Radiation Therapy With Cisplatin, Docetaxel, or Cetuximab After Surgery in Treating Patients With Stage III-IV Squamous Cell Head and Neck Cancer

Study ID
RTOG 1216

Cancer Related

Healthy Volunteers

Study Sites

  • Clements University Hospital
  • UT Southwestern Ambulatory Services
  • Zale Lipshy University Hospital
  • Parkland Health & Hospital System

Susan Cooley

Principal Investigator
David Schwartz, M.D.

Official Title

Randomized Phase II/III Trial of Surgery and Postoperative Radiation Delivered With Concurrent Cisplatin Versus Docetaxel Versus Docetaxel and Cetuximab for High-Risk Squamous Cell Cancer of the Head and Neck

Brief Overview

This randomized phase II/III trial studies how well radiation therapy works when given
together with cisplatin compared to docetaxel or cetuximab and docetaxel after surgery in
treating patients with stage III-IV squamous cell head and neck cancer. Specialized
radiation therapy that delivers a high dose of radiation directly to the tumor may kill more
tumor cells and cause less damage to normal tissue. Drugs used in chemotherapy, such as
cisplatin and docetaxel, work in different ways to stop the growth of tumor cells, either by
killing the cells or by stopping them from dividing. Monoclonal antibodies, such as
cetuximab, can block tumor growth in different ways. Some block the ability of tumor cells
to grow and spread. Others find tumor cells and help kill them or transmit tumor killing
molecules to them. It is not yet known whether radiation therapy is more effective when
given with cisplatin, docetaxel, or cetuximab and docetaxel.



I. To select the better experimental arm to improve disease-free survival (DFS) over the
control arm of radiation and cisplatin. (Phase II) II. To determine whether the selected
experimental arm will improve overall survival (OS) over the control arm of radiation and
cisplatin. (Phase III)


I. To improve local-regional disease control. II. To compare distant metastasis. III. To
compare patterns of cancer failure (local, regional, distant) and correlate with radiation
dose and technique.

IV. To compare acute toxicity profiles during radiation therapy (RT) and at completion of

V. To compare late toxicity profiles at 1, 3, and 5 years after treatment. VI. To compare
overall quality of life. VII. To compare patient-reported outcome. VIII. To compare
swallowing function at 1 and 2 years. IX. To investigate associations between acute mucosal
toxicity, swallowing function, and quality of life (QOL).

X. To compare quality adjusted life years (QALY). XI. To investigate associations between
late toxicity (dysphagia) and QALY. XII. To determine whether specific molecular profiles
are associated with clinical outcomes.

OUTLINE: Patients are randomized to 1 of 3 treatment groups.

ARM 1: Patients undergo intensity modulated radiation therapy (IMRT) once daily (QD) five
days a week and receive cisplatin intravenously (IV) over 1-2 hours once weekly for 6 weeks.

ARM 2: Patients undergo IMRT as in Arm I and receive docetaxel IV once weekly for 6 weeks.

ARM 3: Patients receive cetuximab IV over 120 minutes on week 1 and over 60 minutes once
weekly on weeks 2-7. Patients undergo IMRT as in Arm I and receive docetaxel once weekly for
6 weeks.

After completion of study treatment, patients are followed up at 1 and 3 months, every 3
months for 2 years, every 6 months for 3 years, and then annually thereafter.

Participant Eligibility

Inclusion Criteria:

- Pathologically (histologically or cytologically) proven diagnosis of head and neck
squamous cell carcinoma (HNSCC) involving the oral cavity (excluding lips),
oropharynx (p16 negative), larynx, or hypopharynx within 63 days of registration

- Patients must have undergone gross total surgical resection of high-risk oral cavity,
oropharynx (p16 negative), larynx, or hypopharynx within 63 days prior to

- Patients must have at least 1 of the following high-risk pathologic features:
extracapsular nodal extension or invasive cancer at the primary tumor resection
margin (tumor or ink)

- Pathologic stage III or IV head and neck squamous cell carcinoma (HNSCC), including
no distant metastases, based upon the following minimum diagnostic workup:

- General history and physical examination by a radiation oncologist and/or
medical oncologist within 84 days prior to registration;

- Examination by an ear nose throat (ENT) or head & neck surgeon prior to surgery;
a laryngopharyngoscopy (mirror and/or fiber optic and/or direct procedure), if
appropriate is recommended but not required. Intra-operative examination is
acceptable documentation.

- Pre-op Imaging of the head and neck: A neck computed tomography (CT) (with
contrast) or CT/positron emission tomography (PET) (with contrast) and/or an
magnetic resonance imaging (MRI) of the neck (T1 with Gadolinium and T2) within
84 days prior to surgery; note: this imaging data (diagnostic pre-operative scan
showing gross disease) is to be submitted in Digital Imaging and Communications
in Medicine (DICOM) format via TRIAD; the report is to be uploaded into Rave

- Chest CT scan (with or without contrast) or CT/PET that includes the chest (with
or without contrast) either within 84 days prior to surgery or within 120 days
prior to registration; NOTE: If the CT/PET with or without contrast is done
within 84 days prior to surgery, if fulfills the chest imaging requirement.

- Zubrod performance status of 0-1 within 14 days prior to registration

- Absolute granulocyte count (AGC) >= 1,500 cells/mm^3

- Platelets >= 100,000 cells/mm^3

- Hemoglobin >= 8.0 g/dl (Note: The use of transfusion or other intervention to achieve
hemoglobin [Hgb] >= 8.0 g/dl is acceptable)

- Total bilirubin < 2 x institutional upper limit of normal (ULN) within 14 days prior
to registration

- Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) < 3 x
institutional ULN within 14 days prior to registration

- Serum creatinine institutional ULN within 14 days prior to registration or;
creatinine clearance (CC) >= 50 ml/min within 14 days prior to registration
determined by 24-hour collection or estimated by Cockcroft-Gault formula

- Negative serum or urine pregnancy test within 14 days prior to registration for women
of childbearing potential

- The following assessments are required within 14 days prior to registration: sodium
(Na), potassium (K), chloride (Cl), glucose, calcium (Ca), magnesium (Mg), and
albumin; Note: Patients with an initial magnesium < 0.5 mmol/L (1.2 mg/dl) may
receive corrective magnesium supplementation but should continue to receive either
prophylactic weekly infusion of magnesium and/or oral magnesium supplementation (eg,
magnesium oxide) at the investigator's discretion

- Patients with feeding tubes are eligible for the study

- Women of childbearing potential and male participants who are sexually active must
agree to use a medically effective means of birth control

- Patient must provide study specific informed consent prior to study entry, including
consent for mandatory tissue submission for epidermal growth factor receptor (EGFR)
analysis and for oropharyngeal cancer patients, human papilloma virus (HPV) analysis

Exclusion Criteria:

- Prior invasive malignancy (except non-melanomatous skin cancer) unless disease free
for a minimum of 1095 days (3 years); noninvasive cancers (for example, carcinoma in
situ of the breast, oral cavity, or cervix are all permissible) are permitted even if
diagnosed and treated < 3 years ago

- Patients with simultaneous primaries or bilateral tumors are excluded, with the
exception of patients with bilateral tonsil cancers or patients with T1-2, N0, M0
resected differentiated thyroid carcinoma, who are eligible

- Prior systemic chemotherapy or anti-epidermal growth factor (EGF) therapy for the
study cancer; note that prior chemotherapy for a different cancer is allowable

- Prior radiotherapy to the region of the study cancer that would result in overlap of
radiation therapy fields

- Severe, active co-morbidity, defined as follows:

- Unstable angina and/or congestive heart failure requiring hospitalization within
6 months prior to registration

- Transmural myocardial infarction within 6 months prior to registration

- Acute bacterial or fungal infection requiring intravenous antibiotics at the
time of registration

- Chronic obstructive pulmonary disease exacerbation or other respiratory illness
requiring hospitalization or precluding study therapy at the time of

- Idiopathic pulmonary fibrosis or other severe interstitial lung disease that
requires oxygen therapy or is thought to require oxygen therapy within 1 year
prior to registration

- Hepatic insufficiency resulting in clinical jaundice and/or coagulation defects;
note, however, that laboratory tests for coagulation parameters are not required
for entry into this protocol

- Acquired immune deficiency syndrome (AIDS) based upon current Centers for
Disease and Control (CDC) definition; note: HIV testing is not required for
entry into this protocol; the need to exclude patients with AIDS from this
protocol is necessary because the treatments involved in this protocol may be
significantly immunosuppressive; protocol-specific requirements may also exclude
immuno-compromised patients

- Grade 3-4 electrolyte abnormalities (Common Terminology Criteria for Adverse Events
[CTCAE], v. 4):

- Serum calcium (ionized or adjusted for albumin) < 7 mg/dl (1.75 mmol/L) or > 12.5
mg/dl (> 3.1 mmol/L) despite intervention to normalize levels

- Glucose < 40 mg/dl (< 2.2 mmol/L) or > 250 mg/dl (> 14mmol/L)

- Magnesium < 0.9 mg/dl (< 0.4 mmol/L) or > 3 mg/dl (> 1.23 mmol/L) despite
intervention to normalize levels

- Potassium < 3.5 mmol/L or > 6 mmol/L despite intervention to normalize levels

- Sodium < 130 mmol/L or > 155 mmol/L despite intervention to normalize levels

- Pregnancy or women of childbearing potential and men who are sexually active and not
willing/able to use medically acceptable forms of contraception; this exclusion is
necessary because the treatment involved in this study may be significantly

- Prior allergic reaction to cetuximab