Correspondence

Cetuximab plus Radiotherapy for Head and Neck Cancer

N Engl J Med 2006; 354:2187May 18, 2006

Article

To the Editor:

The trial of cetuximab plus radiotherapy for locally advanced head and neck cancer, as reported by Bonner et al. (Feb. 9 issue),1 showed that patients with oropharyngeal squamous-cell carcinoma who received concomitant hyperfractionated radiotherapy obtained the greatest benefit from cetuximab. However, the study lacked adequate statistical power for subgroup analysis. Furthermore, the authors did not provide details regarding each radiotherapy regimen or primary sites in each group of patients in the trial.

Annie C. Ho, M.B., B.S., F.R.A.N.Z.C.R.
St. George Hospital, Kogarah, NSW 2217, Australia

1 References

1. 1

   Bonner JA, Harari PM, Giralt J, et al. Radiotherapy plus cetuximab for squamous-cell carcinoma of the head and neck. N Engl J Med 2006;354:567-578
   Full Text | Web of Science | Medline

To the Editor:

Cetuximab plus radiation appears to be of most benefit to patients who received a concomitant radiation boost. There does not appear to be much benefit when cetuximab is added to other fractionation schemes of radiation. It would be informative if the authors could state whether the apparent differences in benefit among the various radiation treatments were statistically significant when cetuximab was added.

John G. Armstrong, M.D.
St. Luke's Hospital, Dublin D18, Ireland

To the Editor:

In their study of cetuximab in patients with cancer, Bonner et al. do not mention thrombosis. Was there no thromboembolism among more than 400 patients treated for advanced cancer during two to three years of follow-up?

Frank Hartig, M.D.
Christoph Pechlaner, M.D.
Innsbruck Medical University, A-6020 Innsbruck, Austria
christoph.pechlaner@uibk.ac.at

To the Editor:

When Bonner et al. began their study, chemoradiotherapy with cisplatin was not the standard of care, but there were suggestions of a better outcome with hyperfractionated radiation.1 Although a small number of patients in the study were treated with once-daily radiotherapy, we wonder why the investigators used this schedule for advanced head and neck cancer.

Bonner et al. found that patients with oropharyngeal carcinoma and patients treated with a concomitant radiation-boost technique gained the most benefit from the addition of cetuximab. It is not clear whether this gain was due to the location of the tumor or to the treatment schedule. Did the authors assign more patients with oropharyngeal cancer to a concomitant radiation boost?

Finally, we are curious about the treatment results according to immunostaining for the epidermal growth factor receptor (EGFR), since the prognostic significance of EGFR levels was previously reported.2

Mustafa Cengiz, M.D.
Ferah Yildiz, M.D.
Hacettepe University, 06100 Ankara, Turkey
mcengiz@hacettepe.edu.tr

Mine Genc, M.D.
Selcuk University, 42080 Konya, Turkey

2 References

1. 1

   Horiot JC, Le Fur R, N'Guyen T, et al. Hyperfractionation versus conventional fractionation in oropharyngeal carcinoma: final analysis of a randomized trial of the EORTC cooperative group of radiotherapy. Radiother Oncol 1992;25:231-241
   CrossRef | Web of Science | Medline

2. 2

   Magne N, Pivot X, Bensadoun RJ, et al. The relationship of epidermal growth factor receptor levels to the prognosis of unresectable pharyngeal cancer patients treated by chemo-radiotherapy. Eur J Cancer 2001;37:2169-2177
   CrossRef | Web of Science | Medline

Author/Editor Response

Our trial was not sufficiently powered to detect treatment-related differences for subgroups, such as patients who received once-daily radiotherapy or those with laryngeal or hypopharyngeal cancer. The numbers of patients in these subgroups were too small for definitive conclusions to be drawn; we compared the combination of radiotherapy plus cetuximab with radiotherapy alone, on the basis of the understanding that the trial was sufficiently powered to examine only outcomes in the overall population.

We have no information concerning thrombosis or EGFR staining.

James A. Bonner, M.D.
Sharon A. Spencer, M.D.
University of Alabama at Birmingham, Birmingham, AL 35294

Eric K. Rowinsky, M.D.
ImClone Systems, Branchburg, NJ 08876
eric.rowinsky@imclone.com