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Phase III Trial of Radiotherapy Plus Cetuximab versus Chemoradiotherapy in HPV-Associated Oropharynx Cancer

Description

OBJECTIVES: Primary - To determine whether substitution of cisplatin with cetuximab will result in comparable 5-year overall survival. Secondary - To monitor and compare progression-free survival for "safety". - To compare patterns of failure (locoregional vs distant). - To compare acute toxicity profiles (and overall toxicity burden). - To compare overall quality of life (QOL) short-term (< 6 months) and long-term (2 years). - To compare QOL Swallowing Domains short-term and long-term. - To compare clinician-reported versus patient-reported CTCAE toxicity events. - To explore differences in the cost effectiveness of cetuximab as compared to cisplatin. - To explore differences in work status and time to return to work. - To compare patient-reported changes in hearing. - To compare CTCAE v. 4 late toxicity at 1, 2, and 5 years. - To evaluate the effect of tobacco exposure (and other exposures) as measured by standardized computer-assisted self interview (CASI) on overall survival and progression-free survival. - To pilot CASI collection of patient reported outcomes in a cooperative group setting. - To determine whether specific molecular profiles are associated with overall or progression-free survival. - To investigate associations between changes in serum biomarkers or HPV-specific cellular immune responses measured at baseline and three months with overall or progression-free survival. OUTLINE: This is a multicenter study. Patients are stratified according to T stage (T1-2 vs T 3-4), N stage (N0-2a vs N2b-3), Zubrod performance status (0 vs 1), and smoking history (≤ 10 pack-years vs > 10 pack-years). Patients are randomized to 1 of 2 treatment arms. - Arm I: Patients undergo image-guided intensity-modulated radiation therapy (IMRT) once daily on days 1-4 and twice daily on day 5 weekly for 6 weeks. Patients also receive high-dose cisplatin IV over 1-2 hours on days 1 and 22. - Arm II: Beginning 1 week prior to IMRT, patients receive cetuximab IV over 2 hours. Patients then receive cetuximab IV over 1 hour once weekly for 7 weeks. Patients undergo IMRT as in arm I. Tumor tissue and blood samples are collected at baseline and may also be collected at 3- and 6-month follow-up visits for correlative studies. Patients may complete quality-of-life questionnaires and risk factors for head and neck cancer surveys at baseline, periodically during study, and at follow-up for 1 year. After completion of study therapy, patients are followed up at 1-3 months, every 3 months for 2 years, every 6 months for 3 years, and then annually thereafter.

Phase

Phase 3 - a treatment has shown activity against a particular disease, where it is either added to existing treatment or compared to the standard treatment.

Inclusion and Exclusion Criteria

  • Pathologically (histologically or cytologically) proven diagnosis of squamous cell carcinoma (including the histological variants papillary squamous cell carcinoma and basaloid squamous cell carcinoma) of the oropharynx (tonsil, base of tongue, soft palate, or oropharyngeal walls)
  • No cancer from an oral cavity site (oral tongue, floor mouth, alveolar ridge, buccal, or lip), nasopharynx, hypopharynx, or larynx, even if p16 positive
  • No carcinoma of the neck of unknown primary site origin (even if p16 positive)
  • Cytologic diagnosis from a cervical lymph node is sufficient in the presence of clinical evidence of a primary tumor in the oropharynx
  • Clinical evidence should be documented; may consist of palpation, imaging, or endoscopic evaluation; and should be sufficient to estimate the size of the primary (for T stage)
  • No distant metastasis or adenopathy below the clavicles
  • Patients must be positive for p16, determined by the OSU Innovation Center CLIA lab prior to step 2 registration (randomization)
  • Paraffin-embedded cytology specimens are acceptable for p16 evaluation, but cytology smears are not
  • Patients must have clinically or radiographically evident measurable disease at the primary site or at nodal stations
  • Tonsillectomy or local excision of the primary without removal of nodal disease is permitted, as is excision removing gross nodal disease but with intact primary site
  • Limited neck dissections retrieving ≤ 4 nodes are permitted and considered as non-therapeutic nodal excisions
  • Fine-needle aspirations of the neck are insufficient due to limited tissue for retrospective central review
  • Biopsy specimens from the primary or nodes measuring at least 3-5 mm are required
  • Clinical stage T1-2 N2a-N3 or T3-4 any N, including no distant metastases
  • No clinical stage T1-2 N0-1
  • No simultaneous primaries or bilateral tumors PATIENT CHARACTERISTICS:
  • Zubrod performance status 0-1
  • ANC ≥ 1,500/mm³
  • Platelet count ≥ 100,000/mm³
  • Hemoglobin (Hgb) ≥ 8.0 g/dL (transfusion or other intervention to achieve Hgb ≥ 8.0 g/dL is acceptable)
  • Bilirubin ≤ 2 mg/dL
  • AST or ALT ≤ 3 times upper limit of normal
  • Serum creatinine ≤ 1.5 mg/dL OR creatinine clearance ≥ 50 mL/min
  • Negative pregnancy test
  • Women of childbearing potential and male participants must agree to use a medically effective means of birth control throughout their participation in the treatment phase of the study, and until at least 60 days following the last study treatment
  • Patients who are HIV-positive and have no prior AIDS-defining illness and have CD4 cells of at least 340/mm³ are eligible
  • HIV status must be known prior to registration
  • No multidrug resistance for HIV infection
  • Not seropositive for hepatitis B (hepatitis B surface antigen positive or anti-hepatitis B core antigen positive) or hepatitis C (anti-hepatitis C antibody positive)
  • Immunity to hepatitis B (anti-hepatitis B surface antibody positive) allowed
  • No prior invasive malignancy except non-melanoma skin cancer, or malignancy for which the patient has been disease-free for at least 3 years (e.g., carcinoma in situ of the breast, oral cavity, or cervix)
  • No severe, active co-morbidity, defined as any of the following:
  • Unstable angina and/or congestive heart failure requiring hospitalization within the last 6 months
  • Acute bacterial or fungal infection requiring intravenous antibiotics at the time of registration
  • Transmural myocardial infarction within the last 6 months
  • Chronic obstructive pulmonary disease exacerbation or other respiratory illness requiring hospitalization or precluding study therapy within 30 days of registration
  • Hepatic insufficiency resulting in clinical jaundice and/or coagulation defects
  • Laboratory tests for liver function and coagulation parameters are not required for entry into this protocol
  • Immunocompromised patients
  • No prior allergic reaction to cisplatin or cetuximab PRIOR CONCURRENT THERAPY:
  • See Disease Characteristics
  • No prior systemic chemotherapy for the study cancer
  • Prior chemotherapy for a different cancer allowed
  • No prior radiotherapy to the region of the study cancer that would result in overlap of radiation therapy fields
  • No prior cetuximab or other anti-EGFR therapy
  • No concurrent amifostine as a radioprotector
  • No concurrent granulocyte colony-stimulating factor or erythropoietin

Sites

  • California

    • Roy and Patricia Disney Family Cancer Center at Providence Saint Joseph Medical Center, Burbank, California, 91505
    • Unknown facility, Santa Clara, California, 95051
    • Kaiser Permanente - Division of Research - Oakland, Oakland, California, 94611
    • UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, 94115
    • Radiation Oncology Centers - Cameron Park, Cameron Park, California, 95682
    • Mercy General Hospital, Sacramento, California, 95819
    • Mercy Cancer Center at Mercy San Juan Medical Center, Carmichael, California, 95608
    • Solano Radiation Oncology Center, Vacaville, California, 95687
    • Radiological Associates of Sacramento Medical Group, Incorporated, Sacramento, California, 95815
    • Radiation Oncology Center - Roseville, Roseville, California, 95661
    • Auburn Radiation Oncology, Auburn, California, 95603
    • Enloe Cancer Center at Enloe Medical Center, Chico, California, 95926
  • Nevada

    • Renown Institute for Cancer at Renown Regional Medical Center, Reno, Nevada, 89502
  • Utah

    • Utah Cancer Specialists at UCS Cancer Center, Salt Lake City, Utah, 84106
  • Oregon

    • Dubs Cancer Center at Rogue Valley Medical Center, Medford, Oregon, 97504
    • Providence Cancer Center at PMCC, Medford, Oregon, 97504
    • Clackamas Radiation Oncology Center, Clackamas, Oregon, 97015
    • Providence St. Vincent Medical Center, Portland, Oregon, 97225
  • Colorado

    • Penrose Cancer Center at Penrose Hospital, Colorado Springs, Colorado, 80933
    • Swedish Medical Center, Englewood, Colorado, 80110
    • Porter Adventist Hospital, Denver, Colorado, 80210
    • North Suburban Medical Center, Thornton, Colorado, 80229
    • Rocky Mountain Cancer Centers - Aurora, Aurora, Colorado, 80012
    • McKee Medical Center, Loveland, Colorado, 80539
  • Washington

    • Northwest Cancer Specialists at Vancouver Cancer Center, Vancouver, Washington, 98684
    • North Star Lodge Cancer Center at Yakima Valley Memorial Hospital, Yakima, Washington, 98902
    • CCOP - Virginia Mason Research Center, Seattle, Washington, 98101
  • Oklahoma

    • Oklahoma University Cancer Institute, Oklahoma City, Oklahoma, 73104
    • Natalie Warren Bryant Cancer Center at St. Francis Hospital, Tulsa, Oklahoma, 74136
  • Nebraska

    • Nebraska Medical Center, Omaha, Nebraska, 68198
    • Methodist Estabrook Cancer Center, Omaha, Nebraska, 68114
  • Iowa

    • Siouxland Hematology-Oncology Associates, LLP, Sioux City, Iowa, 51101
    • John Stoddard Cancer Center at Iowa Methodist Medical Center, Des Moines, Iowa, 50309
    • McFarland Clinic, PC, Ames, Iowa, 50010
  • Kansas

    • CCOP - Kansas City, Prairie Village, Kansas, 66208
  • Minnesota

    • Fairview Southdale Hospital, Edina, Minnesota, 55435
    • Park Nicollet Cancer Center, Saint Louis Park, Minnesota, 55416
    • Mercy and Unity Cancer Center at Mercy Hospital, Coon Rapids, Minnesota, 55433
    • Mercy and Unity Cancer Center at Unity Hospital, Fridley, Minnesota, 55432
    • Regions Hospital Cancer Care Center, St. Paul, Minnesota, 55101
  • Missouri

    • Siteman Cancer Center at Barnes-Jewish Hospital - Saint Louis, Saint Louis, Missouri, 63110
    • Cancer Institute of Cape Girardeau, LLC, Cape Girardeau, Missouri, 63703
  • Wisconsin

    • Gundersen Lutheran Center for Cancer and Blood, La Crosse, Wisconsin, 54601
    • University of Wisconcin Cancer Center at Aspirus Wausau Hospital, Wausau, Wisconsin, 54401
    • Medical College of Wisconsin Cancer Center, Milwaukee, Wisconsin, 53226
    • Theda Care Cancer Institute, Appleton, Wisconsin, 54911
    • St. Mary's Hospital Medical Center - Green Bay, Green Bay, Wisconsin, 54303
    • Veterans Affairs Medical Center - Milwaukee, Milwaukee, Wisconsin, 53295
    • Bay Area Cancer Care Center at Bay Area Medical Center, Marinette, Wisconsin, 54143
  • Louisiana

    • Mary Bird Perkins Cancer Center - Baton Rouge, Baton Rouge, Louisiana, 70809
    • CCOP - Ochsner, New Orleans, Louisiana, 70121
  • Illinois

    • Cancer Institute at St. John's Hospital, Springfield, Illinois, 62702
    • Northwest Community Hospital, Arlington Heights, Illinois, 60005
    • Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, Illinois, 60657
  • Mississippi

    • Regional Cancer Center at Singing River Hospital, Pascagoula, Mississippi, 39581
  • Indiana

    • Memorial Hospital of South Bend, South Bend, Indiana, 46601
    • Community Regional Cancer Care at Community Hospital East, Indianapolis, Indiana, 46219
    • Community Regional Cancer Care at Community Hospital North, Indianapolis, Indiana, 46256
    • Elkhart General Hospital, Elkhart, Indiana, 46515
    • Center for Cancer Care at Goshen General Hospital, Goshen, Indiana, 46526
    • Parkview Regional Cancer Center at Parkview Health, Fort Wayne, Indiana, 46805
  • Florida

    • Sacred Heart Cancer Center at Sacred Heart Hospital, Pensacola, Florida, 32504
  • Kentucky

    • James Graham Brown Cancer Center at University of Louisville, Louisville, Kentucky, 40202
  • Ohio

    • Precision Radiotherapy at University Pointe, West Chester, Ohio, 45069
  • Georgia

    • Georgia Cancer Center for Excellence at Grady Memorial Hospital, Atlanta, Georgia, 30303
    • Winship Cancer Institute of Emory University, Atlanta, Georgia, 30322
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