Optimising the therapeutic ratio in head and neck cancer.

The intensity of contemporary treatment for locally advanced head and neck cancer is at the upper limit of human tolerance of acute toxicities. While impressive gains in locoregional control have been achieved, improvements in overall survival have been more modest. We hypothesise that unrecognised sequelae of highly toxic contemporary treatments substantially contribute to patient mortality. This possibility provides motivation to investigate reducing treatment intensity in selected patients with locally advanced head and neck cancer. With the demonstration of a good prognosis among subgroups of patients with head and neck cancer, major improvements in the technical delivery of radiotherapy, and further research into relevant factors in survivorship, we may be able to improve overall survival of patients with locally advanced disease without further increasing, and possibly reducing, treatment intensity.