New Approaches to Postoperative Radiotherapy for Cancer of the Head and Neck

Historically, patients with resectable stage III and IV tumors were treated with combined surgery and radiation. Early attempts at improving results by incorporating chemotherapy in the postoperative setting have been largely unsuccessful or inconsistent. However, longer follow-up of recent landmark trials exploring concurrent chemotherapy and radiotherapy have clarified the issue, supporting concurrent cisplatin based chemotherapy for high risk patients. The survival benefit seen in the concurrent chemoradiotherapy trials appears to stem from improved locoregional control, as no reduction in systemic failure has been observed. Another evolving approach to post-operative head and neck radiotherapy is the use of altered fractionation schedules. There are several recent studies exploring either hyperfractionated or accelerated radiotherapy, as a response to the issue of accelerated tumor repopulation, providing evidence that such treatment is beneficial in selected patients. There are several questions worthy of further clinical research, and these will likely continue to follow the lead of nonsurgically managed head and neck cancer. Preliminary data suggests that IMRT can be tailored to postoperative patients, and target volumes defined such that morbidity can be minimized without jeopardizing tumor control. Biological modifiers of radiotherapy may allow selective radiosensitization without the morbidity of concurrent chemotherapy.