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Responding to the changing clinical landscape of head and neck (H&N) cancer, the American Society for Radiation Oncology (ASTRO) has developed recommendations specific to HPV-positive oropharyngeal cancer.

The incidence of H&N cancer associated with alcohol and smoking has declined in recent years, and HPV-positive disease now accounts for approximately 70% of new cases, particularly oropharyngeal squamous cell cancer (OPSCC). With curative-intent radiation therapy for OPSCC, ASTRO recommends systemic therapy (preferably containing cisplatin), in addition, for patients with high-risk features, such as large tumors or involvement of multiple lymph nodes. Patients who are not candidates for cisplatin may receive cetuximab (Erbitux) or carboplatin/5-fluorouracil.

"This is restricted to HPV-associated oropharyngeal cancer, whereas the previous [2017] guideline applied to both HPV-negative and HPV-positive oropharyngeal cancer," said guideline co-chair David Sher, MD, of the UT Southwestern Medical Center in Dallas. "Several new prospective trials have since been published that were incorporated into this guideline (such as the randomized trials of cetuximab)."

"This guideline provided additional recommendations on treatment volumes, treatment technique, normal tissue considerations, as well as initial patient reassessment following primary treatment," he added.

Uniquely, the guideline has specific radiation doses for normal tissues in patients who receive radiation therapy to just one side of the neck, added co-chair Danielle N. Margalit, MD, of Dana-Farber Cancer Institute in Boston.

"This helps to encourage radiation oncologists to get to the minimal dose possible to patient normal tissues," she told 番茄社区app via email. "I am not aware of any other guideline that provides dose limits for unilateral treatment."

Other noteworthy aspects of the guideline include:

• Following curative-intent surgery, postoperative radiation or chemoradiotherapy is recommended for specific pathologic findings, such as positive surgical margins or high-risk tumor characteristics
• Optimal dosing and fractionation regimens for radiation and chemoradiation therapy in the definitive and postoperative settings
• Recommendations for post-treatment assessment, specifically guidance for the patient's initial restaging and ongoing surveillance using advanced imaging or other methods

Throughout the guideline, recommendations emphasize shared decision-making with patients. The guideline is publicly available in the current issue of Practical Radiation Oncology.

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