The addition of chemotherapy to adjuvant radiation is associated with inferior survival outcomes in intermediate-risk HPV-negative HNSCC

A phase 2 study of neoadjuvant chemotherapy plus durvalumab in resectable locally advanced head and neck squamous cell carcinoma

BACKGROUND

Patients with locally advanced head and neck squamous cell cancer (HNSCC) are treated with surgery followed by adjuvant (chemo) radiotherapy or definitive chemoradiation, but recurrence rates are high. Immune checkpoint blockade improves survival in patients with recurrent/metastatic HNSCC; however, the role of chemo-immunotherapy in the curative setting is not established.

METHODS

This phase 2, single-arm, multicenter study evaluated neoadjuvant chemo-immunotherapy with carboplatin, nab-paclitaxel, and durvalumab in patients with resectable locally advanced HNSCC. The primary end point was a hypothesized pathologic complete response rate of 50%. After chemo-immunotherapy and surgical resection, patients received study-defined, pathologic risk adapted adjuvant therapy consisting of either durvalumab alone (low risk), involved field radiation plus weekly cisplatin and durvalumab (intermediate risk), or standard chemoradiation plus durvalumab (high risk).

RESULTS

Between December 2017 and November 2021, 39 subjects were enrolled at three centers. Oral cavity was the most common primary site (69%). A total of 35 of 39 subjects underwent planned surgical resection; one subject had a delay in surgery due to treatment-related toxicity. The most common treatment-related adverse events were cytopenias, fatigue, and nausea. Post treatment imaging demonstrated an objective response rate of 57%. Pathologic complete response and major pathologic response were achieved in 29% and 49% of subjects who underwent planned surgery, respectively. The 1-year progression-free survival was 83.8% (95% confidence interval, 67.4%-92.4%).

CONCLUSIONS

Neoadjuvant carboplatin, nab-paclitaxel, and durvalumab before surgical resection of HNSCC were safe and feasible. Although the primary end point was not met, encouraging rates of pathologic complete response and clinical to pathologic downstaging were observed.

Trends and Implications of Adjuvant Systemic Therapy for Head and Neck Cancer Without High-Risk Features

OBJECTIVE

Determine trends and survival implications of adjuvant systemic therapy use for lower risk head and neck cancer.

STUDY DESIGN

Retrospective cohort study.

SETTING

US National Cancer Database, 2010 to 2019.

METHODS

Patients with mucosal head and neck squamous cell carcinoma treated with surgery and postoperative radiation therapy were identified. Adjuvant systemic therapy trends in those with and without extranodal extension or positive margins were assessed as annual percent change by JoinPoint analysis. Factors associated with adjuvant systemic therapy and overall survival were assessed with multivariable models and cox proportional hazard models, respectively.

RESULTS

From 2010 to 2019, approximately one-third of head and neck cancer patients without extranodal extension or positive margins received adjuvant systemic therapy. This rate decreased throughout the study period, with the highest annual percent change from 2016 to 2019 (12.21%; 95% confidence interval: 3.73%-19.95%). Younger age, male sex, Hispanic ethnicity, community program setting, advanced stage, and lymphovascular invasion increased the odds a patient would receive adjuvant systemic therapy. Adjuvant systemic therapy was associated with inferior overall survival when used in those without extranodal extension or positive margins after controlling for covariates.

CONCLUSION

Though decreasing, adjuvant systemic therapy use is still common in the absence of extranodal extension and positive margins, and a variety of patient, provider, and oncologic factors may influence its use. The inferior overall survival after adjuvant systemic therapy in the absence of high-risk features suggests any oncologic benefit may not outweigh the costs and morbidity of the therapy.

Adding Concomitant Chemotherapy to Postoperative Radiotherapy in Oral Cavity Carcinoma with Minor Risk Factors: Systematic Review of the Literature and Meta-Analysis

When presenting with major pathological risk factors, adjuvant radio-chemotherapy for oral cavity cancers (OCC) is recommended, but the addition of chemotherapy to radiotherapy (POCRT) when only minor pathological risk factors are present is controversial. A systematic review following the PICO-PRISMA methodology (PROSPERO registration ID: CRD42021267498) was conducted using the PubMed, Embase, and Cochrane libraries. Studies assessing outcomes of POCRT in patients with solely minor risk factors (perineural invasion or lymph vascular invasion; pN1 single; DOI ≥ 5 mm; close margin < 2−5 mm; node-positive level IV or V; pT3 or pT4; multiple lymph nodes without ENE) were evaluated. A meta-analysis technique with a single-arm study was performed. Radiotherapy was combined with chemotherapy in all studies. One study only included patients treated with POCRT. In the other 12 studies, patients were treated with only PORT (12,883 patients) and with POCRT (10,663 patients). Among the patients treated with POCRT, the pooled 3 year OS rate was 72.9% (95%CI: 65.5−79.2%); the pooled 3 year DFS was 70.9% (95%CI: 48.8−86.2%); and the pooled LRFS was 69.8% (95%CI: 46.1−86.1%). Results are in favor of POCRT in terms of OS but not significant for DFS and LRFS, probably due to the heterogeneity of the included studies and a combination of different prognostic factors.