Induction chemotherapy in head and neck cancer: are we too ambitious?

Induction chemotherapy is not to be considered standard of care in locally advanced (LA) squamous cell carcinoma of the head and neck (SCCHN) [1]. The coffin of induction chemotherapy is even about to be nailed [2]. The causes of the apparently imminent demise are diverse. SCCHN is a heterogeneous disease with prognosis depending on tumor site, T and N stage, etiology of the disease (human papilloma virus, smoking or drinking). Consequently, in order to include sufficient patients, most induction chemotherapy trials enrolled patients with a wide variation in risk of local and/or distant relapse.

A reason for failure of induction chemotherapy trials, which is seldom highlighted, is the overambition and/or overoptimism of the head and neck cancer doctors who sought to demonstrate differences in survival of which we can question whether these were realistic. Of course, one of the reasons to seek a large difference was the neccessity to reduce the sample size in a disease that is relatively rare compared with breast cancer, lung cancer and colon cancer, in which disease trials commonly enroll thousands of patients. In order to illustrate this, we will compare the sample size, power and difference sought in recently published or presented SCCHN-induction chemotherapy trials to the sample size, power and difference sought in recent pivotal adjuvant trials in colon cancer, breast cancer and non-small-cell lung cancer (NSCLC).

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