Low-Dose Weekly vs High-Dose Cisplatin

NCT ID: NCT03649048

Last Updated: 2025-07-31

Basic Information

• Recruitment Status: RECRUITING
• Clinical Phase: NA
• Total Enrollment: 100 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2018-11-05
• Study Completion Date: 2028-09-30

Brief Summary

This study is a prospective open-label randomized clinical trial. Following informed consent eligible LASCCHN patients (n=100) planned for CRT will be stratified by tumor p16 status and then randomized in a 1:1 fashion to either concurrent HD cisplatin or concurrent weekly LD cisplatin.

Detailed Description

Human papilloma virus-related oropharynx cancer is increasing in incidence and is now the most common indication for LASCCHN CRT. It more commonly affects younger patients without other comorbidities and is associated with high rates of cure. This creates a survivorship dilemma, as these patients suffer a greater and more prolonged impact from chronic treatment effects such as hearing loss on their HRQOL. Furthermore, this cohort of patients is more likely to be engaged in contributing to societal and economic productivity for a more prolonged period of time. Minimizing long term side effects through strategies to better individualize treatment has been recognized as a priority by the US NIH.

Efforts to identify risk factors for cisplatin toxicity have been previously reported in pediatric cancer patients. Pussegoda and colleagues identified greater risk of hearing loss with cisplatin in children who carried single nucleotide polymorphisms (SNPs) in thiopurine S-methyltransferase (TPMT) and catechol-O-methyltransferase (COMT) genes. However, the role of these genes in predicting ototoxicity risk has remained controversial with both confirmatory and conflicting reports. Two independent studies identified SNPs in the gene acylphosphatase 2 (ACYP2) as being predictive of ototoxicity in pediatric populations. Additional studies have implicated drug transporters involved in cisplatin disposition including the multidrug and toxin extrusion protein 1 (MATE1) to be associated with platinum response and toxicities. In vitro experiments and know-out studies identified cisplatin as a substrate of MATE1. To date, there remains a paucity of data investigating the association between genetic factors and hearing loss in adult LASCCHN patients. A prospective cohort study conducted at LHSC in collaboration with Dr. Richard Kim studied 206 adult LASCCHN patients receiving CRT with cisplatin and identified four independent risk factors for cisplatin-related hearing loss. Risk of hearing loss was increased with the presence of COMT SNPs (HR = 1.75; 95% CI, 1.17 - 2.52) while MATE1 reduced the risk (HR = 0.46; 95% CI, 0.26 - 0.84). The risk of hearing loss was reduced with cisplatin administered on a weekly low dose (LD) compared to a HD schedule. PFS and OS were similar between SNP cohorts and patients treated with weekly LD cisplatin and HD cisplatin regimens. To validate these results and confirm benefits on the pragmatic endpoint of hearing-related QOL, the investigators propose a prospective randomized clinical trial comparing HD and weekly LD cisplatin.

Opinion leaders such as the National Comprehensive Cancer Network guidelines endorse the use of weekly LD cisplatin as a reasonable alternative to HD cisplatin when administered concurrently with radiation. While the study conducted at LHSC observed weekly LD patients had reduced ototoxicity with similar efficacy compared to HD patients, there is no randomized control trial data in LASCCHN to support this practice. Current American Society of Clinical Oncology (ASCO) guidelines support HD cisplatin in this setting based strength of evidence. Therefore, the optimal schedule and dosing of cisplatin when administered as part of CRT in the curative intent treatment of patients with LASCCHN remains unresolved supporting clinical equipoise as to which constitutes the "best" approach.

The investigators primary hypothesis is that LD weekly cisplatin 40 mg/m² is associated with reduced frequency of severe hearing loss and improved hearing-related QOL when compared to conventional HD cisplatin 100 mg/m² days 1, 22 & 43 (control arm) in LASCCHN patients treated with CRT. Furthermore, the investigators hypothesize that a significant proportion of the risk of cisplatin-related hearing loss is attributable to individual differences in pharmacogenomics factors affecting cisplatin disposition that could be identified prior to treatment.

Conditions

Locally Advanced Head and Neck Squamous Cell Carcinoma

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: SUPPORTIVE_CARE
• Blinding Strategy: NONE

Study Groups

ARM 1: High-Dose Cisplatin days 1, 22 & 43 with radiotherapy

Group Type: ACTIVE_COMPARATOR

High-Dose Cisplatin

Intervention Type: DRUG

Intravenous administration of High-Dose Cisplatin

Radiotherapy

Intervention Type: RADIATION

Participating centres are to follow their local radiation treatment planning and delivery techniques.

ARM 2: Low-Dose Cisplatin Q 1 wk + radiotherapy

Group Type: ACTIVE_COMPARATOR

Low-Dose Cisplatin

Intervention Type: DRUG

Intravenous administration of Low-Dose Cisplatin

Radiotherapy

Intervention Type: RADIATION

Participating centres are to follow their local radiation treatment planning and delivery techniques.

Interventions

High-Dose Cisplatin

Intravenous administration of High-Dose Cisplatin

Intervention Type: DRUG

Low-Dose Cisplatin

Intravenous administration of Low-Dose Cisplatin

Intervention Type: DRUG

Radiotherapy

Participating centres are to follow their local radiation treatment planning and delivery techniques.

Intervention Type: RADIATION

Eligibility Criteria

Inclusion Criteria

• Age 18 or older
• Willing and able to provide written informed consent
• Eastern Cooperative Oncology Group (ECOG) performance status 0-2
• Histologically or cytologically confirmed squamous cell carcinoma
• Primary tumor site includes oral cavity, oropharynx, nasal cavity, salivary glands (excluding parotid), hypopharynx, or larynx and primary unknown
• Patients must be deemed suitable for HD cisplatin therapy based on tumor characteristics, clinical condition and comorbidities in the judgement of the treating medical oncologist.
• Patients must be planned to receive radical intent radiation treatment based on clinical condition, comorbidities and tumor characteristics in the judgment of the treating radiation oncologist
• Adequate organ and marrow function independent of transfusion for at least 7 days prior to randomization defined as:

• Hemoglobin > 80 g/L; Absolute neutrophil count >1.5x10⁹ /L, platelets >100x10⁹/L; Bilirubin < 35 umol/L; AST or ALT < 3 x the upper limit of normal; Calculated creatinine clearance (as determined by Cockcroft- Gault) > 50 ml/min

Males:

Creatinine Clearance = Weight (kg) x (140 - Age) (mL/min) 72 x serum creatinine (mg/dL)

Females:

Creatinine Clearance = Weight (kg) x (140 - Age) x 0.85 (mL/min) 72 x serum creatinine (mg/dL)

• Patient must be assessed at head and neck cancer multidisciplinary clinic (with assessment by radiation oncologist and surgeon) and presented at multidisciplinary tumor board prior to randomization.

Exclusion Criteria

• Serious medical comorbidities or other contraindications to radiotherapy and/or chemotherapy.
• Prior history of head and neck cancer within 5 years.
• Nasopharyngeal primary confirmed or suspected.
• Severe hearing loss as determined clinically Pre-existing use of hearing aids.
• Peripheral neuropathy .grade 2 (CTCAE v4.02).
• Prior or planned neoadjuvant chemotherapy prior to CRT.
• Prior head and neck radiation at any time.
• Distant metastatic disease.
• Inability to attend full course of radiotherapy or follow-up visits.
• Prior invasive malignant disease unless disease-free for at least 5 years or more, with the exception of non-melanoma skin cancer or in-situ carcinoma.
• Unable or unwilling to complete QOL questionnaires.
• Pregnant or lactating women.
• Unable to use dual method of contraception.

• Minimum Eligible Age: 18 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

London Health Sciences Centre Research Institute OR Lawson Research Institute of St. Joseph's

OTHER

Sponsor Role: lead

Responsible Party

Responsibility Role: SPONSOR

Principal Investigators

Sara Kuruvilla, MD

Role: PRINCIPAL_INVESTIGATOR

London Health Sciences Centre, London Regional Cancer Program

Locations

Juravinski Cancer Centre

Hamilton, Ontario, Canada

Site Status: RECRUITING

London Regional Cancer Program

London, Ontario, Canada

Site Status: ACTIVE_NOT_RECRUITING

Sunnybrook Health Sciences Centre

Toronto, Ontario, Canada

Site Status: RECRUITING

Countries

Canada

Central Contacts

Sara Kuruvilla, MD

Role: CONTACT

sara@kuruvilla@lhsc.on.ca

(519)685-8500

Facility Contacts

Brandon Meyers, MD

Role: primary

meyersbr@hhsc.ca

905-521-2100

Martin Smoragiewicz, MD

Role: primary

martin.smoragiewicz@sunnybrook.ca

416-480-4617

Other Identifiers

Cisplatin HD vs LD

Identifier Type: -

Identifier Source: org_study_id