Transcript Evolving Treatment Paradigms in Cancer Care Current

New Paradigms in Head & Neck Cancer
Sequential Therapy: Redefining the Role of
Induction Chemotherapy
Marshall R. Posner, MD
Dana-Farber Cancer Institute
Polling Question
• In patients for whom induction chemotherapy is a viable
treatment option, I treat the following proportion of
patients with induction chemotherapy:
1.
2.
3.
4.
5.
6.
0% (don’t use induction chemotherapy)
1%-10%
11%-25%
26%-50%
51%-75%
>75%
Polling Question
•
The main issue(s) which limits the use of induction
chemotherapy is:
1. Toxicity
2. Lack of proven benefit for locoregional tumor control and/or
overall patient survival
3. Patient/physician preference
4. 1 + 2
5. 1 + 3
6. 2 + 3
7. All of the above (1 + 2 + 3)
8. None (use induction chemotherapy when indicated)
Polling Question
• In patients for whom induction chemotherapy is a viable
treatment option, my preferred induction chemotherapy
regimen is:
1.
2.
3.
4.
PF (cisplatin + 5-FU)
PT (platinum + taxane)
TPF (docetaxel + cisplatin + 5-FU)
Other
Case 1: T3N2b Oropharyngeal Tumor
No Significant Comorbidities
• Patient is a 50-year old male
– Presents with a painless right neck mass
• 5 pack-year smoking history, quit 30 years ago
• Wine on weekends
– Exam shows tumor of the right base of tongue, 5 cm right, cystic
level 2 mass of lymph nodes
• T3N2b - stage IVa
• The tumor abuts the midline of the tongue base, does not impair
speech or swallowing, and is not adjacent to the larynx
• It is resectable with a total glossectomy and might be resectable with
a partial glossectomy
Case 1: T3N2b Oropharyngeal Tumor
No Significant Comorbidities
• This patient has resectable stage IVa oropharyngeal
cancer, good PS, and minimal comorbidities
– Marginally resectable for cure
– Risk of swallowing and speech problems with surgery and with
organ preservation
– Survival 30-50% at 5 years
– Intermediate risk of metastases
Case 1: T3N2b Oropharyngeal Tumor
No Significant Comorbidities
• Which treatment option would you recommend?
1. Surgery – total or partial glossectomy
2. Organ preservation – chemoradiotherapy (cisplatin + XRT)
3. Organ preservation – induction chemotherapy (TPF) followed
by radiotherapy
4. Organ preservation – sequential therapy: induction
chemotherapy (TPF) followed by chemoradiotherapy and then
surgery as indicated
Case 2: T3N3 Tumor of the Hypopharynx
No Significant Comorbidities
• Patient is a 65-year old male
– Presents with hoarseness, left ear pain and a left neck mass
• 65 pack-year smoking history, quit 3 months ago
• Wine on weekends
• Hypertension, mild COPD
– Exam shows tumor of the left pyriform sinus with extension into
the parapharyngeal wall, 7.5 cm left, cystic level 2 mass of lymph
nodes fixed to the neck
• T3N3, stage IVb
• On CT imaging, the tumor surrounds the internal carotid
• It is unresectable
CT Image of Neck Mass
Intra-Operative View of Hypopharynx
Pyriform Sinus
Tumor
Case 2: T3N3 Tumor of the Hypopharynx
No Significant Comorbidities
• This patient has unresectable stage IVb hypopharyngeal
cancer, good PS, and minimal co-morbidities
– Surgery is not an option
– Estimated 5-year survival is 20%-30% with chemoradiotherapy
and there is a high rate of distant metastases
Case 2: T3N3 Tumor of the Hypopharynx
No Significant Comorbidities
•
Which treatment option would you recommend?
1. Chemoradiotherapy – cisplatin/carboplatin + paclitaxel, THFX
2. Induction chemotherapy (TPF) followed by radiotherapy
3. Sequential therapy – induction chemotherapy (TPF) followed by
chemoradiotherapy and then surgery as indicated
Case 2: T3N3 Tumor of the Hypopharynx
No Significant Comorbidities
• What is the natural history of hypopharynx cancer?
– Hypopharynx cancer is more aggressive then larynx cancer or
oropharyngeal cancer
– Surgery entails laryngectomy in resectable disease
– Estimated 5-year survival is 20%-30% with stage III/IV cancer and
there is a high rate of distant metastases
CT Image of Neck Mass
After 3 Cycles of TPF
Case 2: T3N3 Tumor of the Hypopharynx
No Significant Comorbidities
• The patient has a CR at the primary site and a PR in the
neck
• Which treatment option would you recommend?
1.
2.
3.
4.
5.
6.
Surgery – perform a total laryngectomy and neck dissection
Surgery – only perform a neck dissection
Radiation therapy
Chemoradiotherapy – bolus cisplatin
Chemoradiotherapy – weekly carboplatin
Chemoradiotherapy – weekly carboplatin and paclitaxel
New Paradigms in Head & Neck Cancer
Sequential Therapy: Redefining the Role of
Induction Chemotherapy
Marshall R. Posner, MD
Dana-Farber Cancer Institute
Hear No Induction – See No Induction
Speak No Induction
Effects of Chemotherapy on Survival at 5-Years
From the Meta-Analysis
Trial Category
No. of Trials
No. Patients
Difference (%)
P value
All trials
65
10,850
+4
<0.0001
Adjuvant
8
1,854
+1
0.74
Induction
31
5,269
+2
0.10
PF
15
2,487
+5
0.01
Other Chemo
16
2,782
0
0.91
Concomitant
26
3,727
+8
<0.0001
Monnerat, et al. Annals of Oncology, 13: 995-1006, 2002
Studio Induction Chemotherapy Trial:
Phase III Study of PF Induction Chemotherapy
S
T
R
A
T
I
F
Y
R
A
N
D
O
M
I
Z
E
Radiotherapy
No Chemotherapy
Surgery
(-) Biopsy
Nodal Surgery
No Surgery
Surgery
Radiotherapy
P
F
(-) Biopsy
No Surgery
4 Cycles of Chemotherapy
Radiotherapy
Nodal Surgery
Chemotherapy
Paccagnella A, et al. J Natl Cancer Inst. 1994;86:265-272
Studio Induction Chemotherapy Trial:
Overall Survival for Operable Patients
1
28
 Conclusion: post-CT surgery did
not improve survival in operable
patients
Overall survival
A group
B group
27
0.5
19
19
14
9
6
15
10
6
0
0
12
24
36
48
60
 Surgery may  risk of localregional recurrence
• Surgical Margins Inadequate
• Tumor repopulation and
resistance enhanced by delay to
XRT
 Lack of primary site preservation
Months from randomization
A group: initial chemotherapy (cisplatin and infusional fluorouracil) followed by locoregional treatment (n=118).
B group: locoregional treatment alone (n=119).
Paccagnella A, et al. J Natl Cancer Inst. 1994;86:265-272
Studio Induction Chemotherapy Trial:
Overall Survival for Inoperable Patients
10-Year Data
100
XRT
Survival (%)
80
PF
60
 Conclusion
 PF induction chemotherapy
improves survival in patients
with unresectable disease
 Improved LRC, reduced DM
40
20
0
0
20
40
60
80
100
120
Months
PF group: initial chemotherapy (cisplatin and infusional fluorouracil) followed by locoregional treatment (n=118).
XRT group: locoregional treatment alone (n=119).
Zorat, P. L. et al. J Natl Cancer Inst 2004
A Cell Kinetic Model for Response and Survival:
The Argument for Timing in Combined Modality Therapy
Treatment A Survival
Treatment B Survival
Tumor Cell Number
Chemotherapy
Death
A B
1012
1011
1010
109
108
107
106
Critical Time Frame
Time
Takimoto & Rowinsky, JCO, 2003
Induction Chemotherapy and Sequential
Therapy – Biological Considerations
• The sequence of chemotherapy  CRT should be brisk and
uninterrupted
– Surgery delays regional therapy
•
•
•
•
Neck surgery permits growth at primary site and partial resistance
Surgery leaves an enhanced growth environment
Accelerated tumor repopulation/potential doubling times
Expanded populations with partial resistance
• The choice of chemoradiotherapy regimen can be risk-based
– Response
– Toxicity
• A weekly regimen would provide more regional sensitization
– Weekly treatment may be more biologically effective and less
systemically toxic then high dose pulsed therapy
Biological Assumptions of
Chemoradiotherapy
SCCHN is a local-regional disease
• Local-regional failure became the dominant concern
–
–
–
–
Local-regional control: persistent disease
Local-regional control: recurrent disease
Local-regional control: new disease
Distant disease
Calais Chemoradiotherapy Regimen
Carboplatin
70 mg/m2 /day x 4 days
5-FU 600 mg/m2/days
x 4 days
QD Radiotherapy
200 cGy/ Fx
Weeks
0
1
2
3
4
5
6
7
Calais G, et al. J Natl Cancer Inst. 1999;91:2081-2086.
Calais Chemoradiotherapy Study
5-Year Survival
100
 Conclusions
CRT
80
Survival (%)
XRT
60
 Borderline statistically
significant (P = .05) better
overall survival with CRT
(22% vs. 16%)
 Absolute 6% improvement
40
 Better LRC (48% vs. 25%),
No change in DM (20%)
20
 CRT is better then XRT
alone for oropharynx cancer
0
0
6
12 18 24 30 36 42 48 54 60 66 72
Months
Denis, F et al. JCO. 2004.
A Phase III Trial of Chemoradiotherapy and Concomitant
Boost Radiotherapy in Locally Advanced SCCHN of the
Oropharynx and Hypopharynx
R
A
N
D
O
M
I
Z
E
A
Concomitant
Boost XRT
70 cGy
C
Carboplatin 70 mg/m2/day x 5 days
F
5-FU 600 mg/m2/day x 5 days
B
Concomitant
Boost XRT
70 cGy
Staar, IJROBP, 2001; 50: 1161-1171
Phase III Trial of Chemoradiotherapy and
Concomitant Boost Radiotherapy
Patients
T4
N2 + N3
5-Year Survival
Oropharynx
Hypopharynx
Distant Metastases
Mucositis > Grade 3
Esophageal Stenosis
Boost -XRT
127
102 (80%)
109 (85%)
13%
22%
19%
52%
25%
CF-XRT
113
91 (82%)
93 (82%)
26%
22%
21%
68%
50%
P < .008
P < .01
(Survivors at 2 years)
Staar , IJROBP, 2001; 50: 1161-1171.
Semrau, IJROBP, 2006.
INT-026: A Phase III Trial of Chemoradiotherapy
in Unresectable Patients
R
A
N
D
O
M
I
Z
E
XRT
A
P
B
XRT
C
P
F
XRT
Surgery
Adelstein, et al: JCO, 2003; 21:92-98
INT-026 – Survival Outcomes
A
B
C
XRT
P-XRT
Evaluable Patients
95
87
89
Dis. Spec. Survival (3-yr)
34%
56%*
42%
Overall Survival (3-yr)
23%
37%*
27%
12.6 Mo
19.1 Mo
13.8 Mo
18% (30%)
22% (51%)
Median Survival
Rate of DM
“Feeding Tube”
*
40%
52%
PF-SC-XRT
19% (29%)
51%
Significant Difference A vs. B
Adelstein, et al: JCO, 2003; 21:92-98
RTOG 91-11
Phase III Trial of Larynx Preservation
547 pts
Stage III/IV
glottic,
supraglottic
intermed.
stage
R
A
N
D
O
M
I
Z
E
A
± Surgery
XRT
P
B
C
± Surgery
XRT
P
F
XRT
Surgery
Forastiere, NEJM, 2003
Forastiere AA, et al. ASCO 2006. Abstract 5517
RTOG 91-11
Laryngectomy-Free Survival
100
% Alive Without Laryngectomy
Failed / Total
/
/
/
/
75
RT + Induction
109 / 173
RT + Concomitant
115 / 171
RT Alone
127 / 171
//
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/// /
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/ / / //// /
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//
/// / / / //
50
25
0
0
1
2
3
4
5
6
7
8
9
10
Years From Randomization
Forastiere AA, et al. ASCO 2006. Abstract 5517
RTOG 91-11
Overall Survival
100
Dead / Total
// //
/
RT + Induction
// /
% Alive
75
89 / 173
RT + Concomitant
// /
RT Alone
/
/ / // /
// / /
/ / // ///////// / //
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//
50
25
106 / 171
96 / 171
0
0
1
2
3
4
5
6
7
8
9
10
Years From Randomization
Forastiere AA, et al. ASCO 2006. Abstract 5517
RTOG 91-11
ASCO 5-Year Update
PF
CRT
XRT
LFS
44.6%
46.6%
33.9%
P < .011
LRC
54.9%*
68.8%*
51%
P < .0018
DM
14.3%
13.2%
22.3%
DFS
38.6%*
39%
27.3%*
Survival
59.2%
54.6%
53.5%
1.
2.
3.
PF was equivalent to CRT for LFS
CRT had better LRC than PF
DFS was identical but overall survival favored PF
4.
Did patients fare better with PF because they had
subtle improvements in function?
P < .0016
Forastiere AA, et al. ASCO 2006. Abstract 5517
GORTEC: 2000-01: A Phase III Trial of TPF vs. PF
Followed by Radiotherapy for Organ Preservation in
Resectable Larynx and Hypopharynx Cancer
R
A
N
D
O
M
I
Z
E
T
P
Surgery
F
No Response
P
F
Response
Daily Radiotherapy:
STD or ACB
TPF: Docetaxel 75D1 + Cisplatin 75D1 + 5-FU 750CI- D1-5 Q 3 weeks x4
PF: Cisplatin 100D1 + 5-FU 1000CI-D1-5 Q 3 weeks x 3
Calais G, et al. ASCO 2006. Abstract 5506
GORTEC Phase III Larynx Preservation Trial Comparing
TPF and PF Induction Therapy for Hypopharynx and
Larynx Cancer
Overall Survival
100
P (Log-rank test) = 0.096
Percent (%)
80
60
40
Induction TPF (n=108)
Induction PF (n=112)
20
0
0
6
12
18
24
30
36
42
Months
Calais G, et al. ASCO 2006. Abstract 5506
GORTEC Phase III Larynx Preservation Trial Comparing
TPF and PF Induction Therapy for Hypopharynx and
Larynx Cancer
Larynx Preservation
100
P (Log-rank test) = 0.036
Percent (%)
80
60
40
Induction TPF (n=108)
20
Induction PF (n=112)
0
0
6
12
18
24
30
36
42
Months
Calais et al. ASCO, 2006. Oral Presentation.
TAX 323: TPF vs. PF Followed by Radiotherapy
A Phase III Study in Unresectable SCCHN
R
A
N
D
O
M
I
Z
E
T
P
F
EUA
P
Surgery
Daily Radiotherapy
F
TPF: Docetaxel 75D1 + Cisplatin 75D1 + 5-FU 750CI- D1-5 Q 3 weeks x4
PF: Cisplatin 100D1 + 5-FU 1000CI-D1-5 Q 3 weeks x 4
Remenar, ASCO, 2006
TAX 323: Survival Update
100
Survival Probability (%)
90
80
Log-Rank P = 0.0052
Hazard Ratio = 0.71
70
60
50
40
30
20
TPF (n=177)
PF (n=181)
10
0
0
6
12
18
24
30
36
42
48
54
60
66
16
15
7
8
4
72
Survival Time (months)
Patients at Risk
TPF: 177
PF: 181
163
150
127
98
91
77
74
57
64
47
60
39
43
33
26
25
Remenar, ASCO, 2006
TAX 323: Severe Adverse Events
Chemotherapy
Toxicity
> 3% of pts
Alopecia
Stomatitis/oral
Infection
Nausea
Vomiting
Diarrhea
Dyspnea
Dysphagia
Pain
Death
PF (n=179)
N (%)
0
20 (11.2)
13 (7.3)
13 (7.3)
9 (5.0)
8 (4.5)
8 (4.5)
5 (2.8)
7 (3.9)
12 (6.6)
TPF (n=174)
N (%)
20
8
15
1
1
5
6
6
11
6
(11.5)
(4.6)
(8.6)
(0.6)
(0.6)
(2.9)
(3.4)
(3.4)
(6.3)
(3.4)
Vermoken, ASCO, 2004
Can TPF Improve Overall Survival?
1.0
Log-Rank = 4.04; P = .04
0.5
20
13
RT
9
PF
6
11
4
0.0
0
12
24
36
48
60
72
84
96
108 120
Zorat JNCI 2004
An Analysis of Failure in Phase II
TPF Induction Trials*
Three Cycles of Induction Therapy Followed by BID Radiotherapy
Trials:
TPF, TPFL5, TPFL4, op-TPFL
Entered:
84*
Local/Regional Failure:
26 (31%)
Local/Regional and DM
5 (6%)
DM only
0
*Excludes 17 Patients with NPC
Haddad, Cancer, 2003
An Analysis of Failure in Phase III
Chemoradiotherapy Trials*
Trials:
LRF
DM
DM % of Failure
INT
22%
23%
51%
EORTC
18%
21%
54%
RTOG
16%
20%
65%
GORTEC
57%
18%
32%
The Rate of DM Was Not Reduced by CRT
*Excludes Larynx Trial 91-11
Adelstein, JCO, 2003
Bernier, NEJM, 2005
Cooper, NEJM, 2005
Denis, JCO, 2005
Induction Chemotherapy and Chemoradiotherapy
in Locally Advanced SCCHN
• PF induction chemotherapy results in a significant 5%
(P <.01) improvement in 5-year survival
(Monnerat, Annals of Oncology, 2002)
– PF was the only induction regimen that was effective
– TPF is better than PF
– After induction chemotherapy and radiotherapy, failure is
frequently local/regional (Haddad, Cancer, 2003)
• CRT results in a significant 8% (P <.0001) improvement in
5-year survival in meta-analysis (Monnerat, Annals of Oncology, 2002)
– There is less local/regional failure, but relatively more distant
metastases
(Adelstein, JCO, 2003; Bernier, NEJM, 2005; Cooper, NEJM, 2005; Denis, JCO, 2005)
Sequential Therapy for Head & Neck Cancer
• Induction chemotherapy
– High response rates, organ preservation, improved survival,
systemic treatment
– Reduced tumor volume, improved functional outcome
– An intermediate assessment of response
• Chemoradiotherapy
– Increased local/regional dose intensity
– Adjustment based on response to induction therapy, potential
toxicity, prognostic factors, and/or planned surgery
• Surgery
– Remove areas of initial bulk disease
– Preserve primary site
Sequential Combined-Modality Therapy
A Phase III Study: TAX 324
TPF vs. PF Followed by Chemoradiotherapy
R
A
N
D
O
M
I
Z
E
T
Carboplatin - AUC 1.5
Weekly
P
F
EUA
Surgery
Daily Radiotherapy
P
F
TPF: Docetaxel 75D1 + Cisplatin 100D1 + 5-FU 1000CI- D1-4 Q 3 weeks x3
PF: Cisplatin 100D1 + 5-FU 1000CI-D1-5 Q 3 weeks x 3
TAX 324: Survival
Intent-to-Treat Population
TPF (n=255)
PF (n=246)
Median Survival (Mo)
70.6 +
30.1
95% CI
49 – NR
20.9 – 51.5
Died *
41%
53%
80% [ 75.0 – 84.9]
67% [61.5 – 73.2]
69% [64.1 – 75.7]
54% [48.2 – 60.8]
62% [55.9 – 68.2]
48% [41.7 – 54.5]
Kaplan-Meir Survival
1–Year
2–Year
3–Year
Hazard Ratio TPF:PF
[95% CI]
Log-Rank P Value
0.70
[0.54 - 0.90]
0.0058
*Cut-off: December 3, 2005; The median follow-up is 42 months
TAX 324: Survival
100
Log-Rank P = 0.0058
Hazard Ratio = 0.70
90
Survival Probability (%)
80
70
60
50
40
TPF 67%
PF 54%
30
TPF 62%
PF 48%
20
TPF (n=255)
PF (n=246)
10
0
0
6
12
18
24
30
36
42
48
54
60
66
72
52
45
37
20
11
36
32
28
10
7
Survival Time (months)
Number of patients TPF: 255 234 196 176 163 136 105 72
at risk
PF: 246 223 169 146 130 107 85 57
1
TAX 324: Toxicity During Chemotherapy
TPF
(n=251)
PF
(n=243)
Grade 3/4
Grade 3/4
Any Event
65%
62%
Stomatitis
Nausea
Lethargy
Vomiting
Diarrhea
Anorexia
21%
14%
5%
8%
7%
12%
27%
14%
10%
10%
3%
12%
Number of Patients
NCIC-CTG Classification
TAX 324: Specific Safety During Chemotherapy
TPF
(n=251)
PF
(n=243)
Neutropenia Grade 3/4
84%
56%
Febrile Neutropenia
12%
7%
Neutropenic Infection
12%
9%
Hematologic Toxicity
Primary Prophylactic Antibiotics Were Given Per Protocol for TPF
TAX 324: Delays During Induction Chemotherapy
TPF
(n=251)
PF
(n=243)
All
(n=494)
73 (29%)
157 (65%)
230 (47%)
Hematologic
11 (4%)
108 (44%)
119 (24%)
Neutropenia
2 (1%)
95 (39%)
97 (20%)
Non-Hematologic
25 (10%)
22 (9.1%)
47 (10%)
Other**
38 (15%)
40 (17%)
78 (16%)
Treatment Delays*
** Logistic, Personal, Vacation
*P < .0001
TAX 324: Exposure to Induction Chemotherapy
TPF
(n=251)
PF
(n=243)
3
3
Median Cycles
Cumulative Dose
(mg/m2)
Relative Median
Dose Intensity
T
P*
F
P*
F
224
299
11,944
299
14,760
.98
.99
.98
.90
.88
*6 Patients in each Arm received carboplatin to replace cisplatin
TAX 324: Exposure to Study Treatment
Chemoradiotherapy (CRT)
TPF
(n=202)
PF
(n=184)
Median Dose Radiotherapy (Gy)
70
70
Median Dose Carboplatinum (AUC)
9.9
9.9
Median Duration CRT (Wks)
7.1
7.1
Chemoradiotherapy (CRT)
Chemoradiotherapy toxicity was not enhanced
by prior docetaxel in TPF
TAX 324: Analysis of Failure
TPF (n=251)
PF (n=243)
All (n=494)
88 (35%)
110 (45%)
198 (40%)
77 (31%)
93 (38%)
170 (34%)
Primary
43 (17%)
49 (20%)
92 (19%)
Neck
22 (9%)
33 (14%)
55 (11%)
Both
12 (5%)
11 (5%)
23 (5%)
14 (5%)
21 (9%)
35 (7%)
11 (4%)
17 (7%)
28 (6%)
3 (1%)
4 (2%)
7 (1%)
9 (4%)
7 (3%)
16 (3%)
Total Failures/Treated
LRF*
Distant Metastases**
Distant Only
Distant and LRF
Second Primaries
*Hazard Ratio 0.73 (0.54-0.99), P = .03
**Hazard Ratio 0.60 (0.30-1.18), P = .18
Experience With Docetaxel-Based Induction
in Locally Advanced SCCHN
Primary
Endpoint
Regimens
Result
PFS
PF RT vs.
TPF RT
TPF led to
higher PFS and
OS (P <.01)
501
(Advanced)
OS
PF CRT
vs.
TPF CRT
TPF improved
OS at 3-years
P (<.01)
213
(Resectable)
LxP
PF vs.
TPF
TPF led to
higher LxP, CR
Study
N (Criteria)
Remenar 2006
358
(Inoperable)
(EORTC 24791/
TAX 323)
Posner 2006
(TAX 324)
Calais 2006*
(GORTEC 2000-01)
All trials showed that TPF had less significant toxicity and no effect on ability to
undergo sequential CRT or RT
*Preliminary results.
TAX 324/323: Questions
• Is 5-FU necessary?
– PT and PF are equivalent in recurrent disease (Gibson, 2004)
– There is synergism with cisplatin and 5-FU and cisplatin and
docetaxel
– TPF is better than PF
– Show us that PT is better than TPF!
• Tax 323 and Tax 324 use somewhat different regimens
– Dose intensity is greater in Tax 324 for cisplatin and 5-FU than in
Tax 323
– Direct evidence for giving 3 or 4 cycles is lacking
– Dose intensity may impact on local regional control and distant
metastases
TAX 324: Conclusions
• TPF significantly improves survival compared to PF
– In Tax 323 and Tax 324 there is significant improvement in 3-year
survival and a 27-30% reduction in mortality (P < 0.006).
• In Tax 324 TPF significantly reduced local regional failure
(P = .03) and showed a trend towards improved DM (P = .18)
• In Tax 323, Tax 324, and GORTEC, TPF was less toxic
than PF
• Induction chemotherapy and sequential therapy with TPF
are tolerable and safe and represent new, acceptable
standards of care for locally advanced SCCHN
• Phase III trials to determine if sequential therapy or
aggressive chemoradiotherapy is best
Hear
About– See
TheNoData
Hear
No Induction
Induction
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No
Induction
Think About The Data
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Evaluate the Data:
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Opinion
New Paradigms in Head & Neck Cancer
Sequential Therapy: Redefining the Role of
Induction Chemotherapy
Discussion