Interventions for the treatment of oral cavity and oropharyngeal cancer: chemotherapy

BACKGROUND

Oral cavity and oropharyngeal cancers are the most common cancers arising in the head and neck. Treatment of oral cavity cancer is generally surgery followed by radiotherapy, whereas oropharyngeal cancers, which are more likely to be advanced at the time of diagnosis, are managed with radiotherapy or chemoradiation. Surgery for oral cancers can be disfiguring and both surgery and radiotherapy have significant functional side effects. The development of new chemotherapy agents, new combinations of agents and changes in the relative timing of surgery, radiotherapy, and chemotherapy treatments may potentially bring about increases in both survival and quality of life for this group of patients. This review updates one last published in 2011.

OBJECTIVES

To determine whether chemotherapy, in addition to radiotherapy and/or surgery for oral cavity and oropharyngeal squamous cell carcinoma results in improved overall survival, improved disease-free survival and/or improved locoregional control, when incorporated as either induction therapy given prior to locoregional treatment (i.e. radiotherapy or surgery), concurrent with radiotherapy or in the adjuvant (i.e. after locoregional treatment with radiotherapy or surgery) setting.

SEARCH METHODS

An information specialist searched 4 bibliographic databases up to 15 September 2021 and used additional search methods to identify published, unpublished and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) where more than 50% of participants had primary tumours in the oral cavity or oropharynx, and that evaluated the addition of chemotherapy to other treatments such as radiotherapy and/or surgery, or compared two or more chemotherapy regimens or modes of administration.

DATA COLLECTION AND ANALYSIS

For this update, we assessed the new included trials for their risk of bias and at least two authors extracted data from them. Our primary outcome was overall survival (time to death from any cause). Secondary outcomes were disease-free survival (time to disease recurrence or death from any cause) and locoregional control (response to primary treatment). We contacted trial authors for additional information or clarification when necessary.

MAIN RESULTS

We included 100 studies with 18,813 participants. None of the included trials were at low risk of bias.  For induction chemotherapy, we reported the results for contemporary regimens that will be of interest to clinicians and people being treated for oral cavity and oropharyngeal cancers. Overall, there is insufficient evidence to clearly demonstrate a survival benefit from induction chemotherapy with platinum plus 5-fluorouracil prior to radiotherapy (hazard ratio (HR) for death 0.85, 95% confidence interval (CI) 0.70 to 1.04, P = 0.11; 7427 participants, 5 studies; moderate-certainty evidence), prior to surgery (HR for death 1.06, 95% CI 0.71 to 1.60, P = 0.77; 198 participants, 1 study; low-certainty evidence) or prior to concurrent chemoradiation (CRT) with cisplatin (HR for death 0.71, 95% CI 0.37 to 1.35, P = 0.30; 389 participants, 2 studies; low-certainty evidence). There is insufficient evidence to support the use of an induction chemotherapy regimen with cisplatin plus 5-fluorouracil plus docetaxel prior to CRT with cisplatin (HR for death 1.08, 95% CI 0.80 to 1.44, P = 0.63; 760 participants, 3 studies; low-certainty evidence).  There is insufficient evidence to support the use of adjuvant chemotherapy over observation only following surgery (HR for death 0.95, 95% CI 0.73 to 1.22, P = 0.67; 353 participants, 5 studies; moderate-certainty evidence). Among studies that compared post-surgical adjuvant CRT, as compared to post-surgical RT, adjuvant CRT showed a survival benefit (HR 0.84, 95% CI 0.72 to 0.98, P = 0.03; 1097 participants, 4 studies; moderate-certainty evidence). Primary treatment with CRT, as compared to radiotherapy alone,  was associated with a reduction in the risk of death (HR for death 0.74, 95% CI 0.67 to 0.83, P < 0.00001; 2852 participants, 24 studies; moderate-certainty evidence).  AUTHORS' CONCLUSIONS: The results of this review demonstrate that chemotherapy in the curative-intent treatment of oral cavity and oropharyngeal cancers only seems to be of benefit when used in specific circumstances together with locoregional treatment. The  evidence does not show a clear survival benefit from the use of induction chemotherapy prior to radiotherapy, surgery or CRT. Adjuvant CRT reduces the risk of death by 16%, as compared to radiotherapy alone. Concurrent chemoradiation as compared to radiation alone is associated with a greater than 20% improvement in overall survival; however, additional research is required to inform how the specific chemotherapy regimen may influence this benefit.

Combined modality treatment of laryngeal squamous cell carcinoma

Squamous cell carcinoma of the larynx is a major public health concern; it causes substantial morbidity and mortality, and arises chiefly as a result of tobacco and alcohol consumption. Early stage disease is best treated with radiation or surgery alone, but for patients with more locally advanced squamous cell carcinoma of the larynx, combined modality treatment has been shown to benefit selected patients, particularly when cisplatin-based chemotherapy and concurrent radiation therapy are employed, with or without altered fractionated radiation therapy. Substantial laryngectomy-associated quality-of-life decrements can be avoided in selected, potentially resectable patients with organ-sparing approaches, without sacrificing survival. Recently, trials have addressed the role of targeted systemic agents to the epidermal growth factor receptor, and other targets are under investigation. The addition of induction chemotherapy to concurrent chemoradiotherapy is a promising treatment strategy that warrants further evaluation, but has not yet emerged as a standard of care; the toxicity of such regimens must be balanced with the potential benefits on a case-by-case basis, and functional outcomes are often quite variable. Treatment planning, management and follow-up are complex, and thus should ideally be performed in a comprehensive, multidisciplinary fashion, in a center accustomed to a high volume of such cases. Future research directions are described herein.

Larynx preservation: what is the standard treatment?

Locally advanced laryngeal and hypo-pharyngeal cancers have a rather poor prognosis. Up until the early 1990s, standard treatment was total laryngectomy, with dramatic functional and social outcome. The introduction of cisplatin based chemotherapy made concurrent chemo-radiotherapy (CCRT) the standard treatment for selected patients, fit for an organ preservation strategy. Over two decades of improvement in nonsurgical management of locally advanced laryngeal cancer is reviewed, including the most recent improvements with the introduction of taxanes and anti-EGFR targeted therapy.

Randomized phase III trial comparing induction chemotherapy followed by radiotherapy to concomitant chemoradiotherapy for laryngeal preservation in T3M0 pyriform sinus carcinoma

CONCLUSIONS

Conventional radiotherapy with concurrent cisplatin is significantly superior to induction cisplatin fluorouracil chemotherapy followed by radiotherapy in terms of laryngeal preservation in patients with T3 hypopharyngeal carcinoma. Despite a high rate of laryngeal preservation no survival benefit was recorded in this selected population.

OBJECTIVES

To compare conventional radiotherapy with concurrent cisplatin to induction chemotherapy with cisplatin fluorouracil followed by conventional radiotherapy. The primary end point was the preservation of the larynx. The secondary end points included toxicity, causes of death, and survival rates.

PATIENTS AND METHODS

Seventy-one adult patients with previously untreated resectable T3 pyriform sinus squamous cell carcinoma were enrolled in the multicenter prospective randomized phase III trial. They were evaluated for organ preservation, survival rates, and toxic reactions.

RESULTS

The rates of laryngeal preservation at 2 years were 68% for the induction chemotherapy (IC) group and 92% for the chemoradiotherapy (CR) group (p = 0.016). At 2 years, the event-free survival rates were 36% and 41% for the IC group and CR group, respectively.

Sequence dependence of cell growth inhibition by EGFR-tyrosine kinase inhibitor ZD1839, docetaxel, and cisplatin in head and neck cancer

BACKGROUND

This study was to explore whether the efficacy of the epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor ZD1839 (Z, Iressa, gefitinib) plus chemotherapeutic agents docetaxel (D) and cisplatin (P) may benefit from sequencing of the combination.

METHODS

Three head and neck cancer cell lines were used to study the effect of various combinations of and relative sequencing of D, P, and Z in cell growth inhibition. A population pharmacokinetic stimulation study was conducted on Z in silico and used together with the growth inhibition data to derive principles for future in vivo use of this drug combination.

RESULTS

The inhibitory effects of Z on combinations of D and P were sequence dependent. Treatment simultaneously with DPZ or with DP followed by Z (DP-->Z) showed synergistic effects in all 3 cell lines. However, sequencing with Z followed by DP (Z-->DP), gave an antagonistic effect, suggesting that D and P should be administered when the effect of Z is low. The induction of apoptosis was also sequence dependent. The in silico pharmacokinetic study suggested the feasibility of deriving a 5-day-on/2-day-off regimen for Z, in which D and P administration commences when levels of Z are low, allowing levels of Z to accumulate sufficiently during the remainder of the cycle.

CONCLUSION

These data suggests that it is feasible to design clinical trials with these settings to maximize the efficacy of this combined drug regimen.

Personalizing cancer care: updates on head and neck cancer

With an emphasis on personalizing cancer care, the American Society of Clinical Oncology 45th Annual Meeting was held from 29 May to 2 June in Orlando (FL, USA). Several abstracts were presented that will significantly impact the management of squamous cell carcinoma of the head and neck both currently and in the near future, especially with respect to patient selection for specific therapies, prognostic biomarkers and novel agents.

[Radiotherapy, chemotherapy and target therapy for treatment of head and neck cancer : new developments]

Approximately 60% of patients initially treated for squamous cell cancer of the upper gastrointestinal tract suffer from advanced tumor disease (UICC stages III and IV). Multimodal strategies lead to overall survival rates of up to 50%. Recent studies show indications that the risk of distant metastases after induction chemotherapy (CT) is less than after primary radiotherapy (RT) or radiochemotherapy (RCT). Hyperfractionation or accelerated radiation with concomitant boost shows superior results compared to classic RT. Intensity-modulated radiotherapy (IMRT) is a new method for better adjusted dose distribution. Targeted therapy with specific antibodies against biological targets, such as epidermal growth factor receptor (EGFR), showed superiority over RT but the comparison to classic RCT is still pending. Targeted therapy against vascular endothelial growth factor (VEGR) showed antiangiogenetic effects on tumors. In cases of non-resectability or distant metastases, palliative CT and target therapy are recommended. Reirradiation or IMRT offer increased locoregional tumor control at the expense of higher toxicity. Overall, advances in research on tumor biology offer increasingly more prognostic factors and markers for customized individual targeted therapy and CT.

Dose intensity comparison between weekly and 3-weekly Cisplatin delivered concurrently with radical radiotherapy for head and neck cancer: a retrospective comparison from New Cross Hospital, Wolverhampton, UK

AIMS

In this retrospective comparison, we describe the differences in dose intensity, delays and toxicity between weekly Cisplatin and 3-weekly Cisplatin given concurrently to patients with locally advanced squamous head and neck cancer (SCCHN) at New Cross Hospital, Wolverhampton.

MATERIALS AND METHODS

Fifty-one patients received radical Cisplatin based chemoradiotherapy for stage 4a SCCHN of the head and neck between September 2000 and December 2004. Twenty-seven patients were treated with 3-weekly inpatient Cisplatin for 3 cycles (20 patients-80 mg/m(2); 7 patients-100 mg/m(2)) concomitantly with radiotherapy (66-70 Gy/33-35 fractions). Twenty-four patients received a similar radiotherapy schedule but received weekly Cisplatin 33-40 mg/m(2).

RESULTS

More patients received a higher cumulative dose of at least 240 mg/m(2) if given weekly Cisplatin 40 mg/m(2) or 3-weekly Cisplatin 80 mg/m(2) compared with those receiving Cisplatin 3-weekly 100 mg/m(2) (p=0.04). Maximum cumulative dose achievable in the latter group was only 200 mg/m(2) and none achieved the full 3 cycles. Mean Cisplatin dose in the weekly Cisplatin 40 mg/m(2) regime (mean 202 mg/m(2)) and 3-weekly arm of 80 mg/m(2) (mean 203 mg/m(2)) was higher than that reached if given 3-weekly Cisplatin 100 mg/m(2) (mean 180 mg/m(2)) although statistically insignificant (p=0.39) due to the small number of patients. More delays (29% vs. 41%) and omission of chemotherapy (5.6% vs. 17.4%) occurred in the 3-weekly compared with the weekly regime. Toxicity, radiotherapy overall treatment time and delays were similar between the two groups.

CONCLUSION

Delivery of 100 mg/m(2) Cisplatin 3-weekly with radiotherapy was less tolerated than 40 mg/m(2) weekly and resulted in less patients achieving cumulative dose beyond 200 mg/m(2), potentially lowering chemotherapy dose intensity.

Current concepts for the management of head and neck cancer: chemotherapy

Chemotherapy can be administered in patients with locoregionally advanced (LA) squamous cell carcinoma of the head and neck (SCCHN) either concurrently with irradiation or as induction chemotherapy prior to local treatment or as palliative therapy in patients with recurrent and/or metastatic disease. Cisplatin-based chemoradiation is still the standard for LA-SCCHN. TPF has emerged as the new standard regimen when induction chemotherapy is indicated. Areas of active investigation in LA-SCCHN are the sequential administration of induction chemotherapy followed by chemoradiation and the integration of targeted therapies. None of the combination chemotherapy regimens demonstrated an overall survival benefit when compared to single agent methotrexate, cisplatin or 5-fluorouracil in recurrent/metastatic disease. Combination chemotherapy in this setting is preferably used in younger patients with a good performance status and with symptomatic disease who require prompt symptom relief. However, a survival benefit was observed when cetuximab was combined with platinum-5-fluorouracil.

Neoadjuvant cisplatin chemotherapy before chemoradiation: a flawed paradigm?

Effective chemotherapy (CT) treatment of solid tumors emerged with the introduction of anthracyclines and platinum CT in the late 1970s, at first with palliative intent, and later extended into the adjuvant setting. High response rates led to the belief that systemic CT might improve locoregional control and also decrease the risk of distant metastases. A new strategy advocated cisplatin-based neoadjuvant CT (NACT) before definitive local treatment-either surgery or radiotherapy (RT). Response to NACT was viewed as a favorable prognostic sign, which allows the selection of patients most likely to benefit from RT or chemoradiotherapy (CRT). The aim of this discussion is to raise the debate regarding NACT in reducing metastases, improving local control and selecting out good responders for nonsurgical treatment in the following sites: head and neck, esophagus, cervix, anus, nasopharynx, and bladder; as well as non-small-cell lung cancer. NACT has almost invariably failed to deliver an improved outcome in terms of disease-free survival (DFS) or overall survival (OS) when delivered before RT or CRT in all solid tumor sites. The evidence that NACT may improve outcome in terms of DFS or OS is strongest when it is administered before surgical resection, but remains scant before RT or CRT. Taxane-containing regimens look more promising than does cisplatin NACT, but have not been shown to improve on concurrent CRT. Future meta-analyses should compare induction CT followed by RT and induction followed by CRT versus RT or CRT alone.

Neoadjuvant chemotherapy in head and neck cancer: Should it be revisited?

Locally advanced SCCHN (LA-SCCHN) is generally treated by a combination of chemotherapy, irradiation and/or surgery. Timing of the chemotherapy has for long been a matter of debate but concurrent chemoradiation was widely adopted as standard of care for locally advanced squamous cell carcinoma of the head and neck after the publication of a large meta-analysis which demonstrated that concurrent chemoradiation confers an absolute survival benefit of 8% at 2 and 5 years. Induction chemotherapy has some appealing advantages including the opportunity of assessing tumor response and selecting the patients who are candidates for organ preservation. The cisplatin-fluorouracil combination has been the induction regimen of choice for two decades but has recently been superseded by a combination of cisplatin, fluorouracil and a taxane which can be considered the standard regimen when induction chemotherapy is appropriate. Multiple large randomized trials designed to compare sequential induction, i.e., chemotherapy followed by CRT to CRT alone are currently underway. New challenges are the integration of targeted therapies into the current treatment strategies and the identification of prognostic biomarkers and of factors predicting the response to treatment which would help to select patients who are likely to benefit most from induction chemotherapy.

Clinical trial design limitations in head and neck squamous cell carcinomas

PURPOSE OF REVIEW

The present article reviews the randomized trials contributing to the establishment of current standards for the treatment of head and neck cancer. It provides critical analysis of their methodology in order to facilitate future trial design.

RECENT FINDINGS

From a prognosis perspective, head and neck cancers are a heterogeneous group of diseases. Following a number of randomized clinical trials evaluating the role of chemotherapy in the induction, concomitant and adjuvant settings, there has been considerable improvement in the treatment of locally advanced head and neck cancers during the last decade. It is, however, difficult to interpret and compare the results optimally and to build on efficient trial designs as most of the trials included patients with different levels of essential prognostic factors.

SUMMARY

All key randomized trials will be reviewed according to eligibility criteria, subgroup issues, trial power and historical controls. Methodological interpretation and possible plans for the next generation of clinical trials will be presented.

The role of taxanes and targeted therapies in locally advanced head and neck cancer

PURPOSE OF REVIEW

This review presents new data on the role of taxanes and targeted therapies in the management of squamous cell carcinoma of the head and neck.

RECENT FINDINGS

Taxane-containing triplets are clearly superior as an induction regimen in locally advanced squamous cell carcinoma of the head and neck when compared with cisplatin/5 fluorouracil which has been the standard for two decades. Preliminary data suggest that the addition of a taxane to cisplatin/5 fluorouracil as induction regimen followed by chemoradiation may be superior to chemoradiation alone. The addition of cetuximab to radiation prolongs locoregional control and survival without increasing mucositis. Areas of active investigation are the search for epidermal growth factor receptor mutations and the optimal way of integrating epidermal growth factor receptor-directed therapies into standard management. Meanwhile new targets are explored.

SUMMARY

Taxane/cisplatin/5 fluorouracil induction chemotherapy is clearly superior to cisplatin/5 fluorouracil. Epidermal growth factor receptor directed therapies can safely be combined with radiation and the combination shows encouraging results.