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Chen AM. De-escalated radiation for human papillomavirus virus-related oropharyngeal cancer: Who, why, what, where, when, how, how much…and what next? Radiother Oncol 2024; 200:110373. [PMID: 38857702 DOI: 10.1016/j.radonc.2024.110373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 05/20/2024] [Accepted: 06/05/2024] [Indexed: 06/12/2024]
Abstract
The emergence of treatment de-escalation as a feasible option for patients with newly diagnosed human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma has generated considerable excitement among both providers and patients alike. Since HPV-positive oropharyngeal carcinoma has been shown to be a unique entity with distinct clinical and molecular characteristics, the rationale for customizing treatment for patients with this disease is compelling. Indeed, evidence has accumulated demonstrating that patients with HPV-positive oropharyngeal cancer have a significantly improved prognosis as a result of their exquisite radiosensitivity compared to their HPV-negative counterparts and thus might possibly be targeted with de-escalated approaches. The fundamental goal of de-escalation is to maintain the high cure and survival rates associated with traditional approaches while reducing the intensity of treatment and thus the incidence of both short- and long-term toxicity. Given the rapidly increasing incidence of this disease, particularly among younger patients who are generally healthy, the focus on quality of life seems germane. Although the exact reason for the improved sensitivity of HPV-positive oropharyngeal carcinoma to treatment is uncertain, prospective studies have now been published demonstrating that de-escalated radiation can successfully maintain the high rates of cure and preserve quality of life for appropriately selected patients with this disease. However, these studies have been fairly heterogeneous in design, and it remains questionable how to apply their findings to real-world practice. The potential of integrating translational approaches into clinical paradigms is also just starting to become recognized. Consequently, multiple uncertainties continue to exist with respect to de-escalation for HPV-positive oropharyngeal cancer, and these questions comprise the crux of this review.
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Affiliation(s)
- Allen M Chen
- Department of Radiation Oncology, Chao Family Comprehensive Cancer Center, University of California- Irvine, School of Medicine, Irvine, CA 92617, United States.
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2
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Chen AM. De-escalated radiation for human papillomavirus virus-related oropharyngeal cancer: evolving paradigms and future strategies. Front Oncol 2023; 13:1175578. [PMID: 37576899 PMCID: PMC10413127 DOI: 10.3389/fonc.2023.1175578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/25/2023] [Indexed: 08/15/2023] Open
Abstract
The incidence of human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma has increased dramatically in recent years reaching epidemic-like proportions. Data has emerged not only showing that these cancers are a unique entity with distinct molecular characteristics but that they also have a significantly improved prognosis as a result of their exquisite radiosensitivity compared to their HPV-negative counterparts. This, it has been increasingly suggested that these tumors can be targeted with de-escalated approaches using reduced doses of radiation. The overriding goal of de-escalation is to maintain the high cure and survival rates associated with traditional approaches while reducing the incidence of both short- and long-term toxicity. Although the exact reason for the improved radiosensitivity of HPV-positive oropharyngeal carcinoma is unclear, prospective studies have now been published demonstrating that de-escalated radiation can successfully maintain the high rates of cure and preserve quality of life for appropriately selected patients with this disease. However, these studies have been complicated by such factors as the relatively limited sample sizes, as well as the variability in treatment, inclusion criteria, and follow-up. As the data continues to mature on de-escalation, it is unquestionable that treatment paradigms for this disease will evolve. The ongoing quest to define a standard regimen comprises the subject of this review.
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Affiliation(s)
- Allen M. Chen
- Department of Radiation Oncology, Chao Family Comprehensive Cancer Center, School of Medicine, University of California- Irvine, Irvine, CA, United States
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3
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Kang JJ, Yu Y, Chen L, Zakeri K, Gelblum DY, McBride SM, Riaz N, Tsai CJ, Kriplani A, Hung T, Fetten JV, Dunn LA, Ho A, Boyle JO, Ganly IS, Singh B, Sherman EJ, Pfister DG, Wong RJ, Lee NY. Consensuses, controversies, and future directions in treatment deintensification for human papillomavirus-associated oropharyngeal cancer. CA Cancer J Clin 2023; 73:164-197. [PMID: 36305841 PMCID: PMC9992119 DOI: 10.3322/caac.21758] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/03/2022] [Accepted: 08/09/2022] [Indexed: 01/19/2023] Open
Abstract
The most common cancer caused by human papillomavirus (HPV) infection in the United States is oropharyngeal cancer (OPC), and its incidence has been rising since the turn of the century. Because of substantial long-term morbidities with chemoradiation and the favorable prognosis of HPV-positive OPC, identifying the optimal deintensification strategy for this group has been a keystone of academic head-and-neck surgery, radiation oncology, and medical oncology for over the past decade. However, the first generation of randomized chemotherapy deintensification trials failed to change the standard of care, triggering concern over the feasibility of de-escalation. National database studies estimate that up to one third of patients receive nonstandard de-escalated treatments, which have subspecialty-specific nuances. A synthesis of the multidisciplinary deintensification data and current treatment standards is important for the oncology community to reinforce best practices and ensure optimal patient outcomes. In this review, the authors present a summary and comparison of prospective HPV-positive OPC de-escalation trials. Chemotherapy attenuation compromises outcomes without reducing toxicity. Limited data comparing transoral robotic surgery (TORS) with radiation raise concern over toxicity and outcomes with TORS. There are promising data to support de-escalating adjuvant therapy after TORS, but consensus on treatment indications is needed. Encouraging radiation deintensification strategies have been reported (upfront dose reduction and induction chemotherapy-based patient selection), but level I evidence is years away. Ultimately, stage and HPV status may be insufficient to guide de-escalation. The future of deintensification may lie in incorporating intratreatment response assessments to harness the powers of personalized medicine and integrate real-time surveillance.
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Affiliation(s)
- Jung Julie Kang
- Yale University School of Medicine, Department of Therapeutic Radiology
| | - Yao Yu
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology
| | - Linda Chen
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology
| | - Kaveh Zakeri
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology
| | | | | | - Nadeem Riaz
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology
| | - C. Jillian Tsai
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology
| | - Anuja Kriplani
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | - Tony Hung
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | - James V. Fetten
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | - Lara A. Dunn
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | - Alan Ho
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | - Jay O. Boyle
- Memorial Sloan Kettering Cancer Center, Department of Surgery
| | - Ian S. Ganly
- Memorial Sloan Kettering Cancer Center, Department of Surgery
| | - Bhuvanesh Singh
- Memorial Sloan Kettering Cancer Center, Department of Surgery
| | - Eric J. Sherman
- Memorial Sloan Kettering Cancer Center, Department of Medicine
| | | | - Richard J. Wong
- Memorial Sloan Kettering Cancer Center, Department of Surgery
| | - Nancy Y. Lee
- Memorial Sloan Kettering Cancer Center, Department of Medicine
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4
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Treating Head and Neck Cancer in the Age of Immunotherapy: A 2023 Update. Drugs 2023; 83:217-248. [PMID: 36645621 DOI: 10.1007/s40265-023-01835-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 01/17/2023]
Abstract
Most patients diagnosed with head and neck squamous cell carcinoma (HNSCC) will present with locally advanced disease, requiring multimodality therapy. While this approach has a curative intent, a significant subset of these patients will develop locoregional failure and/or distant metastases. The prognosis of these patients is poor, and therapeutic options other than palliative chemotherapy are urgently needed. Epidermal growth factor receptor (EGFR) overexpression is an important factor in the pathogenesis of HNSCC, and a decade ago, the EGFR targeting monoclonal antibody cetuximab was approved for the treatment of late-stage HNSCC in different settings. In 2016, the anti-programmed death-1 (PD-1) immune checkpoint inhibitors nivolumab and pembrolizumab were both approved for the treatment of patients with recurrent or metastatic HNSCC with disease progression on or after platinum-containing chemotherapy, and in 2019, pembrolizumab was approved for first-line treatment (either as monotherapy in PD-L1 expressing tumors, or in combination with chemotherapy). Currently, trials are ongoing to include immune checkpoint inhibition in the (neo)adjuvant treatment of HNSCC as well as in novel combinations with other drugs in the recurrent/metastatic setting to improve response rates and survival and help overcome resistance mechanisms to immune checkpoint blockade. This article provides a comprehensive review of the management of head and neck cancers in the current era of immunotherapy.
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Petrelli F, Luciani A, Ghidini A, Cherri S, Gamba P, Maddalo M, Bossi P, Zaniboni A. Treatment de-escalation for HPV+ oropharyngeal cancer: A systematic review and meta-analysis. Head Neck 2022; 44:1255-1266. [PMID: 35238114 DOI: 10.1002/hed.27019] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 02/13/2022] [Accepted: 02/17/2022] [Indexed: 12/12/2022] Open
Abstract
Human Papillomavirus (HPV) related oropharyngeal carcinoma (OPC) carries a better prognosis compared with HPV-counterparts, thereby pushing the adoption of de-intensification treatment approaches as new strategies to preserve superior oncologic outcomes while minimizing toxicity. We evaluated the effect of treatment de-intensification in terms of overall survival (OS), progression-free survival (PFS), locoregional and distant control (LRC and DM) by selecting prospective or retrospective studies, providing outcome data with reduced intensification versus standard curative treatment in HPV+ OPC patients, with a systematic analysis till September 2020. The primary outcome of interest was OS. Secondary endpoints were PFS, LRC, and DM expressed as HR. A total of 55 studies (from 1393 screened references) were employed for quantitative synthesis for 38 929 patients. Among n = 48 studies with data available, de-intensified treatments reduced OS in HPV+ OPCs (HR = 1.33, 95% CI 1.17-1.52; p < 0.01). In de-escalated treatments, PFS was also decreased (HR = 2.11, 95% CI 1.65-2.69; p < 0.01). Compared with standard treatments, reduced intensity approaches were associated with reduced locoregional and distant disease control (HR = 2.51, 95% CI 1.75-3.59; p < 0.01; and HR = 1.9, 95% CI 1.25-2.9; p < 0.01). Chemoradiation improved survival in a definitive curative setting compared with radiotherapy alone (HR = 1.42, 95% CI 1.16-1.75; p < 0.01). When adjuvant treatments were compared, standard and de-escalation strategies provided similar OS. In conclusion, in patients with HPV+ OPC, de-escalation treatments should not be widely and agnostically adopted in clinical practice, as therein lies a concrete risk of offering a sub-optimal treatment to patients.
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Affiliation(s)
| | | | | | - Sara Cherri
- Oncology Unit, Fondazione Poliambulanza, Brescia, Italy
| | - Paolo Gamba
- Otolaryngology Unit, Fondazione Poliambulanza, Brescia, Italy
| | - Marta Maddalo
- Department of Radiation Oncology, University of Brescia and Spedali Civili, Brescia, Italy
| | - Paolo Bossi
- Medical Oncology, Department of Medical and Surgical Specialties, Radiological Sciences, Public Health, University of Brescia, Brescia, Italy
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6
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Wotman MT, Miles BA, Bakst RL, Posner MR. A proposal for risk-based and strategy-adapted de-escalation in human papillomavirus-positive oropharyngeal squamous cell carcinoma. Cancer 2021; 127:4330-4338. [PMID: 34379804 DOI: 10.1002/cncr.33851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 06/16/2021] [Accepted: 06/18/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Michael T Wotman
- The Department of Internal Medicine in the Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brett A Miles
- The Department of Otolaryngology in the Icahn School of Medicine at Mount Sinai, New York, New York
| | - Richard L Bakst
- The Department of Radiation Oncology in the Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marshall R Posner
- The Department of Hematology/Oncology in the Icahn School of Medicine at Mount Sinai, New York, New York
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7
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De Felice F, Belgioia L, Alterio D, Bonomo P, Maddalo M, Paiar F, Denaro N, Corvò R, Merlotti A, Bossi P, Pappagallo GL, D' Angelillo RM, Magrini SM, Arcangeli S. Survival and toxicity of weekly cisplatin chemoradiotherapy versus three-weekly cisplatin chemoradiotherapy for head and neck cancer: A systematic review and meta-analysis endorsed by the Italian Association of Radiotherapy and Clinical Oncology (AIRO). Crit Rev Oncol Hematol 2021; 162:103345. [PMID: 33933569 DOI: 10.1016/j.critrevonc.2021.103345] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 01/30/2021] [Accepted: 04/25/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE To evaluate efficacy and toxicity of weekly cisplatin chemoradiotherapy versus three-weekly cisplatin chemoradiotherapy and identify differences in clinical outcomes and severe toxicity rate. METHODS PICOS/PRISMA methods were used to identify studies on PubMed, EMBASE and Cochrane Library, 2005-2019. RESULTS Six randomized clinical trials (554 patients) were identified. Weekly cisplatin was not associated with significant overall survival (HR 1.13, 95 % CI 0.84-1.51) and progression-free survival (HR 1.23, 95 %CI 0.91-1.65) improvement compared with three-weekly regimen. Severe acute toxicity (RR 0.95), treatment compliance to chemotherapy (RR 1.67) and radiotherapy (RR 0.61) were similar between regimens. CONCLUSION Weekly cisplatin is not associated with better clinical outcomes compared to three-weekly cisplatin. Three-weekly cisplatin chemoradiotherapy should be considered the standard approach in the management of locally advanced head and neck cancer. Methodologically robust RCTs designs are needed to improve the quality of evidence. Differences on long-term toxicity and cost-effectiveness remain to be tested.
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Affiliation(s)
- Francesca De Felice
- Department of Radiotherapy, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy.
| | - Liliana Belgioia
- Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Health Science Department (DISSAL), University of Genoa, Genova, Italy
| | - Daniela Alterio
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Marta Maddalo
- Radiation Oncology Department, ASST Spedali Civili di Brescia - Brescia University, Brescia, Italy
| | - Fabiola Paiar
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Nerina Denaro
- Candiolo Cancer Center - FPO, Candiolo, Turin, Italy
| | - Renzo Corvò
- Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Health Science Department (DISSAL), University of Genoa, Genova, Italy
| | - Anna Merlotti
- Radiation Oncology, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Paolo Bossi
- Department of Medical Oncology, University of Brescia, Brescia, Italy
| | | | | | - Stefano M Magrini
- Radiation Oncology Department, ASST Spedali Civili di Brescia - Brescia University, Brescia, Italy
| | - Stefano Arcangeli
- Department of Radiation Oncology, Policlinico S. Gerardo and University of Milan "Bicocca", Milano, Italy
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Langer C, Wittekindt C, Jensen AD. [The role of chemoradiotherapy in curative treatment of head and neck cancer]. Laryngorhinootologie 2021; 101:22-34. [PMID: 33506441 DOI: 10.1055/a-1351-0417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Radiotherapy and chemotherapy are integral parts of definitive and adjuvant therapy in the treatment of head and neck squamous cell carcinoma (HNSCC). The outcome of therapy is essentially dependent on selection and dosage of chemotherapeutical substances and on the other hand on the radiotherapeutical setting concerning fractionation, time of therapy and technical aspects. Immunotherapeutical substances have an increasing role in the therapy of HNSCC as well as particle therapy is investigated as part of radiotherapy in actual studies. Further challenges relate to treatment of HPV-induced tumors with regard to their differences in tumor biology and consecutively better prognosis.
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Affiliation(s)
- Christine Langer
- HNO, Universitätsklinikum Gießen und Marburg Standort Gießen, Klinik für Hals-Nasen-Ohrenheilkunde, Kopf-Halschirurgie und plastische Operationen, Gießen, Germany
| | | | - Alexandra Désirée Jensen
- Klinik für Strahlentherapie, Universitätsklinikum Gießen und Marburg GmbH Standort Gießen, Gießen, Germany
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9
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Price KAR, Nichols AC, Shen CJ, Rammal A, Lang P, Palma DA, Rosenberg AJ, Chera BS, Agrawal N. Novel Strategies to Effectively De-escalate Curative-Intent Therapy for Patients With HPV-Associated Oropharyngeal Cancer: Current and Future Directions. Am Soc Clin Oncol Educ Book 2020; 40:1-13. [PMID: 32213088 DOI: 10.1200/edbk_280687] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The treatment of patients with HPV-associated oropharyngeal cancer (HPV-OPC) is rapidly evolving and challenging the standard of care of definitive radiotherapy with concurrent cisplatin. There are numerous promising de-escalation strategies under investigation, including deintensified definitive chemoradiotherapy, transoral surgery followed by de-escalated adjuvant therapy, and induction chemotherapy followed by de-escalated locoregional therapy. Definitive radiotherapy alone or with cetuximab is not recommended for curative-intent treatment of patients with locally advanced HPV-OPC. The results of ongoing phase III studies are awaited to help answer key questions and address ongoing controversies to transform the treatment of patients with HPV-OPC. Strategies for de-escalation under investigation include the incorporation of immunotherapy and the use of novel biomarkers for patient selection for de-escalation.
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Affiliation(s)
| | - Anthony C Nichols
- Department of Otolaryngology-Head and Neck Surgery, University of Western Ontario, London, Ontario, Canada
| | - Colette J Shen
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Almoaidbellah Rammal
- Department of Otolaryngology-Head and Neck Surgery, University of Western Ontario, London, Ontario, Canada
| | - Pencilla Lang
- Division of Radiation Oncology, Department of Oncology, University of Western Ontario, London, Ontario, Canada
| | - David A Palma
- Division of Radiation Oncology, Department of Oncology, University of Western Ontario, London, Ontario, Canada
| | - Ari J Rosenberg
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL
| | - Bhisham S Chera
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Nishant Agrawal
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Chicago, Chicago, IL
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Adelstein DJ, Ismaila N, Ku JA, Burtness B, Swiecicki PL, Mell L, Beitler JJ, Gross N, Jones CU, Kaufman M, Le QT, Semrad TJ, Siu LL, Ridge JA. Role of Treatment Deintensification in the Management of p16+ Oropharyngeal Cancer: ASCO Provisional Clinical Opinion. J Clin Oncol 2019; 37:1578-1589. [DOI: 10.1200/jco.19.00441] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE An ASCO provisional clinical opinion offers timely clinical direction to ASCO’s membership after publication or presentation of potentially practice-changing data from major studies. This provisional clinical opinion addresses the role of treatment deintensification in the management of p16+ oropharyngeal cancer (OPC). CLINICAL CONTEXT For patients with p16+ OPC, current treatment approaches are well established. In the good-prognosis subset of nonsmoking p16+ patients with early-stage disease, these treatments have been highly successful, albeit with significant associated acute and late toxicity. Deintensification of surgical, radiation, and medical treatment in an effort to reduce toxicity while preserving high survival rates is an appropriate therapeutic objective currently being explored in patients who are experiencing the best treatment results. However, careful delineation of this good-risk subset is essential. While the current eighth edition of the American Joint Committee on Cancer staging system is prognostically robust, it should not be interpreted as reason to alter therapeutic decisions or justify treatment deintensification. The development of transoral surgical techniques and the adoption of intensity-modulated radiation therapy planning have been transformative in disease management and suggest potentially beneficial approaches. Recent advances in systemic treatments have been notable. The optimal integration and modification of these modalities to ameliorate toxicity has not been defined and remains an important focus of current investigation. PROVISIONAL CLINICAL OPINION The hypothesis that de-escalation of treatment intensity for patients with p16+ OPC can reduce long-term toxicity without compromising survival is compelling and necessitates careful study and the analysis of well-designed clinical trials before changing current treatment standards. Treatment deintensification for these patients should only be undertaken in a clinical trial. Additional information is available at www.asco.org/head-neck-cancer-guidelines .
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Affiliation(s)
| | | | | | | | | | - Loren Mell
- University of California San Diego, La Jolla, CA
| | | | - Neil Gross
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Marnie Kaufman
- Adenoid Cystic Carcinoma Research Foundation, Needham, MA
| | | | | | - Lillian L. Siu
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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11
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Barney CL, Walston S, Zamora P, Healy EH, Nolan N, Diavolitsis VM, Neki A, Rupert R, Savvides P, Agrawal A, Old M, Ozer E, Carrau R, Kang S, Rocco J, Teknos T, Grecula JC, Wobb J, Mitchell D, Blakaj D, Bhatt AD. Clinical outcomes and prognostic factors in cisplatin versus cetuximab chemoradiation for locally advanced p16 positive oropharyngeal carcinoma. Oral Oncol 2018; 79:9-14. [PMID: 29598954 DOI: 10.1016/j.oraloncology.2018.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 01/29/2018] [Accepted: 02/02/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Randomized trials evaluating cisplatin versus cetuximab chemoradiation (CRT) for p16+ oropharyngeal cancer (OPC) have yet to report preliminary data. Meanwhile, as a preemptive step toward morbidity reduction, the off-trial use of cetuximab in p16+ patients is increasing, even in those who could potentially tolerate cisplatin. The purpose of this study was to compare the efficacy of cisplatin versus cetuximab CRT in the treatment of p16+ OPC and to identify prognostic factors and predictors of tumor response. MATERIALS AND METHODS Cases of p16+ OPC treated with cisplatin or cetuximab CRT at our institution from 2010 to 2014 were identified. Recursive partitioning analysis (RPA) classification was used to determine low-risk (LR-RPA) and intermediate-risk (IR-RPA) groups. Log-rank/Kaplan-Meier and Cox Regression methods were used to compare groups. RESULTS We identified 205 patients who received cisplatin (n = 137) or cetuximab (n = 68) CRT in the definitive (n = 178) or postoperative (n = 27) setting. Median follow-up was 3 years. Cisplatin improved 3-year locoregional control (LRC) [92.7 vs 65.4%], distant metastasis-free survival (DMFS) [88.3 vs 71.2%], recurrence-free survival (RFS) [86.6 vs 50.6%], and overall survival (OS) [92.6 vs 72.2%] compared to cetuximab [all p < .001]. Concurrent cisplatin improved 3-year OS for LR-RPA (97.1 vs 80.3%, p < .001) and IR-RPA (97.1 vs 80.3%, p < .001) groupings. CONCLUSION When treating p16+ OPC with CRT, the threshold for substitution of cisplatin with cetuximab should be maintained appropriately high in order to prolong survival times and optimize locoregional and distant tumor control. When cetuximab is used in cisplatin-ineligible patients, altered fractionation RT should be considered in an effort to improve LRC.
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Affiliation(s)
- Christian L Barney
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
| | - Steve Walston
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
| | - Pedro Zamora
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
| | - Erin H Healy
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
| | - Nicole Nolan
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA
| | - Virginia M Diavolitsis
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA
| | - Anterpreet Neki
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
| | - Robert Rupert
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
| | - Panos Savvides
- The University of Arizona Cancer Center at Dignity Health St. Joseph's Hospital, 625 N 6th St, Phoenix, AZ 85004, USA
| | - Amit Agrawal
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
| | - Matthew Old
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
| | - Enver Ozer
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
| | - Ricardo Carrau
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
| | - Stephen Kang
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
| | - James Rocco
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
| | - Theodoros Teknos
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
| | - John C Grecula
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
| | - Jessica Wobb
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
| | - Darrion Mitchell
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
| | - Dukagjin Blakaj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
| | - Aashish D Bhatt
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
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