[Contribution to survival rate improvement]

For patients with locally advanced HNSCC, where the outcome with conventional radiotherapy is poor, meta-analysis and collective data showed a high level of evidence of loco-regional control improvement by altered fractionated radiotherapy, chemo-radiotherapy with a concomitant approach. For these patients, much evidence indicates overall survival may be improved by concomitant chemo-radiotherapy or hyper-fractionated radiotherapy delivered with increased total dose. There was a significant survival benefit with altered fractionated radiotherapy, corresponding to an absolute benefit of 3.4% at 5 years. The benefit was significantly higher with hyper-fractionated radiotherapy (8% at 5 years)than with accelerated radiotherapy (2% with accelerated fractionation without total dose reduction and 1.7% with total dose reduction at 5 years). The effect was greater for the primary tumor than for nodal disease. The effect was also more pronounced in younger patients and in those with good performance status. Hyper-fractionation seemed to yield a more consistent advantage for survival than accelerated fractionated radiotherapy. However, accelerated radiotherapy might be associated with higher non-cancer-related death. Despite hundreds of clinical trials in patients with advanced disease, there is no absolute consensus about patient selection for altered fractionation regimens, type of chemo-radiotherapy association, and radiation of chemotherapy dose schedule. We have to evaluate whether the benefit of hyper-fractionated radiotherapy versus standard radiotherapy persists when combined with concomitant chemotherapy and the benefit of IMRT compared with altered fractionation.