Re: randomized trial of radiation therapy versus concomitant chemotherapy and radiation therapy for advanced-stage oropharynx carcinoma.

Abstract

Calais et al. (1) provide, perhaps, the best evidence yet that adding concomitant chemotherapy to “standard” radiotherapy is beneficial for the patients with oropharyngeal carcinoma. Unfortunately, it is also apparent from their results [see Table 3, B, of (1)] that, even after adding chemotherapy, far too many patients had tumor recurrence, either local (33%), regional (19%), or distant (11%). Although they did not discuss it, their Table 3, C (late toxic effects), is most valuable for considering what may and may not be feasible for further decreasing tumor recurrence. A high incidence of severe cervical fibrosis was observed, which precludes escalation of the external-beam radiotherapy dose and may even warrant a decrease. However, no dose-limiting toxicity related to the primary site was observed, which suggests that higher doses by brachytherapy to the primary site should be delivered for decreasing the rate of recurrence at the primary site (2). Additionally, planned neck dissection may decrease the regional recurrence rate (3). Calais et al. did not state if regional recurrence was more likely among the patients initially presenting with stage N2 or N3 disease than among patients initially presenting with N0 or N1 disease. If such information were available, it may help physicians decide who should undergo neck dissection and who can be spared.