Chemoradiation Lessens Need for Surgery in Head-and-Neck Cancer

RANCHO MIRAGE, Calif., Jan. 23 -- Chemoradiation allows many patients with node-positive head-and-neck cancer to avoid additional surgery to the neck, a researcher reported here.

In a retrospective, non-randomized study, the combination treatment completely controlled the cancer in 85% of patients without the need for nodal dissection, said Ramesh Rengan, M.D., Ph.D., of the University of Pennsylvania, who carried out the work with colleagues while he was at Memorial Sloan-Kettering Cancer Center in New York.

The key is that patients have to have at least a 50% reduction in tumor size during one to three cycles of induction chemotherapy, followed by a complete response, verified by imaging, to the chemoradiation, he said.

Some would argue there is a need for a neck dissection to remove affected lymph nodes, Dr. Rengan said in an interview after he presented 10-year follow-up data to the Multidisciplinary Head and Neck Cancer Symposium.

But these data show that's not so, Dr. Rengan said: "For 85% of patients - as long as they have a complete response at the end of chemotherapy and radiation - you can safely avoid the morbidity and toxicity of neck surgery."

Surprisingly, he said, the nodal status appeared to play no role. "Only 15% will go on to have a failure, regardless of nodal status," he said.

The study was a secondary analysis of 190 patients at Memorial Sloan-Kettering who were enrolled between 1983 and 1996 in larynx-organ preservation protocols. They received from one to three cycles of induction cisplatin, followed by radiotherapy alone or with concomitant cisplatin-based chemotherapy.

About of a quarter of the patients (48) were excluded from the analysis because they had neck surgery before radiation or because they discontinued therapy. Of the remaining 142 patients, 86 had node-positive disease, Dr. Rengan said.

Overall, 69 of the 86 node-positive patients (80%) had a complete response after chemoradiation, although four also underwent an immediate post-radiation neck dissection and were excluded from the survival analysis.

The finding is not surprising, commented Paul Harari, M.D., of the University of Wisconsin at Madison, who was the symposium's chairman.

Dr. Harari said the study is "nice, valuable, well-designed (and) essentially makes the same conclusions" as a number of other single-institution studies in recent years.

"Ultimately, it would be nice to address this in a prospective, randomized, controlled trial, so we could have gold-standard evidence," he said in an interview.

But such a trial is unlikely, because there is no obvious sponsor to cover the costs, he said. In the meantime, on the basis of studies such as the one presented by Dr. Rengan's, "we are seeing a swing of the pendulum" away from neck dissection in these patients.

Dr. Rengan said he and his colleagues have no relevant financial conflicts.