This study is timely for many reasons and raises very important questions in the management of the current rise in HPV-positive patients with oropharyngeal cancer (OPC). The uniqueness of this group within head and neck cancer in terms of favourable response to treatment, with lower rates of locoregional failure, and younger presentation, has led to a need to consider de-escalation of treatment. The rate of treatment failure due to distant metastases however remains unchanged despite this shift in treatment outcomes compared with HPV-negative head and neck cancer, and is the focus of this study. The authors looked at 310 patients with HPV-related OPC stage 3 to 4b, over a 11-year period from a single institution, who were treated with either cisplatin-based chemoradiotherapy or cetuximab-based bioradiotherapy.
Their results revealed that the groups who developed distant metastases were those with T4 disease, active smokers and those receiving cetuximab rather than cisplatin. These groups had distant metastases rates of over 20% and each were found to be independent risk factors of treatment failure.
The main take home message from this study, despite its limitations in size and bias, is that the potential reduced impact of de-escalated treatment on distant metastases in this disease cohort should be carefully considered in patients with T4 disease and in smokers. The role of cetuximab is also raised as an area of concern although they acknowledge a head to head randomised trial is needed to determine this possible link with distant treatment failure.