer Center aims to create de-intensified treatment options for select patients with HPV-associated head and neck cancer. Streamlined methods of treating patients and following their care plans after treatment have allowed the team to focus on long-term quality of life and functional outcomes.
"Ultimately our goal truly is patient-centered care," says Katharine A. Price, M.D., an oncologist for the Cancer Center in Rochester, Minnesota. "The most stressful point of a patient's care journey is the time from diagnosis until they know their treatment plan. We aim to efficiently and effectively walk them through that time."
A multidisciplinary approach with the oropharynx cancer clinic
New cases of HPV oropharynx cancer have been rising for decades and represent the most common type of head and neck cancer diagnosed in the U.S. Most patients require complex multimodality decision-making and treatment. For that reason, the head and neck cancer team at Mayo Clinic implemented a multidisciplinary oropharynx cancer clinic — the first in the U.S.
"We see mainly newly diagnosed patients because that is the point in their care journey where they need the most multidisciplinary support," says Dr. Price. The clinic also sees postoperative patients to discuss the need for radiotherapy and chemotherapy after surgery, and to tailor the treatment regimen to the specific features of the patient's cancer.
Experts on the oropharynx cancer clinic team include head and neck surgeons, radiation and medical oncologists, dental specialists, and speech and swallow therapists. Patient coordination is done through a dedicated head and neck cancer nurse navigator. Most often the team evaluates patients together, providing a powerful visual experience of being treated by an integrated team.
Dr. Price says the benefit of working collaboratively in this way extends beyond the patient experience. Members of the care team find the interactions invaluable in furthering head and neck cancer treatment, education and research.
Advancing HPV-associated cancer care through treatment de-escalation
The collaborative nature of the oropharynx cancer clinic has facilitated advancements in head and neck cancer care and improved clinical trial accrual. One of those advancements is de-escalated adjuvant radiation therapy, also known as DART, for patients with HPV oropharynx cancer. Experts at Mayo Clinic have studied the therapy in a phase 2 and phase 3 trial, with the results indicating that in select patients the DART regimen is non-inferior to standard of care adjuvant therapy.
Standard treatment for HPV-associated oropharynx cancer has been either seven weeks of radiation therapy of 70 Gy combined with cisplatin or surgery, followed by six weeks of adjuvant radiation therapy of 60 to 66 Gy with or without cisplatin. The DART regimen treats select patients after surgery to 30 or 36 Gy over two weeks with two radiosensitizing doses of the chemotherapy docetaxel. Results of the initial clinical trial evaluating DART were published in the August 2019 issue of the Journal of Clinical Oncology, and reported a 98.7% overall survival rate at two years.
"Radiation drives most of the long-term side effects," said Dr. Price. "Many of our HPV-positive patients were young and otherwise healthy. We wanted to strike a balance between cancer outcomes and quality of life."
Preliminary results of the phase 3 trial comparing DART to the standard six-week adjuvant therapy were published in the December 2021 issue of the International Journal of Radiation Oncology - Biology - Physics. The results reported excellent local-regional control, progression-free survival, and overall survival, particularly for patients without extranodal extension. Patients who received DART had less toxicities and improved swallowing function and quality of life when compared with the standard of care.
Health equity and financial impact of DART
Dr. Price and her colleagues, as well as leadership within the Cancer Center, recognize the importance of committing to health equity in cancer care. In its initial phase 2 trial, DART was associated with a 33% reduction in cost for radiation therapy as well as a 21% reduction in overall treatment cost for patients with oropharynx cancer. The benefit to patients of a two-week course of treatment instead of a six-week course of treatment is tremendous, especially for patients with limited social and financial resources.
"To be able to have a treatment that returns people to their lives faster is huge," says Dr. Price. "With DART, patients can spend less time in treatment, recover more quickly, and get back to their lives faster and with fewer side effects."
Experts in the Head and Neck Cancer Center plan to continue work in this space with upcoming clinical trials and work within the community to improve access to HPV vaccination.
For more information
Ma DJ, et al. Phase II evaluation of aggressive dose de-escalation for adjuvant chemoradiotherapy in human papillomavirus-associated oropharynx squamous cell carcinoma. Journal of Clinical Oncology. 2019;37:1909.
Ma DJ, et al. MC1675, a phase III evaluation of de-escalation adjuvant radiation therapy (DART) vs. standard adjuvant treatment for human papillomavirus-associated oropharyngeal squamous cell carcinoma. International Journal of Radiation Oncology*Biology*Physics. 2021;111:1324.
Price K, et al. Long-term toxic effects, swallow function, and quality of life on MC1273: A phase 2 study of dose de-escalation for adjuvant chemoradiation in human papillomavirus-positive oropharyngeal cancer. International Journal of Radiation Oncology*Biology*Physics. 2022;114:256.
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