Adjuvant intravenous methotrexate or definitive radiotherapy alone for advanced squamous cancers of the oral cavity, oropharynx, supraglottic larynx or hypopharynx

Interventions for the treatment of oral cavity and oropharyngeal cancer: chemotherapy

BACKGROUND

Oral cavity and oropharyngeal cancers are the most common cancers arising in the head and neck. Treatment of oral cavity cancer is generally surgery followed by radiotherapy, whereas oropharyngeal cancers, which are more likely to be advanced at the time of diagnosis, are managed with radiotherapy or chemoradiation. Surgery for oral cancers can be disfiguring and both surgery and radiotherapy have significant functional side effects. The development of new chemotherapy agents, new combinations of agents and changes in the relative timing of surgery, radiotherapy, and chemotherapy treatments may potentially bring about increases in both survival and quality of life for this group of patients. This review updates one last published in 2011.

OBJECTIVES

To determine whether chemotherapy, in addition to radiotherapy and/or surgery for oral cavity and oropharyngeal squamous cell carcinoma results in improved overall survival, improved disease-free survival and/or improved locoregional control, when incorporated as either induction therapy given prior to locoregional treatment (i.e. radiotherapy or surgery), concurrent with radiotherapy or in the adjuvant (i.e. after locoregional treatment with radiotherapy or surgery) setting.

SEARCH METHODS

An information specialist searched 4 bibliographic databases up to 15 September 2021 and used additional search methods to identify published, unpublished and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) where more than 50% of participants had primary tumours in the oral cavity or oropharynx, and that evaluated the addition of chemotherapy to other treatments such as radiotherapy and/or surgery, or compared two or more chemotherapy regimens or modes of administration.

DATA COLLECTION AND ANALYSIS

For this update, we assessed the new included trials for their risk of bias and at least two authors extracted data from them. Our primary outcome was overall survival (time to death from any cause). Secondary outcomes were disease-free survival (time to disease recurrence or death from any cause) and locoregional control (response to primary treatment). We contacted trial authors for additional information or clarification when necessary.

MAIN RESULTS

We included 100 studies with 18,813 participants. None of the included trials were at low risk of bias.  For induction chemotherapy, we reported the results for contemporary regimens that will be of interest to clinicians and people being treated for oral cavity and oropharyngeal cancers. Overall, there is insufficient evidence to clearly demonstrate a survival benefit from induction chemotherapy with platinum plus 5-fluorouracil prior to radiotherapy (hazard ratio (HR) for death 0.85, 95% confidence interval (CI) 0.70 to 1.04, P = 0.11; 7427 participants, 5 studies; moderate-certainty evidence), prior to surgery (HR for death 1.06, 95% CI 0.71 to 1.60, P = 0.77; 198 participants, 1 study; low-certainty evidence) or prior to concurrent chemoradiation (CRT) with cisplatin (HR for death 0.71, 95% CI 0.37 to 1.35, P = 0.30; 389 participants, 2 studies; low-certainty evidence). There is insufficient evidence to support the use of an induction chemotherapy regimen with cisplatin plus 5-fluorouracil plus docetaxel prior to CRT with cisplatin (HR for death 1.08, 95% CI 0.80 to 1.44, P = 0.63; 760 participants, 3 studies; low-certainty evidence).  There is insufficient evidence to support the use of adjuvant chemotherapy over observation only following surgery (HR for death 0.95, 95% CI 0.73 to 1.22, P = 0.67; 353 participants, 5 studies; moderate-certainty evidence). Among studies that compared post-surgical adjuvant CRT, as compared to post-surgical RT, adjuvant CRT showed a survival benefit (HR 0.84, 95% CI 0.72 to 0.98, P = 0.03; 1097 participants, 4 studies; moderate-certainty evidence). Primary treatment with CRT, as compared to radiotherapy alone,  was associated with a reduction in the risk of death (HR for death 0.74, 95% CI 0.67 to 0.83, P < 0.00001; 2852 participants, 24 studies; moderate-certainty evidence).  AUTHORS' CONCLUSIONS: The results of this review demonstrate that chemotherapy in the curative-intent treatment of oral cavity and oropharyngeal cancers only seems to be of benefit when used in specific circumstances together with locoregional treatment. The  evidence does not show a clear survival benefit from the use of induction chemotherapy prior to radiotherapy, surgery or CRT. Adjuvant CRT reduces the risk of death by 16%, as compared to radiotherapy alone. Concurrent chemoradiation as compared to radiation alone is associated with a greater than 20% improvement in overall survival; however, additional research is required to inform how the specific chemotherapy regimen may influence this benefit.

Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): An update on 107 randomized trials and 19,805 patients, on behalf of MACH-NC Group

BACKGROUND AND PURPOSE

The Meta-Analysis of Chemotherapy in squamous cell Head and Neck Cancer (MACH-NC) demonstrated that concomitant chemotherapy (CT) improved overall survival (OS) in patients without distant metastasis. We report the updated results.

MATERIALS AND METHODS

Published or unpublished randomized trials including patients with non-metastatic carcinoma randomized between 1965 and 2016 and comparing curative loco-regional treatment (LRT) to LRT + CT or adding another timing of CT to LRT + CT (main question), or comparing induction CT + radiotherapy to radiotherapy + concomitant (or alternating) CT (secondary question) were eligible. Individual patient data were collected and combined using a fixed-effect model. OS was the main endpoint.

RESULTS

For the main question, 101 trials (18951 patients, median follow-up of 6.5 years) were analyzed. For both questions, there were 16 new (2767 patients) and 11 updated trials. Around 90% of the patients had stage III or IV disease. Interaction between treatment effect on OS and the timing of CT was significant (p < 0.0001), the benefit being limited to concomitant CT (HR: 0.83, 95%CI [0.79; 0.86]; 5(10)-year absolute benefit of 6.5% (3.6%)). Efficacy decreased as patients age increased (p_trend = 0.03). OS was not increased by the addition of induction (HR = 0.96 [0.90; 1.01]) or adjuvant CT (1.02 [0.92; 1.13]). Efficacy of induction CT decreased with poorer performance status (p_trend = 0.03). For the secondary question, eight trials (1214 patients) confirmed the superiority of concomitant CT on OS (HR = 0.84 [0.74; 0.95], p = 0.005).

CONCLUSION

The update of MACH-NC confirms the benefit and superiority of the addition of concomitant CT for non-metastatic head and neck cancer.

Carboplatin, Continuous Infusion Fluorouracil and Mid-cycle High-dose Methotrexate as Initial Treatment in Patients with Locally Advanced Head and Neck Cancer

Forty-nine patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN) were treated with 3 cycles of induction chemotherapy prior to definitive local treatment (surgery and/or radiation therapy). Chemotherapy consisted of carboplatin 300 mg/m2 on day 1, fluorouracil 1000 mg/m2 daily as a continuous infusion on days 1 to 5 and high-dose methotrexate 1.2 g/m2 with leucovorin rescue on day 14. After completing the induction chemotherapy, 9 patients (18%) achieved a complete remission (CR), 26 (54%) a partial remission (PR), 7 had stable disease and 7 a progression. The response rates increased to 53% CR and 18% PR following locoregional treatment. Survival at 12 months was 61% and its actuarial probability at 24 months 31%. Median time to progression was 14 months. Toxicity from chemotherapy was generally mild. Nausea was observed in 35%, vomiting in 26%, stomatitis in 57%, anemia in 22%, leukopenia in 36%, thrombocytopenia in 26% and diarrhea in 6% of the patients. In conclusion, the combination of carboplatin, 5-day continuous-infusion fluorouracil and mid-cycle high-dose methotrexate is a moderately effective, well tolerated regimen in patients with SCCHN but does not seem superior to the combination of carboplatin and fluorouracil only.

Induction chemotherapy for squamous cell carcinomas of the oral cavity: A cumulative meta-analysis

Induction chemotherapy (ICT) is a controversial treatment for head and neck squamous cell carcinomas (HNSCC). Despite numerous randomized controlled trials (RCTs), a majority do not have enough statistical power alone to conclude ICT's treatment value among oral squamous carcinoma patients (OSCC) since many addressed HNSCC as one entity instead of by specific subtypes. By performing a systematic review and cumulative meta-analysis, we aim to determine the benefits of ICT in OSCC therapy. A literature search identified for RCTs comparing OSCC patients who received ICT against those without. Log-hazard ratio, and relative risk were used for comparison. Heterogeneity was determined using the I(2) statistic package. The primary endpoint was overall survival (OS), followed by disease-free survival (DFS), locoregional recurrence (LRR) and distant metastasis (DM) as secondary endpoints.

RESULTS

27 randomized trials were included for analysis (n=2872 patients). The shortest median follow-up was 15months whereas the longest was 11.5years. ICT does not improve OS (HR=0.947, 95% CI 0.85-1.05, p=0.318), DFS (RR=1.05, 95% CI 0.92-1.21, p=0.462) and DM (RR=0.626, CI 95% 0.361-1.086, p=0.096) compared to locoregional treatment alone. However, there was a significant improvement to LRR (RR=0.778, 95% CI 0.622-0.972, p=0.027). There is no evidence ICT improves survival outcomes for OSCC patients. However, ICT reduces locoregional recurrence of OSCC, which may need further verification.

Induction chemotherapy decreases the rate of distant metastasis in patients with head and neck squamous cell carcinoma but does not improve survival or locoregional control: a meta-analysis

The definitive effect of induction chemotherapy (IC) on locally advanced head and neck squamous cell carcinoma (HNSCC) remains uncertain and although randomized controlled trials are supposed to provide high levels evidence for clinical guidelines, the data thus far has been conflicted. In an effort to elucidate the potential benefit of IC, a meta-analysis of randomized controlled trials (1965-2011) was performed investigating the impact of IC on survival, locoregional control, distant metastasis, and toxicity in HNSCC. Kaplan-Meier curves were read by a digitizing software-Engauge Digitizer. Data combination was performed using the software-RevMan and trial level log hazard ratio (HR) and variance were pooled and presented. Among the 40 eligible trials, 28 trials encompassing 4189 patients receiving locoregional treatment with or without IC were included in the analysis. The cumulative benefit of IC on overall survival and distant metastasis was 6% (HR = 0.94, 95%CI = 0.87-1.01, P = 0.11) and 7% (95%CI = 0-13%, P = 0.05) respectively while for locoregional control a benefit was not observed as seen by the -2% (95%CI = -11% to 8%, P = 0.73) improved control rate. In a subsite analysis specifically for laryngeal preservation, IC did not significantly improve survival (P = 0.47). There was a significant benefit from the cisplatin and 5-fluorouracil (PF) protocols with an increase in overall survival of 13% (HR = 0.87, 95%CI = 0.78-0.97, P = 0.01), and a reduction in the 5-year distant metastasis rate of 11% (95%CI = 0-21%, P = 0.04). The occurrence of grade 3/4 mucositis, leukopenia and emesis was significantly lower in patients receiving IC compared to patients receiving concomitant chemoradiotherapy. In conclusion, there is not a significant benefit of the pooled IC regimens in HNSCC on survival or locoregional control. In contrast, IC does show significant benefit in the reduction of distant metastasis. When protocols using a PF regimen are analyzed independently, a significant improvement in survival and rate of distant metastases is observed while there is not a benefit in locoregional control. The routine use of IC is still debatable. IC could be applied on larynx preservation strategy.

The Clinical Research Center: a vital part of the ACR mission

The ACR's mission statement identifies five pillars of excellence. One of its pillars is research. ACR is recognized by many as supporting one of the premier research endeavors sponsored by a professional medical society of which the ACR Clinical Research Center is the largest component. The center is comprised of four entities: ACRIN(®), RTOG(®), QRRO(®), and ACR Image Metrix™. The Clinical Research Center encompasses personnel with extensive clinical trial expertise, a state-of-the-art IT infrastructure, and an imaging and radiation oncology core laboratory. This research enterprise supports a global network of researchers in the conduct of medical imaging and radiation oncology clinical trials. This paper's focus is on the Clinical Research Center's value to the radiology and radiation oncology professions, to the practices engaged in the clinical research, and to our patients.

Acute-phase response reactants as objective biomarkers of radiation-induced mucositis in head and neck cancer

BACKGROUND

Current evaluation of radiation-induced mucositis in head and neck cancer relies on subjective scoring with interrater variability. We evaluated serum erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as objective markers of radiation-induced mucositis.

METHODS

Weekly serum CRP and ESR levels were measured in patients treated for head and neck cancer with radiation ± chemotherapy. Acute radiation toxicity was evaluated using National Cancer Institute of Canada-Common Toxicity Criteria (NCIC-CTC) version 2.0 and the Head and Neck Radiotherapy Questionnaire (HNRQ).

RESULTS

ESR and CRP levels were significantly elevated by 3 weeks (p = .01) and 6 weeks (p = .0002), respectively, and independent of age or pretreatment surgery. ESR was significantly dependent on radiation dose (p = .0004) and significantly higher with chemoradiation (p = .03).

CONCLUSION

Serum ESR and CRP rise reliably in a radiation dose-dependent manner. ESR correlated with clinical symptoms and distinguished patients receiving chemoradiation. ESR and CRP may be an objective and sensitive marker of radiation-induced mucositis.

Interventions for the treatment of oral cavity and oropharyngeal cancer: chemotherapy

BACKGROUND

Oral cavity and oropharyngeal cancers are frequently described as part of a group of oral cancers or head and neck cancer. Treatment of oral cavity cancer is generally surgery followed by radiotherapy, whereas oropharyngeal cancers, which are more likely to be advanced at the time of diagnosis, are managed with radiotherapy or chemoradiation. Surgery for oral cancers can be disfiguring and both surgery and radiotherapy have significant functional side effects, notably impaired ability to eat, drink and talk. The development of new chemotherapy agents, new combinations of agents and changes in the relative timing of surgery, radiotherapy, and chemotherapy treatments may potentially bring about increases in both survival and quality of life for this group of patients.

OBJECTIVES

To determine whether chemotherapy, in addition to radiotherapy and/or surgery for oral cavity and oropharyngeal cancer results in improved survival, disease free survival, progression free survival, locoregional control and reduced recurrence of disease. To determine which regimen and time of administration (induction, concomitant or adjuvant) is associated with better outcomes.

SEARCH STRATEGY

Electronic searches of the Cochrane Oral Health Group's Trials Register, CENTRAL, MEDLINE, EMBASE, AMED were undertaken on 1st December 2010. Reference lists of recent reviews and included studies were also searched to identify further trials.

SELECTION CRITERIA

Randomised controlled trials where more than 50% of participants had primary tumours in the oral cavity or oropharynx, and which compared the addition of chemotherapy to other treatments such as radiotherapy and/or surgery, or compared two or more chemotherapy regimens or modes of administration, were included.

DATA COLLECTION AND ANALYSIS

Eighty-nine trials which met the inclusion criteria were assessed for risk of bias and data were extracted by two or more review authors. The primary outcome was total mortality. Trial authors were contacted for additional information or for clarification.

MAIN RESULTS

There is evidence of a small increase in overall survival associated with induction chemotherapy compared to locoregional treatment alone (25 trials), hazard ratio (HR) of mortality 0.92 (95% confidence interval (CI) 0.84 to 1.00, P = 0.06). Post-surgery adjuvant chemotherapy is associated with improved overall survival compared to surgery ± radiotherapy alone (10 trials), HR of mortality 0.88 (95% CI 0.79 to 0.99, P = 0.03), and there is some evidence that this improvement may be greater with concomitant adjuvant chemoradiotherapy (4 trials), HR of mortality 0.84 (95% CI 0.72 to 0.98, P = 0.03). In patients with unresectable tumours, there is evidence that concomitant or alternating chemoradiotherapy is associated with improved survival compared to radiotherapy alone (26 trials), HR of mortality 0.78 (95% CI 0.73 to 0.83, P < 0.00001). These findings are confirmed by sensitivity analyses based on studies assessed at low risk of bias. There is insufficient evidence to identify which agent(s) and/or regimen(s) are the most effective. The additional toxicity attributable to chemotherapy in the combined regimens remains unquantified.

AUTHORS' CONCLUSIONS

Chemotherapy, in addition to radiotherapy and surgery, is associated with improved overall survival in patients with oral cavity and oropharyngeal cancers. Induction chemotherapy may prolong survival by 8 to 20% and adjuvant concomitant chemoradiotherapy may prolong survival by up to 16%. In patients with unresectable tumours, concomitant or alternating chemoradiotherapy may prolong survival by 10 to 22%. There is insufficient evidence as to which agent or regimen is most effective and the additional toxicity associated with chemotherapy given in addition to radiotherapy and/or surgery cannot be quantified.

Interventions for the treatment of oral cavity and oropharyngeal cancer: chemotherapy

BACKGROUND

Oral cavity and oropharyngeal cancers are frequently described as part of a group of oral cancers or head and neck cancer. Treatment of oral cavity cancer is generally surgery followed by radiotherapy, whereas oropharyngeal cancers, which are more likely to be advanced at the time of diagnosis, are managed with radiotherapy or chemoradiation. Surgery for oral cancers can be disfiguring and both surgery and radiotherapy have significant functional side effects, notably impaired ability to eat, drink and talk. The development of new chemotherapy agents, new combinations of agents and changes in the relative timing of surgery, radiotherapy, and chemotherapy treatments may potentially bring about increases in both survival and quality of life for this group of patients.

OBJECTIVES

To determine whether chemotherapy, in addition to radiotherapy and/or surgery for oral cavity and oropharyngeal cancer results in improved survival, disease free survival, progression free survival, locoregional control and reduced recurrence of disease. To determine which regimen and time of administration (induction, concomitant or adjuvant) is associated with better outcomes.

SEARCH STRATEGY

Electronic searches of the Cochrane Oral Health Group's Trials Register, CENTRAL, MEDLINE, EMBASE, AMED were undertaken on 28th July 2010. Reference lists of recent reviews and included studies were also searched to identify further trials.

SELECTION CRITERIA

Randomised controlled trials where more than 50% of participants had primary tumours in the oral cavity or oropharynx, and which compared the addition of chemotherapy to other treatments such as radiotherapy and/or surgery, or compared two or more chemotherapy regimens or modes of administration, were included.

DATA COLLECTION AND ANALYSIS

Trials which met the inclusion criteria were assessed for risk of bias using six domains: sequence generation, allocation concealment, blinding, completeness of outcome data, selective reporting and other possible sources of bias. Data were extracted using a specially designed form and entered into the characteristics of included studies table and the analysis sections of the review. The proportion of participants in each trial with oral cavity and oropharyngeal cancers are recorded in Additional Table 1.

MAIN RESULTS

There was no statistically significant improvement in overall survival associated with induction chemotherapy compared to locoregional treatment alone in 25 trials (hazard ratio (HR) of mortality 0.92, 95% confidence interval (CI) 0.84 to 1.00). Post-surgery adjuvant chemotherapy was associated with improved overall survival compared to surgery +/- radiotherapy alone in 10 trials (HR of mortality 0.88, 95% CI 0.79 to 0.99), and there was an additional benefit of adjuvant concomitant chemoradiotherapy compared to radiotherapy in 4 of these trials (HR of mortality 0.84, 95% CI 0.72 to 0.98). Concomitant chemoradiotherapy resulted in improved survival compared to radiotherapy alone in patients whose tumours were considered unresectable in 25 trials (HR of mortality 0.79, 95% CI 0.74 to 0.84). However, the additional toxicity attributable to chemotherapy in the combined regimens remains unquantified.

AUTHORS' CONCLUSIONS

Chemotherapy, in addition to radiotherapy and surgery, is associated with improved overall survival in patients with oral cavity and oropharyngeal cancers. Induction chemotherapy is associated with a 9% increase in survival and adjuvant concomitant chemoradiotherapy is associated with a 16% increase in overall survival following surgery. In patients with unresectable tumours, concomitant chemoradiotherapy showed a 22% benefit in overall survival compared with radiotherapy alone.

End points for new agents in induction chemotherapy for locally advanced head and neck cancers

More than 60% of patients diagnosed with squamous cell carcinoma of the head and neck present at a locally advanced stage. Although multimodality therapy has improved locoregional control, the 5-year survival rate of this population rarely exceeds 30%. In this review, we analyzed the impact of chemotherapy in the management of locally advanced head and neck cancer and we underline the potential benefit of induction chemotherapy. The Meta-Analysis of Chemotherapy in Head and Neck Cancer collaborative group has suggested a survival advantage of 5% at 5 years for platin-5-fluorouracil induction chemotherapy. We have analyzed cofactors that may affect the survival of head and neck patients and propose new end points for assessment of the efficacy of induction chemotherapy. The detrimental effect of second primary tumors on long-term results is stressed and we have suggested the use of overall 2-year survival as a surrogate end point for induction chemotherapy efficacy. Finally, we have examined the impact of new cytotoxic agents and present the promising results of new taxane-based combinations.

Stage 4 squamous cell carcinoma of the tongue in a child: complete response to chemoradiotherapy

This report describes a complete response to a chemoradiotherapy regimen in a child with an advanced and unresectable squamous cell carcinoma of the tongue. An 8-year-old girl had stage 4 squamous cell carcinoma of the tongue (T4N2M0), causing severe trismus and dysphagia. She received hyperfractionated external beam radiotherapy (total 74.4 Gy) and concomitant intravenous infusion of hydroxyurea (0.313 mg/m2 per min) for 43 days. Grade 3 mucositis and myelosuppression were the main toxicities. There was marked symptomatic improvement, and the patient achieved a complete response. She is disease-free 24 months after treatment, and all the acute symptoms have resolved. The regimen was well tolerated with acceptable toxicity and led to a complete objective response. This regimen needs further evaluation to confirm its efficacy and to ascertain its long-term effects in children.

A phase I clinical trial of prolonged infusion of hydroxyurea in combination with hyperfractionated, accelerated, external radiation therapy in patients with advanced squamous cell cancer of the head and neck

BACKGROUND

Preclinical data suggested that sustained inhibition of the anabolic enzyme, ribonucleotide reductase (RR), by hydroxyurea (HU) may be critical for the anticancer effects of the drug. A phase I trial of continuous infusion HU with concomitant hyperfractionated, accelerated radiation therapy (CHU-CHRT) was initiated to determine the maximum tolerated dose (MTD) and dose limiting toxicities (DLT) of HU in patients with locally advanced squamous cell carcinoma (SCC) of the head and neck.

METHODS

Patients were required to have histologically-documented and radiographically-staged locally advanced SCC of the hypopharynx (AJC stages II, III or IV), oropharynx (AJC stage IV), or oral cavity (AJC stage IV) not amenable to reasonable surgical resection. Eligible patients had adequate bone marrow, hepatic, and renal function and had to give informed consent. Concomitant, hyperfractionated, accelerated radiation therapy (CHRT) consisted of 1.2 Gy BID (6 hour minimum interfraction interval) on weekdays and 1.2 Gy delivered daily on the weekends to a total tumor dose of 74.4 Gy. Continuous infusion hydroxyurea (CHU) was administered at 0.25-0.375 mg/m2/min as a continuous intravenous infusion daily for 5 days with weekends days off for the duration of the radiation therapy. The dose of HU was increased by 0.125 mg/m2/min between dose levels until DLT was reached in 2/6 patients. If the primary had a complete clinical response and biopsies were negative, planned neck dissections were performed.

RESULTS

Fifteen patients were enrolled and are evaluable. The initial dose level, 0.25 mg/m2/min was tolerated by 3/3 patients. At 0.375 mg/m2/min, 3/6 patients experienced grade 3-4 infections, with one patient having a non-fatal, subendocardial infarction. At 0.313 mg/m2/min, no patient experienced DLT.

CONCLUSION

The MTD for CHU-CHRT was 0.313 mg/m2/min. The toxicities were primarily mucosal and a phase II study is in progress.

[Chemoradiotherapy of carcinomas of the upper aerodigestive tract]

The objective of this study was to review randomized trials which evaluated the effect of the radio-chemotherapy in head and neck carcinoma, and which compared radiotherapy alone vs the same local treatment plus chemotherapy. Over 40 such randomized trials have been performed, which generally showed no statistical difference between both arms. However few trials showed a benefit which is almost always in favor of the CT arm. Indeed, some trials of concomitant chemoradiotherapy have shown a statistically significant benefit in favor of the combined treatment. On the contrary, neoadjuvant chemotherapy generally leads to no detectable benefit compared to radiotherapy alone. These results have been reinforced by those of four randomized trials comparing neoadjuvant chemoradiotherapy and the same chemotherapy but given concomitantly with radiotherapy. The global effect of chemotherapy on survival of patients with head & neck squamous cell carcinoma has been recently evaluated by a meta-analysis based on individual patient data which included more than 10,000 patients from 63 randomized trials. The absolute survival rate benefit at 5 years is 4%, but is more pronounced in the concomitant combinations (8% at 5 years). In tumors classified as "T3" of the pharyngo-larynx, neoadjuvant chemotherapy followed by radiotherapy in good responders can avoid a total laryngectomy without significantly compromised survival. In the nasopharynx carcinoma, a few randomized studies have been performed, suggesting a benefit in favor of chemoradiotherapy. Finally, future randomized trials will determine what are the optimal chemoradiotherapy schedules, as well as determining what is the best radiotherapy (accelerated, hyperfractionated) to use in combination with chemotherapy.

The role of chemotherapy in head and neck cancer

We studied the effect of cytoreductive chemotherapy in head and neck cancer and analyzed it in terms of efficacy, remission rates, and duration, as well effect on survival. Single-agent chemotherapy, which formerly was used as a palliative therapy in recurrent and metastatic disease, had little affect on survival. More recently, multi-agent chemotherapy trials have shown significantly higher response rates, but this success has not translated into an added survival benefit. These findings led to the introduction of multi-agent chemotherapy into the induction (neoadjuvant) clinical setting. In these clinical circumstances, better objective response rates were found, particularly in the previously untreated patient. Although this therapy has resulted in better control of local disease, the impact on survival is not yet clear. Adjuvant chemotherapy is most useful in patients who have a high risk of relapse. Therapy appears to decrease its incidence, particularly at distant sites. Finally, chemoradiation trials have shown that this treatment provides a survival advantage, but at the cost of a significant increase in toxicity.

Long-term survival data and prognostic factors of a complete response to chemotherapy in patients with head and neck cancer treated with platinum-based induction chemotherapy: a Hellenic Co-operative oncology Group study

A group of 154 patients with locally advanced head and neck cancer, treated with platinum-based induction chemotherapy, were followed up for 5 years and several pretreatment characteristics were analyzed for possible correlation to a complete response (CR) to chemotherapy, time to progression (TTP) and overall survival (OS). Clinical stage (p = 0.0024) and a history of smoking (p = 0.0125) were selected as important prognostic factors for CR by step wise logistic regression. We also identified response to chemotherapy (p = 0.0120), age (p = 0.0066), clinical stage (p = 0.0363), N stage (p = 0.0028), and tumor grade (p = 0.0101) as significant prognostic variables for TTP. Response to chemotherapy (p < 0.0001) and age (p = 0.0017) were found also significant for OS. These long-term prognostic factors which retain their prognostic significance after several years of follow-up could be helpful in the design of future trials in this patient population.

Evolution of the Radiation Therapy Oncology Group clinical trials for head and neck cancer

During the past 25 years, the Radiation Therapy Oncology Group (RTOG) has played a major role in head and neck cancer clinical research. The major research themes for recent and currently active trials have been: (a) combined modality therapy, (b) altered fractionation radiotherapy, (c) hypoxic cell sensitizers, (d) organ preservation, (e) chemoprevention, and (f) clinical/laboratory correlations. For advanced operable disease, the RTOG showed improved local-regional control with postoperative radiotherapy as compared to preoperative radiotherapy for carcinoma of the supraglottic larynx and hypopharynx. This established the use of surgery followed by postoperative radiotherapy as the standard treatment in subsequent RTOG and Intergroup trials for operable disease. For advanced inoperable disease, the RTOG demonstrated the feasibility of testing altered fractionation radiotherapy in a multiinstitutional clinical trials setting. A Phase III trial comparing hyperfractionation and accelerated fractionation to conventional fractionation is now in progress. Phase I/II combined modality studies established the efficacy of concurrent high-dose cisplatin and radiotherapy in the treatment of advanced disease and provided the basis for further testing in Phase III trials for nasopharyngeal carcinoma, larynx preservation, and high-risk advanced operable disease. Analysis of the extensive RTOG Head and Neck Cancer database established the incidence of second malignancies and their adverse impact on patients whose initial tumors were cured by radiotherapy, and provided the basis for chemoprevention trials. Recursive partitioning analysis identified 6 distinct prognostically homogeneous patient groups based on pretreatment tumor or patient characteristics and/or treatment variables. Retrospective analysis identified tumor p105 antigen density as an independent prognostic indicator in patients irradiated for head and neck cancer. Future trials will continue to focus on the reduction of morbidity and mortality, and improvement of the quality of life of head and neck cancer patients through innovative radiotherapy delivery, multimodality approaches, use of chemical and biological modifiers, and other novel therapies, identification of clinical and biological prognostic indicators, and prevention or diminution of acute morbidity and late complications of the disease and its treatment.

Comparison of median survival times with adjustment for covariates

Brookmeyer and Crowley derived a non-parametric confidence interval for the median survival time of a homogeneous population by inverting a generalization of the sign test for censored data. The 1 - alpha confidence interval for the median is essentially the set of all values t such that the Kaplan-Meier estimate of the survival curve at time t does not differ significantly from one-half at the two-sided alpha level. Su and Wei extended this approach to the two-sample problem and derived a confidence interval for the difference in median survival times based on the Kaplan-Meier estimates of the individual survival curves and a 'minimum dispersion' test statistic. Here, I incorporate covariates into the analysis by assuming a proportional hazards model for the covariate effects, while leaving the two underlying survival curves virtually unconstrained. I generate a simultaneous confidence region for the two median survival times, adjusted to any selected value, z, of the covariate vector using a test-based approach analogous to Brookmeyer and Crowley's for the one-sample case. This region is, in turn, used to derive a confidence interval for the difference in median survival times between the two treatment groups at the selected value of z. Employment of a procedure suggested by Aitchison sets the level of the simultaneous region to a value that should yield, at least approximately, the desired confidence coefficient for the difference in medians. Simulation studies indicate that the method provides reasonably accurate coverage probabilities.

An overview of randomised controlled trials of adjuvant chemotherapy in head and neck cancer

Meta-analysis of the published results from 54 randomised controlled trials of adjuvant chemotherapy in head and neck cancer suggests that chemotherapy might increase absolute survival by 6.5% (95% confidence interval 3.1-9.9%). The odds ratio in favour of chemotherapy is 1.37 (95% confidence interval 1.24-1.5). Single-agent chemotherapy given synchronously with radiotherapy increased survival by 12.1% (95% confidence interval 5-19%). The benefit from neoadjuvant chemotherapy was less: a rate difference of 3.7% (95% confidence interval 0.9-6.5%). The results suggest that the investigation of optimal agents and scheduling for synchronous radiotherapy and chemotherapy might still be important in clinical trials in head and neck cancer.

Head and neck cancer: present status and future prospects of adjuvant chemotherapy

For more than 15 years, active clinical research and continuing efforts in the field of CT in head and neck cancer have produced a modest but definite progress and achievements in this disease. We are a long way away from producing more definitive and acceptable results and higher cure rates in this disease. The achievements of systemic CT in patients with head and neck cancers are summarized in this review. Continuing efforts and investigation are needed to study the efficacy of systemic CT in patients with resectable head and neck cancer. We are continuing to investigate the best timing and sequence of CT as part of CMT and then the efficacy of such treatment in patients with resectable cancer. Efforts are underway to improve on the results in patients with NPC and patients with unresectable disease with the use of chemotherapy as part of CMT. Efforts are also underway to consolidate and improve on the results obtained with systemic CT to preserve laryngeal function. We strongly believe that with continuation of these serious efforts further achievement and impact can be obtained with systemic CT as part of other modalities in these patients.

Chemotherapy in head and neck cancer

Chemotherapy has been used for many years as a palliative approach to advanced squamous cell carcinoma of the head and neck. Regimens employed have slowly evolved during this time, and the combination of cisplatin and 5-fluorouracil is still standard chemotherapy for such a tumour. However, clinical approaches to advanced squamous cell carcinoma of the head and neck are changing dramatically as physicians become increasingly familiar with multidisciplinary treatments. Integrating chemotherapy and radiotherapy, neo-adjuvant or adjuvant treatments and organ preservation are stimulating fields of investigation involving chemotherapy which definitely warrant further investigation.

Evidence-based recommendations against neoadjuvant chemotherapy for routine management of patients with squamous cell head and neck cancer

The objective of this study was to determine appropriate recommendations for neoadjuvant chemotherapy in the treatment of head and neck cancer (HNC). Published reports of randomized trials of neoadjuvant versus standard therapy in patients with stage III and stage IV HNC were identified by literature search. The overall trial results were analyzed using three pooling techniques: vote count, weighted median survival, and meta-analysis of published survival data. Excluded from analysis were articles on intra-arterial therapy, studies without a standard treatment control arm, studies that included adjuvant therapy, and abstracts. Twelve studies were evaluable for vote count, 11 for weighted median survival analysis, and 10 for quantitative meta-analysis. By vote count there was no observed survival difference in 7 trials, a trend favoring control in 3, a statistically significant difference favoring control in 1, and a trend favoring neoadjuvant therapy in 1. The weighted median survival was 20.9 months for control versus 20.0 months for neoadjuvant chemotherapy, with consistent trends for resectable and nonresectable disease and for chemotherapy combinations versus single agents. The common odds ratios for deaths at 12, 24, and 36 months were 1.12, 1.27, and 1.11, respectively, all in favor of control treatment. Data generated using rigorous methodological standards indicate that neoadjuvant chemotherapy should not be offered to patients with locally advanced HNC if improved survival is the outcome of interest. It is premature to recommend neoadjuvant chemotherapy to preserve organ function, although patients should be aware of this option and the limitations of the current data.

Comparison of the addition of T and N integer scores with TNM stage groups in head and neck cancer

The 1987 TNM classification system modified T and N definitions for squamous cell carcinomas of the head and neck. It did not change stage groupings (I through IV). The primary purpose of clinical staging is to divide patients into prognostically meaningful groups. The 1987 changes to the TNM T and N descriptions may not have removed the previously established heterogeneity within stage groups III and IV which existed before 1987. The development of a stage grouping system called TANIS (the T And N Integer Score), which is formed by adding the integer values of the T and N classifications, is reported herein. We compared the prognostic performance of T, N, TNM stage group, and TANIS stage for radiotherapy response and survival using data from 86 patients with newly diagnosed, measurable TNM II (oral cavity), and localized TNM III-IV squamous cell carcinomas of the head and neck, excluding nasopharynx, who were randomized to test 5-fluorouracil-methotrexate sequencing. The sequencing of chemotherapy was shown to make no difference to prognosis. All patients received 60 Gy of radiotherapy in 6 weeks. As compared to T, N, and the TNM stage group system, TANIS was the single best predictor for a complete response to radiotherapy (p = 0.0005). TANIS was also the single best predictor for survival from randomization (p = 5 x 10(-6)). With the 86 patients divided into three groups (TANIS 2 to 3, 4, and 5 to 7), TANIS provided a better prognostic discrimination than did the TNM stage grouping method (TNM II, III, and IV).(ABSTRACT TRUNCATED AT 250 WORDS)

A randomized trial of radiation therapy compared to split course radiation therapy combined with mitomycin C and 5 fluorouracil as initial treatment for advanced laryngeal and hypopharyngeal squamous carcinoma

Two hundred and twelve patients with previously untreated advanced squamous carcinoma of the larynx or hypopharynx were randomized to receive initial treatment with radiotherapy, 50 Gy in 20 fractions in 28 days or split course radiotherapy and concurrent chemotherapy, 25 Gy in 10 fractions in 14 days followed by a 4 week rest and a further 25 Gy in 10 fractions in 14 days starting on day 43; Mitomycin C was given on day 1 and day 43 and 5FU continuous infusions on days 1--4 and days 43--46. Surgery was reserved for persistent or recurrent disease. Two hundred and nine of the 212 patients randomized were included in the analyses. Outcome analyses were performed at a median follow-up interval of 4.4 years. No patients were lost to follow-up. No significant difference was found between the two arms for the end points of local relapse-free rate (p = 0.91), regional relapse-free rate (p = 0.17, adjusted) or overall survival (p = 0.86). Eight-eight patients had attempted surgical resection following radiotherapy failure. The contribution of salvage surgery to overall survival was similar for both arms of the study as was the surgical complication rate. Serious late radiation toxicity was minimal (3% in the RT group, 0% in the radiation therapy plus chemotherapy group). The result of the trial shows no advantage in terms of local control or survival for the experimental treatment arm of split course radiotherapy and concurrent chemotherapy with Mitomycin C and 5 Fluorouracil compared to radiotherapy alone.

Triple therapy for advanced squamous cell cancer of the head and neck

This study presents the results of treatment for Stage III and IV squamous cell carcinoma of the head and neck at the Princess Alexandra Hospital and Queensland Radium Institute, Brisbane. Patients were treated using a programme of sequential chemotherapy, surgery and radiotherapy. Between 1980 and 1988, 116 patients commenced the programme and 85 completed the treatment as planned. The Price-Hill regimen of chemotherapy was used until 1986 after which time it was replaced by cisplatin/5-fluorouracil (5FU). Two courses were usually given achieving an overall response rate of 36% (12% complete response). Cisplatin/5FU produced an overall response rate of 56% compared with 24% for the Price-Hill regimen. Radical surgical resections were performed using a free flap reconstruction in the majority of patients. Radiotherapy fields usually covered the primary site and both cervical lymph node areas to a dose of 50-60 Gy in 5-6 weeks. The lengthy treatment was generally well tolerated although there were two chemotherapy and two perioperative deaths. The overall actuarial survival for the 85 patients completing the triple therapy was 60%. These patients were analysed in more detail for possible prognostic factors.

Induction chemotherapy in advanced head and neck tumors: results of two randomized trials

From March 1983 to December 1989, 208 patients with locally advanced squamous cell carcinoma of the head and neck were successively included into two randomized induction chemotherapy trials. The chemotherapy regimen of the first trial, which included 100 patients, consisted of two cycles of a combination of cisplatin, bleomycin, vindesine and mitomycin C; while that of the second trial, which included 108 patients, consisted of three cycles of a combination cisplatin, 5-fluorouracil by continuous infusion and vindesine. Local treatment was the same in the two trials: primary radiotherapy in all patients. The response was then evaluated; in the case of a poor response at 55 Grays surgery was performed; otherwise, radiotherapy was continued to full doses (possibly followed by salvage surgery). The tumor and lymph node responses to chemotherapy (complete and partial response) were higher in the second trial than in the first: 70% versus 50% for primary lesions, 47% versus 25% for lymph nodes. The toxicity of the two chemotherapy regimens was minimal. In the two trials, an initial major response to chemotherapy predicted subsequent efficacy of irradiation in 80% of the patients. The significance of the complete response at the end of the irradiation varies with the previous response to the chemotherapy. With a median follow-up of 60 months with the first chemotherapy regimen and 30 months with the second, overall survival and disease-free interval were very similar in the two groups. The incidence of distant metastasis was significantly reduced (p less than 0.03) with chemotherapy. This trial suggests the need to test new chemotherapy protocols according to new schemes of treatment, with chemotherapy given concurrently with or following the completion of standard treatment by means of multicenter randomized trials.

Current chemotherapy of head and neck cancer

This article reviews the results of over 50 published trials testing the use of chemotherapy in patients with squamous cell carcinoma of the head and neck. Among the trials using chemotherapy before standard surgery and/or radiotherapy in stage III and IV disease, none has shown an improvement in survival compared with surgery and/or radiotherapy alone. In these studies, the survival at 3 to 5 years has been generally 40% to 50%. Several trials using chemotherapy after standard therapy, however, have reported survival benefits of 10% to 20%, suggested that further evaluation of classic adjuvant chemotherapy in this disease is warranted. Among studies in recurrent head and neck cancer, the most effective chemotherapy regimens appear to be variations of the program consisting of cisplatin followed by a 5-day infusion of 5-fluorouracil. Nevertheless, median survivals in recurrent disease remain short, generally 5 to 10 months.

Prognostic factors in advanced head and neck cancer patients undergoing multimodality therapy

A retrospective analysis was performed to investigate potential prognostic factors for complete remission to neoadjuvant chemotherapy and overall survival in patients with previously untreated stage III and stage IV head and neck cancer. Eighty consecutive patients were treated in one of two studies investigating three or four courses of neoadjuvant chemotherapy. Before local therapy and surgery and/or radiotherapy, 29% attained a complete remission. No strong significant and independent predictor of complete remission was identified. Only nodal stage (N) was found moderately associated with complete remission (p = 0.06). Node-negative patients had higher remission rates. Less important predictors were tumor stage (T) and site of disease; nasopharyngeal patients had superior remission rates (56%). With a median followup of 45 months and estimated 3-year survival rate of 38% (median 23.7 months), individual factors predictive of survival included pretherapy weight loss, performance status, alcohol use, pretherapy serum albumin level, site of disease, and N stage. In multivariate testing weight loss was identified as the strongest independent predictor of survival (p less than 0.0001) and surpassed other health status measures, such as performance status and serum albumin level. In addition, N stage (p = 0.019) and alcohol use (p = 0.017) were found to be predictive. A cross-classification by N stage and weight loss revealed risk groups with distinctly different prognoses, which may be useful for design and analysis in future trials.

Combined chemotherapy and radiation therapy in advanced inoperable squamous cell carcinoma of the head and neck. The final report of a randomized trial

Between 1983 and 1986, the National Institute for Cancer Research in Genoa and affiliated institutions conducted a randomized study to compare two different ways of combining chemotherapy (CT) and radiation therapy (RT). One hundred sixteen patients were randomized to receive neoadjuvant CT followed by definitive RT (treatment arm A) or alternating CT and RT. In treatment arm A, RT consisted of 70 Gy to the involved areas and 50 Gy to the uninvolved neck at 2 Gy/fraction, five fractions per week. In treatment arm B, RT consisted of 60 Gy to involved areas and 50 Gy to the uninvolved neck in three courses of 20 Gy each, 2 Gy/fraction, ten fractions/2 weeks alternated with four courses of CT. CT consisted of vinblastine 6 mg/m2 intravenously followed 6 hours later by bleomycin 30 IU intramuscularly, day 1; methotrexate 200 mg intravenously, day 2; leucovorin rescue, day 3. CT was repeated every 2 weeks up to four courses. The same CT was used in both treatment arms of the study. Fifty-five patients were entered in treatment arm A and 61 in treatment arm B. Complete responses were 7/48 and 19/57 in treatment arms A and B, respectively (P less than 0.03). Four-year progression-free survival was 4% in treatment arm A and 12% in treatment arm B (P less than 0.02), and four-year survival was 10% in A and 22% in B (P less than 0.02). Mucosal tolerance was significantly worse in treatment arm B (P less than 0.00004). The subgroup analysis shows the major improvement of alternating CT and RT in patients with the worst prognostic characteristics.

Concomitant cisplatin chemotherapy and radiotherapy in advanced mucosal squamous cell carcinoma of the head and neck. Long-term results of the Radiation Therapy Oncology Group study 81-17

One hundred twenty-four eligible patients with advanced mucosal squamous cell carcinoma of the head and neck were entered into a pilot study of concomitant cisplatin (100 mg/m2 given every 3 weeks for three doses) and standard irradiation. The initial complete response (CR) was 71% with an additional two cases salvaged by surgery for an overall 73% CR. When no keratin was identified in the histologic specimen (41 patients) the CR was 90%. The nasopharynx showed the best CR (89%) among the sites. At 4 years after treatment, the estimated locoregional tumor control rate was 43% and the survival, 34%. When no keratin was present in the specimen, the estimated locoregional control of tumor was superior (56% versus 38% with keratin identified, P = 0.02) and the estimated survival was also superior (48% versus 26%, P = 0.008). Acute treatment-related toxicities included one death due to renal damage and two patients with life-threatening renal damage. The delivery of radiotherapy was not altered. Late toxicity included necrosis -3%, fibrosis -4%, and one fistula. The results of this study justify a randomized trial for the comparison of this combination of cisplatin and radiotherapy versus radiotherapy alone in advanced mucosal carcinomas of the head and neck.

A randomized study comparing two regimens of neoadjuvant and adjuvant chemotherapy in multimodal therapy for locally advanced head and neck cancer

Two regimens of neoadjuvant chemotherapy for previously untreated patients with locally advanced head and neck cancer were compared with the goal of identifying a regimen with a greater than 50% complete response (CR) rate. Patients with a performance status of 0 to 2 and normal end-organ function were randomized to receive either four cycles of neoadjuvant methotrexate, cisplatin, and continuous infusion 5-fluorouracil (5-FU) (MPF) (arm A), or four cycles of bleomycin, cisplatin, and methotrexate (PBM) alternating with cisplatin and 5-FU (PF) (arm B). Patients with a performance status of greater than 2 or a carbon monoxide diffusion capacity of less than 50% of the predicted value were assigned to the arm A regimen but were analyzed separately (arm C). Local therapy consisted of surgery (for patients with resectable disease) or radiation therapy followed by two cycles of adjuvant chemotherapy with the regimen that was administered initially. Of the 42 patients who were evaluated, 16 were randomized to arm A, 13 to arm B, and 13 to arm C. The clinical CR rate was 19% on arm A (95% confidence interval, 0% to 38%), 39% on arm B (95% confidence interval, 12% to 66%) (P = 0.41), and 54% on arm C (95% confidence interval, 27% to 81%). At a median follow-up time of 35 months, the 2-year actuarial survival rate was 61% on arm A, 69% on arm B (the P value was not significant), and 38% on arm C. The 2-year survival rate for all 42 patients who were treated was 57% and the median survival time was 31 months. Toxicities of neoadjuvant chemotherapy on all arms consisted of mild to moderate myelosuppression and renal toxicity. The incidence of moderate to severe mucositis was significantly higher on arm A than arm B (P = 0.02). Two cycles of adjuvant chemotherapy were administered to only 11 of 42 patients due to patient refusal or cumulative toxicity. In conclusion, both neoadjuvant chemotherapy regimens resulted in similar response and survival rates, but mucositis was more severe with arm A. However, since neither regimen was likely to cause a CR rate of greater than 50%, this study was closed to further patient accrual.

Sequential and Synchronous Chemo-Radiotherapy in the Management of Locally Advanced Carcinoma of the Head and Neck

Thirty-nine consecutive patients with stage III-IV squamous cell carcinoma of the head and neck entered a pilot study of sequential and synchronous chemo-radiotherapy. The study was planned as follows: two cycles of induction chemotherapy (MTX, BLM, DDP) followed by radical radiotherapy (66 Gy) with synchronous weekly administration of DDP (20 mg/m2) as a radiosensitizer. Out of the 39 patients evaluable for induction chemotherapy 25 (64%) achieved partial or complete response. Two patients underwent radical surgery after induction chemotherapy and 3 patients died of treatment. Out of the remaining 34 patients, 25 were untreated and 9 presented recurrence after primary surgery. Grade 4 mucositis was the major side effect of concurrent chemo-radiotherapy. Local control after synchronous therapy was obtained In 11 (44%) previously untreated patients and only in 1 (11%) patient of the surgically pretreated group. At the time of the analysis 11 patients were alive, 8 of them free from disease (4 after salvage surgery). Actuarial 2-year survival for previously untreated patients was 33% and 24% for all the patients. This survival is not significantly different (log rank test) from that of a similar group of 24 patients treated at the same institution with radiotherapy alone. The important toxicity of the induction chemotherapy regimen and the poor 2-year survival do not show any benefit from such a combined approach in locally advanced head and neck carcinoma. Nevertheless, despite our disappointing results many data in the literature suggest a role for chemotherapy-based treatments of locally advanced head and neck cancer. Further controlled randomized studies are required to better define the place of chemotherapy in the multi-modality management of stage III-IV head and neck cancer.

Accelerated fractionation radiotherapy for advanced head and neck cancer

Between 1981 and 1986, 89 patients with advanced head and neck squamous cancer were treated with a continuous accelerated fractionation radiotherapy (AFRT) regimen. Three fractions of 1.80 Gy, 4 h apart, were given on three treatment days per week (Monday, Wednesday, Friday), and the tumour dose was taken to 59.40 Gy in 33 fractions in 24-25 days. Acute mucosal reactions were generally quite severe, but a split was avoided by providing the patient with intensive support, often as an in-patient, until the reactions settled. Late radiation effects have been comparable to those obtained with conventional fractionation. The probability of local-regional control was 47% at 3 years for 69 previously untreated patients, whereas it was only 12% at one year for 20 patients treated for recurrence after radical surgery. Fifty-eight previously untreated patients with tumours arising in the upper aero-digestive tract were analysed in greater detail. The probability of local-regional control at 3 years was 78% for 17 Stage III patients and 15% for 31 Stage IV patients. This schedule of continuous AFRT is feasible and merits further investigation.

Adjuvant chemotherapy in head and neck cancer

An overview is presented of 23 trials of adjuvant chemotherapy in squamous cell carcinoma of the head and neck. These were reviewed from the point of view of design of the trial, analysis of survival, response rates, meta-analysis, site of failure, toxicity and cost. The minimal increase in survival that could be detected ranged from 11 to 51%, with a median of 25%. No trial was big enough to detect the likely increase of survival, which is 5%. Many trials excluded some eligible patients before randomisation, the proportion being 21% in those series with details. A further 9% of treated patients were excluded from analysis. A response rate in four induction studies of 47% equated with a 6% increase in cancer mortality. Meta-analysis showed an insignificant overall improvement in cancer mortality of 0.5%. Induction chemotherapy, synchronous chemotherapy and induction/maintenance chemotherapy did not affect cancer mortality whereas synchronous/maintenance therapy did. Cisplatinum, methotrexate, bleomycin, 5-FU and a variety of other regimens did not affect the death rate from cancer, but the combination of VBM significantly increased it. Neither single agent nor combination chemotherapy produced a significant reduction of cancer deaths. The rate of locoregional failure was significantly lower in the treated arms, whereas the metastatic rate was similar in both arms. Only three papers gave full details of toxicity with grading: these showed a high toxicity rate. The mortality rate from chemotherapy in nine series averaged 6.5%.

Combined modality treatment with radiotherapy and chemotherapy

Combined modality treatment with radiotherapy and chemotherapy is used increasingly for the primary management of a variety of human tumours, with the aim of improving both local and distant control. The present paper reviews methodological issues related to the evaluation of combined modality therapy. Reports that patients have superior outcome in single-arm studies as compared to historical controls treated with radiation alone have limited value because of several types of bias including patient selection, stage migration, the tendency to publish positive results, or inadequate follow-up as compared to the historical series. The observation that response to chemotherapy predicts for survival after combined treatment also conveys no proof that combined treatment is superior to radiation alone. Randomized controlled trials provide the only rigorous method for evaluating combined therapy, but are also subject to misinterpretation. The majority of published trials report negative results but are too small to detect clinically important differences in survival. Even large trials may give spurious results if they seek small benefits of treatment in a spectrum of patients with widely differing prognosis. Some randomized trials have demonstrated improved local control and increased toxicity from combined treatment, a result that might have been achieved by increasing the effective radiation dose. Ideally, combined treatment should be compared with radiotherapy alone at equal levels of normal tissue damage. A review of published data for patients with cancers of the head and neck, lung, gastrointestinal tract and bladder reveals very few trials which have adequately evaluated the role of combined modality therapy (with or without surgery). Most of the large randomized trials have demonstrated no benefit from the use of radiation and chemotherapy, although some of them suggest small therapeutic gains from using thoracic radiation with chemotherapy in small-cell-lung cancer of limited extent, or from combined modality treatment after resection of rectal cancer. Possible reasons for the failure of active drugs to lead to easily detected gains in therapeutic index include insufficient reduction in cell survival from chemotherapy, selective killing of radiosensitive subpopulations, stimulation of the proliferation of surviving cells, or enhancement of metastasis. With the possible exception of radiation and concurrent 5-fluorouracil for squamous cancers of the anal canal, there are no convincing data to mandate the routine combined use of radiotherapy and chemotherapy in any of the above sites.

Treatment selection for base of tongue carcinoma

Sixty-two previously untreated patients with squamous cell carcinoma of the base of tongue were retrospectively analyzed. The American Joint Committee on Cancer (AJCC) Stage distribution was I-3, II-7, III-24, and IV-28. The choice of treatment was nonrandomized. The local control was 10/18 with high-dose preoperative radiation, 17/30 with external beam radiation only, and 4/14 with external beam plus interstitial implantation. The median survival for the three treatment regimens were 63, 51, and 13 months, respectively. Preoperative radiation is suggested for tumors with inferior (laryngeal) spread or those with extensive superior extension (to tonsillar fossa and beyond). For centrally placed lesions in the base of the tongue (with or without lateral hypopharyngeal wall spread), radiation alone is recommended. An interstitial implantation should be restricted to lesions equal to or less than 4 x 3 x 2.5 cm3. Since this insertion is technically more demanding than for tumors of the mobile tongue, they should be performed by the more experienced brachytherapist.

Randomized clinical trial of mitomycin C as an adjunct to radiotherapy in head and neck cancer

A randomized prospective clinical trial was carried out to assess the usefulness of the addition of mitomycin C to radiation therapy used alone or in combination with surgery for the treatment of squamous cell carcinoma of the head and neck region. One hundred and twenty patients with biopsy proven tumor of the oral cavity, oropharynx, larynx, hypopharynx, and nasopharynx were randomly assigned to receive or not receive mitomycin C; all other aspects were similar in the two treatment groups. One hundred and seventeen patients were evaluable with a median follow-up time of greater than 5 years. Acute and chronic normal tissue radiation reactions were equivalent in the two treatment groups. Hematologic and pulmonary toxicity were observed in the drug treated patients. Actuarial disease-free survival at 5 years was 49% in the radiation therapy group and 75% in the radiation therapy plus mitomycin C group, p less than 0.07. Local recurrence-free survival was 66% in the radiation therapy group and 87% in the radiation therapy plus mitomycin C group, p less than 0.02. The findings demonstrate that mitomycin C can be administered safely as an adjunct to radiation therapy in the treatment of head and neck cancer. The drug improves local tumor control without enhancing normal tissue radiation reactions.