Induction treatment prior to chemoradiotherapy in nasopharyngeal carcinoma: triplet or doublet chemotherapy?

Nasopharyngeal carcinoma is a malignancy that is endemic in Asia. The current standard of care for loco-regionally advanced disease is platinum-based concurrent chemo-radiotherapy. However, relapse remains a common issue. Phase II trials have shown encouraging results when induction chemotherapy with gemcitabine and cisplatin is added to chemo-radiation. In a major recent advance, a phase III trial demonstrated significantly improved recurrence-free survival (RFS) and overall survival (OS) for this approach compared to chemo-radiotherapy alone. Results from this trial showed a 4.3% improvement in OS over standard therapy at 3 years, (94.6% vs 90.3%), with an expected increase in acute adverse events. In this article, we put this treatment in context of other proven approaches in nasopharyngeal carcinoma. There is a lack of comparative data in relation to the optimal induction regimen. It remains to be seen whether or not treatment with the gemcitabine-cisplatin doublet differs significantly from the established induction triplet of docetaxel, cisplatin and fluorouracil (TPF) with regard to efficacy or toxicity, but it is likely that many more patients would tolerate gemcitabine-cisplatin compared to TPF. Immunotherapy could prove a promising strategy in combination with induction therapy. Future treatment strategies for nasopharyngeal carcinoma will likely adopt a more personalised approach.