One-Two Punch for Head & Neck Cancers

The May 6 issue of NEJM published the results of two
clinical trials for the treatment of squamous-cell carcinoma
of the head and neck with concurrent radiotherapy and
chemotherapy. Here are the links to the abstracts

Cooper JS, Pajak TF, Forastiere AA, Jacobs J, Campbell BH,
Saxman SB, Kish JA, Kim HE, Cmelak AJ, Rotman M, Machtay M,
Ensley JF, Chao KS, Schultz CJ, Lee N, Fu KK; Radiation
Therapy Oncology Group 9501/Intergroup. Postoperative
concurrent radiotherapy and chemotherapy for high-risk squamous-
cell carcinoma of the head and neck. N Engl J Med. 2004 May
6;350(19):1937-44. <URL:http://content.nejm.org/cgi/content-
/abstract/350/19/1937>

"... Conclusions. Among high-risk patients with resected
head and neck cancer, concurrent postoperative
chemotherapy and radiotherapy significantly improve the
rates of local and regional control and disease-free
survival. However, the combined treatment is associated
with a substantial increase in adverse effects."

Bernier J, Domenge C, Ozsahin M, Matuszewska K, Lefebvre JL,
Greiner RH, Giralt J, Maingon P, Rolland F, Bolla M,
Cognetti F, Bourhis J, Kirkpatrick A, van Glabbeke M;
European Organization for Research and Treatment of Cancer
Trial 22931. Postoperative irradiation with or without
concomitant chemotherapy for locally advanced head and neck
cancer. N Engl J Med. 2004 May 6;350(19):1945-52. <URL:http-
://content.nejm.org/cgi/content/abstract/350/19/1945>

"... Conclusions. Postoperative concurrent
administration of high-dose cisplatin with radiotherapy
is more efficacious than radiotherapy alone in patients
with locally advanced head and neck cancer and does not
cause an undue number of late complications."

Some comments in the article:

Head & Neck Cancer, Chemo & Radiation. One-Two Punch Urged
for Head, Neck Cancers. <URL:http://www.medicinenet.com/scr-
ipt/main/art.asp?articlekey=32453>

--
Matti Narkia

Enthusiasts for combined chemo-radiotherapy (CMT) for head and neck cancer
should bear a few things in mind:

1) Despite the well-recognised bias against accepting
negative studies for publication, the randomised studies
are all over the place, some positive, most negative or
equivocal. Pignon commenting recently in the NEJM that
the absolute survival benefit for CMT vs "standard" RT is
perhaps 4%.

2) All the studies show significantly more acute toxicity
for CMT vs RT alone.

3) The studies showing survival benefits, do so because of
improved local control, not reduction of mets. This could
very likely be achieved by improving the RT alone.

4) All the poistive studies compared CMT versus "standard"
RT - 6000cGy to 7000cGy as primary treatment and 5000cGy
as psot op adjuvant, all at 200cGy er day over 5 to 7
weeks. This treatment has been shown to be significantly
suboptimal in several clinical trials, when compared to
accelerated or hyperfractionated RT. It's perhaps not
surprising that adding a second treatment modality to a
suboptimal treatment leads to a modest improvement....

5) Better radiotherapy may well give the same or better
local control improvements and survival, but at the cost
of worse acute side-effects.

6) Until there is a good, large randomised trial of
hyperfractionated or accelerated radiotherapy alone vs
CMT, the data simply does not support the hype.

7) In the US especially, oncologists are shackled to
200cGy fractions, and often inelegant techniques. This
is a mistake

One-Two Punch for Head & Neck Cancers

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