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

Aims: 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). Materials and methods: 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. Results: 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. Conclusions: 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.