Current management strategies for non-metastatic nasopharyngeal cancer

Abstract

The currently available data on management strategies for non-metastatic nasopharyngeal cancer (NPC) are reviewed. Achievement of locoregional control by best quality radiation therapy (RT) is fundamental and this can reduce the risk of further hematogenous dissemination. The intensity-modulated RT technique is advocated for maximizing conformity of physical dose distribution. With technological advances in diagnostic imaging, RT planning and delivery, excellent locoregional control can now be achieved. However, as more than 25% of patients with advanced stages of NPC still die from distant failure, effective systemic therapy is needed. Of the 14 randomized trials on the therapeutic value of combined chemoradiotherapy (CRT), only three trials using cisplatin-based concurrent ± adjuvant regimens achieved significant improvement in both event-free survival and overall survival. Recent meta-analyses showed that concurrent chemotherapy is the most effective sequence; induction chemotherapy could significantly improve tumor control, but this, per se, did not result in a significant impact on survival and adjuvant chemotherapy was insignificant for all endpoints. The Intergroup-0099 regimen of cisplatin in concurrence with RT at conventional fractionation followed by adjuvant chemotherapy using cisplatin and fluorouracil is widely used. This was the first trial that achieved a significant survival benefit, and the efficacy on tumor control was supported by two confirmatory trials. However, the adjuvant phase is often poorly tolerated and the benefit contributed is uncertain. To further improve the magnitude of gain, various new strategies of administering concurrent CRT are being explored. Phase II studies on these new approaches show encouraging early results. Based on the current evidence, the standard recommendation is to treat stages I-II with RT and stages III-IVB (± bulky IIB) with combined RT and concurrent chemotherapy. Further enhancement of efficacy by using accelerated fractionation for T3-4 tumors, and/or changing the timing of chemotherapy to an induction-concurrent sequence for stage IV may be considered. Verification of therapeutic benefit of these new strategies by randomized trials is urgently awaited. More accurte prognostication for better tailoring of treatment strategy for different risk groups and ways to minimize toxicities should be explored. © 2006 Adis Data Information BV. All rights reserved.