Phase II trial of hyperfractionated intensity-modulated radiation therapy and concurrent weekly cisplatin for Stage III and IVa head-and-neck cancer

Effectiveness of Photobiomodulation and Oral Cryotherapy on Oral Mucositis Among Patients Undergoing Chemotherapy Conditioning Prior to Hematological Stem Cell Transplantation

OBJECTIVES

This review evaluated the best available evidence concerning the effectiveness of photobiomodulation compared to oral cryotherapy in oral-mucositis prevention among patients with hematological stem cell transplantation (HSCT) receiving chemo-conditioning.

DATA SOURCES

An extensive search for published and unpublished studies was conducted in 11 electronic databases and reference lists. Only randomized controlled trials (RCTs) were included. Two reviewers independently screened relevant studies for eligibility, extracted data using a standardized data collection form, and appraised data using the Cochrane Risk of Bias Tool and Grading Recommendations, Assessment, Development and Evaluation (GRADE). Meta-analyses using a random-effect model was performed using Review Manager software. Subgroup analyses were conducted to examine the differential effect of interventions across subgroups and to explore potential sources of heterogeneity. Meta-analyses included 18 RCTs (involving 1,018 patients). Both photobiomodulation and cryotherapy were effective in reducing oral-mucositis severity, severe oral-mucositis incidence, duration, and pain with small to large effect sizes. No significant differences were detected between photobiomodulation and cryotherapy across all outcomes. Subgroup analyses showed significant differences for chemo-conditioning regimens. The overall Grading Recommendations, Assessment, Development and Evaluation quality of evidence was low.

CONCLUSION

Both photobiomodulation and cryotherapy were effective nonpharmacological oral-mucositis prophylaxis and analgesia, with no significant difference in effectiveness. Chemo-conditioning regimens may influence their effectiveness. Future RCTs may directly compare the effectiveness of photobiomodulation and cryotherapy on the HSCT patients. Rigorous cost-effectiveness studies are also required.

IMPLICATIONS FOR NURSING PRACTICE

Photobiomodulation and cryotherapy can be offered to HSCT patients in clinical settings. A clinical guideline of both interventions can be also developed.

In vitro evaluation of photon and carbon ion radiotherapy in combination with cisplatin in head and neck squamous cell carcinoma cell lines

Background

Heavy ion radiotherapy, such as carbon ion radiotherapy (CIRT), has multiple advantages over conventional photon therapy. Cisplatin, as a classic anti-tumor drugs, has been tested and discovered as a photon radiosensitizer in several cell lines, including head and neck squamous cell carcinoma (HNSCC). Hence, the aim of our study is to evaluate whether cisplatin can sensitize CIRT towards HNSCC cell lines in vitro.

Methods

Human nasopharyngeal carcinoma cell line CNE-2, human tongue squamous carcinoma cell line TCA 8113 and human hypopharynx squamous carcinoma cell line FADU were all irradiated with photon beam of 2, 4, 6, 8 Gy (physical dose) and carbon ion beam of 1, 2, 3, 4 Gy (physical dose) and treated with cisplatin. Cell survival was assessed by clonogenic survival assay.

Results

CIRT showed significantly stronger cytotoxic effect than standard photon radiotherapy. The relative biological effectiveness (RBE) of carbon ion beam at 10% survival (RBE10) was calculated 3.07 for CNE-2, 2.33 for TCA 8113 and 2.36 for FADU. Chemoradiotherapy (both photon radiotherapy and CIRT) was more effective than radiotherapy alone. In vitro sensitizer enhancement ratios (SERs) of cisplatin in CNE-2, TCA 8113 and FA DU cell lines after photon irradiation were 1.33, 1.14 and 1.21, while after carbon ion irradiation were 1.02, 1.00 and 0.96, showed that cisplatin sensitized photon irradiation but showed no sensitization effect in carbon ion irradiation in all tested cell lines.

Conclusions

In conclusion, high linear energy transfer (LET) CIRT was more effective than photon irradiation to prevent the proliferation of HNSCC cell lines. Additional treatment with cisplatin could sensitize photon irradiation but showed no effect on carbon ion irradiation.

Current status of systemic therapy in head and neck cancer

There are several controversies in the management of head and neck cancer (SCCHN). Although combined modality treatment is standard in locally advanced SCCHN (LA-SCCHN), the optimal timing of chemotherapy has been debated. Toxicity concerns with chemoradiation (CRT) using high dose cisplatin have prompted use of less intensive approaches. Weekly cisplatin and targeted therapies have been explored in randomized trials. Benefit of neoadjuvant chemotherapy in LA-SCCHN is debated due to lack of impact on overall survival, however, it remains a viable option in the Indian setting where many patients are not eligible for upfront surgery or definite CRT due to advanced stage and poor performance status (PS). The complexity of data of immune check point inhibitors (ICPi) in metastatic setting needs cautious interpretation till an ideal biomarker for their benefit is identified. Their significant cost and promising data of oral metronomic therapy has made the treatment landscape of metastatic SCCHN even more complex. To address these burning issues, we did a critical review of evidence of systemic therapy in SCCHN.

Chemotherapy and radiotherapy in locally advanced head and neck cancer: an individual patient data network meta-analysis

BACKGROUND

Randomised, controlled trials and meta-analyses have shown the survival benefit of concomitant chemoradiotherapy or hyperfractionated radiotherapy in the treatment of locally advanced head and neck cancer. However, the relative efficacy of these treatments is unknown. We aimed to determine whether one treatment was superior to the other.

METHODS

We did a frequentist network meta-analysis based on individual patient data of meta-analyses evaluating the role of chemotherapy (Meta-Analysis of Chemotherapy in Head and Neck Cancer [MACH-NC]) and of altered fractionation radiotherapy (Meta-Analysis of Radiotherapy in Carcinomas of Head and Neck [MARCH]). Randomised, controlled trials that enrolled patients with non-metastatic head and neck squamous cell cancer between Jan 1, 1980, and Dec 31, 2016, were included. We used a two-step random-effects approach, and the log-rank test, stratified by trial to compare treatments, with locoregional therapy as the reference. Overall survival was the primary endpoint. The global Cochran Q statistic was used to assess homogeneity and consistency and P score to rank treatments (higher scores indicate more effective therapies).

FINDINGS

115 randomised, controlled trials, which enrolled patients between Jan 1, 1980, and April 30, 2012, yielded 154 comparisons (28 978 patients with 19 253 deaths and 20 579 progression events). Treatments were grouped into 16 modalities, for which 35 types of direct comparisons were available. Median follow-up based on all trials was 6·6 years (IQR 5·0-9·4). Hyperfractionated radiotherapy with concomitant chemotherapy (HFCRT) was ranked as the best treatment for overall survival (P score 97%; hazard ratio 0·63 [95% CI 0·51-0·77] compared with locoregional therapy). The hazard ratio of HFCRT compared with locoregional therapy with concomitant chemoradiotherapy with platinum-based chemotherapy (CLRT_P) was 0·82 (95% CI 0·66-1·01) for overall survival. The superiority of HFCRT was robust to sensitivity analyses. Three other modalities of treatment had a better P score, but not a significantly better HR, for overall survival than CLRT_P (P score 78%): induction chemotherapy with taxane, cisplatin, and fluorouracil followed by locoregional therapy (IC_TaxPF-LRT; 89%), accelerated radiotherapy with concomitant chemotherapy (82%), and IC_TaxPF followed by CLRT (80%).

INTERPRETATION

The results of this network meta-analysis suggest that further intensifying chemoradiotherapy, using HFCRT or IC_TaxPF-CLRT, could improve outcomes over chemoradiotherapy for the treatment of locally advanced head and neck cancer.

FUNDINGS

French Institut National du Cancer, French Ligue Nationale Contre le Cancer, and Fondation ARC.

Predictors of Quality of Life Change in Head-and-Neck Cancer Survivors during Concurrent Chemoradiotherapy: A Prospective Study

Objective:

Head-and-neck cancer (HNC) and its treatment impact patients' quality of life (QoL) and survival. The symptom burden of HNC survivors severely affects QoL, while hope serves as an impetus for adjustment that enables survivors to sustain basic QoL. This study investigated the change of QoL, symptom burden, and hope and the predictors of QoL change in HNC survivors from diagnosis to 3 months after concurrent chemoradiotherapy (CCRT) completing.

Methods:

This was a prospective, correlational study conducted between January 2016 and April 2017 at a medical center in northern Taiwan. Purposive sampling 54 adults newly diagnosed with HNC had completed the first CCRT. The questionnaires of Functional Assessment of Cancer Therapy-HNC Scale, M. D. Anderson Symptom Inventory, and Herth Hope Index were collected. The five measuring times were before CCRT (T1), the 3^rd–4^th week of CCRT (T2), the last week of CCRT (T3), and 1 month (T4) and 3 months (T5) after the completion of CCRT.

Results:

The change of QoL first declined and then rose at T2–T5. The change of symptom burden increased initially and then declined at T2–T5. The change of hope remained steady between T1 and T5. The change of symptom burden and hope significantly predicted the change of QOL over time.

Conclusions:

Clinicians are suggested to assess symptom burden and hope regularly in HNC during their CCRT and, if needed, promptly provide interprofessional care in time. Reducing symptom burden and maintaining a mindful hope could improve QoL in HNC survivors during CCRT.

DAHANCA 28: A phase I/II feasibility study of hyperfractionated, accelerated radiotherapy with concomitant cisplatin and nimorazole (HART-CN) for patients with locally advanced, HPV/p16-negative squamous cell carcinoma of the oropharynx, hypopharynx, larynx and oral cavity

BACKGROUND

A phase I-II study to evaluate the feasibility and efficacy of intensified, primary radiotherapy (RT) for Locally Advanced Head and Neck Squamous Cell Carcinoma (LAHNSCC) employing dose escalation by hyperfractionation, acceleration of treatment time, concomitant chemotherapy and hypoxic modification.

METHODS

Patients with HPV/p16- LAHNSCC receiving primary hyperfractionated, accelerated RT, 76 Gy/56 fx, 10 fx/week for 5½ weeks, concomitant weekly cisplatin (40 mg/m²) and nimorazole (HART-CN) were included. Primary endpoint was locoregional failure (LRF). Secondary endpoints were overall survival (OS) and toxicity.

RESULTS

50 patients received HART-CN from 2013 to 2017. Median age was 60 years. Most patients had stage IV hypo- or oropharynx cancer with a heavy smoking history. All oropharyngeal cancers were HPV/p16-negative. Ninety-eight percent of patients completed RT, but compliance to cisplatin and nimorazole was lower. Median observation time was 44 months. LRF was diagnosed in 10 patients. All LRFs were in the high-dose CTV. The 3-year actuarial LRF was 21%, and OS was 74%. The peak incidence of acute toxicity showed that 67% of patients experienced severe dysphagia, 61% severe mucositis, and 78% were equipped with feeding tubes. Late severe morbidity was seen in 7 of 29 recurrence-free patients with at least 3 years of followup, who presented with either severe dysphagia (n = 2), severe xerostomia (n = 1), severe fibrosis of the neck (n = 3) or osteoradionecrosis (n = 1). Three were still tube dependent.

CONCLUSION

HART-CN is feasible in patients with HPV/p16- LAHNSCC in good health. Although acute toxicity was pronounced, the proportion of patients with late toxicity was acceptable and outcome at 3 years encouraging.

A comparison of cisplatin cumulative dose and cisplatin schedule in patients treated with concurrent chemo-radiotherapy in nasopharyngeal carcinoma

INTRODUCTION

Three-weekly cisplatin dose is accepted for standard treatment for concurrent chemo-radiotherapy in nasopharyngeal carcinoma. However, different chemotherapy schedules are presented in the literature.

OBJECTIVE

We intend to compare toxicity and outcomes of high dose 3-weekly cisplatin versus low dose weekly-cisplatin and cumulative dose of cisplatin in the patients with nasopharyngeal carcinoma.

METHODS

98 patients were included in the study, between 2010 and 2018. Cumulative doses of cisplatin (≥200mg/m² and <200mg/m²) and different chemotherapy schedules (weekly and 3-weekly) were compared in terms of toxicity and survival. Besides prognostic factors including age, gender, T category, N category and radiotherapy technique were evaluated in uni-multivariate analysis.

RESULTS

Median follow-up time 41.5 months (range: 2-93 months). Five year overall survival, local relapse-free survival, regional recurrence-free survival and distant metastasis-free survival rates were; 68.9% vs. 90.3% (p=0.11); 66.2% vs. 81.6% (p=0.15); 87.3% vs. 95.7% (p=0.18); 80.1% vs. 76.1% (p=0.74) for the group treated weekly and 3 weekly, respectively. There was no statistically significant difference between groups. Five year overall survival, local relapse-free survival, regional recurrence-free survival and distant metastasis-free survival rates were; 78.2% vs. 49.2% (p=0.003); 75.8% vs. 47.9% (p=0.055); 91% vs. 87.1% (p=0.46); 80% vs. 72.2% (p=0.46) for the group treated ≥200mg/m² and <200mg/m² cumulative dose cisplatin. There was statistically significant difference between groups for overall survival and there was close to being statistically significant difference between groups for local relapse-free survival. Age, gender, T category, N category, chemotherapy schedules were not associated with prognosis in the uni-variety analysis. Radiotherapy technique and cumulative dose of cisplatin was associated with prognosis in uni-variate analysis (HR=0.21; 95% CI: 0.071-0.628; p=0.005 and HR=0.29; 95% CI: 0.125-0.686; p=0.003, respectively). Only cumulative dose of cisplatin was found as an independent prognostic factor in multivariate analysis (HR=0.36; 95% CI: 0.146-0.912; p=0.03). When toxicities were evaluated, such as hematological toxicity, dermatitis, mucositis, nausea and vomiting, there were no statistically significant differences between cumulative dose of cisplatin groups (<200mg/m² and ≥200mg/m²) and chemotherapy schedules (3-weekly and weekly). But malnutrition was statistically significant higher in patients treated with 3-weekly cisplatin compared with patients treated with weekly cisplatin (p=0.001).

CONCLUSION

A cisplatin dose with ≥200mg/m² is an independent prognostic factor for overall survival. Chemotherapy schedules weekly and 3-weekly have similar outcomes and adverse effects. If patients achieve ≥200mg/m² dose of cumulative cisplatin, weekly chemotherapy schedules may be used safely and effectively in nasopharyngeal carcinoma patients.

Concurrent chemoradiotherapy with weekly versus triweekly cisplatin in locally advanced squamous cell carcinoma of the head and neck: Comparative analysis

BACKGROUND

Cisplatin-based chemoradiotherapy is standard of care for locally advanced squamous cell carcinoma of the head and neck. This systemic review compared efficacy and safety of weekly vs triweekly cisplatin in locally advanced squamous cell carcinoma of the head and neck.

METHODS

Among 1500 prospective studies published from 1970 to 2015, 39 (18 weekly, 21 triweekly) including 3668 patients qualified for inclusion. Clinical outcomes were analyzed using weighted estimates and 2-tailed t test for comparisons; significance level was 0.05.

RESULTS

Locoregional control was 58% (CI 53%-63%) vs 61% (CI 56%-65%; P = .7). The 2-year overall survival (OS) was 74% (CI 66%-80%) for weekly vs 67% (64%-69%) triweekly groups (P = .67). The 2-year progression-free survival (PFS) was 69% (CI 59%-77%) for weekly vs 62% (CI 58%-65%) triweekly groups (P = .9). Grade 3 to 5 toxicities were 36% vs 40% (P = .37) in weekly vs triweekly groups.

CONCLUSIONS

Weekly cisplatin was comparable in efficacy and safety to the triweekly regimen. Our analysis supports the use of weekly or triweekly cisplatin in locally advanced squamous cell carcinoma of the head and neck, with tolerability being a key factor in selection.

Low-Dose vs. High-Dose Cisplatin: Lessons Learned From 59 Chemoradiotherapy Trials in Head and Neck Cancer

In locally advanced squamous cell carcinomas of the head and neck (LA-SCCHN), concurrent chemoradiotherapy is an integral part of multimodality management both in the adjuvant and in the definitive settings. Although de-intensification strategies have been propelled to the forefront of clinical research in human papillomavirus (HPV) positive oropharyngeal cancer, three cycles of 100 mg/m² cisplatin given every 3 weeks concurrently with conventionally fractionated external beam radiotherapy represent a cost-effective and globally accessible treatment option for the majority of LA-SCCHN cases. Based on four large randomized trials, this regimen has become the non-surgical standard of care for cisplatin-eligible patients. Nevertheless, the outcomes in terms of efficacy, toxicity, and compliance have been rather disappointing. Therefore, there is an unmet need to find a better alternative. With limited support from randomized trials, weekly low-dose cisplatin regimens have replaced the standard high-dose schedule at some institutions. Four prospective trials exploring radiotherapy with and without weekly low-dose cisplatin have been published. Two of them were conducted in the 1980s, one of which had a negative outcome, the third study provided insufficient information on toxicity, and the fourth trial had to be prematurely terminated due to poor accrual. Moreover, the findings of two phase III trials comparing the two concurrent cisplatin regimens favored the high-dose protocol. We performed a composite meta-analysis of 59 prospective trials enrolling a total of 5,582 patients. The primary endpoint was overall survival. Reflecting different radiotherapy fractionation schemes and treatment intents, three meta-analyses were carried out, one for postoperative conventional chemoradiotherapy, one for definitive conventional chemoradiotherapy, and one for definitive altered fractionation chemoradiotherapy. In the former two settings, both high- and low-dose regimens yielded similar survival outcomes, thus, the primary objective was not met. When given concurrently with altered fractionation radiotherapy, patients treated with high-dose cisplatin had significantly longer overall survival than those who received low-dose cisplatin. In this article we provide a synthetic view of the results, discuss the issue of cumulative dose, compare two vs. three cycles of high-dose cisplatin, and present our three-step recommendations for use of the current standard of care, high-dose cisplatin, in clinical practice.

Structured review of the patient-reported outcome instruments used in clinical trials in head and neck surgery

The number of clinical trials that relate to patients with cancer of the head and neck is growing. Patient-reported outcomes, which are rarely the primary outcome, are now an important component, and in this structured review to identify and report the characteristics of the questionnaires that have been used in these trials, we summarise the findings reported. We searched several online databases using the key terms: head and neck oncology, head and neck surgery, reconstruction, clinical trials patient-reported outcomes, questionnaires, quality of life (QoL), validated instruments, and patients' satisfaction. We screened 1342 papers to collect information about the topic of the paper, sample size, selection criteria, main advantages and disadvantages of the patient-reported outcome used, and if it was used in conjunction with another measure. A total of 54 were eligible, and from them we identified 22 questionnaires. The primary reason for using a questionnaire was its relevance to the focus of the paper, such as xerostomia, pain, or swallowing. To allow the experience of patients to be the focus of the primary outcome in a clinical trial, we recommend that the measures used should be appropriate, reliable, valid, responsive, precise, interpretable, acceptable, and feasible. The trials used validated questionnaires, but the patient-reported outcome measures tended not to be the focus. There is merit in such measures being the primary outcomes in future trials and these should be designed around an explicit hypothesis.

Single-Arm Phase 2 Trial of Elective Nodal Dose Reduction for Patients With Locoregionally Advanced Squamous Cell Carcinoma of the Head and Neck

PURPOSE

To evaluate a novel chemoradiation therapy (CRT) regimen for patients with squamous cell carcinoma of the head and neck (SCCHN) incorporating a lower intensity modulated radiation therapy dose to electively treated neck lymph nodes than is currently standard.

METHODS AND MATERIALS

Eligible patients had locally advanced SCCHN of the oral cavity, oropharynx, larynx, or hypopharynx. The 7-week CRT course consisted of weekly cisplatin at 35 mg/m² concurrently with sequential-boost intensity modulated radiation therapy: 36 Gy to high- and low-risk planning target volumes followed by a sequential boost to the high-risk planning target volume to 70 Gy. The primary endpoint was elective nodal failure. Secondary endpoints were survival, toxicity, feeding tube duration, and quality of life evaluated by the FACT-HN and QOL-RTI surveys.

RESULTS

Between 2011 and 2014, 54 patients were enrolled, 31 (57%) of whom had human papillomavirus (HPV)-positive disease. Of the patients, 35 (65%) had stage IVa disease. The median follow-up period for survivors was 36 months (range, 12-66 months). Elective nodal failure did not develop in any patient. The actuarial 3-year survival rate for the entire cohort was 91% (95% confidence interval [CI] 0.79-0.96); for the HPV-negative group, 85% (95% CI 0.61-0.95); and for the HPV-positive group, 96% (95% CI 0.77-0.99). Common grade 3 toxicities were dysphagia (79%), mucositis and/or stomatitis (41%), nausea (20%), xerostomia (13%), vomiting (11%), and neutropenia (10%). The median feeding tube duration was 142 days. Patient FACT-HN scores were higher at 3, 6, and 12 months versus at the end of treatment (P < .0001). Total FACT-HN scores returned to pretreatment baseline by 6 months. Overall QOL-RTI scores were lower from pretreatment to the end of treatment through 12 months (P = .0001).

CONCLUSIONS

This CRT regimen for patients with advanced SCCHN demonstrated the potential feasibility of reducing the elective dose to the neck, a topic that requires additional study in future clinical trials.

Altered fractionation radiotherapy combined with concurrent low-dose or high-dose cisplatin in head and neck cancer: A systematic review of literature and meta-analysis

OBJECTIVES

Altered fractionation radiotherapy and concomitant chemoradiotherapy represent commonly used intensification strategies in the management of locally advanced squamous cell carcinoma of the head and neck (LA-SCCHN). This meta-analysis compares compliance, safety, and efficacy between two single-agent cisplatin schedules given concurrently with altered fractionation radiotherapy.

METHODS

We systematically searched for prospective trials of patients with LA-SCCHN who received post-operative or definitive altered fractionation concurrent chemoradiotherapy. High-dose cisplatin once every three to four weeks (100 mg/m², 2 doses) was compared with a weekly low-dose protocol (≤50 mg/m², ≥4 doses). The primary outcome was overall survival. The secondary endpoints comprised treatment adherence, acute and late toxicities, and objective response rate.

RESULTS

Twelve studies with 1373 patients treated with definitive chemoradiotherapy were included. Compared to the weekly low-dose cisplatin regimen, the three- to four-weekly high-dose cisplatin regimen improved overall survival (p=.0185), was more compliant with respect to receiving all planned cycles of cisplatin (71% versus 95%, p=.0353), and demonstrated less complications in terms of severe (grade 3-4) acute mucositis and/or stomatitis (75% versus 40%, p=.0202) and constipation (8% versus 1%, p=.0066), toxic deaths (4%, versus 1%, p=.0168), 30-day mortality (8% versus 3%, p=.0154), and severe late subcutaneous fibrosis (21% versus 2%, p<.0001). Overall and complete response rates were similar between both chemotherapy schedules.

CONCLUSION

In chemoradiotherapy incorporating altered fractionation, two cycles of high-dose cisplatin with a three to four week interval are superior to weekly low-dose schedules. Further studies should identify those who might derive the greatest benefit from this intensified approach.

Retrospective analysis of self-reporting pain scores and pain management during head and neck IMRT radiotherapy: A single institution experience

AIMS

Head and neck carcinomas are relatively rare in the United Kingdom with an estimated 9000 cases diagnosed annually. However, pain associated with disease and treatment side effects such as oral mucositis present a major issue for therapy radiographers in providing effective care and maintaining radiotherapy treatment compliance, all factors that can compromise patient outcome if not managed appropriately.

METHOD

This retrospective analysis of self-reporting pain scores collected during a course of radiotherapy aims to assess the perceived pain intensity scores in 30 patients. Data was collected during radiographer review sessions held weekly to determine if any variables to perceived pain scores occurred during a course of radiotherapy.

RESULTS

As treatment progressed, the self-reporting pain scores within the cohort increased, in week one the total cohort pain score was 35, this increased to 114 in week 3 and in the final week had totalled 151. An escalation in pain was observed in week 3 of treatment possibly as a result of radiation induced inflammation alongside cytotoxic chemotherapy.

CONCLUSIONS

The findings of this study provide further evidence to an individualised approach to patient pain relief and providing regular on treatment reviews, thus maintaining patient comfort and ensuring continued treatment compliance.

Oral Lapacho-Based Medication: An Easy, Safe, and Feasible Support to Prevent and/or Reduce Oral Mucositis During Radiotherapy for Head and Neck Cancer

The aim of our Phase II study is to demonstrate the benefits, safety, and tolerance of Orasol Plus, an easy and feasible Lapacho-based medication. Orasol Plus is a nutritional, swallowable solution, useful to support the defenses of the oropharyngeal mucosa. Between January and June 2014, 40 consecutive adult patients affected by head and neck cancer were enrolled. Orasol Plus was administered 3 times a day from the first day till the end of radiotherapy. Primary endpoint was to evaluate tolerance and safety of Orasol Plus; secondary endpoint was to evaluate the effect of Orasol Plus on the incidence of treatment discontinuation. Nearly all patients used Orasol Plus easily till the end of radiotherapy without interruptions. Only 11 (27.5%) patients developed oral mucositis (OM) Grade 2 and only 4 (10%) patients OM Grade 3, no patient developed OM Grade 4. No patient discontinued radiotherapy because of OM. Orasol Plus was well tolerated and the compliance of patients was optimal, mainly due to the fact that it can be swallowed. Data from our study are encouraging and they need to be confirmed by a Phase III study.

Hyper-fractionated Intensity Modulated Radiation Therapy (HF-IMRT) in Head and Neck Cancer: The Technical Feasibility and Results of a Short Clinical Series

Among various altered fractionation schedules, only hyper-fractionation has proven increased local control in head and neck cancers. MARCH (Metanalyses of Hyperfractionated or Accelerated radiotherapy in Head and neck cancer) concluded that hyper-fractionated radiotherapy in head and cancers had a survival benefit. This study attempts to combine the benefits of hyper-fractionation with the tissue sparing qualities of intensity modulated radiotherapy. Three patients with advanced oro-pharyngeal cancers were treated with HF-IMRT (Hyperfractionated-IMRT) (2 oropharynx, 1 hypopharynx). Two phase treatment planning with phase I prescribed to high risk volume (HRV) and intermediate risk volume (IRV), 60Gy in 50 fractions at 1.2Gy per fraction, 2 fractions/day, 6-8 h apart. The low risk volume (LRV) received 55Gy to the 95% volume at 1.1Gy per fraction in the same 50 fractions. In phase II, HRV alone was prescribed 1960cGy in 20 fractions over two weeks. Total dose to HRV was 7960cGy in 7 wk. No concurrent chemotherapy was given. Treatment was completed as planned (<60 days; break of 11 days was due to radiation toxicity). Only one patient had grade III toxicity. All three required diet modifications, an average weight loss of 3 kg and no hospitalization required during treatment. This pilot study shows the feasibility of an effective hyper-fractionation with IMRT for head and neck cancers. A Phase II trial is required to prove its efficacy.

Phase I study of vandetanib with radiation therapy with or without cisplatin in locally advanced head and neck squamous cell carcinoma

BACKGROUND

Vandetanib, added to cisplatin and radiation therapy (RT) overcomes chemoradiation therapy (CRT) and epidermal growth factor receptor (EGFR) inhibitor resistance in head and neck squamous cell carcinoma (HNSCC) lines and models.

METHODS

Patients with previously untreated HNSCC received vandetanib daily for 14 days (starting dose 100 mg) and then vandetanib + RT (2.2 Gy/day, 5 days/week) for 6 weeks (regimen 1) or vandetanib + RT (2 Gy/day, 5 days/week) + cisplatin (30 mg/m(2) weekly) for 7 weeks (regimen 2). The primary objective was the maximum tolerated dose (MTD) of vandetanib with RT +/- cisplatin.

RESULTS

Of 33 treated patients, 30 completed therapy (regimen 1, n = 12; regimen 2, n = 18). MTD in regimen 2 was 100 mg (3 dose limiting toxicities [DLTs] at 200 mg), whereas regimen 1 was stopped because of poor recruitment (1 DLT at 200 mg). Most common grade ≥3 adverse events (AEs) were dysphagia (30%), stomatitis (33%), and mucosal inflammation (27%). Five patients discontinued vandetanib because of AEs.

CONCLUSION

Vandetanib with CRT was feasible.

Summary of major radiation fractionation and chemotherapy trials for organ preservation therapy in locally advanced head and neck squamous cell carcinoma

PURPOSE

To review radiation fractionation and chemotherapy trials for patients undergoing organ preservation therapy for locally advanced head and neck squamous cell carcinoma.

METHODS AND MATERIALS

Radiation therapy fractionation and chemotherapy trial results as well as historical evidence are systematically reviewed.

RESULTS

Trial results, which involve nearly 30,000 patients, have been interpreted, compared, and presented in a structured manner to demonstrate the changing approaches in treatment over the years from the 1960s to the present. The review includes data from the split-course radiation therapy era, meta-analyses of chemotherapy and radiation therapy fractionation trials, cetuximab trials, "triple-drug trials," and modern trials of induction chemotherapy followed by concomitant chemotherapy and radiation therapy.

CONCLUSIONS

This summary will be useful to clinicians making treatment decisions today and to investigators designing trials in the future.

Effectiveness of CT assists for intraarterial chemotherapy: therapeutic outcome of chemoradiation for advanced head and neck cancer extending across the anatomical midline

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of CT assist for intraarterial chemotherapy in relation to the therapeutic outcomes of intraarterial chemoradiation for advanced head and neck cancer with extension across the anatomical midline (EAM).

METHODS

This retrospective study evaluated 64 consecutive patients. In total, 26 and 38 patients had cancer with or without EAM, respectively. These patients underwent an intraarterial cisplatin infusion (200 mg/m(2), days 1 and 35) and intravenous 5-FU infusion (800 mg/m(2), days 1-5 and 36-39) concomitantly with radiotherapy. Angiography-assisted CT was performed to confirm complete coverage during the intraarterial chemotherapy. The accuracy of diagnosing tumor vessels by digital subtraction angiography (DSA) was evaluated using receiver-operating characteristic analysis by two radiologists. The overall survival and locoregional control rates were calculated by the Kaplan-Meier method.

RESULTS

DSA was not useful for diagnosing tumor vessels. The 2-year overall survival rates for the patients with cancer with or without EAM were 83 and 90 %, while the 2-year locoregional control rates were 95 and 82 %, respectively. Locoregional control or the overall survival rates showed no significant differences.

CONCLUSIONS

Intraarterial chemotherapy using angiography-assisted CT during chemoradiation therapy can achieve comparable therapeutic outcomes for cancer with and without EAM.

Concurrent therapy with taxane versus non-taxane containing regimens in locally advanced squamous cell carcinomas of the head and neck (SCCHN): a systematic review

BACKGROUND

Platinum compounds remain the most widely utilized systemic agents in combination with radiation for treating SCCHN in the concurrent setting. Despite recent interest in using taxanes in this setting, there is a lack of randomized clinical trials to support this approach. We conducted a systematic review of published clinical trials of taxane-containing versus standard non-taxane-based regimens used in definitive treatment of SCCHN.

METHODS

Trials published between 1994 and 2012 were identified by an electronic search of public databases (MEDLINE, EMBASE, Cochrane library). All prospective studies were independently identified by two authors for inclusion. Studies were excluded if induction therapy was part of the regimen or if targeted agents were used. Trials using cisplatin- or carboplatin-based regimens and paclitaxel or docetaxel were included. Demographic data, treatment response, locoregional failure free rate (LFFR), progression-free and overall survival (PFS, OS) and toxicities were extracted and analyzed using Comprehensive Meta Analysis software (Version 2.0). Outcome data were pooled and reported as weighted response rate (RR), PFS and OS.

RESULTS

A total of 790 studies were retrieved and 42 studies with 3120 patients were included: 804 patients were treated with taxanes (80% males, median age 57years) and 2316 with non-taxanes (86% males, median age 56years). Progression free survival was not different between the two groups. Weighted median survival was compared from those studies that reported these data; taxanes=36.7months (N=197) versus non-taxanes=25months (N=503), P<0.001. Toxicity (grade 3 and above) was higher in non-taxane containing trials.

CONCLUSIONS

The improved overall survival observed supports the choice of taxane-based regimens in the concurrent setting but may also reflect the predominance of single arm multi-agent phase II trials in the taxane arm. Our findings urge the need for better standardization of taxane-based regimens.

Improving therapeutic ratio in head and neck cancer with adjuvant and cisplatin-based treatments

Advanced head and neck cancers are difficult to manage despite the large treatment arsenal currently available. The multidisciplinary effort to increase disease-free survival and diminish normal tissue toxicity was rewarded with better locoregional control and sometimes fewer side effects. Nevertheless, locoregional recurrence is still one of the main reasons for treatment failure. Today, the standard of care in head and neck cancer management is represented by altered fractionation radiotherapy combined with platinum-based chemotherapy. Targeted therapies as well as chronotherapy were trialled with more or less success. The aim of the current work is to review the available techniques, which could contribute towards a higher therapeutic ratio in the treatment of advanced head and neck cancer patients.

Efficacy of intensity-modulated radiotherapy combined with chemotherapy or surgery in locally advanced squamous cell carcinoma of the head-and-neck

Objectives

Long-term locoregional control following intensity-modulated radiotherapy (IMRT) for locally advanced squamous cell carcinoma of the head-and-neck (SCCHN) remains challenging. This study aimed to assess the efficacy and toxicity of IMRT with and without chemotherapy or surgery in locally advanced SCCHN.

Materials and methods

Between January 2007 and January 2011, 61 patients with locally advanced SCCHN were treated with curative IMRT in the Department of Radiation Oncology, Xijing Hospital, Fourth Military Medical University; 28% underwent definitive IMRT and 72% postoperative IMRT, combined with simultaneous cisplatin-based chemotherapy in 58%. The mean doses of definitive and postoperative IMRT were 70.8 Gy (range, 66–74 Gy). Outcomes were analyzed using Kaplan–Meier curves. Acute and late toxicities were graded according to Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer radiation morbidity scoring criteria.

Results

At a median follow-up of 35 months, 3-year local recurrence-free survival (LRFS), regional recurrence-free survival (RRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS) were 83.8%, 86.1%, 82.4%, 53.2%, and 62%, respectively. Postoperative IMRT (n = 44, 72%) had significantly higher LRFS/OS/DMFS than definitive IMRT (n = 17, 28%; P < 0.05). IMRT combined with chemotherapy (n = 35, 58%) had significantly higher LRFS/OS/DMFS than IMRT alone (n = 26, 42%; P < 0.05). One year after radiotherapy, the incidence of xerostomia of grade 1, 2, or 3 was 13.1%, 19.7%, and 1.6%, respectively. No grade 4 acute or late toxicity was observed.

Conclusion

IMRT combined with surgery or chemotherapy achieved excellent long-term locoregional control and OS in locally advanced SCCHN, with acceptable early toxicity and late side-effects.

Weekly chemotherapy with radiation versus high-dose cisplatin with radiation as organ preservation for patients with HPV-positive and HPV-negative locally advanced squamous cell carcinoma of the oropharynx

BACKGROUND

Optimal treatment for locally advanced squamous cell carcinoma of the oropharynx (SCCOP) is not well defined. Here we retrospectively compare survival and toxicities from 2 different organ preservation protocols.

METHODS

The matched dataset consisted of 35 patients from each trial matched for age, stage, smoking, and tumor human papillomavirus (HPV) status. Patients in the University of Michigan Cancer Center (UMCC) trial 9921 were treated with induction chemotherapy (IC) followed by high-dose cisplatin and radiation in responders or surgery in nonresponders. Patients in the UMCC trial 0221 were treated with weekly carboplatin and paclitaxel and radiation.

RESULTS

Survival was comparable for both studies and did not differ significantly across each trial after stratifying by HPV status. Grade 3 and 4 toxicities were more frequent in UMCC 9921. At 6 months posttreatment, gastrostomy tube (G-tube) dependence was not statistically different.

CONCLUSION

These data suggest that survival outcomes in patients with locally advanced SCCOP are not compromised with weekly chemotherapy and radiation therapy, and such treatment is generally more tolerable.

Preservation of organ function in head and neck cancer

Preservation of function is a crucial aspect for the evaluation of therapies applied in the field of head and neck cancer. However, preservation of anatomic structures cannot automatically be equated with preservation of function. Functional outcome becomes increasingly important particularly for the evaluation of alternative treatment options with equivalent oncological outcomes.AS A RESULT, PRESENT STUDIES TAKE INTO ACCOUNT THREE TOPIC AREAS WITH VARYING EMPHASIS: (1) the effects of cancer therapy on essential physiological functions, (2) additional therapy-induced side-effects and complications, and (3) health-related quality of life. The present article summarizes vital aspects of clinical research from recent years. Functional outcomes after surgical and non-surgical treatment approaches are presented according to tumor localization and staging criteria. Additional methodological aspects relating to data gathering and documentation as well as challenges in implementing the results in clinical practice are also discussed.

Transoral resection of pharyngeal cancer: summary of a National Cancer Institute Head and Neck Cancer Steering Committee Clinical Trials Planning Meeting, November 6-7, 2011, Arlington, Virginia

Recent advances now permit resection of many pharyngeal tumors through the open mouth, an approach that can greatly reduce the morbidity of surgical exposure. These transoral techniques are being rapidly adopted by the surgical community and hold considerable promise. On November 6-7, 2011, the National Cancer Institute sponsored a Clinical Trials Planning Meeting to address how to further investigate the use of transoral surgery, both in the good prognosis human papillomavirus (HPV)-initiated oropharyngeal cancers, and in those with HPV-unrelated disease. The proceedings of this meeting are summarized.

Quality-of-life among head and neck cancer survivors at one year after treatment--a systematic review

BACKGROUND

The importance of quality-of-life (QoL) research has been recognised over the past two decades in patients with head and neck (H&N) cancer. The aims of this systematic review are to evaluate the QoL status of H&N cancer survivors one year after treatment and to identify the determinants affecting their QoL.

METHODS

Pubmed, Medline, Scopus, Sciencedirect and CINAHL (2000-2011) were searched for relevant studies, and two of the present authors assessed their methodological quality. The characteristics and main findings of the studies were extracted and reported.

RESULTS

Thirty-seven studies met the inclusion criteria, and the methodological quality of the majority was moderate to high. While patients of the group in question recover their global QoL by 12 months after treatment, a number of outstanding issues persist - deterioration in physical functioning, fatigue, xerostomia and sticky saliva. Age, cancer site, stage of disease, social support, smoking, feeding tube placement and alcohol consumption are the significant determinants of QoL at 12 months, while gender has little or no influence.

CONCLUSIONS

Regular assessments should be carried out to monitor physical functioning, degree of fatigue, xerostomia and sticky saliva. Further research is required to develop appropriate and effective interventions to deal with these issues, and thus to promote the patients' QoL.

Radiochemoimmunotherapy with intensity-modulated concomitant boost: interim analysis of the REACH trial

PURPOSE

To evaluate efficacy and toxicity clinical in the intensified treatment of locally advanced squamous cell carcinoma of the head and neck (SCCHN) with the combination of chemotherapy, the EGFR antibody cetuximab, and intensity-modulated radiation therapy (IMRT) in a concomitant boost concept.

METHODS

REACH is a prospective, bi-centric phase II trial of carboplatin/5-FU and cetuximab weekly combined with IMRT. Primary endpoint is locoregional control, secondary endpoints include acute radiation effects and adverse events. Evaluation of disease response is carried out according to the Response Evaluation Criteria in Solid Tumors (RECIST); toxicity is assessed using NCI CTC v 3.0.

RESULTS

Treatment was tolerated moderately well, acneiforme erythema occurred in 74.1% (grade II/III), mucositis grade III in 28.6%, and radiation dermatitis grade III in 14.3%. Higher-grade side-effects resolved quickly until the first follow-up post treatment. Objective response rates were promising with 28.6% CR at first follow-up and 92.9% thereafter.

CONCLUSION

The combination of standard carboplatin/5-FU and cetuximab is feasible and results in promising objective response rates. The use of an IMRT concomitant boost is practicable in a routine clinical setting resulting in only moderate overall toxicity of the regimen.

TRIAL REGISTRATION NUMBER

ISRCTN87356938.