New Paradigms in Head

1
New Paradigms in Head Neck CancerSequential
Therapy Redefining the Role of Induction
Chemotherapy

• Marshall R. Posner, MDDana-Farber Cancer
  Institute

2
Polling Question

• In patients for whom induction chemotherapy is a
  viable treatment option, I treat the following
  proportion of patients with induction
  chemotherapy
• 0 (dont use induction chemotherapy)
• 1-10
• 11-25
• 26-50
• 51-75
• gt75

3
Polling Question

• The main issue(s) which limits the use of
  induction chemotherapy is
• Toxicity
• Lack of proven benefit for locoregional tumor
  control and/or overall patient survival
• Patient/physician preference
• 1 2
• 1 3
• 2 3
• All of the above (1 2 3)
• None (use induction chemotherapy when indicated)

4
Polling Question

• In patients for whom induction chemotherapy is a
  viable treatment option, my preferred induction
  chemotherapy regimen is
• PF (cisplatin 5-FU)
• PT (platinum taxane)
• TPF (docetaxel cisplatin 5-FU)
• Other

5
Case 1 T3N2b Oropharyngeal TumorNo Significant
Comorbidities

• Patient is a 50-year old male
• Presents with a painless right neck mass
• 5 pack-year smoking history, quit 30 years ago
• Wine on weekends
• Exam shows tumor of the right base of tongue, 5
  cm right, cystic level 2 mass of lymph nodes
• T3N2b - stage IVa
• The tumor abuts the midline of the tongue base,
  does not impair speech or swallowing, and is not
  adjacent to the larynx
• It is resectable with a total glossectomy and
  might be resectable with a partial glossectomy

6
Case 1 T3N2b Oropharyngeal TumorNo Significant
Comorbidities

• This patient has resectable stage IVa
  oropharyngeal cancer, good PS, and minimal
  comorbidities
• Marginally resectable for cure
• Risk of swallowing and speech problems with
  surgery and with organ preservation
• Survival 30-50 at 5 years
• Intermediate risk of metastases

7
Case 1 T3N2b Oropharyngeal TumorNo Significant
Comorbidities

• Which treatment option would you recommend?
• Surgery total or partial glossectomy
• Organ preservation chemoradiotherapy (cisplatin
  XRT)
• Organ preservation induction chemotherapy (TPF)
  followed by radiotherapy
• Organ preservation sequential therapy
  induction chemotherapy (TPF) followed by
  chemoradiotherapy and then surgery as indicated

8
Case 2 T3N3 Tumor of the HypopharynxNo
Significant Comorbidities

• Patient is a 65-year old male
• Presents with hoarseness, left ear pain and a
  left neck mass
• 65 pack-year smoking history, quit 3 months ago
• Wine on weekends
• Hypertension, mild COPD
• Exam shows tumor of the left pyriform sinus with
  extension into the parapharyngeal wall, 7.5 cm
  left, cystic level 2 mass of lymph nodes fixed to
  the neck
• T3N3, stage IVb
• On CT imaging, the tumor surrounds the internal
  carotid
• It is unresectable

9
CT Image of Neck Mass
10
Intra-Operative View of Hypopharynx
Pyriform Sinus Tumor
11
Case 2 T3N3 Tumor of the HypopharynxNo
Significant Comorbidities

• This patient has unresectable stage IVb
  hypopharyngeal cancer, good PS, and minimal
  co-morbidities
• Surgery is not an option
• Estimated 5-year survival is 20-30 with
  chemoradiotherapy and there is a high rate of
  distant metastases

12
Case 2 T3N3 Tumor of the HypopharynxNo
Significant Comorbidities

• Which treatment option would you recommend?
• Chemoradiotherapy cisplatin/carboplatin
  paclitaxel, THFX
• Induction chemotherapy (TPF) followed by
  radiotherapy
• Sequential therapy induction chemotherapy (TPF)
  followed by chemoradiotherapy and then surgery as
  indicated

13
Case 2 T3N3 Tumor of the HypopharynxNo
Significant Comorbidities

• What is the natural history of hypopharynx
  cancer?
• Hypopharynx cancer is more aggressive then larynx
  cancer or oropharyngeal cancer
• Surgery entails laryngectomy in resectable
  disease
• Estimated 5-year survival is 20-30 with stage
  III/IV cancer and there is a high rate of distant
  metastases

14
CT Image of Neck Mass After 3 Cycles of TPF
15
Case 2 T3N3 Tumor of the HypopharynxNo
Significant Comorbidities

• The patient has a CR at the primary site and a PR
  in the neck
• Which treatment option would you recommend?
• Surgery perform a total laryngectomy and neck
  dissection
• Surgery only perform a neck dissection
• Radiation therapy
• Chemoradiotherapy bolus cisplatin
• Chemoradiotherapy weekly carboplatin
• Chemoradiotherapy weekly carboplatin and
  paclitaxel

16
New Paradigms in Head Neck CancerSequential
Therapy Redefining the Role of Induction
Chemotherapy

• Marshall R. Posner, MDDana-Farber Cancer
  Institute

17
Hear No Induction See No InductionSpeak No
Induction
18
Effects of Chemotherapy on Survival at
5-YearsFrom the Meta-Analysis

• Trial Category No. of Trials No.
  Patients Difference () P value
• All trials 65 10,850
  4 lt0.0001
• Adjuvant 8 1,854
  1 0.74
• Induction 31 5,269 2 0.10
• PF 15 2,487
  5 0.01
• Other Chemo 16 2,782 0 0.91
• Concomitant 26 3,727
  8 lt0.0001

Monnerat, et al. Annals of Oncology, 13
995-1006, 2002
19
Studio Induction Chemotherapy TrialPhase III
Study of PF Induction Chemotherapy
Paccagnella A, et al. J Natl Cancer Inst.
199486265-272
20
Studio Induction Chemotherapy TrialOverall
Survival for Operable Patients

• Conclusion post-CT surgery did not improve
  survival in operable patients
• Surgery may ? risk of local-regional recurrence
• Surgical Margins Inadequate
• Tumor repopulation and resistance enhanced by
  delay to XRT
• Lack of primary site preservation

A group initial chemotherapy (cisplatin and
infusional fluorouracil) followed by locoregional
treatment (n118). B group locoregional
treatment alone (n119).
Paccagnella A, et al. J Natl Cancer Inst.
199486265-272
21
Studio Induction Chemotherapy Trial Overall
Survival for Inoperable Patients10-Year Data

• Conclusion
• PF induction chemotherapy improves survival in
  patients with unresectable disease
• Improved LRC, reduced DM

PF group initial chemotherapy (cisplatin and
infusional fluorouracil) followed by locoregional
treatment (n118). XRT group locoregional
treatment alone (n119).
Zorat, P. L. et al. J Natl Cancer Inst 2004
22
Overall Survival OropharynxGETTEC
Domenge C, et al. Br J Cancer. 2000831594-1598.
23
A Cell Kinetic Model for Response and
SurvivalThe Argument for Timing in Combined
Modality Therapy
Takimoto Rowinsky, JCO, 2003
24
Induction Chemotherapy and Sequential Therapy
Biological Considerations

• The sequence of chemotherapy ? CRT should be
  brisk and uninterrupted
• Surgery delays regional therapy
• Neck surgery permits growth at primary site and
  partial resistance
• Surgery leaves an enhanced growth environment
• Accelerated tumor repopulation/potential doubling
  times
• Expanded populations with partial resistance
• The choice of chemoradiotherapy regimen can be
  risk-based
• Response
• Toxicity
• A weekly regimen would provide more regional
  sensitization
• Weekly treatment may be more biologically
  effective and less systemically toxic then high
  dose pulsed therapy

25
Biological Assumptions of Chemoradiotherapy

• SCCHN is a local-regional disease
• Local-regional failure became the dominant
  concern
• Local-regional control persistent disease
• Local-regional control recurrent disease
• Local-regional control new disease
• Distant disease

26
Calais Chemoradiotherapy Regimen
Calais G, et al. J Natl Cancer Inst.
1999912081-2086.
27
Calais Chemoradiotherapy Study5-Year Survival

• Conclusions
• Borderline statistically significant (P .05)
  better overall survival with CRT (22 vs. 16)
• Absolute 6 improvement
• Better LRC (48 vs. 25), No change in DM (20)
• CRT is better then XRT alone for oropharynx cancer

Denis, F et al. JCO. 2004.
28
A Phase III Trial of Chemoradiotherapy and
Concomitant Boost Radiotherapy in Locally
Advanced SCCHN of the Oropharynx and Hypopharynx
Staar, IJROBP, 2001 50 1161-1171
29
Phase III Trial of Chemoradiotherapy and
Concomitant Boost Radiotherapy

• Boost -XRT CF-XRT
• Patients 127 113
• T4 102 (80) 91 (82)
• N2 N3 109 (85) 93 (82)
• 5-Year Survival
• Oropharynx 13 26 P lt .008
• Hypopharynx 22 22
• Distant Metastases 19 21
• Mucositis gt Grade 3 52 68 P lt .01
• Esophageal Stenosis 25 50
• (Survivors at 2 years)

Staar , IJROBP, 2001 50 1161-1171. Semrau,
IJROBP, 2006.
30
INT-026 A Phase III Trial of Chemoradiotherapy
in Unresectable Patients
Adelstein, et al JCO, 2003 2192-98
31
INT-026 Survival Outcomes
A B C XRT P-XRT
PF-SC-XRT Evaluable Patients 95 87 89 Dis.
Spec. Survival (3-yr) 34 56 42 Overall
Survival (3-yr) 23 37 27 Median
Survival 12.6 Mo 19.1 Mo
13.8 Mo Rate of DM 18 (30)
22 (51) 19 (29) Feeding
Tube 40 52 51
Significant Difference A vs. B
Adelstein, et al JCO, 2003 2192-98
32
RTOG 91-11Phase III Trial of Larynx Preservation

• Forastiere, NEJM, 2003
• Forastiere AA, et al. ASCO 2006. Abstract 5517

33
RTOG 91-11 Laryngectomy-Free Survival
Forastiere AA, et al. ASCO 2006. Abstract 5517
34
RTOG 91-11 Overall Survival
Forastiere AA, et al. ASCO 2006. Abstract 5517
35
RTOG 91-11ASCO 5-Year Update

• PF CRT XRT
• LFS 44.6 46.6 33.9 P lt .011
• LRC 54.9 68.8 51 P lt
  .0018
• DM 14.3 13.2 22.3
• DFS 38.6 39 27.3 P lt .0016
• Survival 59.2 54.6 53.5

1. PF was equivalent to CRT for LFS
2. CRT had better LRC than PF
3. DFS was identical but overall survival favored PF
4. Did patients fare better with PF because they had
   subtle improvements in function?

Forastiere AA, et al. ASCO 2006. Abstract 5517
36
GORTEC 2000-01 A Phase III Trial of TPF vs. PF
Followed by Radiotherapy for Organ Preservation
in Resectable Larynx and Hypopharynx Cancer
Calais G, et al. ASCO 2006. Abstract 5506
37
GORTEC Phase III Larynx Preservation Trial
Comparing TPF and PF Induction Therapy for
Hypopharynx and Larynx Cancer

• Increase in larynx preservation with TPF vs. PF
• Larynx preservation observed in 80 and 58 of
  patients following TPF and PF treatment,
  respectively (NR)
• Overall survival trend favors TPF over PF (P
  .096)

TPF () PF () P Value
Larynx preserved (current rate) 63.2 41.4 .036
Response CR PR 82.8 43.4 39.4 60.8 30.4 30.4 .0013
Calais G, et al. ASCO 2006. Abstract 5506
38
GORTEC Phase III Larynx Preservation Trial
Comparing TPF and PF Induction Therapy for
Hypopharynx and Larynx Cancer
Calais G, et al. ASCO 2006. Abstract 5506
39
GORTEC Phase III Larynx Preservation Trial
Comparing TPF and PF Induction Therapy for
Hypopharynx and Larynx Cancer
Calais et al. ASCO, 2006. Oral Presentation.
40
TAX 323 TPF vs. PF Followed by Radiotherapy A
Phase III Study in Unresectable SCCHN
TPF Docetaxel 75D1 Cisplatin 75D1 5-FU
750CI- D1-5 Q 3 weeks x4 PF Cisplatin 100D1
5-FU 1000CI-D1-5 Q 3 weeks x 4
Remenar, ASCO, 2006
41
TN Stage of Primary
Stage T1 T2 T3 T4 Total
N0 1 (lt1) 12 (3) 29 (8) 42 (12)
N1 4 (1) 13 (4) 39 (11) 56 (16)
N2 1 (lt1) 13 (4) 38 (11) 153 (43) 205 (57)
N3 3 (1) 7 (2) 11 (3) 31 (9) 52 (15)
Total 4 (1) 25 (7) 77 (22) 252 (70) 358
3 patients were T3Nx
Vermoken, ASCO, 2004
42
TAX 323 Survival Update
Remenar, ASCO, 2006
43
TAX 323 Severe Adverse EventsChemotherapy
Vermoken, ASCO, 2004
44
Can TPF Improve Overall Survival?
Zorat JNCI 2004
45
Induction Chemotherapy

• Cons
• Systemic toxicity increased
• Survival improvement may be site and stage
  related
• Increased duration of therapy, change in tumor
  biology
• No improvement in local/regional dose intensity
• Cisplatin-based PF was the only effective
  chemotherapy regimen

• Pros
• High dose treatment, systemic exposure, transient
  toxicity
• Improved nutrition and PS
• Reduced tumor volume
• Better preparation for definitive radiotherapy
  and IMRT planning
• Improved function
• Established efficacy in resectable disease and
  organ preservation
• Improved survival
• Intermediate assessment of response/prognosis
• Adjusted intensity of post-induction therapy

46
Chemoradiotherapy

• Pros
• Improved local regional intensity
• Shortened treatment time
• Efficacy in unresectable disease
• Efficacy in organ preservation
• Effective post-operative therapy

• Cons
• Local toxicity increased
• Long-term toxicity not defined and late
• Esophageal stenosis, swallowing impaired
• Mortality from unrecognized toxicity
• Acute severe systemic toxicity
• Systemic chemotherapy resistance
• No acceptable standard
• Assessment of response/prognosis compromised
• No effect on distant metastases in advanced
  disease
• IMRT planning difficult

47
An Analysis of Failure in Phase II TPF Induction
Trials
Three Cycles of Induction Therapy Followed by BID
Radiotherapy

• Trials TPF, TPFL5, TPFL4, op-TPFL
• Entered 84
• Local/Regional Failure 26 (31)
• Local/Regional and DM 5 (6)
• DM only 0

Excludes 17 Patients with NPC
Haddad, Cancer, 2003
48
An Analysis of Failure in Phase III
Chemoradiotherapy Trials

• Trials INT EORTC RTOG GORTEC
• LRF 22 18 16 57
• DM 23 21 20 18
• DM of Failure 51 54 65
  32
• The Rate of DM Was Not Reduced by CRT

Excludes Larynx Trial 91-11
Adelstein, JCO, 2003 Bernier, NEJM, 2005 Cooper,
NEJM, 2005 Denis, JCO, 2005
49
Induction Chemotherapy and Chemoradiotherapy in
Locally Advanced SCCHN

• PF induction chemotherapy results in a
  significant 5 (P lt.01) improvement in 5-year
  survival
• (Monnerat, Annals of Oncology, 2002)
• PF was the only induction regimen that was
  effective
• TPF is better than PF
• After induction chemotherapy and radiotherapy,
  failure is frequently local/regional (Haddad,
  Cancer, 2003)
• CRT results in a significant 8 (P lt.0001)
  improvement in 5-year survival in meta-analysis
  (Monnerat, Annals of Oncology, 2002)
• There is less local/regional failure, but
  relatively more distant metastases
• (Adelstein, JCO, 2003 Bernier, NEJM, 2005
  Cooper, NEJM, 2005 Denis, JCO, 2005)

50
Sequential Therapy for Head Neck Cancer

• Induction Chemotherapy
• Chemoradiotherapy
• Surgery

51
Sequential Therapy for Head Neck Cancer

• Induction chemotherapy
• High response rates, organ preservation, improved
  survival, systemic treatment
• Reduced tumor volume, improved functional outcome
• An intermediate assessment of response
• Chemoradiotherapy
• Increased local/regional dose intensity
• Adjustment based on response to induction
  therapy, potential toxicity, prognostic factors,
  and/or planned surgery
• Surgery
• Remove areas of initial bulk disease
• Preserve primary site

52
TPF vs. PF A Sequential Treatment Study
Optimizing Combined-Modality Therapy

• Three cycles of induction chemotherapy
• EUA after chemotherapy to assess clinical and
  pathological response
• Primary site biopsy for prognosis and monitoring
• Immediate chemoradiotherapy
• Rapid movement to radiation therapy
• Chemoradiotherapy with carboplatin
• Weekly therapy for sensitization, increased
  local/regional intensity
• Easily controlled side effect profile, minimal
  neurotoxicity
• Post-chemoradiotherapy surgery
• Primary site assessed separately
• Complete neck dissection for N2 and N3 nodal
  presentations

53
Sequential Combined-Modality Therapy A Phase
III Study TAX 324TPF vs. PF Followed by
Chemoradiotherapy
54
TAX 324 SurvivalIntent-to-Treat Population
TPF (n255) PF (n246)
Median Survival (Mo) 95 CI 70.6 49 NR 30.1 20.9 51.5
Died 41 53
Kaplan-Meir Survival 1Year 2Year 3Year 80 75.0 84.9 67 61.5 73.2 62 55.9 68.2 69 64.1 75.7 54 48.2 60.8 48 41.7 54.5
Hazard Ratio TPFPF 95 CI 0.70 0.54 - 0.90 0.70 0.54 - 0.90
Log-Rank P Value 0.0058 0.0058
Cut-off December 3, 2005 The median follow-up
is 42 months
55
TAX 324 Survival
Log-Rank P 0.0058 Hazard Ratio 0.70
TPF 62 PF 48
TPF 67 PF 54
56
TAX 324 Progression-Free Survival
Log-Rank P 0.004 Hazard Ratio 0.71
TPF 49 PF 37
TPF 53 PF 42
57
TAX 324 Toxicity During Chemotherapy
Number of Patients TPF (n251) PF (n243)
NCIC-CTG Classification Grade 3/4 Grade 3/4
Any Event 65 62
Stomatitis Nausea Lethargy Vomiting Diarrhea Anorexia 21 14 5 8 7 12 27 14 10 10 3 12
58
TAX 324 Specific Safety During Chemotherapy
Hematologic Toxicity TPF (n251) PF (n243)
Neutropenia Grade 3/4 84 56
Febrile Neutropenia Neutropenic Infection 12 12 7 9
Primary Prophylactic Antibiotics Were Given Per
Protocol for TPF
59
TAX 324 Delays During Induction Chemotherapy
TPF (n251) PF (n243) All (n494)
Treatment Delays 73 (29) 157 (65) 230 (47)
Hematologic 11 (4) 108 (44) 119 (24)
Neutropenia 2 (1) 95 (39) 97 (20)
Non-Hematologic 25 (10) 22 (9.1) 47 (10)
Other 38 (15) 40 (17) 78 (16)
Logistic, Personal, Vacation
P lt .0001
60
TAX 324 Exposure to Induction Chemotherapy
TPF (n251) TPF (n251) TPF (n251) PF (n243) PF (n243)
Median Cycles 3 3 3 3 3
Cumulative Dose (mg/m2) T P F P F
Cumulative Dose (mg/m2) 224 299 11,944 299 14,760
Relative Median Dose Intensity .98 .99 .98 .90 .88
6 Patients in each Arm received carboplatin to
replace cisplatin
61
TAX 324 Toxicity During Chemoradiotherapy
Number of Patients TPF (n203) PF (n184)
NCIC-CTG Grade 3/4 Grade 3/4
Any Event Stomatitis Dysphagia Mouth/Nose Dryness Nausea Rash/itch 65 37 23 5 6 5 66 38 24 4 6 2
62
TAX 324 Exposure to Study TreatmentChemoradiothe
rapy (CRT)
Chemoradiotherapy (CRT) TPF (n202) PF (n184)
Median Dose Radiotherapy (Gy) Median Dose Carboplatinum (AUC) Median Duration CRT (Wks) 70 9.9 7.1 70 9.9 7.1

Chemoradiotherapy toxicity was not enhanced by
prior docetaxel in TPF
63
TAX 324 Analysis of Failure
TPF (n251) PF (n243) All (n494)
Total Failures/Treated 88 (35) 110 (45) 198 (40)
LRF 77 (31) 93 (38) 170 (34)
Primary 43 (17) 49 (20) 92 (19)
Neck 22 (9) 33 (14) 55 (11)
Both 12 (5) 11 (5) 23 (5)
Distant Metastases 14 (5) 21 (9) 35 (7)
Distant Only 11 (4) 17 (7) 28 (6)
Distant and LRF 3 (1) 4 (2) 7 (1)
Second Primaries 9 (4) 7 (3) 16 (3)
Hazard Ratio 0.73 (0.54-0.99), P .03 Hazard
Ratio 0.60 (0.30-1.18), P .18
64
Experience With Docetaxel-Based Induction in
Locally Advanced SCCHN
Study N (Criteria) Primary Endpoint Regimens Result
Remenar 2006 (EORTC 24791/ TAX 323) 358 (Inoperable) PFS PF ?RT vs. TPF ?RT TPF led to higher PFS and OS (P lt.01)
Posner 2006 (TAX 324) 501 (Advanced) OS PF ?CRT vs. TPF ?CRT TPF improved OS at 3-years P (lt.01)
Calais 2006 (GORTEC 2000-01) 213 (Resectable) LxP PF vs. TPF TPF led to higher LxP, CR
All trials showed that TPF had less significant
toxicity and no effect on ability to undergo
sequential CRT or RT
Preliminary results.
65
TAX 324/323 Questions

• Is 5-FU necessary?
• PT and PF are equivalent in recurrent disease
  (Gibson, 2004)
• There is synergism with cisplatin and 5-FU and
  cisplatin and docetaxel
• TPF is better than PF
• Show us that PT is better than TPF!
• Tax 323 and Tax 324 use somewhat different
  regimens
• Dose intensity is greater in Tax 324 for
  cisplatin and 5-FU than in Tax 323
• Direct evidence for giving 3 or 4 cycles is
  lacking
• Dose intensity may impact on local regional
  control and distant metastases

66
TAX 324 Conclusions

• TPF significantly improves survival compared to
  PF
• In Tax 323 and Tax 324 there is significant
  improvement in 3-year survival and a 27-30
  reduction in mortality (P lt 0.006).
• In Tax 324 TPF significantly reduced local
  regional failure (P .03) and showed a trend
  towards improved DM (P .18)
• In Tax 323, Tax 324, and GORTEC, TPF was less
  toxic than PF
• Induction chemotherapy and sequential therapy
  with TPF are tolerable and safe and represent
  new, acceptable standards of care for locally
  advanced SCCHN
• Phase III trials to determine if sequential
  therapy or aggressive chemoradiotherapy is best

67
Hear No Induction See No InductionSpeak No
Induction
Hear About The Data Think About The DataSpeak
About The Data
Evaluate the Data Form Your Own Opinion
68
New Paradigms in Head Neck CancerSequential
Therapy Redefining the Role of Induction
Chemotherapy

• Discussion