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      Drugs & Diseases > Oncology

      Nasopharyngeal Cancer Treatment Protocols

      Updated: Jul 28, 2023
      • Author: Marvaretta M Stevenson, MD; Chief Editor: Guy J Petruzzelli, MD, PhD, MBA, FACS  more...
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      Treatment Protocols

      Treatment protocols for nasopharyngeal cancers are provided below, including generalized first-line therapy based on stage; chemoradiation therapy and induction chemotherapy for locally advanced disease; and first-, second-, and third-line chemotherapy for metastatic or recurrent disease. [1, 2, 3]

      Generalized treatment recommendations for nasopharyngeal cancers

      See the list below:

      • Treatment plans for all disease stages should be discussed at a multidisciplinary tumor conference involving ear, nose, throat (ENT) surgeons; radiation oncologists; and medical oncologists.

      • Selected patients with advanced or metastatic disease may receive additional therapy (radiation or neck dissection) depending on their response to first-line therapy.

      • Surgery at the primary disease site has a very limited role, if any, in nasopharyngeal cancers.

      Radiation therapy for early or localized nasopharyngeal cancers

      Stage I:

      • Patients with early or localized disease may be treated with definitive radiation therapy to the nasopharynx and elective radiation therapy to the neck

      • Radiation doses of 66-70 Gy (2.0 Gy/fraction; daily Monday-Friday in 7wk)

      Chemotherapy with radiation therapy for locally advanced nasopharyngeal cancers

      Stages II-IVB:

      • Patients with stage II-IVB nasopharyngeal cancers are treated with concurrent chemotherapy and radiation +/- adjuvant chemotherapy or with induction chemotherapy followed by concurrent chemoradiation

      Acceptable chemotherapy regimens for advanced nasopharyngeal cancers (stages II-IVB):

      • Induction chemotherapy with gemcitabine 1000 mg/m2 on days 1 and 8 plus cisplatin 80 mg/m2 IV on day 1 every 3 weeks for three cycles, followed by cisplatin 100 mg/m2 IV every 3 weeks for three cycles with concurrent intensity-modulated radiotherapy [4]

      • Induction chemotherapy with docetaxel 70 mg/m2 IV on day 1 plus  cisplatin 75 mg/m2 IV on day 1 plus  fluorouracil (5-FU) 1000 mg/m2/day by continuous IV infusion on days 1-4 for three cycles followed by concurrent chemoradiation with cisplatin 100 mg/m2 IV on days 1, 22, and 43 [5, 6]

      • Cisplatin 100 mg/m2 IV on days 1, 22, and 43 with radiation +/- adjuvant chemotherapy with cisplatin 80 mg/m2 IV on day 1 plus  5-FU 1000 mg/m2/day by continuous IV infusion on days 1-4 every 4wk for 3 cycles [7, 8, 9] or

      • Carboplatin AUC 6 IV every 3 weeks for 3 cycles with radiation +/- adjuvant chemotherapy with carboplatin AUC 5 IV on day 1 plus  5-FU 1000 mg/m2/day by continuous IV infusion on days 1-4 every 3 weeks for two cycles [10]

      • Radiation doses during concurrent chemoradiation are up to 70 Gy (2.0 Gy/fraction)

      First-line chemotherapy for metastatic or recurrent nasopharyngeal cancers

      Stage IVB:

      • Patients with metastatic nasopharyngeal cancers or recurrent disease (after first-line therapy) are treated with standard platinum-based chemotherapies

      • Single agents can be used if patients cannot tolerate platinum-based agents [11, 12]

      Acceptable chemotherapy regimens in patients with metastatic, progressing, or recurrent nasopharyngeal cancers (unless otherwise stated, goal is to complete 4-6 cycles):

      • Cisplatin 80 mg/m2 IV on day 1 plus  gemcitabine 1000 mg/m2 IV on days 1 and 8 every 21 days [13, 12]

      • Cisplatin 75 mg/m2 IV on day 1 plus  docetaxel 75 mg/m2 IV on day 1 every 3wk [14, 15, 16] or

      • Cisplatin 75 mg/m2 IV on day 1 plus paclitaxel 175 mg/m2 IV on day 1 every 3wk [17, 18] or

      • Carboplatin area under the curve (AUC; see the Carboplatin AUC Dose Calculation [Calvert formula] calculator) 6 IV on day 1 plus  docetaxel 65 mg/m2 IV on day 1 every 3wk [19] or

      • Carboplatin AUC 6 IV on day 1 plus  paclitaxel 200 mg/m2 IV on day 1 every 3wk [20, 21, 22] or

      • Cisplatin 100 mg/m2 IV on day 1 plus  5-FU 1000 mg/m2/day by continuous IV infusion on days 1-4 every 3wk [23, 18, 24, 25, 26] or

      • Cisplatin 50-70 mg/m2 IV on day 1 plus  gemcitabine 1000 mg/m2 IV on days 1, 8, and 15 every 4wk [27, 28] or

      • Cetuximab 400 mg/m2 IV on day 1 followed by 250 mg/m2 IV weekly plus  carboplatin AUC 5 IV every 3 weeks for up to eight cycles [29] or 

      • Gemcitabine 1000 mg/m2 IV plus  vinorelbine 25 mg/m2 IV on days 1 and 8 every 21 days [30] or

      • Gemcitabine 1000 mg/m2 IV on days 1, 8, and 15 every 4wk [27, 31] or

      • Gemcitabine 1250 mg/m2 IV on days 1 and 8 every 3wk [32] or

      • Methotrexate 40 mg/m2 IV weekly (3wk equals one cycle) [12, 23] or

      • Paclitaxel 200 mg/m2 IV every 3wk [33] or

      • Docetaxel 75 mg/m2 IV every 3wk [34, 35, 36, 37, 38]  or

      • Capecitabine 1.250 mg/m2 PO BID) on days 1-14 every 21 days for at least two cycles [12, 39]

      Second- and third-line chemotherapy for metastatic or recurrent nasopharyngeal cancers

      Stage IVC:

      • Second-line chemotherapy is given after disease progression or recurrence following completion of first-line therapy

      • Third-line therapies are given after disease progression or recurrence following completion of first- and second-line therapies

      • Second- and third-line regimens are similar to regimens used as first-line therapy but usually offer lower response rates and survival benefits

      • Patients should be treated with platinum-based chemotherapies if they have not previously received a platinum-based drug

      • Some regimens are typically used in head and neck cancers in general, and others have been specifically studied in nasopharyngeal cancer [11, 12]

      Acceptable chemotherapy regimens in patients with metastastic, progressing or recurrent nasopharyngeal cancers after completion of first-line therapy:

      • Cisplatin 75 mg/m2 IV on day 1 plus  docetaxel 75 mg/m2 IV on day 1 every 3wk [14] or

      • Cisplatin 75 mg/m2 IV on day 1 plus  paclitaxel 175 mg/m2 IV on day 1 every 3wk [17, 18] or

      • Carboplatin AUC 6 IV on day 1 plus  docetaxel 65 mg/m2 IV on day 1 every 3wk [19] or

      • Carboplatin AUC 6 IV on day 1 plus  paclitaxel 200 mg/m2 IV on day 1 every 3wk [20, 22, 40] or

      • Cisplatin 100 mg/m2 IV on day 1 plus  5-FU 1000 mg/m2/day by continuous IV infusion on days 1-4 every 3wk [23, 18, 24, 25, 26] or

      • Cisplatin 50-70 mg/m2 IV on day 1 plus  gemcitabine 1000 mg/m2 IV on days 1, 8, and 15 every 4wk [27, 28] or

      • Cetuximab 400 mg/m2 IV on day 1 followed by 250 mg/m2 IV weekly plus  carboplatin AUC 5 IV every 3 weeks for up to 8 cycles [29] or 

      • Gemcitabine 1000 mg/m2 IV plus  vinorelbine 25 mg/m2 IV on days 1 and 8 every 21 days [30] or

      • Gemcitabine 1000 mg/m2 IV on days 1, 8, and 15 every 4wk or

      • Gemcitabine 1250 mg/m2 IV on days 1 and 8 every 3wk [27, 31] or

      • Methotrexate 40 mg/m2 IV weekly (3wk equals 1 cycle) or

      • Paclitaxel 200 mg/m2 IV every 3wk [33] or

      • Docetaxel 75 mg/m2 IV every 3wk [34, 35, 36, 37, 38]  or

      • Nivolumab 3 mg/kg IV q2wk; continue until disease progression or unacceptable toxicity [41]  or

      • Pembrolizumab if the tumor is programmed death ligand 1 (PD-L1) positive; 10 mg/kg IV every 2wk up to 2 years or until disease progression or unacceptable toxicity [42, 12]

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