Oropharyngeal cancer: the role of chemotherapy

Successful management of squamous cell cancer of the oropharynx must address two, sometimes conflicting, treatment goals. The first goal is disease eradication, and the second is preservation of oropharyngeal function. For early cancers, definitive surgical excision often represents the most effective and least morbid approach. When surgery is likely to result in functional deficits of speech or swallowing, definitive radiation therapy can also be used successfully. Often the choice of treatment modality is based on institutional expertise and bias. However, for the more frequent patients with advanced disease, treatment choices become more complex. Historically, surgery and radiation therapy have been used together, often with suboptimal control of locoregional disease and significant long-term functional deficits, reflecting surgical excision, radiation-induced long-term toxicities, and any initial functional impairment resulting from the tumor. The addition of systemic chemotherapy to definitive radiation has now been demonstrated to produce a significant survival benefit for patients with advanced squamous cell head and neck cancer originating in the oropharynx and elsewhere. Although there are still specific indications for primary surgical resection, the use of chemotherapy and radiation has become a standard of care for the management of patients with this disease, with surgery often reserved for salvage of those who fail definitive nonoperative treatment. Debate continues as to the best tolerated and most successful combination of chemotherapy drugs, radiation fractionation schema, and coordination of treatment modalities; however, a reproducible survival benefit has been demonstrated only for the concomitant, platinum-based treatment schedules. The focus of future investigation must be on optimizing these multimodality approaches, minimizing toxicities and functional deficits while maximizing treatment success. It is hoped that the addition of the newer therapeutic approaches, including epidermal growth factor receptor inhibition and gene therapy, may further improve the results of more traditional treatment combinations. Continued enrollment of patients in well-designed and conducted clinical trials is of paramount importance.