A Study Comparing Different Chemoradiation Techniques in the Management of Locally Advanced Head and Neck Squamous Cell Cancers.

ABSTRACT

Concomitant chemoradiation is the treatment of choice for most of head and neck cancer patients in developing countries since these patients present in locally advanced stage. They account for 4% of all cancers. Despite treatment, loco-regional failure is seen in 51-59% patients. There is often a deferral in start of radiation therapy due to large number of cases and lesser number of existing radiation set ups. Hence, several oncologists use neo-adjuvant systemic therapy prior to external beam radiotherapy. Some oncologists prefer hypofractionated radiation therapy over conventional fractionation. Yet there is no data available comparing neoadjuvant chemotherapy followed by hypofractionation with usual concurrent chemoradiation.METHODSBiopsy proved squamous cell carcinoma of larynx and pharynx of stage III & IV excluding IVC were incorporated in this study. Patients attending Bankura Sammilani Medical College Hospital in West Bengal, were randomized to get either concurrent chemoradiation with concomitant weekly injection of cisplatin 40 mg/m2 along with an external beam radiotherapy (EBRT) dose of 70 Gy. in conventional dose fractionation; or neoadjuvant chemotherapy for three cycles with carboplatin AUC 6, injection paclitaxel 175 mg/m2 and injection 5-fluorouracil 1000 mg/m2 day 1-4 followed by hypo-fractionated EBRT (40 Gy. in 16 fractions for 3.5 weeks followed by boost dose of 20 Gy. over 8 fractions in 1.5 weeks) commenced within 3 weeks after completion of chemotherapy. Disease-free survival (DFS) at three years and complications of treatment (using version 5.0 Common-Terminology-Criteria for Adverse-Events) were compared statistically using one-way ANOVA by means of version 20 IBM SPSS Statistics® software.RESULTSCharacteristics of patients were comparable in the two arms. Acute toxicities were less after neoadjuvant chemotherapy followed by hypo fractionated radiotherapy arm. DFS and tumor control were same. Lesser treatment days made this arm more convenient to patients. This is also financially helpful in Bankura where poor patients have to stay near hospital in some rented room or they have to come regularly from long distance by hired vehicle or ambulance. Tumor control and survival advantage was same in both modalities of treatment. Thus hypo fractionated radiotherapy arm was non-inferior statistically when compared to concomitant arm in terms of tumor control and survival.CONCLUSIONSManagement by neo-adjuvant chemotherapy followed by hypo-fractionated radiation is a non-inferior apposite substitute to the usual concurrent chemo-radiation in cancer treatment centers overburdened with patients.