[The radiochemotherapy of advanced head-neck tumors--what is certain?].

BACKGROUND

Loco-regional control and survival after radical conventionally fractionated radiotherapy remains poor in advanced squamous cell head and neck cancer. Therefore during the last 2 decades new modalities were investigated including unconventional fractionation and radiochemotherapy.

PATIENTS AND METHODS

The literature is reviewed and results of a novel protocol of the German Cancer Society ARO 89-1 applying chemotherapy and radiotherapy synchronously are analysed in order to define the current role of chemotherapy in the treatment of newly diagnosed loco-regionally advanced head and neck cancer.

RESULTS

Despite high response rates achieved by induction chemotherapy ultimate survival has not changed in the vast majority of studies reported. Provided the loco-regional disease is controlled 3 courses of active combination chemotherapy reduce the incidence of distant metastases from 25% to 15%. In a prospective randomized multicenter study with 270 evaluable patients conducted from 1989 to 1993 3 courses of split course accelerated radiotherapy were compared with 3 courses radio-chemotherapy. After combined modality loco-regional control increased from 17% to 34% (p < 0.014) and overall survival from 24% to 48% (p < 0.0003). Also fast alternating protocols yield improved loco-regional control rates but not improved survival. When 5-FU is given simultaneously to irradiation continuous infusion rendered superior to bolus injection. Except bleomycin cytotoxic drugs do not increase incidence or severity of chronic radiation sequelae. The total treatment duration considered crucial in radiotherapy alone seems less important in combined modality protocols.

CONCLUSION

Sequential radio-chemotherapy protocols should be omitted in favour of simultaneous or fast alternating protocols. Since the latter are more toxic compared to sequential radio-chemotherapy or radiotherapy alone supportive care is mandatory. Future trials should determine new prognostic factors in order to individualize therapy.