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Ezra Cohen, MD, explains that the incorporation of cetuximab in his practice has primarily been in the setting of metastatic head and neck cancer (HNC), regardless of human papillomavirus (HPV) status. The EXTREME trial demonstrated that the use of platinum (cisplatin or carboplatin)/5-fluorouracil (FU) combined with cetuximab in patients with recurrent or metastatic HNC. The triple combination improved overall survival, progression-free survival, and overall response rates compared with platinum/5FU alone. Cohen says that, in his opinion, the triplet regimen is the best available option for metastatic HNC. He notes, however, that the combination may not be appropriate for everyone, as it involves cytotoxic agents. Cohen initiates triplet therapy in patients who are fairly healthy and have good performance status, and especially in those with symptomatic disease.
Phase III, level 1 evidence showed that cetuximab as an add-on to radiation therapy is beneficial in locally advanced disease, particularly those who are HPV-positive. Most HPV-positive HNC patients tend to be younger, fairly active individuals with few comorbidities, and Cohen considers this a situation where the majority of patients can be cured. He estimates that 70% of HPV-positive patients are cured. However, the relevance of long-term toxicities may be greater, as these patients will likely have to live with the consequences of their disease for many years. A regimen of cetuximab combined with radiation therapy may offer a lower toxicity rate and better long-term quality of life than some of the other available options.