National Comprehensive Cancer Network

NCCN Guidelines^® & Clinical Resources

JNCCN – The Journal of the National Comprehensive Cancer Network

Table of Contents—Volume 6, Number 7: August 2008

• NCCN Clinical Practice Guidelines in Oncology™
• Head and Neck Cancers
• Special Feature
• Low Molecular Weight Heparins as Extended Prophylaxis Against Recurrent Thrombosis in Cancer Patients
• Featured Articles
• The Role of Inhibitors of the Epidermal Growth Factor in Management of Head and Neck Cancer
• Controversies in the Management of Oropharynx Cancer

NCCN Clinical Practice Guidelines in Oncology™

Head and Neck Cancers

Oral cavity, pharyngeal, and laryngeal cancers account for about 3% of new cancer cases in the United States, and approximately 47,560 new cases of are estimated to occur in 2008. Alcohol and tobacco abuse are common etiologic factors in some of these cancers. Moreover, because the entire aerodigestive tract epithelium may be exposed to these carcinogens, patients with head and neck cancer are at risk for developing second primary neoplasms of the head and neck, lung, and esophagus. Human papilloma virus infection appears to be a risk factor for some squamous cancers of the oropharynx (predominately cancers of the lingual and palatine tonsils). Stage at diagnosis is the most predictive factor of survival. This version of the guidelines is limited to tumors arising in the oral cavity, oropharynx, hypopharynx, nasopharynx, and glottic and supraglottic larynx. The complete version can be found on the NCCN Web site at NCCN.org.

Special Feature

Low Molecular Weight Heparins as Extended Prophylaxis Against Recurrent Thrombosis in Cancer Patients
Cocav A Engman, MD, and Leo R Zacharski, MD

Cancer has been shown to be an independent risk factor for the development of venous thromboembolism (VTE). Moreover, active cancer places patients at high risk of recurrent VTE, necessitating extended prophylactic regimens. However, extended prophylaxis in patients with cancer can be problematic because of an increased bleeding risk. Oral anticoagulants have been the standard of care for extended prophylaxis, but maintaining a clinically effective level of anticoagulation is difficult because of a wide range of drug interactions, narrow therapeutic window, and increased risk of bleeding complications. Recent evidence indicates that long-term prophylaxis with low-molecular-weight heparins (LMWHs) is an effective and safe alternative to oral anticoagulation, reducing the risk of recurrent VTE by up to 52%. Some studies have suggested that LMWHs may also have direct antitumor effects, most notably in patients with non-metastatic disease. Further clinical research is needed to evaluate the potential survival benefits of LMWH therapy in patients with cancer.

Featured Articles

The Role of Inhibitors of the Epidermal Growth Factor in Management of Head and Neck Cancer
Bruce Brockstein, MD; Mario Lacouture, MD; and Mark Agulnik, MD

Epidermal growth factor receptor (EGFR) is overexpressed in most head and neck cancers and correlates with poor prognosis. In the past few years, numerous clinical trials for head and neck cancer have tested monoclonal antibodies against EGFRs and small molecule inhibitors of EGFR tyrosine kinase. Results led the FDA to approve cetuximab with concomitant radiotherapy for treating locally or regionally advanced squamous cell carcinoma of the head and neck (SCCHN) or as a single agent in patients with recurrent or metastatic SCCHN for whom prior platinum-based therapy failed. This article reviews the biology of EGFR as it pertains to head and neck cancer, including the important clinical trials of EGFR monoclonal antibodies and tyrosine kinase inhibitors in SCCHN, alone and with concomitant radiotherapy. It also discusses molecular and clinical markers of response and outcome.

Controversies in the Management of Oropharynx Cancer
Francis P. Worden, MD, and Huan Ha, MD

Squamous cell carcinomas of the oropharynx account for approximately 25% of all head and neck squamous cell malignancies. Most patients present with locally advanced tumors and need multimodality treatment, with input from qualified surgeons, radiation oncologists, and medical oncologists, but management of some locally advanced oropharyngeal tumors remains controversial. Another controversial topic is the management of human papilloma virus (HPV)–related head and neck cancers, most of which involve the oropharynx. Because prognosis seems to be much better than for patients with non–HPV- and tobacco-related tumors, some experts are concerned that HPV-related malignancies may be overtreated. Unfortunately, these and other questions about the management of locally advanced oropharyngeal cancers, discussed in this article, are outstanding. Hence, it is critical that eligible patients are screened for and encouraged to participate in clinical trials.