New evidence-based recommendations provide guidance on when to give radiotherapy and chemotherapy to patients with nasopharyngeal carcinoma.
The guidelines, based on data from more than 100 studies, support offering intensity-modulated radiotherapy to all patients with stage II-IVA nasopharyngeal carcinoma. Recommendations for chemotherapy vary according to disease stage, tumor size, number of nodes, and contraindications.
The guidelines, released jointly by the Chinese Society of Clinical Oncology (CSCO) and the American Society of Clinical Oncology (ASCO), were published in the Journal of Clinical Oncology.
“For practicing oncologists in the United States, who often lack experience treating nasopharyngeal cancer, this guideline provides a useful, succinct summary of available evidence and expert recommendations. Nasopharyngeal cancer can be a technically and medically challenging disease to manage, and a multidisciplinary approach should be strongly encouraged,” said ASCO expert Randall J. Kimple, MD, PhD, of the University of Wisconsin–Madison.
“Much of the data guiding our treatment of these patients comes from endemic regions,” he continued. “How these data apply to patients in the U.S. remains a subject of ongoing study. Patients and providers should be encouraged to seek the opinion of a provider with expertise in the management of nasopharyngeal cancer.”
To compile “best practices” for treating nasopharyngeal carcinoma, the ASCO/CSCO expert panel conducted a literature search that included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2020. The panel identified 108 relevant studies and formulated their guidelines based on the evidence.
Recommendations
For all patients with stage II-IVA nasopharyngeal carcinoma, the guidelines recommend intensity-modulated radiation therapy with daily image guidance. The recommended dose is 70 Gy in 33-35 fractions over 7 weeks.
“This has been the standard approach at most institutions that treat a sufficient number of nasopharyngeal cancer patients each year,” Kimple said.
When adding chemotherapy to radiotherapy, two approaches are recommended. The first is induction chemotherapy followed by chemoradiation, and the second is chemoradiation followed by adjuvant chemotherapy.
“There are divergent opinions regarding the optimal approach in these patients, with slightly stronger data supporting the use of induction chemotherapy,” Kimple said. “For patients with earlier stage nasopharyngeal cancer (T1-2N1 or T2N0), chemotherapy can be offered, and is more strongly recommended for those with more advanced disease (T2N1, bulky disease, high EBV load).”
For patients receiving concurrent chemotherapy and radiotherapy, the recommended regimen is cisplatin given either weekly (40 mg/m2) or triweekly (100 mg/m2).
“The stated goal is to achieve a cumulative cisplatin dose in excess of 200 mg/m2 regardless of the approach taken. Several options were provided for patients with a contraindication to cisplatin,” Kimple said.
Patients with contraindications can receive nedaplatin (100 mg/m2 triweekly), carboplatin (area under curve, 5-6 triweekly), oxaliplatin (70 mg/m2 weekly), or fluoropyrimidines (capecitabine, 5-fluorouracil, or tegafur).
For induction, the guidelines recommend platinum-based chemotherapy. Options include gemcitabine plus cisplatin, cisplatin plus 5-fluorouracil, cisplatin plus capecitabine, docetaxel plus cisplatin, and docetaxel plus cisplatin and 5-fluorouracil.
“[T]here is less strong evidence regarding the optimal induction chemotherapy approach for patients with nasopharyngeal cancer. Several possible regimens (doublet or triplet) are offered, with the use of platinum-based regimens being the common theme,” Kimple said.
For adjuvant chemotherapy, the guidelines recommend cisplatin plus 5-fluorouracil or carboplatin plus 5-fluorouracil.
The guidelines also suggest that clinicians take into account a patient’s other chronic conditions when formulating the treatment and follow-up plan.
“Patients with multiple chronic conditions pose a particular challenge to guideline-based care due to being commonly excluded from clinical trials,” Kimple said. “Shared decision-making plays a key role in the recommendations for patients with multiple chronic conditions. In addition, nasopharyngeal cancer patients often have long-term toxicity associated with their care, and, thus, the availability of expertise and resources in management of this disease is important.”
Kimple disclosed relationships with Galera Therapeutics, Mele Associates, and Guidepoint Global. The guideline authors disclosed relationships with a range of pharmaceutical companies, as listed in the article.
This article originally appeared on MDedge.com, part of the Medscape Professional Network.
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