Head and neck cancer specialists agree that induction chemotherapy has a place in the treatment of locally advanced squamous cell cancer of the head and neck, but they differ on its exact role in this setting.
For Everett E. Vokes, MD, induction chemotherapy should be reserved for patients with advanced nodal stage disease. There are not enough randomized trial data to support its more general use, he said. Dr. Vokes is John E. Ultmann Professor of Medicine, and Radiation and Cellular Oncology at the Pritzker School of Medicine at the University of Chicago Medical Center.
Presented by DR. EVERETT VOKES
| • | Cure and organ preservation are primary treatment goals, and chemoradiation is the first option for most patients. |
| • | Several trials have demonstrated that concomitant chemoradiotherapy, either cisplatin(Drug information on cisplatin)- or taxane-based, improves OS rates. |
| • | Induction chemotherapy can be useful in high-risk patients with N3 disease and/or advanced nodal disease. |
Marshall R. Posner, MD, said he would use induction chemotherapy in patients at high risk for locoregional or systemic failure, including those with intermediate-stage and hypopharynx cancer. Dr. Posner is medical director of the head and neck oncology program at Boston's Dana-Farber Cancer Institute and an associate professor of medicine at Harvard Medical School.
The physicians discussed some of pros and cons of induction therapy in SCCHN during an educational session at ASCO 2010.
Concomitant chemoradiation vs induction chemotherapy
Dr. Vokes said that concomitant chemoradiotherapy is the current standard of care for most patients with advanced head and neck cancer. "Cure and organ preservation are our primary treatment goals. The optimal treatment strategy currently is not defined, but chemoradiotherapy is the first option for most patients," he said.
Nevertheless, Dr. Vokes said that induction chemotherapy in addition to concomitant chemoradiotherapy can be useful in high-risk patients with N3 disease and/or advanced nodal disease, depending on performance status and comorbidities. But its use is "not yet evidence based," he emphasized.
Presented by DR. MARSHALL POSNER
| • | Randomized clinical trials have proved that cisplatin and 5-FU induction therapy is equivalent to chemoradiotherapy. |
| • | Induction therapy can benefit patients with N1 and early N2A disease, N2B or N2C disease, bulky N3 disease or any N3 disease, unresectable disease, and T4 primary tumors. |
| • | Acute systemic toxicity is an issue with induction chemotherapy. Also, survival improvement is site- and stage-related. |
Induction chemotherapy has the distinct theoretical advantage of early systemic therapy wherein all therapeutic compartments are addressed, but the locoregional effect may be limited. Concomitant chemoradiotherapy, on the other hand, addresses primarily the locoregional compartment. It sensitizes the tumor cells to the administration of radiation but may necessitate underdosing the remainder of the body, Dr. Vokes said.
Several trials have validated concomitant chemoradiotherapy as the standard of care. Single-agent and combination chemotherapy regimens have been used; most are cisplatin-based but some are taxane-based, he said.
In one trial, the five-year overall survival (OS) rate among oropharyngeal cancer patients was 15.8% in patients who received radiotherapy alone vs 22.4% in patients who received carboplatin(Drug information on carboplatin) and 5-fluorouracil (5-FU) in addition to radiation therapy (P = .005; J Clin Oncol 22: 69-76, 2004).
In an RTOG phase III trial that randomized patients to three different treatments—radiation alone, radiation plus cisplatin, or radiation plus cisplatin/5-FU (PF)—the median three-year OS was 12.6 months for patients treated with radiation alone and 19.1 months with the addition of either chemotherapy regimen (ASCO 2006 abstract 5517).
Recent data from RTOG 97-03 showed 2-year OS rates of between 60% and 70% with combined concurrent chemoradiotherapy using a variety of regimens (J Clin Oncol 22:2856-2864, 2004). "So it may not be about specific drugs but about treatment intensity and the concept of sensitization," he said.
