Induction Chemotherapy in Oropharynx Cancers Produces Good Long-Term Outcomes

Comment: This is a phase 2 study of chemo only followed by surgery for HPV OP cancer. Twenty-nine of 39 patients who underwent surgery avoided radiation. Interesting because it maybe that chemo response may be the future of this treatment. —Adam Zanation, MD

Would an induction regimen with a high response rate and low toxicity partner well with transoral endoscopic surgery to treat transorally resectable squamous head and neck cancer?

Bottom Line
Neoadjuvant, systemic therapy and surgical resection followed by risk-adapted adjuvant therapy resulted in high response rates and excellent long-term outcomes, allowing a high number of patients to avoid radiation therapy.

Background: Treatment of locally advanced oropharynx cancer has evolved substantially, with chemoradiotherapy offering an alternative to large, morbid surgical resections. Induction chemotherapy has been proposed for both HPV-positive patients who have a good prognosis, to de-intensify definitive radiation therapy for patients with an excellent response, and for those with a poorer prognosis, as an additive therapy to standard care.

Study design: Retrospective case-control study of 40 patients accrued between October 3, 2012, and August 23, 2016.

Setting: Department of Hematology and Oncology, Lineberger Comprehensive Cancer Center at the University of North Carolina, Chapel Hill.

Synopsis: Thirty of 40 patients had oropharyngeal cancer; 17 of these patients had low-risk HPV. Twenty percent of patients had stage III disease, and 80% had stage IV disease. Thirty-nine of 40 patients underwent surgery. Thirty-seven of the remaining 39 patients completed three-part therapy. Three patients were hospitalized during induction chemotherapy. (In this study, lapatinib was substituted for cetuximab.) Generally, toxicity was mild, with diarrhea as the most common adverse event. The clinical response rate was 93%, and the clinical complete response rate was 40%. Fourteen of 39 patients had a pathologic complete response. (Clinical response was not associated with pathologic complete response.) Seven patients entered with study-defined, low-risk disease; 25 entered with study-defined, medium-risk disease; and seven entered with study-defined, high-risk disease. Five of the low-risk patients remained in the low-risk group, 21 medium-risk patients changed to the low-risk group, and four high-risk patients changed to the low-risk group. At a median follow-up of 2.4 years, no patient has recurred or died. Patients who received radiation lost more weight between study initiation and one year postsurgery. Swallowing and, on average, voice were well preserved.

Citation: Weiss JM. Grilley-Olson JE, Deal AM, et al. Phase 2 trial of neoadjuvant chemotherapy and transoral endoscopic surgery with risk-adapted adjuvant therapy for squamous cell carcinoma of the head and neck. Cancer. 2018;124:2986–2992.