Recurrent/Metastatic HNSCC: Answers To Frequently Asked Questions With Assuntina G. Sacco, MD

In this video, Dr. Assuntina G. Sacco, Associate Professor of Internal Medicine, Co-Director of the Hanna and Mark Gleiberman Head and Neck Cancer Center, and Disease Team Leader–Head and Neck at UC San Diego Moores Cancer Center, answers questions asked by the audience during her CME/NCPD–approved activity with i3 Health, Recurrent/Metastatic Head and Neck Squamous Cell Carcinoma: New Insights and Real-World Evidence for Improved Patient OutcomesDr. Sacco shares insights into targeted mutations to test for, recommendations for patient education, the future of HPV therapeutic vaccines, monitoring for immune-related adverse events, and more! 

Are there any targeted mutations that you recommend testing for before starting first-line therapy?

Assuntina G. Sacco, MD: Generally not. I will reflexively order genomic profiling on both tumor and blood samples when patients do have recurrent metastatic disease. However, that generally does not inform my first line treatment recommendation because they are going to get immunotherapy regardless, whether it is standard of care or as part of a clinical trial.

Any recommendations for patient education resources that I could refer my patients to?

Dr. Sacco: The Head and Neck Cancer Alliance does have patient education resources that can be helpful, and the American Cancer Society does as well. Usually it’s a smattering of different patient education resources from various sources, but I think the Head and Neck Cancer Alliance is probably most meaningful.

Will human papillomavirus (HPV) therapeutic vaccines be useful in the future, and for which patients?

Dr. Sacco: I’m going to remain hopeful that a therapeutic vaccine will be developed that is useful. There’s a lot of research looking at therapeutic vaccines, and we’ve participated in some of those trials. The efficacy just hasn’t been there yet, but I’m hopeful. In terms of how we’re going to select, I think at the beginning it’s going to be basically agnostic. If it’s HPV-mediated, they’re going to be offered it, and then based on what we see, that will help us further refine. I think that’s basically how it’s going to go.

How long after finishing immunotherapy do you continue monitoring for immune-related adverse events?

Dr. Sacco: I think it’s prudent to monitor for up to a year, just given the data. Inevitably, most of these individuals are under our care for surveillance anyways. We may be monitoring them beyond that, but I would say a minimum of three months, but ideally up to a year if you can.

What factors do you consider when deciding whether to rechallenge immunotherapy after toxicity?

Dr. Sacco: I think it really just depends on the toxicity—where it’s at, how severe, and what I had to do to either resolve it or get it back to a much more manageable level. Then it’s really important that you talk to your patients. For some patients, even if we don’t think the toxicity was that severe or that concerning, they do think so.

Conversely, I had a patient where I had her on pembrolizumab plus cetuximab. She developed a small bowel obstruction, which we suspected was due to the epidermal growth factor receptor (EGFR). I had to stop her therapy because of that scenario. She ended up getting an ostomy and she had a complete response. But after being off of therapy for quite some time, she recurred again. She came back to me and said, “I want to go back on the same therapy because it worked.” I explained to her, “Well, it may or may not work the same way and you had a pretty significant toxicity of bowel obstruction requiring an ostomy.” I spoke with the surgeon. The surgeon said, “She’s already got the ostomy, so from my perspective, if you want to rechallenge, you’re welcome to.” So we did. I will say I wasn’t confident about that, and I felt my anxiety level was much higher. She went back on that therapy and did not have any further bowel issues. She had stable disease for a period of time.

I highlight that just to say, again, it really depends on a variety of factors. You have to talk to your patient and take into context what that toxicity is and your comfort level with rechallenging. If you are going to rechallenge, please make sure that your patient is savvy and you’re seeing them often, in case any acute issues arise abruptly. 

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