Head and neck cancer treatment in India comes of age: Experts

October 8, 2019 0 By FM

The treatment practices in head and neck cancer in India are coming of age, observed leading experts from across the country gathered at Bengaluru for the Cancon 2019 held on July 27-28.

Oncologists from India are making an impact in managing the carcinomas affecting the head and neck.

“Head and neck cancer is treated more successfully today,” noted Dr Ashok Shenoy, Consultant Head & Neck Surgeon, Apollo Hospitals, Bengaluru.

The 2-day event witnessed intense deliberations on the ongoing treatment practices and advances in the field of head and neck oncology with active participation from surgeons, radiotherapists, palliative care specialists, otolaryngologists and residents.

“This is the third consecutive year the Cancon event is being organised. The number of participants is going up every year, demonstrating the increasing acceptance of the meet among the head and neck cancer fraternity,” said Suresh Ramu, CEO, Cytecare Cancer Hospitals, Bengaluru, the organisers of the conference.

Cancon2019 was centered around the theme — ‘Consensus Guidelines
for Management of Oral Cancer – Resection, Reconstruction, Rehabilitation and Research’

The burden of oral cancer is quite high in India. The disease is, largely, pertinent to the Indian population. Though many guidance documents are available for head and neck oncology abroad, it is imperative to bring consensus guidelines on the management and care of the diseases specific to the Indian patient population.

“There is an unmet need to develop consensus guidelines to balance oncological outcomes and functional rehabilitation,” said Dr Vikram Kekatpure, Chairman of the Organising Committee and Senior Consultant, Head & Neck Surgical Oncology, Cytecare.

Advances in radiation techniques, targeted therapy, molecular markers etc are being incorporated into the practice with the intention of improving functional outcome in patients undergoing treatment and rehabilitation. The idea is to formulate a uniform standard treatment approach.

Cancer management guidelines have to be adapted to local needs to take into account local financial, infrastructural and human resources. Advanced stages of cancer need a multidisciplinary approach. 

“MCI approved M Ch on head and neck oncology in 2012. But today after more than six years, there are only 9 M Ch seats available for head and neck super-specialty in India. 4 new seats are announced, recently, for AIIMS, Rishikesh. This underscores the fact that there is a huge gap in trained manpower in head and oncology in India”, Dr Kaustubh Patel, Director, HCG Cancer Centre, Ahmedabad.

Elective neck dissection improves survival

Experts shared their experience in resection techniques, advances in reconstruction, rehabilitation and research in various sessions. 

Elective neck dissection resulted in higher rates of overall and disease-free survival in head and neck cancer patients than therapeutic neck dissection, noted Dr Krishnakumar Thankappan, Professor, Head & Neck Surgery and Oncology, AIMS, Kochi, while delivering a keynote address on the topic “Contribution from India to Oral Cancer Literature and Influence on Driving Management Guidelines”. India comes 4th and is among the most productive in oral cancer research, he pointed out.

“There is 23.6% disease-free survival if you treat neck electively,” said Dr Anil D’Cruz, Director, Tata Memorial Hospital, Mumbai and President, Union of International Cancer Control (UICC), Geneva, while talking on Evolution of Management of Neck for Oral Cancer: Lessons Learnt and Future Directions”

In therapeutic neck dissection, one in every eight patients dies and one-fourth of them see cancer recurrence.

Integrating palliative care into oncology

Commenting on the integration of palliative care in oncology, experts said there is ample evidence that early palliative care can improve the quality of care and median survival rates in certain cancers.

Despite receiving less aggressive end-of-life care, metastatic NSCLC patients in palliative care showed significantly longer survival than standard care group, said Dr BK Mohanti, Radiation Oncologist, Manipal Hospitals, Delhi, citing the findings from a single institution trial conducted at Massachusetts General Hospital, Boston.

While presenting a paper on ‘Newer Perspectives to Address Symptom Burden and Palliative Care in Oral Cancer’, Dr Mohanti said full integration of oncology and palliative care relies on specific knowledge and skills of two modes of care: the tumour directed approach and the host directed approach. While the former mainly focuses on treating the disease, the latter addresses the patients and the disease. It depends upon the practitioner how he combines these two paradigms to achieve the best outcome in patient care. 

Salvage surgery option

Functional and quality of life issues of the patients need to be considered before deciding on salvage surgery options, commented Vikram Kekatpure deliberating on the topic: Deciding Appropriate Salvage Treatment (Evaluation, Surgery, Adjuvant, Outcomes). While surgery remains the main option, re-radiation needs to be considered whenever possible.

However, there are issues like lack of definition of surgical anatomy, poor vascularity and wound healing, fibrosis and scarring etc associated with salvage surgery.

Salvage surgery is also feasible for stage IV disease in view of India’s large burden of head and cancer and stage IV recurrence, he noted.

The conference discussed the latest developments in head and neck oncology through five key sessions: Early Oral Cavity Cancer; Research and Advances; Advanced Oral Cavity Cancer; Oral cavity Reconstruction and Improving Outcomes and Rehabilitation.

Panel discussions were held on various topics including advanced oral cavity cancer, oral cavity reconstruction, preventing morbidity and improving outcomes in oral cancer. A poster presentation was also organised alongside the event. 

Has translational research failed to deliver?

Cancon 2019 was witness to a discussion on “Translational Research Failed to Improve Outcomes in Oral Cancer”.

Presenting the topic, Dr Prasad Nagarajan, Senior Consultant, Medical Oncology, Cytecare, said an increased focus on DNA/RNA, inadequacy of planned research and lack of tangible results that can be put into action are some key reasons for the failure.

Serendipitous science has the glamour and immense news value. But planned research is fraught with setbacks.  

The proposition of translational research is also not practical for low-income settings owing to the huge expenses and the expanded timelines it involves, he argued.

Lack of willing participants, the regulatory burden, fragmented infrastructure, incompatible databases, the paucity of qualified investigators, career disincentives, practice limitations, high research costs and improper funding are among the impediments.

Talking about the emerging drugs for head and neck cancer, he said many drug targets are standing in the queue for methodical evaluation. At least 12 agents for inhibition of the EGFR pathway alone are awaiting development. Drugs exist for targeting VEGFR, c-MET and IGF-1R, P13K/Akt/mTOR, STAT and ras/Raf/MEK/MAPK.

Gene therapy using Adp53/CRAdp53-based treatments (Gendicine, H-101, SCH-58500, ONYX-015) and EGFR antisense DNA are also being explored.

Translational research has given a new direction to the evolution of cancer care in head and neck and other sites. Improvements in outcomes have given a fillip, not only to translational science, but also to basic clinical research as well, irrespective of one’s economic status. 

Dr Nagarajan observed that factors other than science, such as laws and regulations, sensitization to a trial culture, opportunity for training, public funding would increasingly determine outcomes in the years to come.

Countering the view, Dr P Arun, Head & Neck Surgeon, Tata Medical Centre Cancer Hospital, Kolkata, said: Even though it remains a fact that translational research requires a lot of time and effort to make it work, it has certainly not failed. It is simply taking the course of investigation.

Experts in the audience too did not agree with the view that translational research has not improved survival. Translational research has made significant contributions in the field of head and oncology. “I don’t think it is fair to say translational research has failed. In fact, we are all passive recipients of the fruits of others’ research,” quipped Dr Moni Abraham Kuriakose, Cochin Cancer Research Centre, Kochi.   

Adjuvant RT for residual disease

In another debate, Dr BK Mohanti, Radiation Oncologist, Manipal Hospitals, Delhi and Dr Rajiv Sharan, Head & Neck Surgeon at Tata Medical Centre, Kolkata argued the topic: “Residual Microscopic Disease Can Be Salvaged by Adjuvant Chemoradiation”

Strongly favouring adjuvant radiotherapy, Dr Mohanti argued that radiation can irradiate the microscopic disease that surgery cannot remove.

Rebutting it, Dr Sharan said that there is currently no level 1 evidence to substantiate the claim even though chemo plus radiation is the standard practice for margin positive head and neck cancer.

“Chemoprevention is a Failed Strategy for Oral Cancer” and “Free Flap are Only Options Following Salvage Surgery for Recurrent Oral Cancer” were other topics of debate in the two-day event.