Controversies and challenges in the current management of nasopharyngeal cancer

Nasopharyngeal carcinoma is uncommon worldwide, but poses a significant public health burden in endemic regions. Primary treatment for nonmetastatic disease is by radiation therapy, which has evolved from simple 2D-planning techniques to intensity-modulated radiation therapy. The role of systemic therapy has also become more prominent, with concurrent cisplatin-based chemoradiation the current standard of care for locally advanced disease based on multiple Phase III studies. Based on these advances, the prognosis of nasopharyngeal carcinoma appears to have improved significantly over the past two decades. Nevertheless, there are areas of substantial uncertainty and divergent views in the optimal treatment strategy. Distant metastases have become the dominant mode of treatment failure with the excellent local control provided by intensity-modulated radiation therapy. Recent studies have focused on this challenge of treating micrometastases while keeping toxicities manageable. Radiation therapy techniques continue to be refined to maintain consistently high locoregional tumor control while decreasing the probability of acute and late toxicities. This article discusses some of the current issues confronting the multidisciplinary team managing this disease.