Head and Neck Cancer
PV QA 2 - Poster Viewing Q&A 2
Purpose/Objective(s): Though Intergroup 0099 established CCRT as the standard treatment for NPC, many fail distantly. Trials in Asia attempted to examine NAC+CCRT versus CCRT alone, with improvement in 3 year failure free survival (80% vs. 72%). However, more Western studies have not been examined. The purpose of our study is to determine whether NAC+CCRT compared to CCRT alone provides an overall survival (OS) benefit among high risk patients.
Materials/Methods: Of 13,929 patients with NPC treated from 2004-2014 at cancer centers part of the American College of Surgeons Commission on Cancer, we limited our study to non-metastatic, non-surgical/palliative patients treated with definitive chemotherapy and radiation (N=5424). 968 patients received NAC+CCRT and 4286 CCRT alone. We examined predictors of NAC use with logistic regression. Survival analyses with Cox proportional hazards analyses were performed to examine the effect of NAC on OS. Propensity score matching was performed with 1:2 matching of NAC (N=968) to CCRT alone (N=1914). Survival analyses were also stratified by risk group including N3 disease, type 1 histology, and high risk group (stage IV or type 1 histology).
Results: On multivariate analysis (MVA), patients with T3 disease (OR 1.25), clinical stage IV (OR 1.65), and type I histology (OR 1.16) predicted for treatment with NAC, whereas age 65+(OR 0.67), females (OR 0.80), and Asian patients (OR 0.74) did not (p<0.05). At a median follow up of 3.3 years, median OS for NAC was 9.4 years and 8.7 years for CCRT alone (log rank p =0.87). After adjusting for confounders on MVA, NAC improved OS compared to CCRT alone (HR 0.89; 95% CI [0.79,1.00]; p = 0.049). On univariate stratified analyses, NAC did not statistically significantly improve OS (HR 0.77, p=0.088) among N3 patients, with minimal association among N0-2 patients (HR 1.01 p= 0.823). On MVA, NAC improved OS among patients with type 1 histology (HR 0.82, p=0.015), N3 disease (HR 0.73, p=0.047), and high risk disease (HR=0.85, p=0.022). Among propensity matched patients(N=2882), NAC did not affect OS compared to CCRT alone (HR 0.98, p=0.771) in the entire cohort, but did improve OS among N3 patients (n=336) with HR 0.71, 95% CI: 0.51 – 0.99, p=0.046.
Conclusion: Using NAC plus CCRT to treat patients with nonmetastatic NPC may improve OS among patients with higher risk disease. Patients with N3 disease, who are at increased risk of distant micrometastases may particularly benefit from NAC. A subset of patients presenting with locally advanced disease with a higher propensity to metastasize and those with unfavorable histology who are most resistant to radiation therapy may benefit from treatment with NAC plus CCRT, underscoring the necessity of additional future phase III trials to confirm these results.
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