Role of multimodal treatment in oropharynx, larynx, and hypopharynx cancer

Due to recent advances in radiation fractionation, radiochemotherapy, and c onservative surgical techniques, the concept of multimodal therapy in head and neck cancer is currently changing. The recently published RTOG Phase II I trial 9003, with 1,113 patients accrued, showed that hyperfractionation a nd accelerated fractionation with concomitant boost are more efficacious th an standard fractionation for locally-advanced head and neck cancer: Acute, but not late, toxicity was also increased. Three meta-analyses have sugges ted that the impact of chemotherapy in head and neck cancer is small but is highly associated with the timing of therapy. Concomitant administration o f radiation therapy and chemotherapy led to an absolute benefit in 5-year s urvival of about 10%. This finding has been further supported by recently p ublished randomized prospective trials comparing concomitant radiochemother apy with radiotherapy alone in advanced head and neck cancer. There is now clear evidence that radiochemotherapy provides a substantial and statistica lly significant improvement in survival and local-regional control, as comp ared to radiotherapy alone. Radiochemotherapy should be considered an accep ted standard of care in cancers of the oropharynx, particularly for patient s with locally-advanced disease who have a good performance status. Two ran domized studies conducted by the Department of Veterans' Affairs and the EO RTC, with a total of 534 patients accrued, showed that induction chemothera py followed by radiotherapy of responders yields survival rates equal to th ose of total laryngectomy with postoperative radiotherapy. After 4 years. o ne-half to two-thirds of survivors of the chemotherapy arm retained a funct ional larynx. Larynx preservation using induction chemotherapy can now be r egarded as feasible but still investigational. Current phase II studies sho w excellent larynx preservation rates using a primary concomitant radiochem otherapy with an altered fractionation regimen. More clinical and laborator y research is required to further evaluate the different treatment options of the multimodality concept, and to develop prognostic models that will al low individualization of the therapy. (C) 2001 Wiley-Liss, Inc.