A Prospective Randomised Study of Clinical Outcome and Toxicity Patterns of Head and Neck Squamous Cell Carcinoma Treated with Accelerated Fractionated Radiotherapy versus Concurrent Chemoradiotherapy
Professor and Head, Department of Radiation Oncology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh, India.
Introduction: Locally advanced Head and Neck Squamous Cell Carcinoma (HNSCC) is a diverse group of patients and the treatment needs to be individualised. Although Concurrent Chemoradiotherapy (CTRT) remains the standard of care, not all patients are suitable to receive the same. Accelerated Fractionated Radiotherapy (AFRT) is one of the treatment options in these patients and may achieve equivalent therapeutic ratio.
Aim: To compare outcomes of patients of HNSCC treated with concurrent CTRT versus AFRT in a prospective randomised trial.
Materials and Methods: A total of 322 patients of Stage III-IV (AJCC, 6th Edition), HNSCC of oropharynx, larynx and hypopharynx were randomised to receive either definitive CTRT or AFRT. Radiotherapy (RT) dose was 70 Gray (2 Gray, 5 fractions per week over 7 weeks) to the primary and nodes and 46-60 Gray to the elective neck nodes. RT was delivered 5 fractions per week along with concurrent cisplatin 35-40 mg/m2 weekly in the CTRT arm. In the AFRT arm, RT was delivered as 6 fractions per week of 2 Gray each over 6 weeks. Acute and late toxicities were graded as per RTOG morbidity scoring. Kaplan Meier method was used for survival analysis.
Results: Patients characteristics were balanced between CTRT arm and AFRT arm (161 patients each). Median overall treatment time for CTRT and AFRT arms were 43 and 49 days respectively. A 5-year actuarial locoregional control, disease-free survival and overall survival was 32% vs. 42%; 28% vs. 35% and 30% vs. 35% respectively for CTRT vs. AFRT arm. Need of Ryleâ€™s tube feeding (p=0.001), acute mucositis (p=0.015), late subcutaneous toxicity (p=0.05) and late xerostomia (p=0.042) rates were higher for CTRT arm.
Conclusion: AFRT was associated with comparable clinical outcome as compared to CTRT in patients of HNSCC, albeit with reduced acute and late toxicities.