Concurrent chemoradiotherapy versus induction chemotherapy followed by chemoradiotherapy (sequential approach) in the management of head and neck cancer

Abstract

Concurrent chemoradiation is considered the standard-of-care for locally advanced head and neck cancer of the hypopharynx, oropharynx and larynx, as well as unresectable disease. This paradigm was challenged by the introduction of induction chemotherapy (IC), which demonstrated non-inferiority in regards of overall survival (OS), along with increased organ preservation, when compared to the surgery and radiotherapy. More recently, IC followed by concurrent chemoradiation, the so-called sequential approach was developed in an attempt to decrease metastatic spread and improve locoregional control (LRC) rates, with much controversy amongst experts. A careful evaluation by a multidisciplinary team is necessary to recognize which patients should be offered this therapeutic approach due to a significantly greater rate of toxicity. Herein, we analyze the most current available evidence regarding the use of sequential therapy versus concurrent chemoradiation. Different factors including toxicity profile, adherence and patient characteristics play a major role in choosing the most appropriate treatment regimen.

Efficacy and safety of a cisplatin and paclitaxel induction regimen followed by chemoradiotherapy for patients with locally advanced head and neck squamous cell carcinoma

“…Both studies terminated early because of poor accrual, failing to meet their primary endpoint. 17,18,33,[39][40][41][42] The TP regimen used in this study proved to be safe and tolerable with low toxicity during the induction phase, permitting CRT based on cisplatin in the majority of patients included. The efficacy of the TP regimen was also promising in these predominantly HPV-negative patients (overall response rate after induction chemotherapy with TP regimen was 82.5% for patients with resectable disease and 55.5% for unresectable disease) that are comparable to previous reports regarding intensive induction chemotherapy as a TPF regimen (TPF regimen showed overall response rate of 68% in the TAX 323 trial and an overall response rate of 72% in the TAX 324 trial).…”

“…Although induction chemotherapy has a proven role in organ preservation and might reduce the incidence of distant metastases, its efficacy in prolonging OS has not been demonstrated, and the role of induction chemotherapy before concurrent CRT remains controversial …”

“…Unfortunately, in both trials, patients in the induction arms were treated with CRT regimens that are not generally considered the standard of care, and a large number of biologically distinct HPV‐positive patients were included. Both studies terminated early because of poor accrual, failing to meet their primary endpoint …”

“…10 Although induction chemotherapy has a proven role in organ preservation and might reduce the incidence of distant metastases, its efficacy in prolonging OS has not been demonstrated, 16,39 and the role of induction chemotherapy before concurrent CRT remains controversial. 17,33,[40][41][42] The DeCIDE and PARADIGM trials sought to address whether the addition of induction chemotherapy to definitive CRT improved survival. Unfortunately, in both trials, patients in the induction arms were treated with CRT regimens that are not generally considered the standard of care, and a large number of biologically distinct HPVpositive patients were included.…”

Quimioterapia de indução seguida de cirurgia com ou sem radioterapia adjuvante para pacientes com diagnóstico de câncer de cavidade oral: revisão sistemática e metanálise

“…Apesar das melhorias nas modalidades técnicas terapêuticas envolvidas (73,108,109) , o controle local e a sobrevida global ainda são baixos (110,111) . (112) .…”