The shift in patient and disease profile means that comparing patient outcomes between single-institution trials or with historical studies can easily lead to faulty conclusions. Thus, the large phase III randomized trials become even more important. The studies are large enough that patient subgroups-including anatomical location of primary tumor and HPV-positive patients-can be examined separately to get a window into how they respond to therapy.
Explore This IssueMay 2008
In one prospective study, investigators found that HPV-positive patients had a 70% lower risk of distant disease progression relative to individuals with tobacco- and alcohol-associated disease, according to Dr. Forastiere. Therefore it is hard to know what to make of small studies like the one from the Oklahoma group. The question is if you intensify treatment by adding induction chemotherapy to chemoradiation, are the patients really benefiting from that, or would they do as well with chemoradiation alone, because HPV-positive cancer is a different disease that has a much better prognosis and greater sensitivity to chemotherapy and radiation, she observed.
The HPV question will be the focus of a National Cancer Institute (NCI) State of the Science meeting in late 2008, according to Dr. Trotti, who, along with Dr. Forastiere, co-chairs the National Cancer Institute (NCI) Head and Neck Steering Committee that is responsible for approving NCI trials. HPV is perhaps the most important biologic question facing head and neck cancer today. We plan to gather the best minds in the field to design the next series of trials with a focus on how HPV status may impact response or prognosis. There is a lot changing at one time in head and neck cancer. It will take more planning and collaboration if we are going to answer these important biologic and clinical questions, he said.
As for the value of induction chemotherapy, only the results of the phase III trials, which are still years away, will answer that question. Until then, many investigators agree that induction chemotherapy should only be used within a clinical trial, though some researchers feel that there is already sufficient evidence to support using induction for patients with advanced stages of cancer.
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