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)

Early Death in T3-T4 Head and Neck Cancer: NCDB Comparison of Surgical vs. Non-Surgical Approaches

BACKGROUND

Surgeries for T3-T4 head and neck squamous cell carcinoma (HNSCC) are often complex and high-risk with the potential for early death, which is both clinically devastating and a negative quality indicator for health systems. This study aims to compare surgical and non-surgical approaches in an aggressive subset of HNSCC for early death.

METHODS

This is a retrospective analysis of the National Cancer Database (NCDB) v2018 for advanced T3-T4 HNSCC patients from 2004 to 2018. Univariate and multivariate logistic regression analyses were performed with the primary goal of comparing 30-day mortality in patients undergoing primary surgery (PS) versus radiation with or without chemotherapy (CRT). Subgroup analysis between treatment groups was performed with respect to HPV status.

RESULTS

A total of 79 677 advanced head and neck cancer patients with a mean (SD) age of 62.5 (12.0) years, predominantly male (74.0%), were included in the analysis. Patients with T3-T4 HNSCC undergoing upfront surgery had an early death rate of 1.1%, compared to 4.7% for CRT (p < 0.001). This translated to significantly lower odds of early death with PS compared to CRT (OR = 0.25, 95% CI 0.22-0.28), adjusting for age, comorbidity index, stage III or IV, subsite, insurance status, and grade. Subset analysis showed survival benefits of PS irrespective of HPV status. Age ≥ 65 years, T4 tumors, higher Charlson Comorbidity Index (CCI), and uninsured status were consistently associated with increased mortality risk.

CONCLUSION

This study suggests that an upfront surgical approach is associated with decreased early death compared to non-surgical treatment for HNSCC. HPV-based subgroup analysis has shown a more focused predictor of early death. Cancer treatment paradigms should account for the observation of these findings for advanced HNSCC.

Predictors of Radiation Resistance and Novel Radiation Sensitizers in Head and Neck Cancers: Advancing Radiotherapy Efficacy

Radiation resistance in head and neck squamous cell carcinoma (HNSCC), driven by intrinsic and extrinsic factors, poses a significant challenge in radiation oncology. The key contributors are tumor hypoxia, cancer stem cells, cell cycle checkpoint activation, and DNA repair processes (homologous recombination and non-homologous end-joining). Genetic modifications such as TP53 mutations, KRAS mutations, EGFR overexpression, and abnormalities in DNA repair proteins like BRCA1/2 additionally affect radiation sensitivity. Novel radiosensitizers targeting these pathways demonstrate the potential to overcome resistance. Hypoxia-activated drugs and gold nanoparticles enhance the efficacy of radiotherapy and facilitate targeted distribution. Integrating immunotherapy, especially immune checkpoint inhibitors, with radiation therapy, enhances anti-tumor responses and reduces resistance. Epigenetic alterations, such as DNA methylation and histone acetylation, significantly influence radiation response, with the potential for sensitization through histone deacetylase inhibitors and non-coding RNA regulators. Metabolic changes linked to glucose, lipid, and glutamine metabolism influence radiosensitivity, uncovering new targets for radiosensitization. Human papillomavirus (HPV)-associated malignancies exhibit increased radiosensitivity relative to other tumors due to impaired DNA repair mechanisms and heightened immunogenicity. Furthermore, understanding the interplay between HPV oncoproteins and p53 functionality can enhance treatment strategies for HPV-related cancers. Using DNA damage response inhibitors (PARP, ATM/ATR), cell cycle checkpoint inhibitors (WEE1, CHK1/2), and hypoxia-targeted agents as radiosensitizing strategies exhibit considerable promise. Immunomodulatory approaches, including PD-1 and CTLA-4 inhibitors in conjunction with radiation, enhance anti-tumor immunity. Future directions emphasize personalized radiation therapy using genetics, sophisticated medication delivery systems, adaptive radiotherapy, and real-time monitoring. These integrated strategies seek to diminish radiation resistance and improve therapeutic efficacy in HNSCC.

Weekly Cisplatin Cycles and Outcomes for Chemoradiation in Head and Neck Cancer

Importance

National Comprehensive Cancer Network guidelines recommend weekly cisplatin as an alternative concurrent systemic therapy for definitive chemoradiation in patients with head and neck cancer. However, the impact of different levels of adherence to weekly cisplatin on outcomes stratified by human papillomavirus p16 status remains unclear.

Objective

To evaluate the association between the number of weekly cisplatin cycles and outcomes.

Design, Setting, and Participants

This retrospective, observational, single-institution cohort study at The Ohio State Comprehensive Cancer Center included patients with a diagnosis of nonmetastatic head and neck cancer between December 1, 2011, and March 30, 2020, who received chemoradiation. Data analysis was performed between March and May 2024.

Exposure

A total of 5, 6, or 7 to 8 weekly cisplatin cycles.

Main Outcomes and Measures

The primary outcomes were overall survival (OS), progression-free survival (PFS), locoregional failure (LRF), and distant failure (DF). Cox multivariable analysis was performed for variables associated with OS and PFS, and Fine-Gray multivariable analysis was performed for variables associated with LRF and DF.

Results

A total of 142 patients met the criteria (119 men [83.8%]; median [IQR] age, 59 [54-63] years). Median (IQR) follow-up was 46.8 (40.8-55.6) months. Among 92 patients with reasons for cisplatin interruption reported, the most common reason was low blood counts (42 patients [45.7%]). Those who missed weekly cisplatin cycles had worse OS (adjusted hazard ratio [aHR], 2.22; 95% CI, 1.19-4.17; P = .01) and PFS (aHR, 1.83; 95% CI, 1.06-3.15; P = .03) than those who received 7 to 8 cycles. Cancer control outcomes were comparable between these groups (LRF aHR, 0.53; 95% CI, 0.15-1.93; P = .34; DF aHR, 1.51; 95% CI, 0.60-3.82; P = .38). Patients with p16-negative tumors who missed weekly cisplatin cycles had worse OS (for every missing cisplatin cycle, aHR, 11.34, 1.51-84.94; P = .02) than those treated with 7 to 8 cycles. However, for those with p16-positive tumors, there were no statistically significant differences in OS between those who missed weekly cisplatin cycles vs others who received 7 to 8 cycles (aHR, 1.21; 95% CI, 0.47-3.14; P = .69).

Conclusions and Relevance

In this cohort study of patients with head and neck cancer who received definitive chemoradiation, those with p16-negative tumors who missed weekly cisplatin cycles had lower OS than those who received 7 to 8 cycles, although OS was comparable between these groups for p16-positive tumors. Cytopenia represented the most common reason for cisplatin interruption.

Pilot Feasibility and Safety Study of Hydrogen Gas Inhalation in Locally Advanced Head and Neck Cancer Patients

Purpose

Hydrogen (H2) gas inhalation might alleviate acute radiotherapy toxicities by scavenging free radicals produced by ionizing radiation and anti-inflammatory properties. This study aimed to investigate the feasibility and safety of H2 gas inhalation during concurrent chemoradiotherapy (CCRT) in patients with locally advanced head and neck cancer (LAHNC).

Patients and Methods

We designed a pilot prospective study combining CCRT with aerosol inhalation of H2 gas. Each patient was scheduled to receive daily intensity-modulated radiotherapy (IMRT) in 33 fractions on a weekday and six cycles of weekly chemotherapy. All patients inhaled H2 gas through a cannula or mask 1 hour per day, 1-2 hours before IMRT. The primary endpoint was the feasibility of H2 inhalation. Eighty percent of the patients who completed at least 20 applications of H2 gas inhalation were considered feasible. The secondary endpoints were safety profiles during H2 gas inhalation (vital signs and symptoms related to H2 gas inhalation) and acute toxicities during CCRT.

Results

We enrolled 10 patients with LAHNC between July 2023 and December 2023. All patients received 33 fractions of H2 gas inhalation on the same day as the IMRT. Vital signs during and at the end of H2 gas inhalation were stable in all patients. None of the 10 patients had hypertension or hypotension during any of the 33 inhalations. No adverse events related to H2 gas inhalation, such as cough, nasal bleeding, dizziness, headache, nausea, or vomiting, were reported. Grade 3 leukopenia was found in two patients (20%) during the 5th week of CCRT. Grade 2 radiation dermatitis and pharyngitis were found in three patients (30%).

Conclusion

H2 gas inhalation combined with CCRT is feasible and safe for patients with LAHNC.

Gold-siRNA supraclusters enhance the anti-tumor immune response of stereotactic ablative radiotherapy at primary and metastatic tumors

Strategies to enhance the anti-tumor immune response of stereotactic ablative radiotherapy (SABR) at primary tumors and abscopal sites are under intensive investigation. Here we report a metabolizable binary supracluster (BSCgal) that combines gold nanoclusters as radiosensitizing adjuvants with small interfering RNA (siRNA) targeting the immunosuppressive mediator galectin-1 (Gal-1). BSCgal comprises reversibly crosslinked cationic gold nanoclusters and siRNA complexes in a polymer matrix that biodegrades over weeks, facilitating clearance (90.3% in vivo clearance at 4 weeks) to reduce toxicity. The particle size well above the renal filtration threshold facilitates passive delivery to tumors. Using mouse models of head and neck cancer, we show that BSCgal augments the radiodynamic and immunotherapeutic effects of SABR at the primary and metastatic tumors by promoting tumor-inhibitory leukocytes, upregulating cytotoxic granzyme B and reducing immunosuppressive cell populations. It outperforms SABR plus Gal-1 antagonists, chemoradiation drug cisplatin or PD-1 inhibitor. This work presents a translatable strategy to converge focal radiosensitization with targeted immune checkpoint silencing for personalized radioimmunotherapy.

Effect of acute kidney injury and overall survival in patients with postoperative head and neck cancer who received chemoradiotherapy with cisplatin: A supplementary analysis of the phase II/III trial of JCOG1008

BACKGROUND

In a randomized phase II/III trial (JCOG1008), weekly cisplatin (40 mg/m2) was non-inferior to 3-weekly cisplatin (100 mg/m2) for postoperative high-risk head and neck cancer. We investigated how acute kidney injury (AKI), a major dose-limiting toxicity effect of cisplatin, affects overall survival (OS).

METHODS

We analyzed 251 patients from JCOG1008 receiving chemoradiotherapy. AKI was defined based on AKI Network criteria (serum creatinine increase of ≥0.3 mg/dL or ≥1.5-fold [≥ stage I]) within 30 days after completing chemoradiotherapy. OS in the two arms was compared according to AKI development using the log-rank test.

RESULTS

The total incidence of AKI was lower in the weekly arm than in the 3-weekly arm (38/122 [31.1%] vs. 56/129 [43.4%]). Additionally, stage II/III AKI occurred less frequently in the weekly arm than in the 3-weekly arm (8/122 [6.6%] vs. 19/129 [14.7%]). Cisplatin doses were similar in the weekly arm for patients with and without AKI (median, 238.6 mg/m2 vs. 239.2 mg/m2; p = 0.94), but lower in the 3-weekly arm for those who developed AKI (median, 276.3 mg/m2 vs. 297.4 mg/m2; p = 0.007). In the weekly arm, there was no difference in OS between patients with and without AKI (hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.53 to 2.10). However, in the 3-weekly arm, patients with AKI had poorer OS than those without AKI (HR, 1.83; 95% CI, 1.04 to 3.21).

CONCLUSIONS

In this supplementary analysis of JCOG1008 data, AKI impacted the OS of patients with head and neck cancer undergoing postoperative chemoradiotherapy in the 3-weekly arm but not in the weekly arm. Our results further endorse the utilization of weekly cisplatin at 40 mg/m2 in this setting.

Association of low adherence to weekly cisplatin with outcomes in patients with head and neck squamous cell carcinoma: a retrospective cohort study

BACKGROUND

The National Comprehensive Cancer Network (NCCN) guideline recommends consideration of weekly cisplatin as an alternative option for patients with head and neck cancer undergoing definitive chemoradiation. However, in a recent phase III trial (ConCERT), 20% of patients treated with weekly cisplatin could not receive a total of 200 mg/m2, and the association of low adherence to weekly cisplatin and cancer control outcomes remains unclear. To fill this knowledge gap, we performed an observational cohort study of patients with head and neck cancer undergoing definitive chemoradiation with weekly cisplatin.

METHODS

Our institutional database was queried for patients with non-metastatic head and neck cancer who underwent definitive chemoradiation with weekly cisplatin (40 mg/m2) between November 2007 and April 2023. Adherence to weekly cisplatin was defined as receiving at least 5 cycles with a total cumulative dose of 200 mg/m2. Survival outcomes were evaluated using Kaplan-Meier method, log-rank tests, Cox proportional hazard multivariable (MVA) analyses. Logistic MVA was performed to identify variables associated with low adherence to weekly cisplatin. Fine-Gray MVA was performed to analyze failure outcomes with death as a competing event.

RESULTS

Among 119 patients who met our criteria, 51 patients (42.9%) had low adherence to weekly cisplatin. Median follow up was 19.8 months (interquartile range 8.8-65.6). Low adherence to weekly cisplatin was associated with worse overall survival (adjusted hazards ratio [aHR] 2.94, 95% confidence interval [CI] 1.58-5.47, p < 0.001) and progression-free survival (aHR 2.32, 95% CI 1.29-4.17, p = 0.005). It was also associated with worse distant failure (aHR 4.55, 95% CI 1.19-17.3, p = 0.03), but not locoregional failure (aHR 1.61, 95% CI 0.46-5.58, p = 0.46). KPS < 90 was the only variable associated with low adherence to weekly cisplatin (adjusted odds ratio [aOR] 2.67, 95% CI 1.10-6.65, p = 0.03).

CONCLUSION

Our study suggested that over 40% of patients underwent fewer than 5 weekly cisplatin cycles and that low adherence to weekly cisplatin was an independent, adverse prognostic factor for worse survival and distant failure outcomes. Those with reduced adherence to weekly cisplatin were more likely to have poor performance status. Further studies are warranted to improve the adherence to chemotherapy and outcomes.

Risk prediction model for cisplatin-induced acute kidney injury in patients with head and neck cancer receiving chemoradiotherapy: A re-analysis of a phase II/III JCOG1008 trial

OBJECTIVES

Acute kidney injury (AKI) represents a major toxicity associated with cisplatin. We developed a risk prediction model for cisplatin-induced AKI in patients with postoperative high-risk head and neck cancer who received chemoradiotherapy during a randomized phase II/III trial, JCOG1008.

MATERIALS AND METHODS

Two hundred and fifty-one patients received radiotherapy with weekly cisplatin at 40 mg/m2 (weekly arm) or 3-weekly cisplatin at 100 mg/m2 (3-weekly arm). AKI was defined using the AKI Network classification/staging system as increased serum creatinine of ≥0.3 mg/dL or a ≥1.5-fold increase from baseline 30 days after completing chemoradiotherapy. The Akaike information criterion was used to explore the optimal model by combining explanatory variables at registration.

RESULTS

Among the 251 patients (210 men and 41 women (median age; 62 years)), 94 (37.5 %) developed cisplatin-induced AKI. The optimal cisplatin-induced AKI risk prediction model comprised four factors, including a primary site of hypopharynx/larynx (vs. oral cavity/oropharynx), 3-weekly arm (vs. weekly arm), serum albumin of ≤3.5 g/dL (vs. >3.5 g/dL) and creatinine clearance (CCr) of <90 mL/min (vs. ≥90 mL/min). The incidence of cisplatin-induced AKI rose with cumulative count of the four factors. When the cumulative count was ≥2, the positive predictive value for cisplatin-induced AKI was 50.3 %.

CONCLUSIONS

We developed a risk prediction model for cisplatin-induced AKI in patients with head and neck cancer who received postoperative chemoradiotherapy using primary site, cisplatin administration method, serum albumin, and CCr. Patients with risk factors unrelated to the cisplatin administration method should adopt a weekly cisplatin regimen.

Beneficial Effects of Resveratrol and γ-Cyclodextrin on the Hematological and Biochemical Parameters of Healthy Wistar Rats Treated with Cisplatin: A PCA Approach

It is well known that platinum-based antineoplastic agents, including cisplatin (CP), have side effects that limit their use. Nefrotoxicity, neurotoxicity, and hemolytic anemia are the most common side effects. There are few studies on the reduction in these effects that involves nanoencapsulation; however, almost none involve cyclodextrins (CDs). Changes in the hematological and biochemical parameters of healthy Wistar rats treated with solutions of γ-cyclodextrin/resveratrol/cisplatin (γ-CD/Rv/CP) ternary complexes are investigated for the first time. They are intraperitoneally injected with γ-CD/Rv/CP solutions containing 5 mg CP/kg.b.w. Single shots were administered to six groups of Wistar rats (six individuals for every group) using γ-CD/Rv/CP, γ-CD/CP, γ-CD/Rv complexes, as well as positive- and negative-control groups, respectively. Thirty-two hematological and biochemical parameters were evaluated from blood samples and used as input variables for the principal component analysis (PCA) discrimination of the groups. The best protection was obtained for the γ-CD/Rv/CP ternary complex, which determined closer biochemical values to the control group. These values significantly differ from those of the γ-CD/CP treated group, especially for the IP, UA, and T-Pro kidney-related biochemical parameters. This finding proves the beneficial influence of Rv during CP administration through CD-based carriers.

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

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

Concurrent chemoradiotherapy with cisplatin given once-a-week versus every-three weekly in head and neck squamous cell carcinoma: Non-inferior, equivalent, or superior?

Cisplatin-based concurrent chemoradiotherapy is the contemporary standard-of-care in curative-intent management of loco-regionally advanced head and neck squamous cell carcinoma. The most optimal dose-schedule of concurrent cisplatin remains debatable with widespread variability in clinical practice. High-quality evidence in favour of cisplatin-based chemoradiotherapy is largely based on high-dose cisplatin given as 100 mg/m² every three-weekly for up to three cycles. However, such dosing is typically associated with high rates of significant acute hematological and renal toxicity prompting the need for alternative lesser toxic dose-schedules. Compliance to three doses of three-weekly high-dose cisplatin is reportedly suboptimal with nearly 40% of patients unable to receive the third cycle thereby achieving cumulative cisplatin dose of 200 mg/m² which is generally regarded sufficient for beneficial anti-tumor effect. The most common alternative schedule is low-dose (20-50 mg/m²) cisplatin once-weekly during radiotherapy. Such low-dose weekly regimens have undergone less rigorous prospective evaluation versus RT alone but continue to be widely used in co-operative group trials and routine clinical practice. In the last decade, several small prospective randomized controlled trials have reported significantly lesser toxicity and comparable disease-related outcomes with low-dose weekly cisplatin. However, two recent randomized controlled trials have re-ignited the debate globally due to their contradictory results, inferences, and conclusions. Through this commentary, we critically appraise and summarize the existing evidence-base to inform contemporary clinical practice and guide future research. There is increasingly emerging evidence that chemoradiotherapy with once-weekly cisplatin is non-inferior to three-weekly cisplatin for disease-related outcomes in curative-intent management of loco-regionally advanced head and neck cancer.

Optimizing the prescription doses and tolerability of systemic therapy in head and neck cancer patients

PURPOSE OF REVIEW

Squamous cell carcinoma of the head and neck accounts for 330 000 deaths and 650 000 cases worldwide annually. Systemic therapy is an essential pillar of multimodal therapy despite being accompanied with substantial toxicity. This article reviews the latest advances in systemic therapy for the treatment of locoregionally advanced and reccurent/metastatic head and neck cancer from a tolerability perspective.

RECENT FINDINGS

Multiple recent attempts have been made to optimize tolerability (and efficacy) of systemic therapy utilizing new regimens, modified prescription doses, drugs such as immunotherapies or genotyping to tailor the systemic therapy to the individual patient.

SUMMARY

Although treatment benefit has to be weighed against potential toxicity, it is reasonable to anticipate potential side effects of systemic therapies. In a vulnerable elderly or Asian patient population upfront dose modifications of cytotoxic chemotherapies might be reasonable. Special attention should be laid on the patient's nutritional status and early intervention recommended. Dihydropyrimidine dehydrogenase genotyping can predict 5-fluorouracil toxicity and identify patients for whom alternative regimens are more suitable. As for immune checkpoint inhibitor therapy, despite being well tolerated, the identification of biomarkers to predict reduced tolerability or severe toxicity would be highly desirable.

Three weekly versus weekly concurrent cisplatin: safety propensity score analysis on 166 head and neck cancer patients

Background

Radio-chemotherapy with CDDP is the standard for H&N squamous cell cancer. CDDP 100 mg/m²/q3 is the standard; alternative schedules are used to reduce toxicity, mostly 40 mg/m²/q1.

Methods

Patients were treated from 1/2010 to 1/2017 in two Radiation Oncology Centres. Propensity score analysis (PS) was retrospectively used to compare these two schedules.

Results

Patients analyzed were 166. Most (114/166) had 1w-CDDP while 52 had 3w-CDDP. In the 3w-CDDP group, patients were younger, with better performance status, smaller disease extent and a more common nodal involvement than in the 1w-CDDP. Acute toxicity was similar in the groups. Treatment compliance was lower in the w-CCDP. Overall survival before PS was better for female, for oropharyngeal disease and for 3w-CDDP group. After PS, survival was not related to the CDDP schedule.

Conclusions

3w-CDDP remains the standard for fit patients, weekly schedule could be safely used in selected patients.

Current Therapeutic Strategies in Patients with Oropharyngeal Squamous Cell Carcinoma: Impact of the Tumor HPV Status

Simple Summary

Contrary to other head and neck subsites, oropharyngeal squamous cell carcinoma (OPSCC) has shown a considerable increase in incidence over the past 20 years. This growing incidence is largely due to the increasing place of human papillomavirus (HPV)-related tumors. HPV-positive and HPV-negative OPSCC are two distinct entities with considerable differences in terms of treatment response and prognosis. However, there are no specific recommendations yet in the therapeutic management of OPSCC patients according to their tumor HPV-status. The aim of this review is therefore to discuss the therapeutic management of patients with OPSCC and the impact of HPV status on treatment selection.

Abstract

Since there is no published randomized study comparing surgical and non-surgical therapeutic strategies in patients with oropharyngeal squamous cell carcinoma (OPSCC), the therapeutic management of these patients remains highly controversial. While human papillomavirus (HPV)-positive and HPV-negative OPSCC are now recognized as two distinct diseases with different epidemiological, biological, and clinical characteristics, the impact of HPV status on the management of OPSCC patients is still unclear. In this review, we analyze the current therapeutic options in patients with OPSCC, highlighting the most recent advances in surgical and non-surgical therapies, and we discuss the impact of HPV status on the therapeutic strategy.