Multidisciplinary Treatment Planning
The tumor board mindset
Treatment planning in head and neck cancer is fundamentally a function-preservation and risk-stratification exercise. You must understand when single modality suffices (early-stage disease, favorable pathology) versus combined modality (advanced disease, adverse features). Key adverse features after surgery include positive margins and ENE (strong indications for adjuvant chemoradiation) versus other risk factors like perineural invasion, lymphovascular invasion, or multiple nodes (adjuvant radiation alone often considered).
Sequencing and trade-offs
Know the rationale for primary surgery versus primary chemoradiation by site: oral cavity is generally surgical; larynx and pharynx often favor organ preservation with chemoradiation in appropriately selected patients; nasopharynx is primarily nonsurgical. Understand that adding chemotherapy to radiation improves outcomes in high-risk adjuvant and in definitive organ-preservation settings, but increases toxicity. Consider patient factors: performance status, swallowing function, dental status, and ability to tolerate treatment.
Traps
Questions test whether you know which adverse feature mandates chemotherapy versus radiation alone, and whether you recognize that "organ preservation" does not mean "no surgery ever" (salvage surgery remains an option and is often the plan). Another trap is choosing combined modality for early disease where it adds toxicity without survival benefit.
Rule of thumb
Use the two-feature framework: positive margin or ENE → adjuvant chemoradiation; lesser adverse features → adjuvant radiation. For the primary, ask whether surgery can achieve clear margins with acceptable function; if not, consider definitive radiation-based therapy. Example: a resected oral tongue cancer with a close margin and no ENE may get adjuvant radiation; add concurrent chemotherapy if the margin is frankly positive or ENE is present.