Introducing the BECT (biologically enhanced cytotoxic treatment) concept in cancer treatment

Individual patients' data meta-analyses in head and neck cancer

PURPOSE OF REVIEW

This is a review of the experience obtained at the Institute Gustave Roussy, evaluating the role of chemotherapy and of altered fractionated radiotherapy in locally advanced head and neck cancer. The database included nearly 120 randomized trials, and about 25,000 patients, with a median follow-up of 6 years.

RECENT FINDINGS

In the chemotherapy database (Meta-Analysis of Chemotherapy in Head, Neck Cancer and Meta-Analysis of Chemotherapy in Nasopharynx Carcinoma), concomitant cisplatin-based radiotherapy-chemotherapy provided the most significant benefit on locoregional control and survival, both in head and neck squamous cell carcinomas and nasopharyngeal carcinomas. In head and neck squamous cell carcinomas, the benefit of adding concomitant chemotherapy was found to be in the same order of magnitude whether radiotherapy was postoperative or definitive. In the altered radiotherapy database (Meta-Analysis of Radiotherapy in Carcinoma of Head and Neck), among the different types of altered fractionated radiotherapy, hyperfractionation provided the most significant benefit. The benefit associated with altered fractionated radiotherapy and of concomitant chemotherapy markedly decreased with increasing age.

SUMMARY

This database provided a unique tool to evaluate long-term effects of chemotherapy and altered fractionated radiotherapy in head and neck cancer. This allowed the oncological community to obtain a reliable characterization of the magnitude of the treatment benefits in this type of cancer and to base patient care and future research on strong evidence.

Exploitable mechanisms for combining drugs with radiation: concepts, achievements and future directions

Widening indications for combining radiation therapy with cytotoxic or molecular-targeted drugs have mainly been driven by pragmatic clinical trials. With a flurry of novel drugs in various stages of preclinical and clinical development there is a need to revise the framework that has traditionally been used for discussing possible drug-radiation interactions, especially because many of the new drugs are directed at a specific molecular target. Spatial cooperation, cytotoxic enhancement, biological cooperation, temporal modulation and normal tissue protection are proposed as five primary exploitable mechanisms for the rational combination of drugs with radiation for cancer therapy. These five mechanisms produce different clinical outcomes and, therefore, the optimum clinical end point for assessing therapeutic benefit will depend on the mechanism tested. The dependence of outcome on these mechanisms also affects the selection of preclinical models and the optimum scheduling of the two modalities, i.e. the timing and dosing of the drug relative to the radiation dose fractions. These considerations are discussed in some detail for each mechanism and illustrated with specific clinical examples. Multi-modality therapy for head and neck squamous-cell carcinoma is used to illustrate these concepts. Further clinical progress in this field will require hypothesis-driven trials to ensure efficient identification of treatments with the most favorable risk:benefit ratio.