CHART revisited: a conservative approach for advanced head and neck cancer

To evaluate the long-term late adverse effects and treatment outcome in patients treated for advanced squamous cell carcinomas of the head and neck with continuous, hyperfractionated, accelerated radiation therapy (CHART).

One hundred and twenty-six consecutive patients were entered into a non-randomised study of CHART alone with salvage treatment reserved for locoregional recurrence. The primary end points were locoregional control and late treatment-related morbidity. Time-incidence curves and statistical comparisons were obtained by computing actuarial event-free intervals using the product-limit (Kaplan-Meier) method. The prevalence rate of adverse effects was calculated using yearly intervals. Patients have been followed over a 15-year period.

The actuarial 12-year locoregional recurrence-free rate after radiotherapy alone was 46%, which was increased by 15% with the use of salvage treatment (hazard ratio for recurrence with CHART alone 1.23, confidence interval 1.017-1.494; P=0.033). Actuarial estimates of severe adverse effects at this time were: dysphagia 12% (grade 4); subcutaneous fibrosis 3%; xerostomia 15%. Ulcers of mucous membranes were observed in 18% of patients. As expected, the prevalence of events was lower than that calculated by the life-table method.

Few, if any, studies have documented and reported on long-term adverse effects and treatment outcomes as in this pilot trial of CHART (median follow-up time of those alive at 5 years or more is 11 years and the maximum follow-up time is 18 years). The low level of moderate to severe long-term morbidity together with a good and maintained level of locoregional tumour control indicates that CHART achieves a therapeutic benefit in patients with advanced squamous cell carcinoma of the head and neck.