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.

Keywords::

• chemoradiation
• head and neck cancer
• induction chemotherapy
• locally advanced squamous cell carcinoma of the head and neck
• squamous cell carcinoma of the head and neck
• sequential therapy

Financial & competing interests disclosure

ES Santo is on the speaker bureau for Bristol-Myers-Squibbs. The authors have no other affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Radiation therapy alone is not as effective as concurrent chemoradiotherapy (CRT) treatment for head and neck cancer. The addition of chemotherapy to radiotherapy improves survival.

• • CRT remains standard of care for patients for locally advanced squamous cell carcinoma of head and neck.

• • The addition of induction chemotherapy to CRT to further improve outcome through eradication of systemic metastases was prospectively evaluated in highly anticipated randomized clinical trials with results showing no superiority over CRT alone.

• • Acute toxicities are higher in patients receiving sequential approach versus CRT.

• • Compliance rate is higher in patients receiving CRT when compared to the sequential approach.

• • The use of induction chemotherapy followed by CRT may confer an additional advantage in locoregional and distant disease control, particularly in the high-risk subset of patients with extensive nodal involvement (N2c and/or N3 disease).