Chemoradiation Therapy vs Surgery in HPV-Positive Head and Neck Cancer

In this Q&A with Jacqueline R. Kelly, MD, MSc, of the Yale Cancer Center and Smilow Cancer Hospital in New Haven, Connecticut, we discuss a retrospective study that looked at survival outcomes in human papillomavirus (HPV)-positive oropharyngeal cancer patients treated with either definitive chemoradiation therapy (CRT) or primary surgery. Dr. Kelly presented the results of the study (abstract 94) at the 2017 American Society for Radiation Oncology (ASTRO) Annual Meeting in San Diego.

-Interviewed by Ian Ingram  

Cancer Network: Who were the patients involved in this study, and what were you looking to find?

Dr. Kelly: HPV-positive oropharyngeal cancer is becoming increasingly common in the United States. Current guidelines for treating oropharyngeal cancer recommend that we use either a primary surgical approach or CRT, but these guidelines are outdated and based on a different patient population, so we wanted to see if these two treatment options are really equal in HPV-positive oropharynx cancer patients.

We used the National Cancer Database, which captures about 70% of newly diagnosed cancers in the United States, and narrowed our patients down to those with locally advanced HPV-positive oropharyngeal cancers-notably, clinical T2N1 or T1–2N2a–2b disease. We ended up with a cohort of 3,168 patients, with one half receiving full dose concurrent CRT (n = 1,576) and the other half receiving primary surgery (n = 1,592) with or without adjuvant therapy.

Cancer Network: What were the findings from the study and what surprised you?

Dr. Kelly: At a median follow-up of 32 months we found that both treatments appear to have comparable 3-year overall survival outcomes in this patient cohort (90.8% with CRT vs 92.5% with primary surgery). Upfront surgery was also not associated with improved overall survival compared with CRT on multivariable Cox regression analysis (hazard ratio, 1.10; P = .48) or in a subset analysis of patients with margin-negative resection (3-year overall survival of 90.1% with CRT vs 93.5% with primary surgery; P = .14).

The other notable finding from the study is specific to our surgical patients. We looked at these patients and how they were treated in the adjuvant setting-to see if they received any radiation or chemotherapy following surgery-and found that 61% of surgical patients received CRT after surgery. That’s important because that’s considered trimodality therapy, which we know is both more expensive and more morbid than definitive CRT.

Cancer Network: What future research would you like to see in this patient population?

Dr. Kelly: Clearly across the country we’re not selecting our surgical patients as appropriately as we could be to avoid the need for adjuvant treatment. I think an important question for future research is: How can we better select surgical patients, how can we pick only those that are going to require minimal or no adjuvant therapy so that we’re not giving nearly two-thirds of these patients CRT? I’d like to see more research focusing on that.