Induction chemotherapy (IC) is significantly inferior to primary surgery in patients with advanced tongue cancer, according to a comparative study published online December 26, 2013, inJAMA Otolaryngology – Head and Neck Surgery.
Referencing his team's failure as "complete" and "spectacular," lead investigator Douglas Chepeha, MD, from the University of Michigan Comprehensive Cancer Center in Ann Arbor, toldMedscape Medical News that patients should seek a good reconstructive team and undergo surgery to boost their chances of survival.
"I would tell patients in my office that surgery is the best thing if you want to see your child graduate. I'd rather give you a 70% chance of survival than a very good chance of being able to eat and speak, albeit not as well as before you developed cancer," Dr. Chepeha explained.
The research team compared outcomes in 19 patients with advanced tongue cancer who had undergone induction selection and a matched cohort of 53 patients who underwent primary surgery. The analysis controlled for factors such as age and clinical stage.
Patients who underwent surgery had significantly better outcomes than those who received IC, including overall 5-year survival (65% vs 32%; hazard ratio [HR], 2.51; P = .01), 5-year progression-free survival (75% vs 46%; HR, 3.59 P = .001), and the likelihood of locoregional control (72% vs 26%; P < .001).
"It was a negative study that we had to stop early because the patients did so poorly, and we are leaders in the use of induction chemotherapy for head and neck cancers, as well as experts in reconstructive surgery," Dr. Chepeha noted. However, IC remains the optimal choice in laryngeal cancer, he said.
Survival Equally Low for IC Responders and Nonresponders
Nineteen patients with unresectable stage III or IV oral cavity squamous cell carcinoma were treated with IC. The researchers found that only 10 (53%) responded with a 50% reduction in tumor size. Of those 10, only 3 (30%) had a complete response after concomitant chemoradiotherapy and remained disease-free at 5 years. One patient (14%) underwent successful salvage therapy and also survived.
Kaplan–Meier survival analysis revealed no difference in 5-year progression-free survival between responders and nonresponders in the IC group — only 2 of the 9 nonresponders treated with surgery survived with no evidence of disease (22%). Factors such as age, sex, stage, T and N status, tobacco exposure, and alcohol consumption failed to predict response in the IC group.
Moreover, IC was linked to an increased risk for serious adverse events; 3 patients (16%) developed osteoradionecrosis and 1 (5%) developed a massive myocardial infarction during the treatment. Reliance on a gastrostomy tube was significantly higher in the IC group than in the primary surgery group (42% vs 9%).
"I often use breast cancer as a parallel to explain the body image issues associated with tongue cancer, but unlike breast cancer, you can't just use a step-wise approach with chemotherapy to see how it goes. The fact is that the mouth is a very sensitive area, and patients with tongue cancer just can't handle it as well as surgery with follow-up radiation," Dr. Chepeha concluded.
The study was supported by a training grant from the University of Michigan, a SPORE grant, and a grant from the National Institute of Dental and Craniofacial Research. The authors have disclosed no relevant financial relationships.
JAMA Otolaryngol Head Neck Surg. Published online December 26, 2013. Abstract
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