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April is Head and Neck Cancer Awareness Month. The National Cancer Institute estimates that head and neck cancers comprise 4% of cancers diagnosed each year. In 2021, more than 65,000 people were impacted by newly diagnosed head and neck cancers. These cancers are diagnosed more often in women and also more often among people over age 50.
CAP Cancer Protocols play an important role in disease management, ensuring that all pathology reports contain necessary data elements to improve patient care. The CAP has nine protocols for head and neck-related cancers, as Raja Seethala, MD, FCAP, explains in this CAPcast episode. Dr. Seethala is the Director of the Head and Neck/Endocrine Pathology Center of Excellence at the University of Pittsburgh Medical Center. Dr. Seethala is also a member of the CAP Cancer Committee and Biomarker Committee serving as a subject matter expert on cancers of the head and neck.
Details
Julie McDowell:
April is Head and Neck Cancer Awareness Month. The National Cancer Institute estimates that head and neck cancers comprise 4% of cancers diagnosed each year. In 2021, more than 65,000 people were impacted by newly diagnosed head and neck cancers. These cancers are diagnosed more often in women and also more often among people over 50.
CAP Cancer Protocols play an important role in disease management, ensuring that all pathology reports contain necessary data elements to improve patient care. The CAP has nine protocols for head and neck related cancers, as Dr. Raja Seethala explains in this CAPcasts episode. Dr. Seethala is director of the Head and Neck Endocrine Pathology Center of Excellence at the University of Pittsburgh Medical Center. Dr. Seethala is also a member of the CAP Cancer Committee and Biomarker Committee, serving as a subject matter expert on cancers of the head and neck.
Dr. Seethala, thank you for discussing this topic today. As mentioned in the introduction, the CAP has nine protocols for head and neck-related cancers. What should a pathologist or trainee keep in mind when selecting and using the protocols for cancer reporting?
Dr. Raja Seethala:
That's a very good question. The CAP Protocols importantly, arguably, represent the best effort at synthesizing and harmonizing guidelines and concepts from a variety of sources and disciplines to ensure that our reporting provides optimal and consistent care. Any disagreements and controversy surrounding certain parameters in the instance of oral cavity, margins, depth of invasion, worst pattern infiltration, these issues may be unavoidable. However, the goal of the protocol is to address these in a rational, practical, evidence-based manner.
With that said, the Protocols are continuously evolving and take into account user input to remove outdated or erroneous information. For trainees, the CAP Protocols are perhaps the best teaching tool for the practical signout of head and neck cancers, and the explanatory notes provide more functional knowledge than most textbooks or review articles.
Julie McDowell:
Now, have there been any significant recent updates to the protocols that users should be aware of when using these Protocols?
Dr. Raja Seethala:
Well, perhaps not too new, but still very critical. The AJCC Oral Cancer TNM categorization has undergone several revisions with Errata, some of which did not make it into print. I would like to emphasize that CAP protocol actually contains the most up-to-date version, thus the 'correct' version.
Additionally, across the board, the head and neck protocols have reduced redundancy, as well as provided options for more granularity in terms of reporting of distances, measurements, and enumeration of items such as lymph nodes.
Finally, the head and neck biomarker protocol is now electronic and incorporates some of the latest advances in terms of salivary and sionasal molecular classifiers, putting more of a theranostic emphasis when relevant. For instance, NTRK fusions, which are targeted by TRK inhibitors, can be documented in dedicated fields rather than as in [inaudible]. This may be important for some salivary gland cancers, typically secretory carcinoma.
Julie McDowell:
And what is on the horizon for head and neck protocols?
Dr. Raja Seethala:
Well, the new WHO Blue Book of Classification of Head and Neck Tumors will be out shortly, and this will result in revision of nomenclature and classification of numerous tumor types. Additionally, a cutaneous head and neck squamous cell carcinoma protocol is in the works.
Julie McDowell:
How can CAP members have their input considered during the process of updating protocols?
Dr. Raja Seethala:
Well, that's a very good question. CAP members can submit queries regarding protocols in general or specifically the electronic format via a feedback email address that's listed on the CAP website. These requests are tracked in the project database and forwarded to the appropriate content expert. The expert then makes a decision and provides a rationale for the decision.
Occasionally, this necessitates further discussion and direct communication between the protocol lead and the user. For instance, I recently did this, and with user feedback, we modified the syntax for carcinoma ex pleomorphic adenoma. The resolution is then recorded in the tracker.
Now, I do get requests directly via email, and while I appreciate those, it's best to use a CAP protocol email. This allows for consistent and timely treatment of requests, documentation of the chronology of a particular issue. This is very important, especially when a protocol lead rotates off of the committee, so there's a track record of this.
It also identifies themes for prioritization, if a consistent issue pops up. And theoretically, in some cases, it may even inform the possibility of major revisions to a protocol. In addition to this common avenue for feedback, major revisions and new protocols typically have a public comment period that is announced to the CAP membership for their input as well.
Julie McDowell:
So finally, before we wrap up, the past few years have seen several advances in immunotherapy treatments for head and neck cancers. Perhaps you could talk about those advances and what pathologists should be watching for in the future.
Dr. Raja Seethala:
Sure. Great. The role of immunotherapy in head and neck cancers is still evolving and currently focuses on checkpoint inhibitors targeting the program depth pathway in squamous cell carcinoma.
Based on the key findings of phase three studies, such as Keynote 48, Keynote 40, the pathologist's main role is to evaluate program depth ligand one, or PDL one, immunoexpression to assist in determining which cancers may be treated with checkpoint inhibitors.
As our understanding becomes more nuanced, clinical assessment of the immune subpopulations may also help guide management. This is already being done in some centers, notably CD8 counts. Particularly [inaudible] in this context are automated digital image assisted quantitative assays to achieve this otherwise laborious task.
Julie McDowell:
Well, thank you very much for this discussion.
Dr. Raja Seethala:
Thank you for having me.
Julie McDowell:
For more information on head and neck cancer protocols as well as other CAP Cancer Protocols, please visit the protocols and guidelines section of cap.org. Thank you for listening to this CAPcast. To listen to other episodes, find us on the MyCAP app, available for CAP members, as well as SoundCloud, Apple Podcasts, Stitcher, Google Podcasts, and Amazon Music. Just search for CAPcasts from the College of American Pathologists on these apps. Once you find our podcast, be sure to click the subscribe button so you don't miss any new CAPcast episodes.