Lee Anna, Chow James C H, Lee Nancy Y
Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
now with Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston.
JAMA Oncol. 2020 Dec 23. doi: 10.1001/jamaoncol.2020.6154.
Since the advent of modern radiotherapy techniques and incorporation of systemic chemotherapy for nasopharyngeal cancer, locoregional control has been excellent. However, the rate of treatment-related complications, many of which are irreversible, remains high. New approaches are being explored to determine whether the toxic effects of treatment can be relieved while maintaining disease control. This review presents the current state of deescalation strategies for nasopharyngeal cancer.
A review of the literature shows that deescalation approaches can be generally categorized into deescalating systemic therapy vs deescalating radiotherapy. This review discusses studies that have explored sparing chemotherapy in selected patients with stage II cancer as well as altering the chemotherapy scheduling, dosing, and agent from the current standard of care, cisplatin. Deescalating radiotherapy has involved decreasing the dose and the treatment volume. In many cases, these approaches are being guided by measuring Epstein-Barr virus DNA levels, which is a robust biomarker for screening, treatment monitoring, and surveillance. Ongoing work with various imaging modalities, such as fluorodeoxyglucose positron emission tomography and dynamic contrast-enhanced or diffusion-weighted magnetic resonance imaging sequences, have shown promise as another biomarker to safely guide practitioners toward deescalation.
Various strategies to deescalate treatment in nasopharyngeal cancer have been explored, and outcomes have remained excellent in most approaches. Patient selection remains key, and long-term outcomes and late complications are still to be determined. Continued investigation with prospective, multi-institutional studies are needed to better elucidate how treatment for nasopharyngeal carcinoma can best be individualized and deescalated.
自从现代放疗技术出现以及鼻咽癌全身化疗被纳入治疗方案以来，局部区域控制效果一直很好。然而，与治疗相关的并发症发生率仍然很高，其中许多是不可逆的。正在探索新的方法，以确定在维持疾病控制的同时是否可以减轻治疗的毒性作用。本综述介绍了鼻咽癌降阶梯治疗策略的现状。
文献综述表明，降阶梯方法通常可分为全身治疗降阶梯和放疗降阶梯。本综述讨论了探索在部分II期癌症患者中减少化疗以及改变化疗方案（从目前的标准治疗药物顺铂改变化疗的给药时间、剂量和药物）的研究。放疗降阶梯包括降低剂量和缩小治疗体积。在许多情况下，这些方法以检测爱泼斯坦-巴尔病毒DNA水平为指导，该病毒DNA水平是用于筛查、治疗监测和随访的可靠生物标志物。使用各种成像方式（如氟脱氧葡萄糖正电子发射断层扫描以及动态对比增强或扩散加权磁共振成像序列）的正在进行的研究，已显示有望作为另一种生物标志物，安全地指导医生进行降阶梯治疗。
已经探索了多种鼻咽癌治疗降阶梯策略，大多数方法的治疗效果仍然很好。患者选择仍然是关键，长期疗效和晚期并发症仍有待确定。需要通过前瞻性、多机构研究继续进行调查，以更好地阐明如何最好地实现鼻咽癌治疗的个体化和降阶梯。
