Cetuximab Plus Chemoradiotherapy in Immunocompetent Patients With Anal Carcinoma: A Phase II Eastern Cooperative Oncology Group–American College of Radiology Imaging Network Cancer Research Group Trial (E3205)

Abstract

Purpose Squamous cell carcinoma of the anal canal (SCCAC) is characterized by high locoregional failure (LRF) rates after sphincter-preserving definitive chemoradiation (CRT) and is typically associated with anogenital human papilloma virus infection. Because cetuximab enhances the effect of radiation therapy in human papilloma virus-associated oropharyngeal squamous cell carcinoma, we hypothesized that adding cetuximab to CRT would reduce LRF in SCCAC. Methods Sixty-one patients with stage I to III SCCAC received CRT including cisplatin, fluorouracil, and radiation therapy to the primary tumor and regional lymph nodes (45 to 54 Gy) plus eight once-weekly doses of concurrent cetuximab. The study was designed to detect at least a 50% reduction in 3-year LRF rate (one-sided α, 0.10; power 90%), assuming a 35% LRF rate from historical data. Results Poor risk features included stage III disease in 64% and male sex in 20%. The 3-year LRF rate was 23% (95% CI, 13% to 36%; one-sided P = .03) by binomial proportional estimate using the prespecified end point and 21% (95% CI, 7% to 26%) by Kaplan-Meier estimate in a post hoc analysis using methods consistent with historical data. Three-year rates were 68% (95% CI, 55% to 79%) for progression-free survival and 83% (95% CI, 71% to 91%) for overall survival. Grade 4 toxicity occurred in 32%, and 5% had treatment-associated deaths. Conclusion Although the addition of cetuximab to chemoradiation for SCCAC was associated with lower LRF rates than historical data with CRT alone, toxicity was substantial, and LRF still occurs in approximately 20%, indicating the continued need for more effective and less toxic therapies.

Pooled Analysis of external-beam RADiotherapy parameters in phase II and phase III trials in radiochemotherapy in Anal Cancer (PARADAC)

“…LRF was the predominant pattern of relapse, with a 5-year LRF rate in accordance with recent trials [28][29][30]. Shorter OTTs were significantly associated with less LRF, as were small tumor sizes for tumors of the anal canal and female gender.…”

Anal cancer: French Intergroup Clinical Practice Guidelines for diagnosis, treatment and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, SNFCP)

“…The use of cetuximab in combination with standard radio-chemotherapy appeared deleterious, with particularly low response rates. However, in contrast a recent Phase II study seems to show promising results [51,52].…”

Cancer in People Living With HIV, Version 1.2018, NCCN Clinical Practice Guidelines in Oncology

“…In a post hoc analysis of ECOG 3205, the 3-year locoregional failure rate was 21% (95% CI, 7%-26%). 179 The toxicities associated with the regimen in ECOG 3205 (immunocompetent patients) were substantial, with grade-4 toxicity occurring in 32% of the study population and 3 treatment-associated deaths (5%). In AMC045 (PLWH), the 3-year locoregional failure rate was 20% (95% CI, 10%-37%) by Kaplan-Meier estimate.…”