Induction chemotherapy with cisplatin and fluorouracil alone or in combination with docetaxel in locally advanced squamous-cell cancer of the head and neck: long-term results of the TAX 324 randomised phase 3 trial

Abstract

Background: At a minimum follow-up of 2 years, the TAX 324 study showed a significant survival benefit of induction chemotherapy with docetaxel, cisplatin, and fluorouracil (TPF) versus cisplatin and fluorouracil (PF) in locally advanced head and neck cancer. We report the long-term results at 5 years' minimum follow-up.

Methods: TAX 324 was a randomised, open-label phase 3 trial comparing three cycles of TPF induction chemotherapy (docetaxel 75 mg/m(2), followed by intravenous cisplatin 100 mg/m(2) and fluorouracil 1000 mg/m(2) per day, administered as a continuous 24-h infusion for 4 days) with three cycles of PF (intravenous cisplatin 100 mg/m(2), followed by fluorouracil 1000 mg/m(2) per day as a continuous 24-h infusion for 5 days) in patients with stage III or IV squamous-cell carcinoma of the head or neck. Both regimens were followed by 7 weeks of chemoradiotherapy with concomitant weekly carboplatin. Randomisation was done centrally with the use of a biased-coin minimisation technique. At study entry, patients were stratified according to the site of the primary tumour, nodal status (N0 or N1 vs N2 or N3), and institution. For this long-term analysis, data as of Dec 1, 2008, were gathered retrospectively from patients' medical records. Overall and progression-free survival were the primary endpoints. Tracheostomy and dependence on a gastric feeding tube were used as surrogate measures for treatment-related long-term toxicity. The intention-to-treat analysis included data from all 501 patients (255 TPF, 246 PF); data from the initial analysis in 2005 were used for 61 patients who were lost to follow-up. TAX 324 was registered at ClinicalTrials.gov, NCT00273546.

Findings: Median follow-up was 72·2 months (95% CI 68·8-75·5). Overall survival was significantly better after treatment with TPF versus PF (hazard ratio [HR] 0·74, 95% CI 0·58-0·94), with an estimated 5-year survival of 52% in patients treated with TPF and 42% in those receiving PF. Median survival was 70·6 months (95% CI 49·0-89·0) in the TPF group versus 34·8 months (22·6-48·0) in the PF group (p=0·014). Progression-free survival was also significantly better in patients treated with TPF (median 38·1 months, 95% CI 19·3-66·1, vs 13·2 months, 10·6-20·7; HR 0·75, 95% CI 0·60-0·94). We detected no significant difference in dependence on gastric feeding tubes and tracheostomies between treatment groups. In the TPF group, three (3%) of 91 patients remained feeding-tube dependent, compared with eight (11%) of 71 patients in the PF group. Six (7%) of 92 patients had tracheostomies in the TPF group, versus eight (11%) of 71 in the PF group.

Interpretation: Induction chemotherapy with TPF provides long-term survival benefit compared with PF in locally advanced head and neck cancer. Patients who are candidates for induction chemotherapy should be treated with TPF.

Funding: Sanofi-Aventis.

Figure 1

A) OS and B) PFS functions estimated by the Kaplan-Meier method for 501 patients treated on TPF and PF arms.

Figure 1

A) OS and B) PFS functions estimated by the Kaplan-Meier method for 501 patients treated on TPF and PF arms.

Figure 2

A: PFS functions estimated by the Kaplan-Meier method for 166 patients with hypopharyngeal and laryngeal primary tumor sites The median PFS for subjects treated on TPF and PF arms are 20.9 mo, (95%CI 12.4–58.7) months and 10.1 mo, (the 95%CI 7.7–13.6) months, respectively; p=0.037, the log-rank test . The HR is 0.68 (the 95%CI 0.47–0.98), corresponding to a 32% reduction in risk for disease progression or death for patients who received TPF. B: OS for patients with oropharyngeal cancer. OS functions estimated by the Kaplan-Meier method for 264 patients with oropharyngeal cancer. OS was significantly superior in patients with oropharyngeal primary tumors who received induction chemotherapy with TPF (p=0.045, the log rank test).

Figure 2

A: PFS functions estimated by the Kaplan-Meier method for 166 patients with hypopharyngeal and laryngeal primary tumor sites The median PFS for subjects treated on TPF and PF arms are 20.9 mo, (95%CI 12.4–58.7) months and 10.1 mo, (the 95%CI 7.7–13.6) months, respectively; p=0.037, the log-rank test . The HR is 0.68 (the 95%CI 0.47–0.98), corresponding to a 32% reduction in risk for disease progression or death for patients who received TPF. B: OS for patients with oropharyngeal cancer. OS functions estimated by the Kaplan-Meier method for 264 patients with oropharyngeal cancer. OS was significantly superior in patients with oropharyngeal primary tumors who received induction chemotherapy with TPF (p=0.045, the log rank test).