Linda Brookes, MSc


October 17, 2013

In This Article

Reducing Toxicity by De-escalation of Therapy

Because HPV/p16-positive patients respond well to treatment, current studies are investigating whether de-escalation of treatment can reduce toxicity without compromising the very good outcome in this group. Recent retrospective analyses have suggested that it is possible.[12] Ongoing phase 3 randomized trials aimed at identifying strategies to safely and effectively de-escalate treatment include RTOG 1016 (United States)[13] and TROG 12.01[14] (Australia), which will both assess substitution of high-dose cisplatin with cetuximab in chemoradiotherapy. "RTOG 1016 will also perform translational research within the trial, so hopefully it may provide some answers in terms of smoking history and tumor biology," Dr. Lassen noted. However, "it is important that we remember that within this group of HPV/p16-positive tumors, we have patients with a significantly poorer outcome than the truly low-risk patients, and at present we do not know how to identify those patients," she added.

Induction Chemotherapy: An Undefined Role

There are big differences in the approach to induction (neoadjuvant) chemotherapy between Europe and the United States, Dr. Lassen acknowledged to Medscape. "To my knowledge, we have no preclinical data demonstrating that HPV-positive tumor cells actually respond better to chemotherapy alone, and I think that induction -- or neoadjuvant -- chemotherapy would not be a strategy that we would go with, especially in light of the meta-analysis demonstrating that in head and neck cancer patients there seems to be no benefit in favor of induction chemotherapy,"[15] she said.

In the United States there are ongoing trials investigating induction chemotherapy followed by de-escalation, depending on the response of the tumors, she noted. "In this very select group of patients with very good prognosis, it is going to be very difficult to display differences in terms of outcome because they respond so well. If you take induction chemotherapy and compare it with what we do now, I am not sure that you are going to find a difference," she said.