- The guideline first addresses the addition of chemotherapy to curative RT for oropharyngeal cancer:
- Recommending concurrent chemoradiation for patients with:
- Stage IV disease or
- Stage III disease with large-volume tumors:
- But not for patients with:
- Stage I to II disease
- But not for patients with:
- Recommendations by disease stage are as follows:
- Stage IV:
- Patients with stage IVA to IVB tumors receiving definitive RT should receive:
- Concurrent high-dose intermittent cisplatin:
- Advanced-stage patients who are medically unfit for high-dose cisplatin:
- Should receive:
- Concurrent cetuximab or carboplatin-fluorouracil
- Weekly cisplatin may be considered for these patients:
- With the caveat that there is limited prospective evidence to support its use
- Concurrent cetuximab:
- Should not be co-delivered to patients receiving definitive chemoradiation (CRT), nor
- Should intra-arterial chemotherapy be used in this population
- Should receive:
- Advanced-stage patients who are medically unfit for high-dose cisplatin:
- Concurrent high-dose intermittent cisplatin:
- Patients with stage IVA to IVB tumors receiving definitive RT should receive:
- Stage III:
- Patients with stage III OPSCC receiving definitive RT should receive:
- Concurrent systemic therapy for:
- T3, N0 to N1 tumors
- CRT may be considered:
- For larger volume T1 to T2, N1 tumors:
- That are at substantial risk for locoregional recurrence
- For larger volume T1 to T2, N1 tumors:
- Systemic therapy for other stage III patients:
- May convey unnecessary toxicity
- Concurrent systemic therapy for:
- Patients with stage III OPSCC receiving definitive RT should receive:
- Stage I to II:
- Concurrent systemic therapy:
- Is not recommended for patients:
- With stage I to II OPSCC receiving definitive RT:
- Due to a lack of evidence supporting its use for early-stage disease
- With stage I to II OPSCC receiving definitive RT:
- Is not recommended for patients:
- Concurrent systemic therapy:
- Stage IV:
- Recommending concurrent chemoradiation for patients with:
- The guideline also provides guidance for the use of radiation and chemoradiation following primary surgery for OPSCC:
- Post-operative, or adjuvant, RT is recommended:
- For patients who show pathologic risk factors for disease recurrence, such as:
- Positive surgical margins
- Positive lymph nodes following surgery:
- Although concurrent chemoradiation is strongly recommended:
- Only for high-risk patients
- Although concurrent chemoradiation is strongly recommended:
- For patients who show pathologic risk factors for disease recurrence, such as:
- Recommendations by treatment type and risk level are as follows:
- Concurrent systemic therapy:
- For high-risk patients:
- Systemic therapy, specifically high-dose intermittent cisplatin:
- Should be delivered with post-surgical RT for patients with:
- Positive surgical margins and/or
- Extracapsular extension
- Should be delivered with post-surgical RT for patients with:
- Weekly cisplatin may be delivered to post-operative patients:
- Who are unable to tolerate high-dose intermittent cisplatin:
- Post-operative patients who are unable to tolerate cisplatin-based chemoradiotherapy:
- Should not routinely receive concurrent chemotherapy:
- Existing prospective data do not support the use of cetuximab, concurrent weekly carboplatin or routine concurrent weekly docetaxel with post-operative RT, although clinical trials are underway to examine these alternative agents
- Should not routinely receive concurrent chemotherapy:
- Systemic therapy, specifically high-dose intermittent cisplatin:
- For high-risk patients:
- Adjuvant therapy for lower-risk patients:
- Concurrent chemoradiation:
- Should not be routinely used in intermediate-risk disease
- Adjuvant RT is strongly recommended for post-operative OPSCC patients:
- At significant risk of locoregional recurrence but only conditionally recommended in scenarios:
- Pathologic N1 disease
- Perineural invasion
- Lymphovascular invasion
- With a more uncertain risk of locoregional failure:
- Adjuvant radiotherapy may be delivered to patients:
- Without conventional adverse pathologic risk factors:
- Only if the clinical and surgical findings imply a particularly significant risk of locoregional recurrence
- Without conventional adverse pathologic risk factors:
- Adjuvant radiotherapy may be delivered to patients:
- At significant risk of locoregional recurrence but only conditionally recommended in scenarios:
- Concurrent chemoradiation:
- Concurrent systemic therapy:
- Post-operative, or adjuvant, RT is recommended:
- The guideline also outlines optimal dosing and fractionation schedules based on treatment approach, disease profile and risk of recurrence:
- Recommendations by treatment setting are as follows:
- Definitive RT:
- Patients with stage III to IV OPSCC should receive:
- A cumulative dose of 70 Gray (Gy):
- Delivered to the primary tumor site and positive nodes:
- Over seven weeks
- Delivered to the primary tumor site and positive nodes:
- As well as an equivalent dose of 50 Gy delivered in 2-Gy daily fractions:
- To the regions at risk for tumor spread
- A cumulative dose of 70 Gray (Gy):
- For stage IVA to IVB patients not receiving concurrent systemic therapy:
- Altered fractionation schedules (either accelerated or hyperfractionated):
- Are recommended
- Altered fractionation schedules (either accelerated or hyperfractionated):
- For Stage IVA – IVB patients undergoing concurrent CRT:
- Either standard or accelerated fractionation may be implemented
- Altered fractionation also should be used for patients:
- With T3 N0 to N1 disease not receiving concurrent chemoradiation, and
- It may be used for patients with T1 to T2, N1 or T2 N0 disease:
- At high risk for recurrence
- Patients with stage III to IV OPSCC should receive:
- Post-surgical / Adjuvant RT:
- Post-operative OPSCC patients at high risk for recurrence:
- Those with positive surgical margins should receive:
- A total dose of 60 to 66 Gy delivered to the positive margins and region of extranodal extension in 2-Gy daily fractions:
- High-risk patients:
- Not undergoing concurrent systemic therapy:
- Should receive the upper limit of this range
- Not undergoing concurrent systemic therapy:
- While the 60-Gy total dose is recommended for:
- Patients with negative margins following surgery
- Early T-stage tonsillar carcinoma:
- Ipsilateral RT:
- Which involves treating only one side of the oropharyngeal area:
- Is strongly recommended for the subset of OPSCC patients with early-stage tonsillar cancer:
- Specifically well-lateralized T1 to T2 N0 to N1 tumors
- Is strongly recommended for the subset of OPSCC patients with early-stage tonsillar cancer:
- It is conditionally recommended for patients with:
- Lateralized T1 to T2 N0 to N2a disease without evidence of extra-capsular extension
- Which involves treating only one side of the oropharyngeal area:
- Ipsilateral RT:
- Definitive RT:
- Recommendations by treatment setting are as follows:
References:
- Smith BD, Haffty BG, Wilson LD et al. Smith BD, Haffty BG, Wilson LD et al. The future of radiation oncology in the United States from 2010 to 2020: will supply keep pace with demand? J Clin Oncol.2010 Dec 10; 28(35): 5160-5.
- Chaturvedi AK, Engels EA, Pfeiffer RM, et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol. Nov 10 2011;29(32):4294-4301.
- Gillison ML, D’Souza G, Westra W, et al. Distinct risk factor profiles for human papillomavirus type 16-positive and human papillomavirus type 16-negative head and neck cancers. J Natl Cancer Inst.Mar 19 2008;100(6):407-420.
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