Giving chemotherapy at the same time as radiotherapy to patients with locally advanced head and neck cancer (who have not had surgery) more than doubles their event-free survival to 2.2 years, compared with 1.0 years with radiotherapy alone. Wherever possible, chemo-radiation should become the standard for all patients with advanced head and neck cancer in whom surgery is not appropriate, concludes an Article in The Lancet Oncology.

People at highest risk of head and neck cancer are those who consume large amounts of alcohol or who smoke. There are about 7500 new cases diagnosed in the UK each year and 45 000 in the US, and the numbers are increasing. Standard traditional treatment for these patients involves radiotherapy with or without surgery, but recent research suggests that the addition of chemotherapy can increase survival. However, the best ways of combining these treatments is not clear, and some of the chemotherapy drugs can be toxic.

To provide more evidence, The UK Head and Neck (UKHAN) cancer group examined the effect of giving chemotherapy at the same time as or after radiotherapy with or without surgery on the 10-year outcomes of 966 patients with locally advanced head and neck cancer.

Patients who had not undergone surgery were randomly assigned to one of four groups: radiotherapy alone (233 patients), two courses of SIM (simultaneous) chemotherapy given at the same time as radiotherapy (166), or after completing radiotherapy (SUB subsequent; 160), or both (SIM+SUB; 154). Patients who previously had surgery were randomly assigned to radiotherapy alone (135) or SIM alone (118).

Overall, findings showed that non-platinum-based chemotherapy given at the same time as radiotherapy reduced deaths and recurrences in patients without previous surgery, with acceptable toxicity. However, patients who had undergone previous surgery did not benefit from the addition of chemotherapy. Additionally, chemotherapy given after radiotherapy (SUB) was shown to be ineffective and did not improve survival, and also doubled the rate of toxicity.

In the 74% of patients who did not have surgery, the median survival time was 2.6 years in the radiotherapy group, and 4.7, 2.3 and 2.7 years, respectively, in patients who received SIM alone, SUB alone, and SIM+SUB. The median event free survival (EFS) was 1.0 years in the radiotherapy group, 2.2, 1.0 and 1.0 years, respectively, in patients who received SIM alone, SUB alone, and SIM+SUB.

The authors estimate that compared with radiotherapy alone, for every 100 patients (non-surgical group) given chemotherapy at the same time as radiotherapy, there would be 11 fewer events (recurrences, new tumours, or deaths) by 10 years after starting treatment.

According to the authors, these findings show the long-term benefit of non-platinum agents that are: “inexpensive, relatively easy to deliver, and have lower toxicity then platinum therapies…[which] considerably improves the likelihood of completing treatment, essential for improving the chance of a cure”.