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Case history

image An 82-year-old man presented with a 2 month history of sore throat and a neck lump. He was a heavy smoker with a 60 pack-year history. His past medical history included emphysema, hypertension, hypothyroidism and alcohol misuse. His repeat prescription list detailed inhalers, furosemide, losartan, amlodipine, levothyroxine, thiamine and vitamin B complex. He admitted not taking his medications regularly.

At a slow pace, he could walk about 150 m on the flat before stopping and had been hospitalized once in the last year with pneumonia. He lived alone in a two-storey maisonette without carers, but his nephew visited him weekly.

Examination revealed a man wearing trousers two sizes too large with a BMI of 18 kg/m2. His chest was barrel-shaped and peripheral oedema was evident. Blood tests revealed macrocytic anaemia, low creatinine, and albumin 27 g/l. The right-sided cervical lymph nodes were palpable. Imaging of his head and neck demonstrated a right tonsillar tumour with ipsilateral level II pathological lymph nodes. Ultrasound-guided fine needle aspiration from the node confirmed p16-negative moderately differentiated squamous cell carcinoma. Following MRI and PET/CT, he was staged as T2N2bM0 and referred on to the local preoperative assessment clinic for further evaluation of his cardiorespiratory and nutritional status.

A detailed assessment at the clinic identified:

  • Multifactorial malnutrition (dysphagia, poor dentition, alcoholism, financial hardship and difficulties shopping).

  • Stage III airflow obstruction (FEV1 45%) with grade 3 dyspnoea (MRC scale) and poor inhaler technique.

  • An unwillingness to alter his smoking habit.

  • Functional decline, with difficulty getting to shops and bank.

At the subsequent joint head and neck clinic, the risks and benefits of surgical and radiotherapy interventions as well as palliative options were discussed in detail alongside exploration of the patient's personal goals for treatment. A decision was made to proceed with radical radiotherapy after a short period of medical and nutritional optimization.

What is the evidence base for his treatment options?

What treatment factors influenced decision making in this case?

What patient factors influenced decision making in this case?

Why is the finding of malnutrition so important?

How can this patient's comorbidities be optimized prior to treatment?

What is the evidence base for his treatment options?

This patient had locally advanced head and neck cancer, for which the primary treatment modalities are surgery and external beam radiotherapy. Aggressive surgical management in the older population has been shown to be effective but poses a higher risk of systemic complications.1 On the other hand, radical radiotherapy offers the benefit of functional organ preservation. There are no large randomized controlled trials comparing chemoradiation versus a surgical approach in patients with locally advanced oropharyngeal cancer. Nevertheless, excellent overall survival (OS) and swallowing results have been reported with chemoradiation approaches for advanced oropharyngeal cancer,2 which increasingly have become the preferred treatment modality.

Concomitant platinum-based chemotherapy with radiotherapy improves 5 year OS by 6.5%, but subgroup analyses demonstrated harm ...

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