Is it appropriate to dose de-escalate in low risk HPV+ SCC of the oropharynx outside of a clinical trial setting?

I am going to write specifically on de-escalating HPV-OPSCC in the adjuvant setting first, important caveats for adjuvant de-escalation, and then about the general philosophy on de-escalation in clinical trials.

Concerning adjuvant treatment, after careful consent, we are de-escalating patients with ...

I think it is absolutely inappropriate to de-escalate outside of a clinical trial.

Further, even if HN002 is published, it is inappropriate to do so according to the trial as it is a phase II randomized study. For example, would one ever consider T3N2b treated with RT alone?

Until we have randomized...

With appropriate informed consent, I think it is acceptable to de-intensify to 60 Gy at 2Gy/fx with weekly cisplatin 30 to 40 mg/m2 in 6 weeks. In the community setting, I would only offer this to patients with 1) HPV-associated OPSCC (p16 positive), 2) T1-T2 N1 to N2b and T3 N0 to N2b (AJCC 7th edi...

Some thoughts on de-escalation and treatment of HPV+ vs -ve patients below:

One of my themes has been that the principle reason for de-escalation is that we over-escalated treatment largely by historically calling nearly every patient locally-advanced. This is most evident in our HPV patients as man...

De-escalate to me means marginally less than 70 Gy in 35 fractions because I have a heavy foot. I’m comfortable dropping to 66/33 which is standard of care. I would not drop to less than 64/32 unless on an IRB approved study.

What would happen if a patient, who would be eligible for de-escalation on various protocols, receives de-escalation off study, the cancer recurs, and he/she sues the oncologist because treatment was not according to community standards (invoking NCCN and Astro consensus guidelines)?

Can anyone with...

The answer is more nuanced. This is not an either-or answer. We are clearly in an era of transition. We now have a greater understanding of the molecular composition of tumors, a greater understanding of biology esp. HPV+ histologies. I for one have never been an absolutist because, as many of us we...

Yes.

In 2021, is there any more convincing evidence that dose de-escalation is safe and accepted for treatment in the community?

On review of the NRG-HN002 protocol introduction, 60 Gy/6w with cisplatin was chosen as the standard arm with 60 Gy/5w without cisplatin as the experimental arm. As a standard ...