Head and neck cancer: past, present and future
Head and neck cancer consists of a diverse group of cancers that ranges from cutaneous, lip, salivary glands, sinuses, oral cavity, pharynx and larynx. Each group dictates different management. In this review, the primary focus is on head and neck squamous cell carcinoma (HNSCC) arising from the mucosal lining of the oral cavity and pharynx, excluding nasopharyngeal cancer. Presently, HNSCC is the sixth most prevalent neoplasm in the world, with approximately 900,000 cases diagnosed worldwide. Prognosis has improved little in the past 30 years. In those who have survived, pain, disfigurement and physical disability from treatment have had an enormous psychosocial impact on their lives. Management of these patients remains a challenge, especially in developing countries where this disease is most common. Of all human cancers, HNSCC is the most distressing since the head and neck is the site of the most complex functional anatomy in the human body. Its areas of responsibility include breathing, the CNS, vision, hearing, balance, olfaction, taste, swallowing, voice, endocrine and cosmesis. Cancers that occur in this area impact on these important human functions. Consequently, in treating cancers of the head and neck, the effects of the treatment on the functional outcome of the patient need the most serious consideration. In assessing the success of HNSCC treatment, consideration of both the survival and functional deficits that the patient may suffer as a consequence of their treatment are of paramount importance. For this reason, the modern-day management of head and neck patients should be carried out in a multidisciplinary head and neck clinic. 
Risk Factors in Head and Neck Cancer
THE National Cancer Institute estimates that 51,000 new cases of head and neck cancer will occur in 1982 and will result in 16,000 deaths. These cases will include 26,600 cancers of the buccal cavity and oropharynx (9150 deaths), 10,700 cancers of the larynx (3700 deaths), 9900 thyroid cancers (1050 deaths), and 3800 cancers of the nose, paranasal sinuses, nasopharynx, and cervical esophagus (2100 deaths). As a group, these tumors account for about 5 per cent of all cancers in the United States. In other parts of the world, the percentages are higher. For example, head and neck cancers in Bombay, . . . 
The molecular landscape of head and neck cancer
Head and neck squamous cell carcinomas (HNSCCs) arise in the mucosal linings of the upper aerodigestive tract and are unexpectedly heterogeneous in nature. Classical risk factors are smoking and excessive alcohol consumption, and in recent years, the role of human papillomavirus (HPV) has emerged, particularly in oropharyngeal tumours. HPV-induced oropharyngeal tumours are considered a separate disease entity, which recently has manifested in an adapted prognostic staging system while the results of de-intensified treatment trials are awaited. Carcinogenesis caused by HPV in the mucosal linings of the upper aerodigestive tract remains an enigma, but with some recent observations, a model can be proposed. In 2015, The Cancer Genome Atlas (TCGA) consortium published a comprehensive molecular catalogue on HNSCC. Frequent mutations of novel druggable oncogenes were not demonstrated, but the existence of a subgroup of genetically distinct HPV-negative head and neck tumours with favourable prognoses was confirmed. Tumours can be further subclassified based on genomic profiling. However, the amount of molecular data is currently overwhelming and requires detailed biological interpretation. It also became apparent that HNSCC is a disease characterized by frequent mutations that create neoantigens, indicating that immunotherapies might be effective. In 2016, the first results of immunotherapy trials with immune checkpoint inhibitors were published, and these may be considered as a paradigm shift in head and neck oncology. 
Induction Chemotherapy as a Predictor for Definitive Treatment in Bulky Locally Advanced Squamous Cell Carcinoma of the Head and Neck: A Schedule More Suited to Sub Himalayan Region
Purpose: Use of induction chemotherapy (IC) as a predictor for definitive treatment in bulky locally advanced head and neck cancer (LA HNSCC) patients, who are not feasible for any upfront radical treatment in sub-Himalayan population.
Materials and Methods: 33 patients (stage IVA and IVB, T4, N3) LA HNSCC were treated with induction chemotherapy (TP) from April 2013 to August 2015. All patients were considered inoperable or not feasible for upfront radical treatment and Eastern Cooperative Oncology Group (ECOG) Performance status was ≤ 2.
All patients were reviewed at multidisciplinary tumor board and considered for initial 3 cycles of induction chemotherapy in view of bulky stage IV LAHNSCC. Subsequent Radical (CTRT or Sx → CT RT) or palliative treatment was decided by tumor board after response assessment of NACT. The Statistical Package for the Social Sciences software (SPSS version 16.0) was used for analysis. The response rate, toxicity (accordance with CTCAE vs. 4.02), completion rate of radical treatment post NACT and overall survival was reported.
Results: Median follow up was 22 months (18-26 months). After 3 cycles of IC, 20 patients (60.66%) underwent radical treatment and remaining 13 patients (39.33%) were treated with palliative treatment. Overall grade 2-3 toxicity was seen in 12 patients. No toxicity related mortality was noted. The completion rate of radical treatment post IC was 93.5%. The median OS was 18 month ((95% CI 9.00 to 31.00). Total 16 Patients are alive, in which 11 is disease free. Twelve patients expired and 5 patients were lost to follow up.
Conclusion: Our present experience suggests that neoadjuvant chemotherapy with doublet regime is reasonably well tolerated and feasible in limited resource setting of patients with locally advanced disease who are not fit for upfront radical treatment. 
Comparative Analysis of Serum Zinc and Vitamin A in Patients with Head and Neck Squamous Cell Carcinoma and Healthy Individuals
Background: Deficiency of micro nutrients and trace elements has been associated with Head and Neck Squamous cell carcinomas (HNSCC). There is however a paucity of studies demonstrating this association in the West African sub-region.
Aim: To determine the serum level of zinc, vitamin A and nutritional status of HNSCC patients at the University College Hospital, Ibadan.
Methods: This was a case-control study of 65 consecutive patients with histological diagnosis of HNSCC. The controls were 65 healthy volunteers similar in age, sex and socioeconomic status. The participants’ height, weight, mid upper arm and waist circumference were measured and, serum Zinc and Vitamin A (Retinol) levels were assayed. The data from cases were analysed and compared with the controls using statistical package for social sciences version 15 software. Significance was set at p < 0.05.
Results: The mean ages of cases and controls were 50.9±15.2 years and 49.49±16.35 years respectively. The commonest sites of HNSCC were the Nasopharynx and Sinonasal regions. Fifty five (84.6%) HNSCC patients presented with advanced form of the disease (stage III and IV). The mean body mass index of cases and controls was 22.66±4.70 and 23.14±3.8 respectively (p=0.524). The mean serum zinc level of the controls (113.63±6.04) was significantly higher than the cases (89.84±14.27) (p=0.000). The mean serum vitamin A (retinol) level of the controls (77.74 µg/dl±2.82) was significantly higher than the cases (61.34±5.89) (p=0.000).
Conclusion: There are more Head and Neck Squamous cell carcinoma patients with malnutrition than the healthy population. Although no abnormality of serum zinc and retinol was found in both groups, there is a trend of lower levels of these nutrients in the patients than healthy individuals. 
 Chin, D., Boyle, G.M., Porceddu, S., Theile, D.R., Parsons, P.G. and Coman, W.B., 2006. Head and neck cancer: past, present and future. Expert review of anticancer therapy, 6(7), pp.1111-1118.
 Decker, J. and Goldstein, J.C., 1982. Risk factors in head and neck cancer. New England Journal of Medicine, 306(19), pp.1151-1155.
 Leemans, C.R., Snijders, P.J. and Brakenhoff, R.H., 2018. The molecular landscape of head and neck cancer. Nature Reviews Cancer, 18(5), p.269.
 Nautiyal, V., Bansal, S., Pattanayak, M., S. Pruthi, D., Ahmad, M. and Saini, S. (2017) “Induction Chemotherapy as a Predictor for Definitive Treatment in Bulky Locally Advanced Squamous Cell Carcinoma of the Head and Neck: A Schedule More Suited to Sub Himalayan Region”, Journal of Cancer and Tumor International, 6(4), pp. 1-10. doi: 10.9734/JCTI/2017/38073.
 Daniel, A., Fasunla, A., Elumelu, T. and Nwaorgu, O. (2015) “Comparative Analysis of Serum Zinc and Vitamin A in Patients with Head and Neck Squamous Cell Carcinoma and Healthy Individuals”, Journal of Advances in Medicine and Medical Research, 11(12), pp. 1-9. doi: 10.9734/BJMMR/2016/22204.