Transoral Surgery Followed By Low-Dose or Standard-Dose Radiation Therapy With or Without Chemotherapy in Treating Patients With HPV Positive Stage III-IVA Oropharyngeal Cancer

Phase 2

Active, not recruiting

Conditions: Stage III Squamous Cell Carcinoma of the Oropharynx
Stage IVB Squamous Cell Carcinoma of the Oropharynx
Human Papilloma Virus Infection
Stage IVA Squamous Cell Carcinoma of the Oropharynx

Interventions: Procedure: Transoral surgery
Radiation: intensity-modulated radiation therapy
Drug: cisplatin
Drug: carboplatin

Registration Number: NCT01898494

Lead Sponsor: ECOG-ACRIN Cancer Research Group

Brief Summary: This randomized phase II trial studies how well transoral surgery followed by low-dose or standard-dose radiation therapy works in treating patients with human papilloma virus (HPV) positive stage III-IVA oropharyngeal cancer. Radiation therapy uses high-energy x-rays to kill tumor cells. Drugs used in chemotherapy work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Giving radiation therapy with chemotherapy may kill any tumor cells that remain after surgery. It is not yet known how much extra treatment needs to be given after surgery.

Detailed Description: PRIMARY OBJECTIVES:

I. Accrual, risk distribution, and surgical quality will be used to determine the feasibility of a prospective multi-institutional study of transoral surgery for HPV positive (+) oropharynx cancer followed by risk-adjusted adjuvant therapy.

II. To assess the oncologic efficacy following transoral resection and adjuvant therapy in patients determined to be at "intermediate risk" after surgical excision, the 2-year progression free survival (PFS) rate will be examined.

SECONDARY OBJECTIVES:

I. To estimate the patient distribution with various histologic risk features. II. To assess and compare early and late toxicities associated with transoral surgery (TOS) and the different doses of adjuvant postoperative radiotherapy (PORT).

III. To evaluate swallowing function before and after TOS and risk-adjusted adjuvant therapy.

IV. To evaluate quality of life (QOL), swallowing perception and performance, voice outcomes, and head and neck symptoms.

TERTIARY OBJECTIVES:

I. To correlate tumor TP53 mutation and other associated mutation profile with pathologic findings, with PFS and other outcome parameters in patients with resectable HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) after the above treatments.

II. To evaluate radiation resistance markers, including excision repair cross complementing 1 (ERCC1) single nucleotide polymorphism and protein expression, and correlate them with treatment efficacy.

III. To investigate the usefulness of biomarkers in predicting progression-free survival and biomarkers, including tumor ERCC1, epidermal growth factor receptor (EGFR), plasma cytokine/chemokines, cellular immunity to HPV, and oral HPV deoxyribonucleic acid (DNA).

OUTLINE: All patients undergo transoral surgery (TOS) in Step 1.

ARM S: Patients undergo transoral resection of the oropharyngeal tumor.

Then patients are classified by risk status (low risk, intermediate risk, or high risk) in Step 2 and assigned to the appropriate treatment group. Patients classified as intermediate risk are randomized to arms B or C.

ARM A (low risk; observation): Patients receive observation.

ARM B (intermediate risk): Patients undergo low-dose (50Gy) intensity modulated radiation therapy (IMRT) once daily (QD) over 25 fractions.

ARM C (intermediate risk): Patients undergo standard-dose (60Gy) IMRT QD over 30 fractions.

ARM D (high risk): Patients receive IMRT at 66 Gy QD for 33 fractions. Patients also receive cisplatin intravenously (IV) over 60 minutes on days 1, 8, 15, 22, 29, 36, and 43 during radiation therapy.

After completion of study treatment, patients are followed up every 3 months for 2 years and then every 6 months for 3 year.

Recruitment & Eligibility

Status: ACTIVE_NOT_RECRUITING

Sex: All

Target Recruitment: 519

Inclusion Criteria

Registration to Surgery (Arm S)

Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1
Patients must have newly diagnosed, histologically or cytologically confirmed squamous cell carcinoma or undifferentiated carcinoma of the oropharynx; patients must have been determined to have resectable oropharyngeal disease; patients with primary tumor or nodal metastasis fixed to the carotid artery, skull base or cervical spine are not eligible
Patients must have American Joint Committee on Cancer (AJCC) TNM tumor stage III, IV a, or IV b (with no evidence of distant metastases) as determined by imaging studies (performed < 30 days prior to pre-registration) and complete head and neck exam; the following imaging is required: computed tomography (CT) scan with IV contrast or magnetic resonance imaging (MRI)
Patients must have biopsy-proven p16+ oropharynx cancer; the histologic evidence of invasive squamous cell carcinoma may have been obtained from the primary tumor or metastatic lymph node. It is required that patients have a positive p16 IHC (as surrogate for HPV) status from either the primary tumor or metastatic lymph node.
Carcinoma of the oropharynx associated with HPV as determined by p16 protein expression using immunohistochemistry (IHC) performed by a Clinical Laboratory Improvement Amendments (CLIA) approved laboratory; using p16 antibody obtained from Roche mtm laboratories AG (CINtec, clone E6H4) is recommended
Patients with a history of a curatively treated malignancy must be disease-free for at least two years except for carcinoma in situ of cervix and/or non-melanomatous skin cancer
Patients with the following within the last 6 months prior to pre-registration must be evaluated by a cardiologist and/or neurologist prior to entry into the study
- Congestive heart failure > NYHA Class II
- Cerebrovascular accident (CVA)/transient ischaemic attack (TIA)
- Unstable angina
- Myocardial infarction
Absolute neutrophil count >= 1,500/mm^3
Platelets >= 100,000/mm^3
Total bilirubin =< the upper limit of normal (ULN)
Calculated creatinine clearance must be > 60 ml/min using the Cockcroft-Gault formula

Registration/Randomization to Step2 - Arms A, B, C and D

Histopathologic assessment of surgical pathology must include examination for perineural invasion (PNI) and lymphovascular invasion (LVI) and reported as absent or present; the absence or presence of extracapsular extension (ECE) requires gross and microscopic assessment and is defined to be:
- Absent (negative or nodal metastasis with smooth/rounded leading edge confined to thickened capsule/pseudocapsule),
- Present - minimal (tumor extends =< 1 mm beyond the lymph node capsule), or
- Present - extensive (gross, tumor extends > 1 mm beyond the lymph node capsule (includes soft tissue metastasis)
Patient must be stratified/classified into one of the following risk categories (the highest risk feature assessed pathologically will determine the patient's category/treatment arm assignment):
- Low Risk: T1-T2, N0-N1 AND clear (≥ 3mm) margins, AND no ECE or PNI/LVI
- High Risk: Any of the following features: one or more positive margin(s) with any T stage, OR "Extensive" (> 1mm) ECE, OR ≥ 5 metastatic lymph nodes (regardless of primary tumor margin status)
- Intermediate Risk: Any of the following features: one or more "close" (< 3mm) margin(s), OR "Minimal" (≤ 1mm) ECE, OR N2a (1 or more lymph node > 3cm in diameter), OR N2b (2-4 lymph nodes positive, any diameter ≤ 6cm), OR with perineural invasion or lymphovascular invasion.
- Unknown Risk: Patients found to have N2C or N3 disease on final pathologic analysis are at unknown risk for recurrence, but are not candidates for deintensified adjuvant therapy in this trial. These patients will be treated on Arm C.
- Patients not categorized into the appropriate risk category will be considered ineligible for the study
Patient must be registered/randomized to Step 2 within a maximum of 7 weeks following surgery
Women of childbearing potential and sexually active males are strongly advised to use an accepted and effective method of contraception

Exclusion Criteria

Registration to Surgery (Arm S)

Prior radiation above the clavicles
Evidence of extensive or "matted/fixed" pathologic adenopathy on preoperative imaging
Women must not be pregnant or breast-feeding due to the teratogenicity of chemotherapy; all females of childbearing potential must have a blood test or urine study within 2 weeks prior to registration to rule out pregnancy; a female of childbearing potential is any woman, regardless of sexual orientation or whether they have undergone tubal ligation, who meets the following criteria: has not undergone a hysterectomy or bilateral oophorectomy; or has not been naturally postmenopausal for at least 24 consecutive months (i.e., has had menses at any time in the preceding 24 consecutive months)
Any intercurrent illness likely to interfere with protocol therapy or prevent surgical resection
Uncontrolled diabetes, uncontrolled infection despite antibiotics or uncontrolled hypertension within 30 days prior to pre-registration

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Arm S (Surgery) then Arm D (High risk, IMRT, chemotherapy)	intensity-modulated radiation therapy	Patients undergo transoral surgical resection of the oropharyngeal tumor. After transoral surgical resection of the oropharyngeal tumor, high risk patients then receive IMRT (66Gy) QD five days a week for 6-7 weeks. Patients also receive cisplatin IV over 60 minutes on days 1, 8, 15, 22, 29, 36, and 43 during radiation therapy.
Arm S (Surgery) then Arm A (Low risk, observation)	Transoral surgery	Patients undergo transoral surgical resection of the oropharyngeal tumor. After transoral surgical resection of the oropharyngeal tumor, low risk patients are under observation.
Arm S (Surgery) then Arm B (Intermediate risk, low-dose IMRT)	intensity-modulated radiation therapy	Patients undergo transoral surgical resection of the oropharyngeal tumor. After transoral surgical resection of the oropharyngeal tumor, intermediate risk patients receive low-dose IMRT (50 Gy) QD five days a week for 5 weeks.
Arm S (Surgery) then Arm D (High risk, IMRT, chemotherapy)	Transoral surgery	Patients undergo transoral surgical resection of the oropharyngeal tumor. After transoral surgical resection of the oropharyngeal tumor, high risk patients then receive IMRT (66Gy) QD five days a week for 6-7 weeks. Patients also receive cisplatin IV over 60 minutes on days 1, 8, 15, 22, 29, 36, and 43 during radiation therapy.
Arm S (Surgery) then Arm D (High risk, IMRT, chemotherapy)	carboplatin	Patients undergo transoral surgical resection of the oropharyngeal tumor. After transoral surgical resection of the oropharyngeal tumor, high risk patients then receive IMRT (66Gy) QD five days a week for 6-7 weeks. Patients also receive cisplatin IV over 60 minutes on days 1, 8, 15, 22, 29, 36, and 43 during radiation therapy.
Arm S (Surgery) then Arm B (Intermediate risk, low-dose IMRT)	Transoral surgery	Patients undergo transoral surgical resection of the oropharyngeal tumor. After transoral surgical resection of the oropharyngeal tumor, intermediate risk patients receive low-dose IMRT (50 Gy) QD five days a week for 5 weeks.
Arm S (Surgery) then Arm C (Intermediate risk, standard-dose IMRT)	intensity-modulated radiation therapy	Patients undergo transoral surgical resection of the oropharyngeal tumor. After transoral surgical resection of the oropharyngeal tumor, intermediate risk patients receive standard-dose IMRT (60 Gy) QD five days a week for 6 weeks.
Arm S (Surgery) then Arm C (Intermediate risk, standard-dose IMRT)	Transoral surgery	Patients undergo transoral surgical resection of the oropharyngeal tumor. After transoral surgical resection of the oropharyngeal tumor, intermediate risk patients receive standard-dose IMRT (60 Gy) QD five days a week for 6 weeks.
Arm S (Surgery) then Arm D (High risk, IMRT, chemotherapy)	cisplatin	Patients undergo transoral surgical resection of the oropharyngeal tumor. After transoral surgical resection of the oropharyngeal tumor, high risk patients then receive IMRT (66Gy) QD five days a week for 6-7 weeks. Patients also receive cisplatin IV over 60 minutes on days 1, 8, 15, 22, 29, 36, and 43 during radiation therapy.

Primary Outcome Measures

Name	Time	Method
Proportion of Patients With Grade III or IV Oropharyngeal Bleeding or Positive Margins	Assessed during surgery and directly after surgery	Surgery quality was evaluated based on grade 3-4 bleeding events per Common Terminology Criteria for Adverse Events (CTCAE) v5.0 during surgery and positive margins after surgery. Per CTCAE v5.0, grade 3 = severe and grade 4 = life-threatening. Having grade 3-4 bleeding or positive margins indicates worse outcomes.
Progression-free Survival Rate at 2 Years	Assessed every 3 months for 2 years	Progression-free survival is defined as the time from randomization/assignment of post-surgical treatment to the appearance of lesions, including primary, nodal or new site, or death, whichever occurs first. These patients are considered disease-free after surgery so the appearance of any lesions is counted as progression. Kaplan-Meier estimate was used to characterize progression-free survival rate at 2 years.

Secondary Outcome Measures

Name	Time	Method
Swallowing Function Before Surgery Assessed Using MD Anderson Dysphagia Inventory (MDADI)	Assessed at baseline	The MDADI measures swallowing-related quality of life (QOL) in patients with swallowing dysfunction in a 20-item written questionnaire. It evaluates the patient's physical (P), emotional (E) and functional (F) perceptions of swallowing dysfunction. This instrument has been psychometrically validated in head and neck cancer patients. Two summary scores can be obtained from the MDADI: 1) global and 2) composite. The global scale is a single question, scored individually, to assess the overall impact that swallowing abilities have on quality of life ("my swallowing impacts my day-to-day life"). The composite MDADI score summarizes overall performance on remaining 19-items of the MDADI, as a weighted average of the physical, emotional, and functional subscale questions. This study reports the composite MDADI score. The summary MDADI scores are normalized to range from 20 (extremely low functioning) to 100 (high functioning).
Quality of Life (QOL) at 6 Months After Treatment Assessed by Functional Assessment of Cancer Therapy - Head and Neck Cancer (FACT-HN) Total Score	Assessed at 6 months after treatment	The FACT-H\&N (version 4) consists of a cancer-specific questionnaire, FACT-G, in addition to 12 H\&N cancer-specific items (the HN subscale). FACT-G is a 27-item measure that assesses general cancer quality of life. FACT-HN total score ranges between 0 and 148. The higher the score, the better the QOL.
Distribution of Histologic Risk Status	Assessed after directly surgery	Low Risk: T1-T2, N0-N1 AND clear (\> 3mm) margins, AND no extranodal extension (ENE) or PNI/LVI. Intermediate Risk: Any of the following features: one or more "close" (\< 3mm) margin(s), OR "Minimal" (\< 1mm) ENE, OR N2a (1 or more lymph node \>3cm in diameter), OR N2b (2-4 lymph nodes positive, any diameter \< 6cm), OR with perineural invastion or lymphovascular invasion. High Risk: Any of the following features: one or more positive margin(s) with any T stage, OR "Extensive" (\> 1mm) ENE, OR \> 5 metastatic lymph nodes (regardless of primary tumor margin status).
Swallowing Function After Surgery Assessed Using MD Anderson Dysphagia Inventory (MDADI)	Assessed 4-6 weeks after surgery	The MDADI measures swallowing-related quality of life (QOL) in patients with swallowing dysfunction in a 20-item written questionnaire. It evaluates the patient's physical (P), emotional (E) and functional (F) perceptions of swallowing dysfunction. This instrument has been psychometrically validated in head and neck cancer patients. Two summary scores can be obtained from the MDADI: 1) global and 2) composite. The global scale is a single question, scored individually, to assess the overall impact that swallowing abilities have on quality of life ("my swallowing impacts my day-to-day life"). The composite MDADI score summarizes overall performance on remaining 19-items of the MDADI, as a weighted average of the physical, emotional, and functional subscale questions. This study reports the composite MDADI score. The summary MDADI scores are normalized to range from 20 (extremely low functioning) to 100 (high functioning).

Trial Locations

Locations (58): Emory University Hospital Midtown
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Atlanta, Georgia, United States
Thomas Jefferson University Hospital
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Philadelphia, Pennsylvania, United States
UT Southwestern/Simmons Cancer Center-Dallas
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Dallas, Texas, United States
University of Washington Medical Center
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Seattle, Washington, United States
Dana-Farber Cancer Institute
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Boston, Massachusetts, United States
Boston Medical Center
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Boston, Massachusetts, United States
University of Pittsburgh Cancer Institute (UPCI)
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Pittsburgh, Pennsylvania, United States
Case Western Reserve University
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Cleveland, Ohio, United States
Cleveland Clinic Foundation
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Cleveland, Ohio, United States
M D Anderson Cancer Center
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Houston, Texas, United States
UCLA / Jonsson Comprehensive Cancer Center
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Los Angeles, California, United States
University of Virginia Cancer Center
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Charlottesville, Virginia, United States
Ohio State University Comprehensive Cancer Center
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Columbus, Ohio, United States
PinnacleHealth Cancer Center-Community Campus
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Harrisburg, Pennsylvania, United States
Memorial Sloan-Kettering Cancer Center
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New York, New York, United States
Sentara Virginia Beach General Hospital
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Virginia Beach, Virginia, United States
Rocky Mountain Cancer Centers-Penrose
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Colorado Springs, Colorado, United States
Rocky Mountain Cancer Centers-Boulder
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Boulder, Colorado, United States
Penrose-Saint Francis Healthcare
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Colorado Springs, Colorado, United States
University of Kansas Cancer Center
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Kansas City, Kansas, United States
UCSF Medical Center-Mount Zion
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San Francisco, California, United States
University of Miami Miller School of Medicine-Sylvester Cancer Center
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Miami, Florida, United States
Henry Ford Hospital
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Detroit, Michigan, United States
Duke University Medical Center
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Durham, North Carolina, United States
Vanderbilt University/Ingram Cancer Center
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Nashville, Tennessee, United States
Fox Chase Cancer Center
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Philadelphia, Pennsylvania, United States
University of Miami Sylvester Comprehensive Cancer Center at Deerfield Beach
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Deerfield Beach, Florida, United States
University of Arkansas for Medical Sciences
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Little Rock, Arkansas, United States
Dartmouth Hitchcock Medical Center
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Lebanon, New Hampshire, United States
Greater Baltimore Medical Center
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Baltimore, Maryland, United States
Mercy Hospital Springfield
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Springfield, Missouri, United States
University of Alabama at Birmingham Cancer Center
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Birmingham, Alabama, United States
Mayo Clinic in Arizona
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Scottsdale, Arizona, United States
City of Hope Comprehensive Cancer Center
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Duarte, California, United States
Kaiser Permanente Oakland-Broadway
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Oakland, California, United States
Stanford Cancer Institute
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Palo Alto, California, United States
Emory University/Winship Cancer Institute
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Atlanta, Georgia, United States
University of Iowa/Holden Comprehensive Cancer Center
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Iowa City, Iowa, United States
Johns Hopkins University/Sidney Kimmel Cancer Center
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Baltimore, Maryland, United States
Brigham and Women's Hospital
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Boston, Massachusetts, United States
University of Pennsylvania/Abramson Cancer Center
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Philadelphia, Pennsylvania, United States
Inova Fairfax Hospital
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Falls Church, Virginia, United States
Sentara Cancer Institute at Sentara CarePlex Hospital
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Hampton, Virginia, United States
Sentara Hospitals
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Norfolk, Virginia, United States
Porter Adventist Hospital
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Denver, Colorado, United States
Yale University
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New Haven, Connecticut, United States
University of Nebraska Medical Center
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Omaha, Nebraska, United States
Florida Hospital Orlando
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Orlando, Florida, United States
Nebraska Methodist Hospital
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Omaha, Nebraska, United States
Providence Portland Medical Center
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Portland, Oregon, United States
Oregon Health and Science University
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Portland, Oregon, United States
Medical University of South Carolina
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Charleston, South Carolina, United States
Froedtert and the Medical College of Wisconsin
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Milwaukee, Wisconsin, United States
Zablocki Veterans Administration Medical Center
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Milwaukee, Wisconsin, United States
University of Kentucky/Markey Cancer Center
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Lexington, Kentucky, United States
University of New Mexico
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Albuquerque, New Mexico, United States
Montefiore Medical Center - Moses Campus
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Bronx, New York, United States
University of Wisconsin Hospital and Clinics
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Madison, Wisconsin, United States