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:
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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
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Selected patients with advanced or metastatic disease may receive additional therapy (radiation or neck dissection) depending on their response to first-line therapy
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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:
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Patients with early or localized disease may be treated with definitive radiation therapy to the nasopharynx and elective radiation therapy to the neck
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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:
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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):
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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 fluorouracil (5-FU) 1000 mg/m2/day by continuous IV infusion on days 1-4 every 4wk for 3 cycles [4, 5, 6] or
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Carboplatin AUC 6 IV every 3 weeks for 3 cycles with radiation +/- adjuvant chemotherapy with carboplatin AUC 5 IV on day 1 plus fluorouracil (5-FU) 1000 mg/m2/day by continuous IV infusion on days 1-4 every 3 weeks for 2 cycles [7]
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Radiation doses during concurrent chemoradiation are up to 70 Gy (2.0 Gy/fraction)
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Induction chemotherapy with docetaxel 70 mg/m2 IV on day 1 plus cisplatin 75 mg/m2 IV on day 1 plus 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 [8]
First-line chemotherapy for metastatic or recurrent nasopharyngeal cancers
Stage IVB:
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Patients with metastatic nasopharyngeal cancers or recurrent disease (after first-line therapy) are treated with standard platinum-based chemotherapies
Acceptable chemotherapy regimens in patients with metastatic, progressing, or recurrent nasopharyngeal cancers (unless otherwise stated, goal is to complete 4-6 cycles):
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Cisplatin 75 mg/m2 IV on day 1 plus paclitaxel 175 mg/m2 IV on day 1 every 3wk [14, 15] or
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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 [16] or
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Cisplatin 50-70 mg/m2 IV on day 1 plus gemcitabine 1000 mg/m2 IV on days 1, 8, and 15 every 4wk [24, 25] or
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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 [26] or
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Gemcitabine 1000 mg/m2 IV plus vinorelbine 25 mg/m2 IV on days 1 and 8 every 21 days [27] or
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Gemcitabine 1250 mg/m2 IV on days 1 and 8 every 3wk [29] or
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Methotrexate 40 mg/m2 IV weekly (3wk equals one cycle) [10, 20] or
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Paclitaxel 200 mg/m2 IV every 3wk [30] or
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Capecitabine 1.250 mg/m2 PO BID) on days 1-14 every 21 days for at least two cycles [10, 36]
Second- and third-line chemotherapy for metastatic or recurrent nasopharyngeal cancers
Stage IVC:
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Second-line chemotherapy is given after disease progression or recurrence following completion of first-line therapy
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Third-line therapies are given after disease progression or recurrence following completion of first- and second-line therapies
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Second- and third-line regimens are similar to regimens used as first-line therapy but usually offer lower response rates and survival benefits
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Patients should be treated with platinum-based chemotherapies if they have not previously received a platinum-based drug
Acceptable chemotherapy regimens in patients with metastastic, progressing or recurrent nasopharyngeal cancers after completion of first-line therapy:
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Cisplatin 75 mg/m2 IV on day 1 plus docetaxel 75 mg/m2 IV on day 1 every 3wk [11] or
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Carboplatin AUC 6 IV on day 1 plus docetaxel 65 mg/m2 IV on day 1 every 3wk [16] or
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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 [26] or
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Gemcitabine 1000 mg/m2 IV plus vinorelbine 25 mg/m2 IV on days 1 and 8 every 21 days [27] or
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Gemcitabine 1000 mg/m2 IV on days 1, 8, and 15 every 4wk or
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Methotrexate 40 mg/m2 IV weekly (3wk equals 1 cycle) or
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Paclitaxel 200 mg/m2 IV every 3wk [30] or
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Pembrolizumab if PD-L1 positive; 10 mg/kg IV every 2wk up to 2 years or until disease progression or unacceptable toxicity [39, 10]
