Surgery Vs Chemoradiation for Oropharyngeal Cancer- A Phase II/III Integrated Design Randomized Control Trial (SCOPE)

Surgery Vs Chemoradiation for Oropharyngeal Cancer- A Phase II/III Integrated Design Randomized Control Trial

Primary Surgery Vs Primary Chemoradiation for Oropharyngeal Cancer (Scope Trial) - A Phase II/III Integrated Design Randomized Control Trial

All India Institute of Medical Sciences, New Delhi, Amrita Institute of Medical Sciences & Research Center

The oropharyngeal areas mainly comprises of the tonsil, base tongue (BOT), soft palate and the posterior pharyngeal wall. Traditionally, surgical resection of oropharyngeal cancers (OPC) was a standard procedure, often performed through mutilating incisions with mandibulotomies, rendering significant post-operative functional deficits. Over the past 2 decades, there has been a major shift in treatment strategy with a majority of these cancers now being treated by primary concurrent chemoradiation (CCRT) with a trend towards organ and function preservation.

The oropharyngeal region primarily comprises the tonsil, base tongue (BOT), soft palate and posterior pharyngeal wall. Traditionally, surgical resection of oropharyngeal cancers (OPC) was a standard procedure, often performed through mutilating incisions with mandibulotomies, rendering significant post-operative functional deficits. Over the past 2 decades, there has been a major shift in treatment strategy with a majority of these cancers now being treated by primary concurrent chemoradiation (CCRT) with a trend towards organ and function preservation. The landmark trial determining effective treatment options for OPCs was by the RTOG group (0129) that provided strong evidence for HPV status being an independent prognostic factor for overall survival (OS) and progression-free survival (PFS), with these patients having significantly improved outcomes. Furthermore, after adjusting for demographics, T stage, N stage and smoking status, the HPV positive population had a 58% reduction in the risk of death and a 51% reduction in risk of progression or death. Most of the discussion today in HPV positive OPC is based on treatment- intensification to improve quality of life (QOL) measures. A more concerning issue is the poor outcome, both survival, and QOL, seen in the "high-risk" HPV negative OPCs. When treated with radical CCRT, HPV negative patients have substantially reduced survival, both in terms of locoregional control (LRC) and OS. In the RTOG 0129, the HPV negative population had a 25.1% reduction in OS at 3 years (57.1% vs 82.4%) when compared to patients with HPV positive tumors. The locoregional relapse rate at 3 years was 21% higher in these patients (35.1% vs 13.6% for HPV positive tumors). Moreover, the salvage rates in oropharyngeal cancers that have undergone radical CCRT are quite low with only a third of the recurrences being amenable for salvage surgery. This led to a trend of intensification of management for these HPV negative tumors with altered fractionation schema,CCRT, multi-drug induction chemotherapy and targeted molecular therapies. Even with all these efforts, simply altering the method of radiation delivery, dosing and/or adding different types of concurrent chemotherapy is not seeming to be sufficient to improve oncologic outcomes in HPV negative tumors. In the contemporary literature, an approach to further intensify treatment would be the addition of upfront surgery on this high-risk HPV negative OPCs. The recent advances in head neck surgery incorporate minimally invasive techniques and some focus around a transoral approach. These include transoral laser microsurgery (TLM) and transoral robotic surgery (TORS). Compared to the open approaches, these have minimal or no external incisions and do not require morbid access procedures. TLM is a surgical technique used in combination with an endoscope or direct laryngoscopy, operating microscope and a carbon dioxide (CO2) laser. TORS is performed using a robotic system, the arms of which are placed within the patient's mouth but controlled by a surgeon sitting at a remote console. The surgeon is provided with an endoscopically derived 3-dimensional view used to perform an enblocresection of the oropharyngeal tumor. Open surgery today incorporates modified techniques in osteotomy design, fixation and reconstruction methods to reduce and/or eliminate the traditional complications and have the additional advantage of direct visualization of the tumor. To add to this, radiotherapy techniques have also improved with more concentrated dosing obtained with intensity-modulated radiotherapy (IMRT) resulting in fewer complications. Irrespective of the management received, patients with oropharyngeal tumors have a significant impact on the swallowing function and quality of life (QOL). Multiple factors are thought to contribute to the severity of this dysphagia, including multimodality therapy (surgery, RT, chemotherapy), total radiation dose, dosimetry to organs at risk (OAR) and intrinsic patient radiosensitivity and susceptibility to fibrosis. Majority of the current data on QOL are from single institution studies. Sinclair et al found that patients undergoing TORS for early OPCs have an initial decrease in mean dysphagia scores using the MD Anderson Dysphagia Inventory-Head and Neck (MDADI-HN) in the immediate postoperative period when compared to baseline pre-operative scores, although a gradual increasing improvement was observed over time. The global and physical subscales were most affected in the immediate postoperative period with the recovery of scores observed at last follow up. Postoperative chemotherapy predicted gastrostomy tube dependence for greater than 3 months. Hurtuk et al have shown a decrease from baseline immediately after surgery in speech, eating, aesthetic, social, and overall QOL domains, using the Head and Neck Cancer Inventory (HNCI). However, at 1 year, the health-related QOL in the aesthetic, social, and overall domains were high. Eating function and attitude were the only variables not returning to the high domain. In another population-based analysis of head neck cancers, oropharyngeal cancers had the second-highest prevalence of dysphagia, with 31% of patients demonstrating elevated episodes of aspiration relative to baseline greater than 1 year after receiving treatment. Weinstein et al reported long-term dependence on tracheostomy and gastrostomy was seen in 2.4% and 5%, respectively.(21) Even in the RTOG study,43% of the patients had severe long-term Grade 3 or 4 toxicity requiring a feeding tube/gastrostomy for more than 2 years or longer and death without cancer progression. Nichols et al recently attempted to answer some of these questions (ORATOR trial) in a randomized trial for early OPCs treated with CCRT versus TORS. They found the MDADI scores at 1-year were statistically superior in the RT arm (p = 0.042), but not meeting the definition of a clinically meaningful change (powered to detect a 10-point improvement). For the other QOL metrics, outcomes were similar at 1-year. Feeding tube rates were 3% in the RT arm vs 0% in the TORS arm. Even the rates of treatment-related grade ≥2 adverse events (AEs) were similar, with more neutropenia, constipation, and tinnitus in the RT arm and more trismus in the TORS arm. The findings of aspiration on modified barium swallow (MBS) have been significantly predictive of pneumonia in many trials of chemotherapy and IMRT in oropharyngeal cancer (p=0.017, Sensitivity 80%, Specificity 60%), and silent aspiration was evident on MBS studies in 63% of patients who developed pneumonia. In addition, pharyngeal residue in MBS studies was significantly associated with the development of pneumonia after chemotherapy and IMRT (p<0.01). These results offer compelling support for the examination of objective swallowing impairment (ie, "airway protection" and "pharyngeal transit") as these health-related endpoints cannot be obtained by patient-reported outcome (PROs) measures alone. Even the long-term results of RTOG 9111 study showed unknown mortality in 30% of the patients who received chemo-radiation, possibly due to silent aspiration. Hence, a lot of unanswered questions remain in determining the optimum management of OPCS that have minimal complications and maximum survival advantage.

Stage III Oropharyngeal (p16-Negative) Carcinoma AJCC v8, Stage IV Oropharyngeal (p16-Negative) Carcinoma AJCC v8

There will be two groups/arms in the study to evaluate the efficacy of primary surgery versus primary chemoradiation. Participants will be assigned to one of two or more groups for the duration of the study

Patients would undergo appropriate surgery via open, endoscopic, TLM, TORS or a combination. The primary and the neck would be addressed. For N0 neck, clearance of levels II-IV will be required, with levels I and/or V electively dissected at the discretion of the operating surgeon and based on extension of nodal disease. For N+ neck and tumors approaching to within 1cm of the midline, we recommend a contralateral neck dissection be performed as well of levels II-IV but to be done as per operating team's discretion. For lateralized lesions of the BOT and tonsil, ipsilateral neck dissection will be performed. A minimum of 18 lymph nodes per dissected side of the neck is required and will be subject to quality assurance review

Patients will receive IMRT with normal tissue sparing techniques (70Gy/35# or 66Gy/ 30#) along with concurrent weekly cisplatin. Weekly cisplatin will be administered during IMRT at a dose of 40 mg/m2 IV on days 1, 8, 15, 22, 29, 36, and 43 for a total of up to 7 weekly doses, administered during the course of IMRT. For patients with T1-2 lateralized tonsil tumors with <1 cm invasion into the soft palate, no invasion of BOT, and N1 neck involvement, unilateral neck will be irradiated. The contralateral neck will be addressed for some BOT tumors<1cm or at the midline and may be considered in patients with N2 and N3status. For patients with residual neck disease after CCRT, a formal neck dissection will be performed. For patients with residual primary disease after CCRT, surgery for the primary will be performed if feasible.

An appropriate surgery as open, endoscopic, TLM, TORS or a combination with or without neck dissection e.g. levels dissected, sparing or sacrifice of the SCM, accessory nerve, etc as per patient disease and status will be performed

Patients will receive IMRT with normal tissue sparing techniques (70Gy/35# or 66Gy/ 30#) along with concurrent weekly cisplatin. Weekly cisplatin will be administered during IMRT at a dose of 40 mg/m2 IV on days 1, 8, 15, 22, 29, 36, and 43 for a total of upto 7 weekly doses, administered during the course of IMRT.

Cisplatin (dose-40 mg/m2weekly,upto6-7cycles) cycle 1 will be administered within first 2 # of radiation. The rest of the cycles will be given weekly.

Event Free Survival will be defined as the time between the date of randomization till the date of recurrence of the disease (either local, regional or distant failure) or death due to disease.

Overall Survival (OS) will be defined as the time between the date of randomization and the date of death due any cause

Disease free survival (DFS) will be defined as the time between the date of randomization till the date of recurrence or second primary disease (either locoregional or distant).

Progression of disease would be defined as an increase in any dimension of the disease or recurrence of disease

Locoregional control (LRC) will be defined as the time between the date of randomization and the date of local or regional failure

evaluate the swallowing function using MBS with/without video assisted measure (Functional Endoscopic Evaluation of Swallo (FEES) or videofluroscopy)

M.D. Anderson Dysphagia Inventory Head and neck cancer-specific quality of life and patietn reproted outcomes (QOL and PROs)

M.D. Anderson Dysphagia Inventory in the short-term after completion of 1year and long-term after completion of 3years post enrollment

EORTC HN35 Head and neck cancer-specific quality of life and patietn reproted outcomes (QOL and PROs)

EORTC HN35 in the short-term after completion of 1year and long-term after completion of 3years post enrollment

Inclusion Criteria: Histopathology proven diagnosis of squamous cell carcinoma of the oropharynx, localized to the tonsil and/or lateralized tongue-base ECOG Performance Status ≤2 Age ≥18 to 70 years Anesthetic fitness obtained for surgery under general anesthesia Resectable primary tumor with an anticipation of achieving resection free margins either by minimally invasive/open techniques Clinical stage III or IV, i.e. T1-T2 or T3-T4 with N0-N3. Nodal disease withextranodal extension on clinical examination/imaging may be included at the surgeon's discretion, if the nodal disease is deemed resectable by the operating surgeon HPV negative status determined by p16 status. No distant metastases below the clavicles, based upon the following minimum diagnostic workup: History/physical examination by the physician. Imaging of the head and neck (Contrast enhanced MRI for local workup and Chest CT/PET-CT for distant metastatic workup) Patients with no contraindications to Cisplatin chemotherapy and radiotherapy Adequate organ function Hematological- Hb> 10 g/L, ANC ≥ 1.5 x 109/L, platelets ≥ 100 x 109/L. Liver functions- bilirubin ≤ 2 x upper limit normal (ULN), AST/ALT/ ALP ≤ 2.5 x ULN, S. albumin ≥ 30 g/L. Renal function- Creatinine ≤ 1.5 ULN, Creatinine clearance > 50 mL/min. Women of child bearing age should have a negative pregnancy test at the time of randomization and should be willing to use adequate contraception during the treatment phase of the trial Patients who can be followed up and must be able to provide informed consent prior to study entry Exclusion Criteria: Prior head and neck malignancy Prior invasive malignancy, unless disease free for a minimum of 3 years Prior chemotherapy for a different cancer administered within 3 years prior to registration Patients who have received any neoadjuvant/ induction chemotherapy Prior radiotherapy to the region of the head and neck that would result in overlap of radiation therapy fields Unresectable primary or nodal disease involving the carotid vessels, prevertebral fascia or skull base Large soft palate involvement >1 cm Deep extension into larynx, pre-epiglottic space and deep invasion into extrinsic muscles of tongue Calculated GFR < 50 cc/min Patients who have uncontrolled cardiac comorbidity QTc prolongation (a value of >450 milliseconds) Ejection fraction below 50% Presence of regional wall akinesia Presence of previous episode of thrombosis or embolism or presence of a prothrombotic condition in last 1 year Presence of severe malnutrition as defined by body mass index of below 16kg per m2 or presence of weight loss of greater than 20% in last 6 months Severe active co-morbidities such as severe cardiac failure, severe pulmonary compromise, type 1or 2 diabetes mellitus (Hb1ac of > 8 mg/dl) severe and active infections or life expectancy less than 6 months Prior allergic reaction to cisplatin Radiographic evidence of retropharyngeal and/or level VI metastasis Patients on other investigational drugs within last 30 days

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