6.9.15: 15. Treatment Modifications in Poorly Resourced Settings

Inability to stage cancers due to unavailability P16 testing: “Is AJCC/UICC Staging Still Appropriate for Head and Neck Cancers in Developing Countries?”

Postoperative radiotherapy (PORT): when weighing up need with marginal indications, consider:

• Expense
• Morbidity e.g. 25% risk of hypothyroidism from radiating central neck
• Social support and likelihood of completing treatment
• Competing institutional needs for radiation therapy or for operating time

Platinum-based adjuvant chemotherapy: when weighing up need with marginal indications, consider:

• Patient’s fitness
• Morbidity and mortality related to treatment
• Social support and likelihood of completing treatment
• Only 4% lifetime survival advantage with addition of chemotherapy to radiation therapy in an adjuvant setting

Unavailability of postoperative radiation therapy (PORT)

• Most patients with T3/T4 malignancies normally receive PORT (Indications for PORT)
• Consider who not to offer surgery for advanced tumors when outcomes without PORT will be poor
• Not having PORT to treat residual microscopic cancer or nodal metastases has the following surgical implications:
• Wider than usual tumour resection margins
• Low threshold to convert a selective neck dissection to modified neck dissection

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