Do you give two or three cycles of cisplatin to patients with H&N squamous cell carcinoma receiving chemoradiation with Q3 week cisplatin?

The data from an old RTOG study show that a total of 2 cycles of cisplatin 100 mg/m2 concurrently with accelerated RT is as good as 3 cycles with standard RT. My experience is that most patients do not tolerate cycle 3 of high dose cisplatin and therefore, not given.

Personally, I do not routinely use high dose cisplatin. Weekly cisplatin 40 mg/m2 is more tolerable. To date, there is no conclusive evidence that weekly 40 mg/m2 is inferior to every 3 weeks 100 mg/m2.

I use cisplatin 100 mg/m2 concurrently with RT in nasopharyngeal carcinoma.

Great question!

I prefer to use the weekly 40 mg/m2 cisplatin concurrently with XRT for HN cancer. It is more tolerable and total 280 mg/m2. We know that weekly cisplatin 30 mg/m2 (total 210 mg/m2) has inferior outcome compared to weekly cisplatin 40 mg/m2 for radiosensitizer.

If I have to give high dose cisplatin concurrently with RT for HN cancer, I prefer to give the 3 doses if patient clinical status permits. The closer to total 300 mg/m2, the better the outcome extrapolating from data above. If for some reason the patient can’t continue with high dose cisplatin after 1-2 doses (eg, renal insufficiency), I consider switching to another agent until the end of RT.

I've asked experts at different centers and (as has been noted in their publications & editorials), the range of answers indicates a high anecdotal influence. It seems q 3 wk 100mg/m2 is preferable particularly for the HPV negative patients, but many of those patients (smoker/drinker) are frail & are better off with weekly 40mg/m2 x 5-6 wks (and most skip wk 6; that regimen is still tough and can become myelosuppressive too). For the high dose regimen, it's occasionally 3 cycles for robust patients, but most get 2.

Finally, the major subjective problem with high dose cisplatin- nausea & vomiting thankfully seems finally attenuated using olanzepine 10mg daily x 4, along with standard ondansetron/decadron/emend premedication. Hope this helps.

I will be using weekly 40/m2 CDDP which is well tolerated by most patients, and particularly now when the risk of hospital admission for febrile neutropenia or some other complication related to higher dose concomitant chemo/RT could lead to an entirely novel set of dangers for our patients. Please forgive the tiny pun. Target dose of at least 200/m2 can be reached in this way over 5-6 weeks. Avoiding hospitalization in our immune suppressed patients in a metropolitan or suburban area is now more than ever a major concern to be factored in to our thinking about dose intensity in this setting.