Why has induction chemotherapy for advanced head and neck cancer become a United States community standard of practice?

Abstract

Induction chemotherapy for advanced head and neck (H&N) cancer has been studied in clinical trials for more than two decades without clear demonstration of benefit for locoregional tumor control or overall patient survival. Nonetheless, its use has become a common community standard of practice in the United States (US). This report examines some of the factors that may have contributed to this phenomenon. A mail survey was conducted of 300 US community cancer specialists (equally divided among otolaryngologists, radiation oncologists, and medical oncologists) to solicit their most frequent therapy approach for patients with locoregionally advanced, nonmetastatic H&N cancer. The rationale for selection of treatment strategy was identified by each respondent. Two hundred eighteen physicians (73%) completed and returned the survey, representing 47 US states. The single most common treatment approach reported for patients with locoregionally advanced H&N cancer was that of sequential chemoradiation (61%), specifically, induction chemotherapy with fluorouracil (5-FU)/cisplatin followed by radiation therapy. Four percent of respondents indicated that induction chemotherapy was administered within the context of a controlled clinical trial, whereas 96% indicated that therapy was administered off study. The primary objectives cited by respondents for the use of induction chemotherapy included the desire to improve locoregional tumor control (67%), to improve overall survival (56%), to maintain a spirit of multidisciplinary care (34%), to improve quality of life (29%), and to decrease distant metastases (26%). Review of the published trials between 1970 and 1995 and of the published meta-analyses show no clear evidence for an improvement in locoregional tumor control or survival for H&N cancer patients treated with 5-FU/cisplatin induction chemotherapy regimens. Nonetheless, this induction chemotherapy approach for advanced H&N cancer patients has become a dominant community practice in the US. Factors that may have contributed to this paradox are reviewed.