0-7-21 hypofractionated palliative radiotherapy: an effective treatment for advanced head and neck cancers

Objective:

We report our experience in providing palliative radiotherapy (RT) to patients with head and neck cancers (HNCs). Our hypofractionated regimen, “0-7-21”, treats patients with 24 Gy in three fractions.

Methods:

Patients, disease and response data were retrieved for candidates of 0-7-21 from 2005 to 2012. Primary end points included symptom and tumour size responses to RT based on response evaluation criteria in solid tumours (RECIST) guidelines. Secondary end points included progression-free survival (PFS) within the irradiated field, overall survival (OS) and symptomatic PFS (SPFS), calculated using Kaplan–Meier method and adverse events. Cox proportional hazards regression and logistic regression were used to investigate for prognostic factors.

Results:

A total of 110 patients were included. Among the patients, 40% and 31% had complete response for symptoms and tumour size, respectively; 42% and 50% had partial response for symptoms and tumour size, respectively; and 15% had stability of symptoms and tumour size. Median 6-month OS was 51%, and PFS within the irradiated field was 39%. Planning target volume was predictive of OS (p < 0.001), PFS (p < 0.001) and SPFS (p < 0.005), while higher TNM stage was associated with poorer tumour response (p = 0.02).

Conclusion:

0-7-21 is an effective and well-tolerated palliative RT regimen for patients with HNC. There was excellent symptom and local control with acceptable toxicity profile in these patients.

Advances in knowledge:

This is the first study to describe the outcomes of 0-7-21 in treating advanced HNCs. The positive results suggest that 0-7-21 provides excellent palliation with minimal toxicity, with significantly less on-treatment time than current published palliative RT regimen.Head and neck cancer (HNC) is the sixth most common solid malignancy,¹ and the seventh leading cause of cancer death worldwide.² Up to 70% of patients present with locally advanced disease where cure is difficult to achieve.³ In these cases, palliative radiotherapy (RT) is often necessary, as these patients are highly symptomatic from their disease situated at critical locations in the upper aerodigestive tract.Currently, there is no consensus or guideline for palliative RT for patients with locally advanced HNC, unlike other clinical situations such as for patients with metastatic disease to the bone or brain or even for advanced lung cancer.^4–6 There are few retrospective reviews of the diverse schedules of palliative RT in advanced HNC. However, most of these studies use palliative therapy as a synonym for failed radical therapy. Although longer courses with higher total RT doses have been associated with marginally better outcomes in retrospective reviews,^7,8 patients not amenable to curative treatments continue to have a dismal prognosis with a median survival of 3–12 months, even with protracted treatments.^3,7,9,10 Furthermore, delivering an extended course of RT often constitutes a challenge given the poor performance status of these patients. Therefore, the question arose as to whether a shorter course of RT with a high biological effective dose would be more appropriate, assuming it offered satisfactory symptom and disease control.In our institution at the Juravinski Cancer Centre, a palliative hypofractionated RT regimen, termed “0-7-21”, is often proposed to patients with advanced incurable and unresectable HNC, especially those with poor performance status and/or multiple comorbidities or evidence of distant metastatic disease. This treatment course consists of three fractions of 8 Gy, given over 3 weeks for a total of 24 Gy. We undertook a retrospective study of our experience, analysing the efficacy of 0-7-21.