Adjuvant chemo may be Barred.
Top Line: Patients with detectable Epstein Barr Virus (EBV) DNA after treatment have worse disease control and survival following chemoradiation for nasopharyngeal cancer (NPC). What can we do about it?
The Study: This international phase 3 trial enrolled almost 800 patients with no residual or metastatic disease 6-8 weeks after definitive chemoradiation for NPC, and screened them for EBV DNA. Roughly 75% of these patients were negative and underwent routine surveillance. The other 25% were randomly assigned to observation or 6 cycles of cisplatin and gemcitabine. Now, this is an import juncture. Adjuvant chemotherapy in this setting is controversial, especially among endemic populations. The Intergroup 0099 trial compared radiation alone to chemoradiation plus adjuvant chemo to show a huge improvement in overall survival with the latter. The problem is, it married adjuvant chemo to concurrent chemoradiation. A subsequent Chinese trial and the MAC-NPC meta-analysis, however, argue that the survival benefit is driven by the concurrent chemo, not the adjuvant. So, what does this trial show? As expected, those with persistent EBV DNA had worse disease control and survival. Sadly, there was no benefit in the primary endpoint of relapse-free survival at 5 years with (49%) versus without (55%) adjuvant chemo.
Bottom Line: Persistent EBV DNA is a very important prognostic indicator of worse outcomes with NPC, but adjuvant cisplatin and gemcitabine following definitive chemoradiation didn’t help. | Chan, J Clin Oncol 2018
The Study: This international phase 3 trial enrolled almost 800 patients with no residual or metastatic disease 6-8 weeks after definitive chemoradiation for NPC, and screened them for EBV DNA. Roughly 75% of these patients were negative and underwent routine surveillance. The other 25% were randomly assigned to observation or 6 cycles of cisplatin and gemcitabine. Now, this is an import juncture. Adjuvant chemotherapy in this setting is controversial, especially among endemic populations. The Intergroup 0099 trial compared radiation alone to chemoradiation plus adjuvant chemo to show a huge improvement in overall survival with the latter. The problem is, it married adjuvant chemo to concurrent chemoradiation. A subsequent Chinese trial and the MAC-NPC meta-analysis, however, argue that the survival benefit is driven by the concurrent chemo, not the adjuvant. So, what does this trial show? As expected, those with persistent EBV DNA had worse disease control and survival. Sadly, there was no benefit in the primary endpoint of relapse-free survival at 5 years with (49%) versus without (55%) adjuvant chemo.
Bottom Line: Persistent EBV DNA is a very important prognostic indicator of worse outcomes with NPC, but adjuvant cisplatin and gemcitabine following definitive chemoradiation didn’t help. | Chan, J Clin Oncol 2018
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