Dose De-escalation in Human Papillomavirus-Associated Oropharyngeal Cancer: First Tracks on Powder.

Abstract

Current radiation therapy (RT) treatment schedules for head and neck squamous cell carcinoma (HNSCC) are derived from a combination of rigorous radiobiology and data from prospective clinical trials. Human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) is now appreciated to be biologically distinct from the traditional type of HNSCC resulting from tobacco and alcohol use. Remarkably high 5-year survival rates, not previously observed in the head and neck cancer patient population, are observed among patients with HPV-positive OPSCC when treated with platinum-based chemoradiation therapy (CRT). Additionally, the patient population afflicted with HPV-positive OPSCC is younger, healthier, and far more likely to be alive to deal with the long-term consequences of therapy. Clinicians who treat HPV-positive OPSCC are now faced with the problem that current treatment paradigms were developed in an era when the traditional HNSCC patient (tobaccoand alcohol-related) predominated. This has led to an appropriate re-examination of treatment paradigms as applied to the HPV-positive OPSCC patient, as well as a new appreciation for the problem of chronic toxicity. We note that it is provocative (and frightening) to “mess with success.” For this reason, the proposition of dose deescalation (of chemotherapy and/or RT) or substitution with