TSA postcheck.

Top Line: Not for lack of clinical trial funding, the utility of adding induction and/or adjuvant chemo to definitive chemoradiation for locally-advanced nasopharyngeal cancer—though currently preferred by the NCCN—remains iffy.

The Study: Instead of creating yet another clinical trial from the ground up, this Chinese group had the audacity to use this meta-analysis to "examine whether and when the current evidence is sufficient.” In other words, when is enough enough? In the end, they had 28(!) prospective randomized trials dating back to 1979 with >8K patients from which to draw a conclusion. As expected, chemo concurrent to radiation consistently improved survival across all subgroups. More interesting, induction chemo also consistently improved survival (HR 0.84), likely due to a significant decrease in distant mets (HR 0.67). Adjuvant chemo, on the other hand, improved neither overall, progression-free, distant met-free, nor local recurrence-free survival. They then used a more scrupulous analytical tool called “trial sequential analysis,” or TSA, a random effects model designed to minimize the chance of a false positive in the setting of a mounting number of events. TSA again confirmed consistent survival benefits with chemo given concurrent and prior to radiation, but not after.

TBL: While NCCN remains neutral, more evidence (in a sense, a LOT more evidence) supports induction, not adjuvant, chemo in addition to definitive chemoradiation for locally-advanced nasopharyngeal cancer. | Zhang, JAMA Netw Open 2019