Do patients with head and neck human papillomavirus-related carcinoma need a different treatment approach?

Abstract

We congratulate Mizumachi and colleagues [1] on their assessment of ‘‘Improved survival of Japanese patients with human papillomavirus-positive oropharyngeal squamous cell carcinoma’’. However, we would like to raise several points regarding the necessity of less intensive therapy for patients with human papillomavirus (HPV)associated carcinoma. Numerous case series have established that HPV-positive oropharyngeal cancers have unique demographic and clinical characteristics [2, 3]. The prevalence of HPVrelated oropharyngeal carcinoma is rising in Western Europe and the USA. However, this correlation (as Mizumachi et al. have shown) has not been fully evaluated in Japan [1]. Indeed, HPV-positive tumor status is an important prognostic factor associated with a favorable outcome. However, the optimal treatment for HPV-positive head and neck squamous cell carcinoma is not yet defined. Moreover, quality of life (QoL) is receiving increasing attention as a criterion for the assessment of different treatment modalities [4]. Broglie et al. recently reported that patients treated by either surgery alone or surgery with adjuvant radiotherapy complained significantly less about troubles with dry mouth, teeth and senses compared to the non-surgically treated group. Moreover, HPV-positive patients appeared to have a better QoL independent of treatment strategy. Therefore, the authors consider that these patients could tolerate more intensive treatment without impairment of QoL [4]. Nevertheless, Lassen et al. [5] have recently reported that long-term morbidity was influenced neither by fractionation schedule nor by tumor HPV/p16 status in patients undergoing accelerated fractionated radiotherapy. In our opinion, although HPV-positive patients may have a better treatment tolerance, ‘‘less-intensive treatment’’ should be administered based on an understanding of the treatmentrelated risk factors that are independently associated with late swallowing complications (such as the volume of pharynx irradiated and radiation dose) [6, 7]. For example, patients with low volume stage III–IV disease (T1–2 and N1–2a/b) could be spared from aggressive multimodal treatment. It would therefore be interesting to corroborate these results in Japan too. Mizumachi et al. [1] have interestingly shown that patients in Japan with HPV-positive oropharyngeal cancers have a better prognosis than those with HPV-negative carcinomas. These results are consistent with those obtained in Europe and North America. However, to date there is insufficient data to justify a change in the treatment strategies for HPV-positive oropharyngeal cancer outside of clinical trials. From this point of view, these authors mention that HPV status should at least be included as a stratification factor into future randomized controlled trials to optimize the treatment of patients with this type of cancer in Japan [1]. J. Cacicedo Fernandez de Bobadilla (&) P. Bilbao Radiation Oncology Department, Cruces University Hospital, c/Plaza de Cruces s/n, 48903 Barakaldo, Vizcaya (Basque Country), Spain e-mail: jon.cacicedofernandezbobadilla@osakidetza.net