1. General principles for treatment selection Jeffrey Myers MD PhD

2. General principles for treatment selection Site/subsite Stage Histology Biomarkers

3. Site

4. Tonsil Base of tongue Pharyngeal wall Soft palate Subsites

5. Histology –Grade Differentiation Status Ploidy –Other Findings Perineural Invasion Extracapsular spread Margin

6. Biomarkers HPV p16 EGFR Genomic/Proteomic Profiles

7. Molecular Classification Identifies a Subset of Human Papillomavirus– Associated Oropharyngeal Cancers With Favorable Prognosis Journal of Clinical Oncology, Vol 24, No 5 (February 10), 2006: pp. 736-747

8. EGFR and SCCHN Treatment Outcomes L Milas & KK Ang J Clin Oncol. 2007 AK El-Naggar, JJ Lee, L Mao J Clin Oncol. 2007 KK Ang & L Milas Cancer Res. 2002

10. Stage T- Stage –Tx –Tis –T 1-2 –T 3-4 N-Stage –N0 –N1 –>N1 –ECS Overall Stage Other Considerations –Depth of Invasion –Growth Pattern

11. Myers,. Cancer 2002; 92(12):3030

12. Greenberg. Cancer 2003;97:1464.

13. Overall Stage and Treatment Selection: Cisplatin and Fluorouracil Alone or with Docetaxel in Head and Neck Cancer N Engl J Med. 2007 Oct 25;357(17):1705-15

14. Treatment Options Surgery Radiation Therapy Systemic Therapy Chemoradiotherapy –Induction –Concurrent –Induction followed by Concurrent –Adjuvant Targeted Molecular Therapy + Radiotherapy

15. Surgery-Primary/Neck Staging Surgery Debulking Surgery Definitive Surgery Open Surgery –Transoral Microsurgery –Robotic surgery Planned Surgery after non-surgical Therapy Salvage Surgery

16. Radiation Therapy –Particles Electrons Neutrons Protons –Fields -Parallel Opposing -IMRT -Stereotactic Radiosurgery –Fractionation Conventional Hyperfractionation Concomitant Boost Hypofractionation

17. Systemic Therapy: Chemotherapy/Biologic Therapy Chemoprevention Induction Concomitant Adjuvant

18. Summary Site, Stage, and Histology are our main guides for selecting therapy More Level I evidence is needed to guide the use of biomarkers in impacting treatment choices The menu of treatment options is large and individualized treatment decisions should be made by experienced multi-disciplinary teams keeping oncologic and quality of life issues in mind Where possible it is best to use the fewest modalities needed to effect a cure