Phase II Study of Low-Dose Paclitaxel and Cisplatin in Combination with Split-Course Concomitant Twice-Daily Reirradiation in Recurrent Squamous Cell Carcinoma of the Head and Neck (SCCHN): Long-term follow-up of NRG Oncology Radiation Therapy Oncology Group (RTOG) Protocol 9911

Locoregionally recurrent squamous cell carcinoma of the head and neck (SCCHN) and second primary tumors (SPTs) in previously irradiated fields, if not resectable, are virtually always fatal. Chemotherapy alone yields a median survival of 10-11 months and 5-year overall survival (OS) rates of <5%. Concurrent re-irradiation and chemotherapy constitutes an alternative, non-standard strategy. Herein, we report the long-term outcomes of NRG Oncology RTOG 9911, a phase II trial of split course radiation (RT) and concurrent paclitaxel and cisplatin. Eligibility stipulated measurable, recurrent SCCHN or SPT in previously irradiated fields, PS 0-1, and adequate end-organ indices. Patients received split course, twice-daily RT (1.5 Gy/fraction BID x 5d every 2 weeks x4), plus cisplatin (15 mg/m2 QD x 5) and paclitaxel (20 mg/m2 QD x5) every 2 weeks for four cycles. G-CSF was administered days 6-13 of each 2-week cycle. Primary endpoint was OS relative to historical control, NRG Oncology RTOG 9610. Secondary endpoints included progression-free survival (PFS), toxicities, and patterns of failure. Between March, 2000 and June, 2003, 105 patients were enrolled; 100 patients were analyzable (76% male, median age 60 years). Oropharynx (41%) and oral cavity (27%) were the predominant primary sites. 23% had SPT. Median prior RT dose was 65.7 Gy. 73% of patients completed all chemotherapy. 9 treatment-related deaths (9%) occurred: 5 in the acute and 4 in the late setting. Survival was significantly improved over historical control (p=0.01) with 5-year survival increased from 3.8% (95% confidence interval CI 0.0, 8.0) to 14.9% (95% CI 7.9, 21.9). Five-year PFS was 7.0% (95% CI 2.0, 12.0). 64.9% died from the incident cancer, 3.2% from SPT, and 22.3% from non-cancer or unknown causes. In 1-year survivors, the rate of subsequent late grade 4-5 toxicity was significantly higher than historical control (p=0.02), with 5-year cumulative incidence of 22.4% (95% CI 11.8, 35.1) compared with 3.2% (95% CI 0.2, 14.5). Despite a high incidence of grade 5 toxicity, OS rates for this trial evaluating concurrent split course BID re-irradiation with cisplatin and paclitaxel exceeded results seen historically with chemotherapy alone.