The comparison of weekly and three-weekly cisplatin chemotherapy concurrent with radiotherapy in patients with previously untreated inoperable non-metastatic squamous cell carcinoma of the head and neck

Weekly versus 3-weekly cisplatin along with radiotherapy for locoregionally advanced non-nasopharyngeal head and neck cancers: Is the equipoise in literature addressed yet?

Concurrent chemoradiotherapy with 3-weekly cisplatin 100 mg/m2 has been the standard of care for locoregionally advanced head and neck cancer (LA-HNC) with level I evidence. While the outcomes in terms of efficacy have been well established, the toxicity profile, compliance, and real-world applicability has been an area of ongoing concern for this regimen, leading the oncologists to explore weekly cisplatin chemoradiotherapy regimen to potentially address the issue. A review of literature was conducted in Pubmed, Scopus, and Medline to compare and evaluate the present role of weekly cisplatin chemotherapy along with radiotherapy versus 3-weekly cisplatin chemotherapy along with radiotherapy in both adjuvant and definitive settings for locoregionally advanced head and neck cancers. Nasopharyngeal subsites were excluded from the literature review and 50 relevant articles were included in the analysis. Recently published evidences of noninferiority of weekly over 3-weekly cisplatin chemoradiotherapy regimen in definitive as well as adjuvant settings in locoregionally advanced head and neck cancers is highlighted and interpreted. Results supporting and against the above in different publications is elaborated in this article. Trials designed to demonstrate noninferiority of the weekly cisplatin chemoradiotherapy regimen over 3-weekly regimen, especially in definitive setting may conclude the debate in future. A lacunae in the existing literature is noted in the form of lack of superiority trials on the above topic, which may impact future conclusions.

Efficacy and safety of weekly versus triweekly cisplatin treatment concomitant with radiotherapy for locally advanced nasopharyngeal carcinoma: A systematic review and pooled analysis

Background: Most nasopharyngeal carcinoma cases are diagnosed at an advanced stage due to their hidden anatomical structure and atypical clinical symptoms and often require chemoradiotherapy. Here, we present a systematic review and pooled analysis to synthesize existing research on the efficacy and adverse effects of weekly versus triweekly cisplatin chemotherapy concomitant with radiotherapy for locally advanced nasopharyngeal carcinoma (LANPC). Methods: We searched the PubMed, Embase, and Cochrane Library databases from inception to 1 September 2021, for relevant original research articles published in English. The literature search and data extraction were done independently by two investigators. We used random-effects models to provide point estimates [95% confidence interval (CI)] of overall response rate (ORR), overall survival (OS), progression-free survival (PFS), locoregional recurrence-free survival (LRFS), distant metastasis-free survival (DMFS) and the incidence rate of adverse effects (AEs) and with subgroup analysis according to each study type. The primary endpoints were ORR, OS, and PFS; LRFS, DMFS, and grade ≥3 acute AEs were secondary endpoints. Results: In total, 2,305 patients of eight studies were included in this review. We found that patients who were administered cisplatin weekly or triweekly had no differences in ORR, OS, PFS, DMFS, LRFS, severe mucositis, dermatitis, nausea/vomiting or nephrotoxicity. Patients who were administered weekly cisplatin were at a higher risk of hematological toxicity compared with patients who received the chemotherapy triweekly. Conclusion: Our findings suggest that both regimens could be recommended as the standard of care for the chemoradiotherapy treatment of LANPC, the perceived benefit of lower toxicity with weekly cisplatin could not be established.

Efficacy and safety of weekly versus triweekly cisplatin concurrent with radiotherapy in nasopharyngeal carcinoma: A meta-analysis

BACKGROUND

Cisplatin-based concurrent chemoradiotherapy is a standard of care for locally advanced nasopharyngeal carcinoma (NPC), and weekly and triweekly cisplatin are both alternative regimens based on the results of squamous cell carcinoma of the head and neck. However, there is a lack of direct evidence on the efficacy and safety of weekly versus triweekly cisplatin concurrent with radiotherapy in NPC alone. This meta-analysis aimed to identify which regimen is more superior between weekly and triweekly cisplatin in patients with NPC treated with concurrent chemoradiotherapy.

METHODS

The PubMed, Embase, and Cochrane Library were searched for eligible literatures. Clinical outcome measures including 1-year overall survival (OS), 3-year OS, 5-year OS, 5-year loco-regional failure-free survival, 5-year distant metastasis-free survial and the most common 3 grade or higher acute toxicities (hematological toxicity, mucositis and nausea and vomiting) were analyzed by RevMan 5.4 software; significance level was 0.05.

RESULTS

Seven clinical controlled studies with 1795 patients were included in the meta-analysis. There were no significant differences between weekly and triweekly cisplatin in 1-year OS, 3-year OS, 5-year OS, 5-year loco-regional failure-free survival, and 5-year distant metastasis-free survial) (all P > .05). Grade 3 or higher mucositis and nausea and vomiting showed similar between the 2 arms. However, grade 3 or higher hematological toxicity of weekly cisplatin was significantly higher than that of triweekly cisplatin (1.55; 95% CI, 1.22-1.98, P = .0004).

CONCLUSIONS

Weekly cisplatin resulted in similar survival benifit as triweekly cisplatin, but with higher hematological toxicity.

Head and neck cancer: Current challenges and future perspectives

Head and neck cancers are a heterogeneous, aggressive and genetically complex collection of malignancies of the oral cavity, nasopharynx, oropharynx, hypopharynx, larynx, paranasal sinuses and salivary glands, which are difficult to treat. About 90% of all head and neck cancers are squamous cell carcinomas (HNSCC). Larynx and Oral cavity carcinomas are generally related with tobacco consumption, alcohol abuse (or both), but pharynx carcinomas are generally associated with infection of human papillomavirus (HPV), especially HPV-16 subtype. Thus, usually HNSCC can be separated into HPV-negative and HPV-positive categories. Despite substantial efforts invested into therapeutic development of HNSCC, the 5-year survival rate of patients with HNSCC still remains dismal. The primary reason being late diagnosis, recurrent metastasis, relapse and resistance to therapies. Currently surgery and radiotherapy represent the baseline treatment options for most initial stage HNSCC patients, but these treatments are associated with significant morbidity and poor prognosis. Moreover, the issue of resistance to both radiotherapy/chemotherapy and recurrent relapse are common in HNSCC. Elucidation of the genetic landscape, tumor microenvironment and aberrant signaling pathways have generated new insights into the molecular pathogenesis of this disease. Thus, the scientific research has therefore been focused on the understanding of HNSCC biology and immunobiology to identification of predictive/prognostic biomarkers, which will be key to develop more effective targeted therapies with less toxicity and high specificity.

Randomized trial on acute toxicities of weekly vs three-weekly cisplatin-based chemoradiation in head and neck cancer

Background

The current first‐line treatment of locally advanced head and neck carcinoma (LAHNC) is concurrent chemoradiation with three‐weekly cisplatin 100 mg/m². However, prescribing cisplatin at this dose increases the treatment toxicity, which may compromise the treatment results. An alternative schedule is weekly 40 mg/m² cisplatin.

Aim

To compare the acute hematologic and renal toxicities of these two regimens.

Methods

This randomized clinical trial included 77 LAHNC patients who were allocated to a high dose (100 mg/m² every 3 weeks) or low dose (40 mg/m² weekly) cisplatin group concurrent with radiotherapy. Hematologic and renal indices were measured weekly during chemoradiation.

Results

The average age of patients was 55.3 years. Overall, 71.4% of patients were treated in a definitive setting. The incidence of severe hematologic events was not significantly different. However, the average estimated glomerular filtration rate (eGFR) was significantly greater in the three‐weekly group (67.85 vs. 58.57% mL/min per 1.73 m²; P‐value = .02). Cumulative cisplatin dose of ≥240 mg/m² was significantly greater in the weekly group. Totally, treatment breaks occurred in 40.3% of patients due to treatment toxicity. Treatment interruption was primarily due to neutropenia in the three‐weekly and renal dysfunction and thrombocytopenia in the weekly group.

Conclusions

Severe acute hematologic toxicities were comparable for three‐weekly and weekly groups. The decrease in eGFR through treatment was more significant with weekly cisplatin. Further follow‐up, however, is needed to confirm its impact on delayed renal function.

Phase IIb trial comparing two concurrent cisplatin schedules in locally advanced head and neck cancer

Background:

Concurrent chemoradiation with 3 weekly cisplatin (100 mg/m²) is the standard of care for locally advanced head and neck cancer. However, this regimen has been shown to be associated with lesser compliance and higher toxicities. Hence, there is a need to explore alternative concurrent cisplatin regimens.

Objectives:

The objective of this study was to compare the efficacy and toxicities of 3 weekly cisplatin (100 mg/m²) with weekly cisplatin (40 mg/m²) concurrently with radiation in patients with locally advanced head and neck cancer.

Patients and Methods:

This phase IIb trial randomized 56 patients with Stage III and IV squamous cell carcinoma of oropharynx, hypopharynx, and larynx to Arm A or Arm B. Arm A received cisplatin 100 mg/m² 3 weekly and Arm B received cisplatin 40 mg/m² weekly concurrently with radiation. The primary end point was disease-free survival (DFS) and secondary end points were overall survival (OS) and acute toxicity. DFS and OS were estimated using Kaplan–Meier method, and log-rank test was used to assess the difference in these distributions with respect to treatment.

Results:

The 2-year DFS in Arm A and Arm B was 64.5% and 52.8%, respectively (P = 0.67). The OS at 2 years was 71% and 61.1% in Arm A and Arm B, respectively (P = 0.61). There were no significant differences in acute hematological, renal, or mucosal toxicities between the two arms.

Conclusion:

This study showed a nonsignificant improvement in DFS and OS in the 3 weekly cisplatin arm over the weekly arm with comparable toxicities. The trial is registered with Clinical Trial Registry of India (CTRI registration number: CTRI/2013/05/003703, URL-http://ctri.nic.in).

Patient reported outcomes in patients with head and neck cancer treated with concurrent chemoradiation with weekly versus bolus cisplatin

BACKGROUND

Patient Reported Outcome (PRO) data comparing bolus (B-CP) with weekly (W-CP) cisplatin concurrent with radiation are lacking.

METHODS

We performed a retrospective study comparing PRO among 99 patients with head and neck radiation, 26% who received concurrent B-CP and 73% treated with W-CP.

RESULTS

W-CP patients had a higher Charlson comorbidity index (CCI) (P = .004). There were no differences in median cisplatin dose, PROs, percutaneous endoscopic gastrostomy (PEG) dependence or hospitalization between arms. Patients with a greater decline in their self-reported dysphagia score were more often PEG dependent at the end of radiation therapy (P = .03). There was also a trend toward PEG dependence with a higher maximum dysphagia score and greater change in aspiration score (P = .06). The maximum decline in white cell count and absolute neutrophil count were greater in the W-CP group (P = .04, P = .01).

CONCLUSION

Both B-CP and W-CP are well tolerated. PROs do not suggest a benefit to W-CP.

Cisplatin Weekly Versus Every 3 Weeks Concurrently with Radiotherapy in the Treatment of Locally Advanced Head and Neck Squamous Cell Carcinomas: What Is the Best Dosing and Schedule?

PURPOSE

The aim of this prospective randomized study is to compare cisplatin at 2 dose levels given concurrently with intensity modulated radiation therapy (IMRT) in the treatment of locally advanced HNSCC. The main objectives were to evaluate treatment toxicities, loco-regional control, tumor response and patients compliance.

METHODS

Patients were randomized into two groups that either received 30 mg/m2 cisplatin weekly (arm A) or 100 mg/m2 once every 3 weeks (arm B). Radiotherapy prescribed dose was 70Gy in 33 fractions. Treatment adverse events were documented.

RESULTS

Sixty patients with locally advanced HNSCC were included in this study. Recruitment started at the beginning of July 2016 and ended in July 2019. The Median follow-up was 24 months. Acute non-hematological toxicities of grade 3 or higher during the treatment course were significantly more observed in Arm B patients (76.6%) compared to Arm A patients (56.6%) with a P-value of 0.007. Hematological toxicities in the form of anemia, leucopenia and neutropenia were also significantly higher in Arm B patients with a p-value of 0.435, 0.002 & 0,002, respectively. The median 2 year loco-regional control rate in Arm B was 72.8% versus 57.6% in Arm A with a p-value of 0.015. Complete responses were similar between both groups (77%). Compliance to treatment was better in Arm A with 70% of the patients received at least 6 weekly doses where as 60% of the patients in Arm B completed the three cycles of treatment and 40 % received only 2 cycles.

CONCLUSION

Once weekly low dose cisplatin treatment showed lower acute toxicity and a better compliance compared to once every 3 weeks high dose cisplatin treatment at the expense of a lower loco-regional control.

The changing therapeutic landscape of head and neck cancer

Head and neck cancers are a heterogeneous collection of malignancies of the upper aerodigestive tract, salivary glands and thyroid. In this Review, we primarily focus on the changing therapeutic landscape of head and neck squamous cell carcinomas (HNSCCs) that can arise in the oral cavity, oropharynx, hypopharynx and larynx. We highlight developments in surgical and non-surgical therapies (mainly involving the combination of radiotherapy and chemotherapy), outlining how these treatments are being used in the current era of widespread testing for the presence of human papillomavirus infection in patients with HNSCC. Finally, we describe the clinical trials that led to the approval of the first immunotherapeutic agents for HNSCC, and discuss the development of strategies to decrease the toxicity of different treatment modalities.

A prospective randomized study comparing concurrent chemoradiation with weekly and 3 weekly cisplatin in locally advanced oropharyngeal carcinoma

INTRODUCTION

The chemotherapy schedules with cytotoxic dose or weekly regimes are still challenging, weighing the benefits versus toxicities. This prospective randomized study is an attempt to assess the efficacy of two schedules of cisplatin in management of locally advanced HNSCC.

OBJECTIVES

The objectives of this study was to evaluate tolerance, tumour response and toxicities of concurrent chemoradiation with cisplatin in weekly and three weekly regimes.

METHODS

Locally advanced oropharyngeal squamous cell carcinoma patients fit for concurrent chemoradiation with cisplatin 40 mg/m2 (weekly) and 100 mg/m2 (3 weekly) were randomized to Arm A and B concurrently with radiotherapy of 70Gy/35frs/7 weeks.

STATISTICAL ANALYSIS

Chi-square/ Fisher Exact test has been used to find the significance of study parameters on categorical scale between the groups. The statistical software SPSS 15.0 was used.

RESULTS

Between December 2010 and January 2013, 60 patients were enrolled. The median cycles of cisplatin in Arm-A was 5 and 2 in Arm-B. The complete response of 80.9% vs 75% and partial response of 14.3% vs 12.5% was observed in both arms respectively. There was no statistical difference in acute radiation and hematological toxicities between the two groups. With median follow up of 28 months, the 2 and 5 years overall survival was 55% and 58%; 41.6% and 32.3% in arms A and B respectively.

CONCLUSION

In our study of locally advanced oropharyngeal carcinoma treated with radical radiotherapy comparing concurrent chemotherapy with cisplatin weekly vs 3 weekly had no significant difference in overall response, complete response and acute toxicities.

Comparison of weekly and triweekly cisplatin regimens during concurrent chemoradiotherapy for nasopharyngeal carcinoma

BACKGROUND

We compared the survival outcomes and acute toxicities of weekly and triweekly cisplatin regimens during concurrent chemoradiotherapy (CCRT) in nasopharyngeal carcinoma (NPC) patients.

METHODS

Patients were treated with CCRT alone. CCRT was initiated on the first day of RT. Cisplatin 30-40 mg/m² was infused on days 1, 8, 15, 22, 29, 36 and 43 in the Weekly Group, while cisplatin 80-100 mg/m² was delivered on days 1, 22 and 43 in the Triweekly Group. The survival outcomes were revealed by the Kaplan-Meier method and Cox regression modelling to measure 5-year overall survival (OS), disease-free survival (DFS), locoregional relapse-free survival (LRFS) and distant metastasis-free survival (DMFS).

RESULTS

Ninety-three (28.9%) patients received three to 7 cycles of cisplatin weekly (Weekly Group) and 229 (71.1%) patients received two to 3 cycles of cisplatin triweekly (Triweekly Group). Five-year OS (weekly vs. triweekly, 96.7% vs. 88.3%, P = 0.036) and DFS (weekly vs. triweekly, 90.7% vs. 80.5%, P = 0.028) were better in the Weekly Group than in the Triweekly Group. The weekly vs. triweekly 5-year DMFS and LRFS rates were: DMFS, 96.7% vs. 91.4%, χ² = 2.694, P = 0.101; LRFS, 96.3% vs. 93.5%, χ² = 1.317, P = 0.251. Cisplatin delivery regimen was not an independent prognostic factor. The incidence rate of acute toxicities was similar between the groups.

CONCLUSIONS

Compared with Triweekly cisplatin regimen, Weekly regimen may be a better choice during CCRT.

Concurrent chemoradiotherapy with weekly versus triweekly cisplatin in locally advanced squamous cell carcinoma of the head and neck: Comparative analysis

BACKGROUND

Cisplatin-based chemoradiotherapy is standard of care for locally advanced squamous cell carcinoma of the head and neck. This systemic review compared efficacy and safety of weekly vs triweekly cisplatin in locally advanced squamous cell carcinoma of the head and neck.

METHODS

Among 1500 prospective studies published from 1970 to 2015, 39 (18 weekly, 21 triweekly) including 3668 patients qualified for inclusion. Clinical outcomes were analyzed using weighted estimates and 2-tailed t test for comparisons; significance level was 0.05.

RESULTS

Locoregional control was 58% (CI 53%-63%) vs 61% (CI 56%-65%; P = .7). The 2-year overall survival (OS) was 74% (CI 66%-80%) for weekly vs 67% (64%-69%) triweekly groups (P = .67). The 2-year progression-free survival (PFS) was 69% (CI 59%-77%) for weekly vs 62% (CI 58%-65%) triweekly groups (P = .9). Grade 3 to 5 toxicities were 36% vs 40% (P = .37) in weekly vs triweekly groups.

CONCLUSIONS

Weekly cisplatin was comparable in efficacy and safety to the triweekly regimen. Our analysis supports the use of weekly or triweekly cisplatin in locally advanced squamous cell carcinoma of the head and neck, with tolerability being a key factor in selection.

3-weekly or weekly cisplatin concurrently with radiotherapy for patients with squamous cell carcinoma of the head and neck - a multicentre, retrospective analysis

Background

Concurrent chemoradiotherapy with cisplatin is standard for patients (pts) with loco-regionally advanced squamous cell carcinoma of the head and neck (LA-SCCHN) and for patients with resected SCCHN with high-risk features. The standard regimen includes 3-weekly cisplatin, but weekly regimens are often used to lower toxicity. Reaching a cumulative dose of ≥200 mg/m² cisplatin was shown being associated with improved outcome. We herein investigated cumulative dose reached and toxicities between the 3-weekly and weekly cisplatin regimens with concurrent radiotherapy.

Methods

Multicentre, retrospective analysis of all patients undergoing combined RCT with cisplatin treated at 3 centres in Switzerland between 06/2008 and 12/2015.

Results

Three hundred fourteen pts. were included (3-weekly, N = 127; weekly, N = 187). Median cumulative cisplatin dose was 200 mg/m² (IQR 150–300) for pts. treated with a 3-weekly schedule and 160 mg/m² (120–240) for the weekly schedule, consequently more pts. treated with a 3-weekly schedule reached a cumulative dose ≥200 mg/m² (75.6% vs. 47.1%, p < 0.001). This association was also observed in multivariable analysis adjusted for age and sex (OR 3.46, 95% confidence interval [CI], 2.1–5.7). The 3-weekly regimen led to a higher rate of acute renal toxicity (33.1% vs. 20.9%, p = 0.022). In the landmark analysis, we could not confirm that a cisplatin dose ≥200 mg/m² is associated with better survival (HR 1.3, 95% CI 0.8–1.9).

Conclusions

Significantly more patients receive a cumulative cisplatin dose of ≥200 mg/m², when treated with a 3-weekly schedule compared to weekly dosing. The previously reported association between a cumulative cisplatin dose ≥200 mg/m² and improved outcome could not be shown in our study.

A meta-analysis of weekly cisplatin versus three weekly cisplatin chemotherapy plus concurrent radiotherapy (CRT) for advanced head and neck cancer (HNC)

Purpose

This study was performed to compare the efficacies and acute toxicities in weekly- and three weekly- cisplatin based concurrent chemoradiotherapy (CCRT) for advanced HNC patients.

Results

779 patients of 10 studies were eligible. No difference in the 2-, 3-year OS or 1-, 2-year LRFS was observed, whereas patients in three weekly CCRT arm tended to have a better 5-year OS (HR=1.79, 95%C 0.97-3.31, p=0.06). Weekly arm seemed to show less gastrointestinal toxicities (RR=0.59, 95%CI 0.34-1.02, p=0.06), but similar hematologic toxicity compared to three weekly arm. Subgroup analysis displayed more grade ≥3 mucositis (RR=1.72, p=0.01), and more chemotherapy related delay/interrupt (RR=2.68, p<0.0001) in weekly arm for non-nasopharynx carcinoma (non-NPC) HNC.

Methods

We conducted the meta-analysis by searching PubMed, MEDLINE, ScienceDirect, Cochrane Library and China National Knowledge Infrastructure (CNKI) databases. The primary endpoint was overall survival (OS) with secondary endpoints locoregional recurrence-free survival (LRFS) and grade≥3 acute adverse events. RevMan 5.2 was used to perform statistical analyses.

Conclusions

Three weekly cisplatin-based CCRT might achieve a higher long-term OS with no significant difference in a shorter OS and LRFS. Weekly arm was associated with less gastrointestinal toxicities but more grade≥3 mucositis and chemotherapy related delay/interrupt. Large randomized trials were urgent to further define superiority of these two regimens.

Once-a-Week Versus Once-Every-3-Weeks Cisplatin Chemoradiation for Locally Advanced Head and Neck Cancer: A Phase III Randomized Noninferiority Trial

Purpose Chemoradiation with cisplatin 100 mg/m² given once every 3 weeks is the standard of care in locally advanced head and neck squamous cell cancer (LAHNSCC). Increasingly, low-dose once-a-week cisplatin is substituted because of perceived lower toxicity and convenience. However, there is no level 1 evidence of comparable efficacy to cisplatin once every 3 weeks. Patients and Methods In this phase III randomized trial, we assessed the noninferiority of cisplatin 30 mg/m² given once a week compared with cisplatin 100 mg/m² given once every 3 weeks, both administered concurrently with curative intent radiotherapy in patients with LAHNSCC. The primary end point was locoregional control (LRC); secondary end points included toxicity, compliance, response, progression-free survival, and overall survival. Results Between 2013 and 2017, we randomly assigned 300 patients, 150 to each arm. Two hundred seventy-nine patients (93%) received chemoradiotherapy in the adjuvant setting. At a median follow-up of 22 months, the estimated cumulative 2-year LRC rate was 58.5% in the once-a-week arm and 73.1% in the once-every-3-weeks arm, leading to an absolute difference of 14.6% (95% CI, 5.7% to 23.5%); P = .014; hazard ratio (HR), 1.76 (95% CI, 1.11 to 2.79). Acute toxicities of grade 3 or higher occurred in 71.6% of patients in the once-a-week arm and in 84.6% of patients in the once-every-3-weeks arm ( P = .006). Estimated median progression-free survival in the once-a-week arm was 17.7 months (95% CI, 0.42 to 35.05 months) and in the once-every-3-weeks arm, 28.6 months (95% CI, 15.90 to 41.30 months); HR, 1.24 (95% CI, 0.89 to 1.73); P = .21. Estimated median overall survival in the once-a-week arm was 39.5 months and was not reached in the once-every-3-weeks arm (HR, 1.14 [95% CI, 0.79 to 1.65]; P = .48). Conclusion Once-every-3-weeks cisplatin at 100 mg/m² resulted in superior LRC, albeit with more toxicity, than did once-a-week cisplatin at 30 mg/m², and should remain the preferred chemoradiotherapy regimen for LAHNSCC in the adjuvant setting.

The comparison of acute toxicity in 2 treatment courses: Three-weekly and weekly cisplatin treatment administered with radiotherapy in patients with head and neck squamous cell carcinoma

The most appropriate cisplatin treatment schedule delivered with radiotherapy in patients with head and neck squamous cell carcinoma (HNSCC) is unknown. The aim of this study was to compare the acute toxicity and its impact on the course of the treatment, administered cisplatin and radiation doses, the length of hospitalization and supportive drugs administration in patients with HNSCC receiving 2 different cisplatin treatment schedules administered with radiotherapy.In this retrospective analysis, 104 patients with HNSCC were enrolled. Patients received radiation concurrently with 100 mg/m cisplatin administered 3-weekly (n = 50; group A) or 35 to 40 mg/m cisplatin administered weekly (n = 54; group B). Chemoradiotherapy was performed in locally and/or regionally advanced disease (stage III-IV), in a definitive radical upfront setting (71.1%) or after surgical resection in patients with high-risk factors (28.8%).Both study groups were equally distributed in terms of age, gender, stage of the disease, Eastern Cooperative Oncology Group performance score, chronic diseases and primary tumor site. The schedule of cisplatin dosing did not influence the duration of hospitalization, the number of additional supportive drugs (antibiotics, opioids) administered or total doses of received radiotherapy. However, postponement of radiotherapy due to adverse events was significantly more frequent in patients treated with 35/40 mg/m (55.56% vs 32%; P = .015). Furthermore, patients treated with weekly treatment schedule received lower total cisplatin dose (160 mg/m) in comparison to those treated with the 3-weekly schedule (200 mg/m). Grade 3 and 4 mucositis occurred more frequently in patients treated in group A (70% vs 50%; P = .037). Leukopenia was also observed more frequently in group A (88% vs 72.2%; P = .04), however there was no difference in grade 3/4 leukopenia between both study arms. There was no statistically significant difference in any other adverse effects.These results do not demonstrate the advantage of modified weekly schedule over standard 3-weekly cisplatin treatment plan. However, severe mucositis occurred more frequently in patients receiving 3-weekly cisplatin, both chemotherapy schedules seemed to present similar toxicity. Due to conflicting efficacy and toxicity, the results and compliance of weekly and 3-weekly cisplatin schedules should be evaluated in further randomized, controlled trials and retrospective studies.

The evidence on effectiveness of weekly vs triweekly cisplatin concurrent with radiotherapy in locally advanced head and neck squamous cell carcinoma (HNSCC): a systematic review and meta-analysis

OBJECTIVE

This study aims to synthesize the current available evidences on the effectiveness of weekly vs triweekly cisplatin concurrent with radiotherapy in the primary and adjuvant treatment of locally advanced head and neck squamous cell carcinoma (HNSCC).

METHODS

A systematic review and meta-analysis of literature were undertaken to assess the effectiveness of weekly vs triweekly schedule in primary and adjuvant treatment for HNSCC with adverse risk features. Search of relevant articles from electronic database from 2000 to March 2016 and appraisal of studies were done.

RESULTS

Only one randomized controlled trial (RCT) and six retrospective studies were included in this review. The RCT showed less severe mucositis (75 vs 38.5%, p = 0.012) and more patients receiving at least 200 mg/m² (62.5% vs 88.5%, p = 0.047) of cisplatin in triweekly arm. There was no difference in 1-year progression-free survival (60% vs 71.1%, p = 0.806) and 1-year overall survival (OS) (71.6 vs 79.3%, p = 0.978) between the weekly and triweekly arm. Pooling of data from six studies showed no difference in 5-year progression-free survival (RR 0.84, 95%, CI 0.67-1.07), 5-year OS (RR 0.88, 95% CI 0.73-1.07), severe renal events (RR 0.66, 95% CI 0.42-1.04), severe mucositis (RR 0.92, 95% CI 0.71-1.21), severe dermatitis (RR 0.61, 95% CI 0.37-1.03), treatment interruptions (RR 1.06, 95% CI 0.74-1.52) and number of patients receiving at least 200 mg/m² (RR 0.83, 95% CI 0.67-1.03).

CONCLUSION

The current evidence showed that weekly schedule is not superior to triweekly in improving oncological outcomes and decreasing early effects of treatment. In the absence of compelling data, triweekly schedule should remain the standard of care while more RCTs are warranted. Advances in knowledge: While some have proposed that low-dose weekly cisplatin is safer and less toxic, this study emphasized that there is no difference in acute toxicity of the two schedules and it is safe to utilize high-dose cisplatin every 3 weeks to reach the threshold dose of 200 mg/m² faster. Uniquely, this study excluded nasopharyngeal cancer patients as the biology and treatment response are different with other HNSCC.

Weekly Low-Dose Versus Three-Weekly High-Dose Cisplatin for Concurrent Chemoradiation in Locoregionally Advanced Non-Nasopharyngeal Head and Neck Cancer: A Systematic Review and Meta-Analysis of Aggregate Data

BACKGROUND

Three-weekly high-dose cisplatin (100 mg/m²) is considered the standard systemic regimen given concurrently with postoperative or definitive radiotherapy in locally advanced squamous cell carcinoma of the head and neck (LA-SCCHN). However, due to unsatisfactory patient tolerance, various weekly low-dose schedules have been increasingly used in clinical practice. The aim of this meta-analysis was to compare the efficacy, safety, and compliance between these two approaches.

MATERIALS AND METHODS

We systematically searched literature for prospective trials of patients with LA-SCCHN who received postoperative or definitive conventionally fractionated concurrent chemoradiation. Radiation doses were usually 60-66 gray (Gy) in the postoperative setting and 66-70 Gy in the definitive setting. Standard, three-weekly high-dose cisplatin (100 mg/m², 3 doses) was compared with the weekly low-dose protocol (≤50 mg/m², ≥6 doses). The primary endpoint was overall survival. Secondary outcomes comprised response rate, acute and late adverse events, and treatment compliance.

RESULTS

Fifty-two studies with 4,209 patients were included in two separate meta-analyses according to the two clinical settings. There was no difference in treatment efficacy as measured by overall survival or response rate between the chemoradiation settings with low-dose weekly and high-dose three-weekly cisplatin regimens. In the definitive treatment setting, the weekly regimen was more compliant and significantly less toxic with respect to severe (grade 3-4) myelosuppression (leukopenia p = .0083; neutropenia p = .0024), severe nausea and/or vomiting (p < .0001), and severe nephrotoxicity (p = .0099). Although in the postoperative setting the two approaches were more equal in compliance and with clearly less differences in the cisplatin-induced toxicities, the weekly approach induced more grade 3-4 dysphagia (p = .0026) and weight loss (p < .0001).

CONCLUSION

In LA-SCCHN, current evidence is insufficient to demonstrate a meaningful survival difference between the two dosing regimens. Prior to its adoption into routine clinical practice, the low-dose weekly approach needs to be prospectively compared with the standard three-weekly high-dose schedule.

IMPLICATIONS FOR PRACTICE

Given concurrently with conventional radiotherapy in locally advanced head and neck cancer, high-dose three-weekly cisplatin has often been replaced with weekly low-dose infusions to increase compliance and decrease toxicity. The present meta-analysis suggests that both approaches might be equal in efficacy, both in the definitive and postoperative settings, but differ in toxicity. However, some toxicity data can be influenced by unbalanced representation, and the conclusions are not based on adequately sized prospective randomized studies. Therefore, low-dose weekly cisplatin should not be used outside clinical trials but first prospectively studied in adequately sized phase III trials versus the high-dose three-weekly approach.

Three Weekly Versus Weekly Cisplatin as Radiosensitizer in Head and Neck Cancer: a Decision Dilemma

Cisplatin-based concurrent chemoradiation plays an undisputed key role as definitive treatment in unresectable patients with locally advanced squamous cell carcinoma head and neck or as an organ preservation strategy. Treatment with 100 mg/m2 3-weekly cisplatin is considered the standard of care but is often associated with several adverse events. The optimum drug schedule of administration remains to be defined and presently, there is insufficient data limiting conclusions about the relative tolerability of one regimen over the other. This review addresses regarding the optimal dose schedule of cisplatin focusing mainly on three-weekly and weekly dose of cisplatin based concurrent chemoradiotherapy in locally advanced head and neck cancer with an emphasis on mucositis, dermatitis, systemic toxicity, compliance, and treatment interruptions. To derive a definitive conclusion, large prospective randomized trials are needed directly comparing standard 3-weekly cisplatin (100 mg/m2) with weekly schedule (30 - 40 mg/m2) of concurrent cisplatin based chemoradiotherapy in locally advanced squamous cell carcinoma head and neck.

A Comparative Study on Weekly Versus Three Weekly Cisplatinum Based Chemoradiation in Locally Advanced Head and Neck Cancers

INTRODUCTION

Head and Neck Cancers constitute around 30% of cancers occurring in India and majority of cases present with locoregionally advanced disease. Cisplatin based concurrent chemoradiation is the most common modality of definitive treatment in these advanced cases. However, it is unclear regarding priority of weekly versus three weekly cisplatin based concurrent chemoradiation schedule in treatment of such advanced diseases.

AIM

To evaluate the efficacy in terms of response, locoregional control, and disease status in both the arms, and to compare the acute and late toxicity in both arms.

MATERIALS AND METHODS

Thirty untreated patients of locally advanced Squamous Cell Carcinoma of head and neck were randomized into two arms: Arm A (n=15) patients received injection cisplatin 30 mg/m² weekly along with radiation; Arm B (n=15) patients received injection cisplatin 100 mg/m² on a three weekly basis along with radiation. Radiotherapy was delivered to a total dose of 66 Gy in conventional fractionation schedule in telecobalt machine.

RESULTS

Major toxicities included mucositis, dermatitis, vomiting, neutropenia, and anaemia. There was a trend towards increase in grade-III leukopenia and grade-III dermatitis in arm A compared to arm B, and increase in grade-III mucositis and grade-III vomiting in arm B in comparison to arm A although statistically not significant. Within a median follow-up of seven months, in arm A complete response was 73.33% (11/15) and partial response was 26.67%; whereas in arm B complete response was 85.71% (12/14) and partial response was 14.29%, which was not statistically significant. However, there was a trend towards better efficacy in arm B.

CONCLUSION

We conclude that, weekly cisplatin arm is as good as three weekly cisplatin arms. But efficacy is not statistically significant. However, there was a trend of three weekly cisplatin arms towards better efficacy, with comparable haematological and mucosal toxicities.

Primary Concurrent Chemoradiation in Head and Neck Cancers with Weekly Cisplatin Chemotherapy: Analysis of Compliance, Toxicity and Survival

Introduction Concurrent chemoradiation is the standard of care in inoperable locally advanced squamous cell head and neck cancers. The most widely accepted schedule of concomitant cisplatin is 100mg/m² given on a 3 weekly basis but the optimal regime is unknown.

Objective The objective of this study is to assess the tolerability, compliance, and clinical outcomes of weekly cisplatin (40mg/m²).

Methods During the period of January 2007–December 2009, we analyzed retrospectively 122 patients with histologically proven squamous cell carcinoma of head and neck (nasopharynx, oropharynx, larynx, hypopharynx, and oral cavity) treated with definitive chemoradiation. All patients received 63 Gy in 30 daily fractions with concomitant weekly cisplatin 40mg/m². We assessed treatment toxicities and patient compliance. We estimated overall survival using the Kaplan-Meier method.

Results Sixty-eight percent of patients managed to complete all six cycles of chemotherapy while 87% of patients completed at least 5 cycles of weekly cisplatin. Incidence of grade 3/4 toxicity was as follows: mucositis 33%, dermatitis 41%, dysphagia 15%, mouth/neck pain 17%, neutropenia 2%, and renal impairment 3%. 53% patients required at least one hospital admission for symptom control. The 5-year overall survival rate was 60%.

Conclusion Concurrent chemoradiotherapy using weekly cisplatin at 40mg/m² per week is an effective, well tolerated regimen allowing most patients to receive at least 5 cycles of chemotherapy. However, a phase III randomized control trial comparing the standard dose of 100mg/m² cisplatin tri-weekly with a weekly regimen is needed to establish the long term clinical outcome.

Radiotherapy potentiation with weekly cisplatin compared to standard every 3 weeks cisplatin chemotherapy for locoregionally advanced head and neck squamous cell carcinoma

Background

Despite its toxicity, cisplatin every 3 weeks (q3w) is the standard potentiation of chemo-radiotherapy for head and neck squamous cell carcinoma. This study aimed to determine whether weekly cisplatin (q1w) could be a safe and effective alternative.

Patients and methods

Two hundred and sixty-two patients with head and neck squamous cell carcinoma, irradiated in our institution with cisplatin (q1w or q3w) between January 2004 and December 2008, were retrospectively included. Overall survival (OS) and progression-free survival (PFS) were evaluated. Survival distributions were estimated by Kaplan–Meier method and compared using the log-rank test. Prognostic effect of chemo-radiotherapy was explored using Cox model.

Results

A total of 165 and 97 patients received q1w and q3w cisplatin, respectively. Median age, stage at diagnosis, alcohol consumption, intensity-modulated radiation therapy use, median weight, and renal failure before radiotherapy were significantly different, showing lower risk in the q3w group. Q3w cisplatin was found to be more toxic in terms of weight loss, renal failure, worse chemotherapy plan completion, and grade 3/4 mucositis and dermatitis, with more patients requiring analgesics, secondary hospitalization, and radiotherapy interruption (≥3 days), and patients affected by long-term toxicities. With a median follow-up of 73 months (95% confidence interval [CI] [68.9–76.2]), OS was found to be significantly better with q3w (5 years OS: 62.3%; 95% CI [51.6–71.3]) than with q1w cisplatin (5 years OS: 52.6%; 95% CI [44.5–60.0]) (log-rank P=0.0146). More number of patients treated according to the q1w schedule experienced a recurrence: 47.3% vs 30.9% (P=0.009). Thus, the PFS for q3w schedule was found to be globally better (5 years PFS: 55.8%; 95% CI [45.0–65.3]) than for q1w schedule (5 years PFS: 43.6%; 95% CI [35.9–51.0]) (log-rank P=0.0161). However, both multivariate analyses, OS and PFS, produce no significant hazard ratio for chemo-radiotherapy modality once adjusted on unbalanced covariates according to the descriptive analysis.

Conclusion

Though q1w seemed to be safer than q3w according to the descriptive analysis, multivariate analyses failed to conclude about its efficiency. Therefore, we conclude that the q3w schedule should remain the standard and prospective comparisons are needed.

Management of locally advanced HPV-related oropharyngeal squamous cell carcinoma: where are we?

HPV-related (HPV+) oropharyngeal cancer (OPC) has a better prognosis compared to HPV unrelated (HPV-) OPC. This review summarizes and discusses several of the controversies regarding the management of HPV+ OPC, including the mechanism of its treatment sensitivity, modern surgical techniques, chemotherapy regimens, and treatment de-intensification protocols. We also discuss and reconsider potential adverse prognostic factors such as tumor EGFR expression, tumor hypoxia, and patient smoking history, as well as the significance of retropharyngeal adenopathy. Finally, we discuss elective nodal treatment of uninvolved lymph node stations. While this review does not exhaust all controversies related to the management of HPV+ OPC, it aims to highlight some of the most clinically relevant ones.

Cumulative cisplatin dose in concurrent chemoradiotherapy for head and neck cancer: A systematic review

BACKGROUND

The optimal cumulative dose and timing of cisplatin administration in various concurrent chemoradiotherapy protocols for nonmetastatic head and neck squamous cell carcinoma (HNSCC) has not been determined.

METHODS

The absolute survival benefit at 5 years of concurrent chemoradiotherapy protocols versus radiotherapy alone observed in prospective randomized trials reporting on the use of cisplatin monochemotherapy for nonnasopharyngeal HNSCC was extracted. In the case of nonrandomized studies, the outcome results at 2 years were compared between groups of patients receiving different cumulative cisplatin doses.

RESULTS

Eleven randomized trials and 7 nonrandomized studies were identified. In 6 definitive radiotherapy phase III trials, a statistically significant association (p = .027) between cumulative cisplatin dose, independent of the schedule, and overall survival benefit was observed for higher doses.

CONCLUSION

Results support the conclusion that the cumulative dose of cisplatin in concurrent chemoradiation protocols for HNSCC has a significant positive correlation with survival. © 2015 Wiley Periodicals, Inc. Head Neck 38: E2151-E2158, 2016.

Pretreatment Epstein-Barr virus DNA load and cumulative cisplatin dose intensity affect long-term outcome of nasopharyngeal carcinoma treated with concurrent chemotherapy: experience of an institute in an endemic area

BACKGROUND

We retrospectively compared the long-term efficacy of concurrent chemoradiotherapy (CCRT) regimens (docetaxel vs. cisplatin), total dose intensity of cisplatin (> 200 vs. ≤ 200 mg/m2) and pretreatment plasma levels of Epstein-Barr virus (EBV) DNA for nasopharyngeal carcinoma (NPC), and investigated the prognostic factors.

METHODS

We enrolled 214 patients diagnosed with NPC and treated with CCRT. 41 patients received weekly docetaxel and 173 weekly cisplatin. 62 received cumulative cisplatin of ≤ 200 mg/m2 and 111, > 200 mg/m2. Pretreatment levels of EBV DNA were available for 155 patients.

RESULTS

Patients receiving concurrent weekly docetaxel and cisplatin had similar 5-year rates for overall survival (OS) (p = 0.306), progression-free survival (PFS) (p = 0.133), distant failure-free survival (DFS) (p = 0.110), and locoregional failure-free survival (LFS) (p = 0.452). Cumulative cisplatin of > 200 mg/m2 improved the 5-year rates of PFS (p = 0.018) and DFS (p = 0.042) significantly in comparison with cumulative cisplatin of ≤ 200 mg/m2. EBV DNA levels of ≥ 1,500 copies/ml was closely associated with poor DFS (p = 0.011), PFS (p = 0.006), and OS (p = 0.004).

CONCLUSIONS

Weekly cisplatin was well tolerated in CCRT, during which cumulative cisplatin of > 200 mg/m2 improved PFS and DFS. The long-term efficacy of concurrent docetaxel was similar to that of concurrent cisplatin. The EBV DNA level was the most significant prognostic factor.

Analysis of ECOG performance status in head and neck squamous cell carcinoma patients: association with sociodemographical and clinical factors, and overall survival

PURPOSE

In the present study, we analyzed sociodemographical and clinical factors, and the Eastern Cooperative Oncology Group performance status (ECOG-PS) scale in head and neck squamous cell carcinoma (HNSCC) patients. We evaluated the impact of a range of variables on overall survival.

METHODS

We investigated a sample of HNSCC patients (n = 671), using sociodemographical and clinical information, and survival data collected from a review of epidemiological, clinical, and treatment reports. Statistical associations were analyzed by bivariate and multivariate statistical tests. Statistical significance was set at p < 0.05.

RESULTS

Of patients 85.4% recorded good ECOG-PS scores. Poor ECOG-PS scores were associated with the covariates indicative of dysphagia [odd ratios (OR) = 2.660, CI 95% = 1.661–4.260, p = 0.000] and large-size malignant disease (T3–T4; OR = 5.337, CI 95% = 2.251–12.652, p = 0.000). Overall survival analysis revealed that ECOG-PS scores (OR = 1.879, CI 95% = 1.162–3.038, p = 0.010), tumor size (OR = 1.665, CI 95% = 1.035–2.680, p = 0.036), and the presence of cervical metastasis (OR = 3.145, CI 95% = 2.008–4.926, p = 0.000) were independent predictors.

CONCLUSION

Evaluation of physical consumption in head and neck cancer patients at diagnosis may indicate a more aggressive type of malignant disease. Thus, the ECOG-PS scale may help to identify HNSCC patients in need of rapid referral, who may benefit from specific therapeutic and rehabilitative interventions.

The comparison between weekly and three-weekly cisplatin delivered concurrently with radiotherapy for patients with postoperative high-risk squamous cell carcinoma of the oral cavity

Background

The aim of this study was to compare the outcomes of postoperative adjuvant concomitant chemoradiotherapy using two different schedules of cisplatin for patients with high-risk oral squamous cell carcinoma (OSCC).

Methods

From Feb. 2008 to Aug. 2010, 55 patients with high-risk OSCC were included in this study. Patients were randomized into treatment groups that either received 100 mg/m² cisplatin once every 3 weeks (arm A) or 40 mg/m² cisplatin once per week (arm B). All patients were irradiated with 66 Gy in 33 fractions.

Results

Of the 50 eligible patients, 26 were assigned to arm A, and 24 were assigned to arm B. Both groups of patients received the same mean doses of radiotherapy and cisplatin. However, 88.5% of patients in arm A and 62.5% of those in arm B (p = 0.047) received ≥ 200 mg/m² of cisplatin in total. The overall toxicity was significantly greater in arm B (p = 0.020), and all of the grade 4 toxicities occurred in patients in arm B.

Conclusions

Three-weekly high-dose cisplatin treatment showed higher compliance, and lower acute toxicity compared to weekly low-dose cisplatin treatment.

Phase III study of radiation therapy with or without cis-platinum in patients with unresectable squamous or undifferentiated carcinoma of the head and neck: an intergroup trial of the Eastern Cooperative Oncology Group (E2382)

PURPOSE

The Head and Neck Intergroup conducted a Phase III randomized trial to determine whether the addition weekly cisplatin to daily radiation therapy (RT) would improve survival in patients with unresectable squamous cell head-and-neck carcinoma.

METHODS AND MATERIALS

Eligible patients were randomized to RT (70 Gy at 1.8-2 Gy/day) or to the identical RT with weekly cisplatin dosed at 20 mg/m(2). Failure-free survival (FFS) and overall survival (OS) curves were estimated with the Kaplan-Meier method and compared with the log rank test.

RESULTS

Between 1982 and 1987, 371 patients were accrued, and 308 patients were found eligible for analysis. Median follow-up was 62 months. The median FFS was 6.5 and 7.2 months for the RT and RT + cisplatin groups, respectively (p = 0.30). The p value for the treatment difference was p = 0.096 in multivariate modeling of FFS (compared to a p = 0.30 in univariate analysis). Expected acute toxicities were significantly increased with the addition of cisplatin except for in-field RT toxicities. Late toxicities were not significantly different except for significantly more esophageal (9% vs. 3%, p = 0.03) and laryngeal (11% vs. 4%, p = 0.05) late toxicities in the RT + cisplatin group.

CONCLUSION

The addition of concurrent weekly cisplatin at 20 mg/m(2) to daily radiation did not improve survival, although there was evidence of activity. Low-dose weekly cisplatin seems to have modest tumor radiosensitization but can increase the risk of late swallowing complications.

Radical radiotherapy with concurrent weekly cisplatin in loco-regionally advanced squamous cell carcinoma of the head and neck: a single-institution experience

BACKGROUND

The dominant pattern of failure for squamous cell carcinoma of head and neck remains loco-regional, although distant metastases are now being increasingly documented. Radical radiotherapy with concurrent chemotherapy is contemporary standard of care in the non-surgical management of these loco-regionally advanced cancers, based on large randomized controlled trials utilizing high-dose cisplatin (80-100 mg/m2) cycled every three-weekly during definitive radiotherapy. Although efficacious, this is associated with high acute morbidity necessitating intensive supportive care with attendant resource implications. The aim of this retrospective study was to assess the efficacy and acute toxicity of an alternative schedule i.e. concurrent weekly cisplatin-based radical radiotherapy and it's potential to be an optimal regimen in advanced head and neck cancers.

METHODS

Outcome data of patients with Stage III & IV head and neck squamous cell carcinoma, excluding nasopharynx, planned for radical radiotherapy (66-70 Gy) with concurrent weekly cisplatin (30 mg/m2) treated in a single unit between 1996-2004 was extracted.

RESULTS

The dataset consisted of 264 patients with a median age of 54 years. The median radiotherapy dose was 70 Gy (range 7.2-72 Gy) and median number of chemotherapy cycles was 6 (range 1-7). Two-thirds (65%) of patients received > or = 85% of planned cisplatin dose. With a mean follow-up of 19 months, the 5-year local control; loco-regional control; and disease free survival was 57%; 46%; and 43% respectively. Acute grade 3 or worse mucositis and dermatitis was seen in 77 (29%) and 92 (35%) patients respectively, essentially in patients receiving doses > or = 66 Gy and 6 or more cycles of chemotherapy. Other toxicities (hematologic, nausea and vomiting) were mild and self-limiting. Overall, the acute toxicity of this concurrent weekly chemo-radiation regimen though mildly increased did not mandate intensive supportive care. Stage grouping, primary site, and intensity of treatment were significant predictors of loco-regional control and disease free survival.

CONCLUSION

Radical radiotherapy with concurrent weekly cisplatin has moderate efficacy and acceptable acute toxicity with potential to be an optimal regimen in loco-regionally advanced squamous cell carcinoma of the head and neck, particularly in limited-resource settings. Stage grouping, primary site, and treatment intensity are important determinants of outcome.