Here is the question and answer session that followed the excellent presentation by Dr. Alex Lin offering some general history, basic concepts, and specifics about radiation in the setting of head/neck cancer.  We cover management of radiation-associated side effects, some emerging techniques, and how radiation oncologists make decisions about what treatment to recommend for a particular patient.

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The origin of head and neck cancer (HNC) has been linked to smoking and alcohol consumption, and more recently to infection by human papillomavirus family viruses (HPV). But an area that was obscure and where recent research is being unveiled is the actual cell of origin of HNC.

Ask any cancer survivor what his or her greatest fear is, and chances are he or she’ll reply: “The cancer coming back.” Recurrence rates from different cancers can vary widely, from 5 to 95 percent depending on how far the original tumor had spread, its particular molecular characteristics and other clinical factors. But what makes cancer come back?

A possible answer may get to the root of the cancer problem: cancer stem cells (CSCs).

CSCs can be thought of as generals in a war. There aren’t very many of them, they are located at the rear, and organize the battles and send in the troops to invade. They build the armies. Many scientists believe that CSCs originate and keep tumors growing, invading and spreading into new places. They also may make up less than 0.1 percent, or one in 1,000 cells, of a solid tumor’s bulk. They are not related to embryonic stem cells, other than their name who indicates that they are at the root of an event; in the case of embryonic stem cells it means that they give rise to an embryo, in the case of CSC it implies that they give rise to cancer.

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Most of the abstracts are now available online at http://abstract.asco.org/abst_files/HeadNeck_5500-5601.pdf for those with interest.  Below, you will find a summary of the three clinical science symposium abstracts and the poster discussion abstracts.  There’s a lot to cover…

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The incidence of head and neck cancer (HNC) has been gradually increasing over the last 3 decades. Although certain subsets of HNC (such as larynx cancer) have decreased in incidence in parallel with the reduction in smoking, rates of oral cavity tumors (including tongue and tonsil) have risen among young (<45 years old) men and women.  In addition to the classic risk factors of tobacco and alcohol use (that used to be responsible for the majority of HNC) recent data have linked infection with a virus to cases of HNC especially from the oral cavity and related sites. The virus strains responsible belong to the human papillomavirus family (HPV). HPV is the main cause for cervix cancers in women, and the HPV subtypes associated with HNC are rather similar with those causing cervical cancer.  Subtype HPV16 accounts for the majority of HPV-positive cases (> 65% of oral tumors, >80% of oropharynx cancers, and 70% of laryngeal cases), with HPV18 having a far second place (around 5-8% of HPV-positive cases).  Epidemiological data seem to suggest that sexual transmission is important but other transmission routes are under investigation.

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Is this patient really incurable?

The first question to ask when addressing incurable SCCHN is to be sure that the cancer really is incurable.  When SCCHN recurs, it often recurs locally, at or near the site of the original cancer.  For this reason, local salvage therapies such as surgery, radiation, chemoradiation or even repeat chemoradiation can sometimes elicit a cure for the patient with a local or local-regional recurrence.  These topics are important and will likely be the subject of future posts on GRACE. The rest of this post will assume that the patient truly is incurable, either because local maneuvers are no longer possible, the cancer has spread to distant sites, or the patient has made a choice to not receive further surgeries or radiation.

Why Chemotherapy for Incurable Disease?

Every cancer therapy has two purposes: to improve duration of life, and to improve quality of life.  Every other measure of chemotherapy success, such as response rate or progression-free-survival, is a surrogate to these two true goals.

For the patient with metastatic disease, chemotherapy is the most important treatment for achieving these two goals.  “Incurable” is not the same as “untreatable.”  Cure means eliminating every last cancer cell.  Treatment means providing real benefit, in the form of achieving these two goals.

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What is cancer?

One of my patients once told me that a cancer cell is akin to a misbehaving child, which is an appropriate analogy. When a baby is born, it begins as a sperm fertilizing an egg, which combines to create a single cell. That cell is pluripotent, meaning that it is capable of eventually forming all of the different kinds of cells that will ultimately be needed to create the human body.  That fertilized egg once implanted into the uterus, will divide billions of times and begin to differentiate into different types of cells which will eventually form the various tissues of the human body.  By the time the child is born after 9 months of increasingly complex cellular division and differentiation, the baby has many different kinds of cells, each with very specialized functions, most of which have lost the ability to further divide or spread to other parts of the body.  They are programmed to die in response to signals from other cells.

Each of these cells is akin to a little factory, performing specified functions.  The tools that the cell uses to carry out these functions are called proteins.  In order to make a protein, the cell starts with the DNA blueprint that is housed in a structure called the nucleus.  The nucleus can be thought of as a little fortress-enclosed island containing stacks of blueprints instructing the cell how to replicate itself.  The DNA is transcribed (copied) into a similar structure called RNA, which travels out of the nucleus into the cytoplasm (which could be thought of like the water in the lake).  In the lake, the RNA attaches to a structure called the ribosome (think of it as a small, floating protein factory) where it is translated into a protein.  These proteins are the worker bees of the human bodies and carry out nearly every important function required for life.

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