MSK radiation oncologist Dr. Nancy Lee pioneered a new treatment approach that uses reduced radiation doses for HPV-related throat cancer, which greatly reduces side effects. “The difference in toxicity is dramatic,” she says.
An innovative radiation treatment approach that is typically given to patients after surgical removal of HPV-positive head and neck tumors may now help some of those patients avoid surgery altogether.
The approach, pioneered by Memorial Sloan Kettering Cancer Center (MSK) radiation oncologist Nancy Lee, MD, greatly reduces the overall radiation dose to minimize side effects.
“This has been an absolute game-changer for treating certain people with throat cancers” caused by the human papillomavirus (HPV), Dr. Lee says, and it can be extended to all other types of HPV-positive head and neck cancers. “The difference in toxicity is dramatic.”
The lower-dose treatment results in a much-improved quality of life by decreasing often-debilitating side effects that make eating and swallowing difficult and unpleasant. Multiple studies at MSK suggest that de-escalating treatment this way can still effectively control the cancer.
Radiation dosage is measured in units called Gray (Gy). The standard approach for treating head and neck cancer has been 70 Gy. In recent years, pioneering work by Dr. Lee has shown that many HPV-positive head and neck tumors can be safely treated with a 30-Gy dose. Dr. Lee is Vice Chair of the Department of Radiation Oncology, Service Chief of Head and Neck Radiation Oncology, and Service Chief of Proton Therapy at MSK.
Clinical Trial Results Presented at ASCO Annual Meeting
Results from a phase 2 clinical trial presented by Dr. Lee at the 2024 annual meeting of the American Society of Clinical Oncology show that many patients with HPV-positive throat cancer receiving lower doses of radiation can avoid surgery.
The trial involved 150 people with HPV-positive throat cancer. By using a specialized imaging technique, researchers could determine which patients would respond well to the reduced treatment without needing surgery first.
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111 patients (74%) were eligible for the reduced radiation treatment without surgery.
- The lower radiation dose controlled the HPV positive throat cancers effectively, with the overall survival rate at a median of 2 years being 100% for all patients who received the lower dose.
“We are challenging the traditional dogma of using a one-size-fits-all approach to treat cancer and changing it to a more personalized treatment,” Dr. Lee says. “This latest advance takes it even further, allowing most patients to avoid the risks that come with surgery — like bleeding, infection, and longer hospitalization.”
New Clinical Trial Enrolling to Test Low-Dose Radiation and Chemotherapy
MSK has now opened a randomized phase 3 clinical trial testing the low-dose technique in nearly 300 patients with HPV-positive throat cancer at seven MSK locations in the New York City area.
“We are looking forward to testing this approach in an even larger group,” Dr. Lee says.
For more information or to see if you can join this study, please call Dr. Lee’s office at 212-639-3341.
FMISO PET Scans Identify Low-Dose Radiation Patients
It is crucial to determine which patients are suitable for this approach in order to make sure that 30 Gy is high enough to treat their specific tumor. A specialized imaging technique called FMISO PET, which can reveal oxygen levels in tumors, is key to selecting the right patients.
Most head and neck cancers, including throat cancers, are non-hypoxic, which means they have normal levels of oxygen. Patients with these types of cancers are eligible for the lower dose of radiation. Hypoxic tumors, which have low oxygen levels, do not respond as well to radiation or chemotherapy, so they are not suitable for low-dose treatments.
In the January 2024 edition of the Journal of Clinical Oncology, Dr. Lee and colleagues reported earlier results from the same phase 2 clinical trial: FMISO PET reliably identified people with non-hypoxic tumors, validating that the low-dose approach was sound.
The latest results show that use of FMISO PET could enable certain patients to avoid surgery before the radiation.
“Dr. Lee has really pioneered using hypoxia imaging to pick out tumors that are more sensitive for this de-escalated regimen,” radiation oncologist Nadeem Riaz, MD, MSc, says. “MSK is a world leader in this approach.”
MSK researchers are also investigating ways for the FMISO PET approach to be used more widely. While MSK’s nuclear medicine physicians are highly trained at reading FMISO PET images to determine if a tumor is hypoxic, there has been no standardized criteria to guide physicians with less experience. This has presented a barrier for the low-dose radiation treatment approach to be approved by the FDA for widespread use.
A team led by nuclear medicine physicians Heiko Schöder, MD, and Rick Wray, MD, have developed a training program with standardized criteria so physicians of all levels know how to read the images and make the correct evaluation about hypoxic status of the tumor. They recently reported in the Journal of Nuclear Medicine that this approach worked well for nuclear medicine physicians of varying experience levels.
“Doctors have to be confident the right patients are being selected for the low-dose approach,” Dr. Wray says. “A standardized way of interpreting the images would make it possible for this method to be used almost anywhere FMISO PET is available.”
The standardized approach will be used in the phase 3 trial that is now beginning enrollment.
MSK’s History of Improving Quality of Life for Patients
The latest advance holds promise for helping many of the more than 20,000 people diagnosed with HPV-related head and neck cancers in the United States every year, according to the Centers for Disease Control. Cases have surged in recent years, especially in men. These types of cancer, sometimes grouped together as oropharyngeal cancer, usually respond well to a combination of surgery, radiation, and chemotherapy. In addition to the 70 Gy given with standard treatment, patients also have typically received three rounds of chemotherapy.
This standard treatment produces a high survival rate — close to 90% — but the treatment takes a major toll. Chemotherapy and radiation can cause mouth sores, difficulty swallowing, dry mouth, changes in taste, and nausea. Patients typically lose 20 to 30 pounds and may not be able to work for several months.
Noting earlier studies showing that only 30 Gy was needed to successfully treat HPV-positive anal cancer, Dr. Lee wanted to test that lower dose on certain HPV-positive head and neck cancers. In 2015, MSK radiation oncologists began treating select patients with only 30 Gy over three weeks and using only two cycles of chemotherapy. Patients had less throat pain, less fatigue, and less radiation burn.
“It’s really hard to describe the huge difference this makes,” Dr. Riaz says. “Using the smaller dose over just three weeks, they have almost no radiation side effects.”
Decreasing chemotherapy also eases the burden for patients. “Anytime we can safely reduce the amount of chemotherapy someone needs, we go for it,” says head and neck oncologist Anuja Kriplani, MD, MPH. “I always tell patients that I want them not only to be cancer free, but also to have a good quality of life after all of this is done.”
How MSK Is Expanding Low-Radiation Treatments to More Patients
Dr. Lee and colleagues have sought to broaden the use of the low-dose protocol. Some people with HPV-positive cancers are not eligible for the 30 Gy approach because of their tumor characteristics — usually if the tumors are too large. Also, the special imaging and frequent monitoring required for the de-escalated approach might not be feasible for a widespread population that is farther from major hospitals.
For these patients, MSK developed a slightly different, more accessible treatment plan. It involves first giving 30 Gy over three weeks to the visible tumor and its surrounding area to kill any stray cancer cells. Then, 40 more Gy are delivered in a highly precise manner — only to the visible tumor. The tumor still gets 70 Gy total, but the large surrounding regions receive only 30 Gy.
This hybrid approach means a larger patient group can benefit from reduced radiation. In 2022, Dr. Lee and other MSK colleagues reported the effectiveness of this technique in JAMA Oncology.
“Our approach of ‘30 Gy to the larger standard field, followed by 40 Gy customized to the visible tumor only’ works just as well, while significantly reducing side effects,” Dr. Lee says.
Dr. Lee and colleagues continue to investigate ways to deliver less-toxic treatments to more patients. The goal is to make 80% to 85% of people diagnosed with HPV-related head and neck cancers candidates for lower-dose therapy.
“In addition to dramatic improvement to patients’ quality of life, we’re saving them the hassle of having to come in every day,” Dr. Lee says. “They can get back to doing the things they love.”
Dr. Lee’s research receives essential philanthropic support from the MSK Giving community, including James and Diane Rowen and Nancy and Howard Marks.
This story was originally published in 2017 and has been updated multiple times with new information.
