xRead - Nasal Obstruction (September 2024) Full Articles

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KUANetal.

Cost

Addition of chemotherapy incurs increase in treatment cost. Cost comparison analyses have not been undertaken. Preponderance of benefits over harms. Addition of concurrent chemotherapy is justified in advanced-stage NPC, unless patient has reduced performance status.

Harm

Additional toxicities from anti-EGFR especially in addition to CRT. The true effect on oncological control is unclear. Cost comparison analyses have not been undertaken.

Benefits–harm assessment

Cost

Value

Benefits–harm assessment

Balance of benefits and harms.

judgments

Value

Routine use of anti-EGFR with radiation is not advised as its efficacy has not been assessed in prospective randomized controlled trials.

Policy level Strong recommendation. Intervention Concurrent chemotherapy with cisplatin is

judgments

recommended for advanced-stage NPC. There is no difference in survival outcomes for weekly cisplatin regimen versus every 3 weeks dosing.

Policy level Option. Intervention Concurrent anti-EGFR treatment with RT

could be considered only in advanced-stage NPC patients who have contraindications for concurrent cisplatin chemotherapy. Addition of anti-EGFR to CRT is not advisable as there is no evidence to support survival benefit and there is increased toxicity.

Role of concurrent chemoradiation therapy in treatment of early-stage NPC Aggregate grade of evidence A (Level 1: two studies; Level 2: one study) Benefit Addition of concurrent chemotherapy during

RT improves survival in advanced-stage NPC, but the benefit is less clear in earlier stage disease. Addition of concurrent chemotherapy significantly increases the risk of acute grade 3–4 neutropenia. Addition of chemotherapy increases treatment cost. Cost comparison analyses have not been undertaken. Preponderance of harms over benefits. Except for T2N1 disease with bulky lymph node metastasis, addition of chemotherapy may not improve survival especially for patients receiving IMRT. Routine CRT is not routinely recommended in stage II NPC as it is associated with increased toxicity with unclear survival benefits.

10 Role of induction/neoadjuvant chemotherapy

Harm

Induction (neoadjuvant) chemotherapy (IC) has been used in treating locoregionally advanced head and neck cancer since early 2000s. Multiple trials of IC with conventional RT and before the era of CRT, 3DCRT, and IMRT had been performed and had shown some benefits in sur vival or local control in NPC (Table XXV.7). However, with the advent of CRT and IMRT, the role of IC needs to be redefined. Theoretically, there are two benefits of IC. In patients with advanced nodal disease, IC can tar get occult distant metastases. For advanced local disease, especially disease with significant intracranial extension, IC can shrink the tumor, allowing the radiation oncologist to plan RT with adequate tumor coverage while protecting critical SARs. A phase III RCT in 2016 demonstrated the benefit of cisplatin, fluorouracil, and docetaxel (TPF) IC in addi tion to CRT with IMRT in OS and failure-free survival (FFS). 1687,1688 Another RCT using mitomycin, epirubicin, cisplatin, and 5-FU or leucovorin (MEPFL) as IC agents followed by CRT showed improved 5-year DFS in the IC arm. 1689 The above two studies used three or more agents as IC, which has increased toxicities. A phase III RCT com paring IC with TPF versus cisplatin and 5-flurouracil (PF) showed similar survival benefits, with omission of doc etaxel that in the TPF group was responsible for increased grade 3–4 toxicities to the hematological system. 1690 More recently, Zhang et al. reported the results of a large phase III RCT with stage 3 and 4 NPC, comparing IC using gem citabine (G) 1 g/m 2 on day 1 and day 8 + cisplatin (P)

Cost

Benefits–harm assessment

Value

judgments

Policy level Recommendation against Intervention CRT with cisplatin should only be considered in stage II patients with bulky nodal disease.

Role of anti-EGFR in treatment of NPC Aggregate grade of evidence

B (Level 2: two studies; Level 3: one study)

Benefit

Addition of anti-EGFR to RT may be considered in patients who are not eligible

for platinum-based chemotherapy. Concurrent anti-EGFR therapy was

reported to have similar survival outcomes as CRT in one retrospective cohort study. (Continued)