ASTRO Guideline Establishes Standard of Care for Curative Treatment of Oropharyngeal Cancer with Radiation Therapy

  • 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
    • 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
      • 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
          • Systemic therapy for other stage III patients:
            • May convey unnecessary toxicity
      • 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
  • 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
    • 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
          • 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
      • 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
  • 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
          • As well as an equivalent dose of 50 Gy delivered in 2-Gy daily fractions:
            • To the regions at risk for tumor spread
        • For stage IVA to IVB patients not receiving concurrent systemic therapy:
          • Altered fractionation schedules (either accelerated or hyperfractionated):
            • Are recommended
        • 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
      • 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
        • 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
            • It is conditionally recommended for patients with:
              • Lateralized T1 to T2 N0 to N2a disease without evidence of extra-capsular extension

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.

#Arrangoiz #HeadandNeckSurgeon #CancerSurgeon #SurgicalOncologist #OropharyngealCancer

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