Head and Neck Cancer in Elderly Patients: What to Do When Data Are Limited?

Head and neck cancers encompass a heterogenous group of malignancies that arise from the paranasal sinuses, nasal cavity, oral cavity, pharynx, and larynx. The majority are of a squamous cell histology and present typically without evidence of distant disease, which allows the possibility of curative treatment. The main risk factors for squamous cell cancer of the head and neck are tobacco abuse and a prior local infection with human papillomavirus (HPV). Tobacco-related head and neck squamous cell cancer is widely accepted as a disease that disproportionally affects elderly individuals. In contrast, HPV-related disease is thought to occur predominately in middle-aged individuals. New evidence, however, suggests the increased incidence of oral squamous cell cancer among elderly patients is a direct consequence of increased rates of oral HPV infections and consequent HPV-driven cancers.1 Similar to other malignancies, there is a paucity of data on how to treat elderly patients with head and neck squamous cell cancer. Treatment paradigms in this patient population are frequently derived from subgroup analysis, retrospective data, or by extrapolating and adapting treatment designed for a younger and fitter population.2 This practice carries the risk of administering therapy that leads to unacceptable adverse events or, on the other end of the spectrum, undertreating patients, which jeopardizes their chance of cure and long-term survival. In this issue of Journal of Oncology Practice, Jelinek et al3 review the management of early head and neck cancer in elderly patients. Early-stage head and neck squamous cell cancer is typically treated with surgery or radiotherapy alone. Recent novel therapies in these fields, such as transoral robotic surgery or intensity modulated radiotherapy, allow better tumor control with less incidence of long-term adverse effects, providing a safer alternative for elderly patients. The authors discuss the treatment selection based on anatomic sites and adapt their recommendation to a geriatric population. One of their main conclusions is that the majority of treatment strategies have not been rigorously studied in this patient population and randomized controlled trials in elderly patients are desperately needed. This is the unfortunate truth not only in this setting but also in other areas of oncology. For the treating oncologist, it is very important to note that chronologic age alone is not a predictor of treatment-related toxicity. Geriatric patients are an extremely heterogenous group; therefore, it is imperative that we