Overview

The goal of this clinical research study is to learn which chemotherapy combination may be more effective in treating locally advanced head and neck squamous cell carcinoma (HNSCC). The side effects of these combinations will also be studied.

This study treatment consists of intensity-modulated radiation therapy (IMRT) and concurrent chemotherapy. For study chemotherapy, patients will be randomized between cisplatin or the combination of docetaxel and cetuximab. Subjects will be stratified depending on HPV status and the presence of ERCC-1 [4F9] in the tumor prior to randomization. The study will evaluate cisplatin vs. docetaxel-cetuximab in the overall population, and test which radiation and chemotherapy combination works best in relationship to how much ERCC-1 [4F9] is expressed in a tumor.

Eligibility

Inclusion Criteria:

• Pathologically confirmed squamous cell carcinoma, undifferentiated carcinoma, or poorly differentiated carcinoma of the oropharynx, larynx, or hypopharynx with no evidence of distant metastasis. Biopsy sampling of primary tumor with pathology report documenting diagnostic tissue type is required.
• Patients must have stage III, IVa or IVb disease as determined by imaging studies and complete head and neck exam. Staging evaluation should be in accordance with the American Joint Committee on Cancer Staging Manual, 7th edition.
• Patients with oropharyngeal squamous cell carcinoma may have p16(+) or p16(-) disease; in these patients, p16 status must be known prior to randomization. Assessment of p16 status may occur locally or centrally. Note: The definition of p16(+) disease is diffuse nuclear and cytoplasmic staining in ≥ 70% of tumor cells.
• Patients must be untreated with curative-intent surgery for current diagnosis of Stage III, IVa, or IVb disease. Diagnostic biopsy of primary tumor and/or nodal sites is permitted.
• Diagnostic simple tonsillectomy is permitted, provided patient has RECIST-measurable residual tumor and/or nodal disease.
• Patients with a second HNSCC primary tumor are eligible for this study, provided more than 2 years have elapsed since the first diagnosis of HNSCC, the original tumor was managed with surgery only (no adjuvant chemotherapy/radiotherapy), and has not recurred.
• Patients with simultaneous primaries or bilateral tumors are excluded, with the exception of patients with bilateral tonsil cancers or patients with T1-2, N0, M0 resected differentiated thyroid carcinoma, who are eligible.
• No prior systemic treatment (chemotherapy or biologic/molecular targeted therapy) or radiation treatment for head and neck cancer.
• Patients may have received chemotherapy or radiation for a previous, curatively treated non-HNSCC malignancy, provided at least 2 years have elapsed.
• Patients must be untreated with radiation above the clavicles.
• Patients with a history of curatively-treated non-HNSCC malignancy must be disease-free for at least 2 years except for carcinoma-in-situ of cervix, non-melanomatous skin cancer, or T1-2, N0, M0 resected differentiated thyroid carcinoma.
• Diagnostic primary tumor tissue must be available for ERCC1 staining
• Eastern Cooperative Oncology Group (ECOG) Performance Status 0-1 (See Appendix 8)
• Age ≥ 18
• Patients must have measurable disease according to RECIST 1.1
• Patients must have the following laboratory values measured within 14 days of

  registration

• Absolute neutrophil count (ANC) > 1500/mm3
• Hemoglobin (Hb) > 8.0 g/dL
• Platelet count (PLT) > 100,000/mm3
• Creatinine clearance ≥ 45 ml/min determined by 24-hour collection or estimated by the Cockraft-Gault formula:

        Calculated Creatinine Clearance = [(140-age) X (actual body weight in kg) X (0.85 if
        female)]/(72 X serum creatinine)
          -  Serum bilirubin < 2 mg/dL
          -  AST (aspartate aminotransferase) and ALT (alanine aminotransferase) < 3 times upper
             limit of normal (ULN)
          -  The following assessments are required within 14 days prior to registration: Na, K,
             Cl, glucose, Ca, Mg, and albumin. The following metabolic values will exclude patients
             from study enrollment:
          -  Serum calcium (ionized or adjusted for albumin) < 7 mg/dl (1.75 mmol/L) or > 12.5
             mg/dl (> 3.1 mmol/L) despite intervention to normalize levels
          -  Magnesium < 0.9 mg/dl (< 0.4 mmol/L) or > 3 mg/dl (> 1.23 mmol/L) despite intervention
             to normalize levels
          -  Potassium < 3.5 mmol/L or > 6 mmol/L despite intervention to normalize levels
          -  Sodium < 130 mmol/L or > 155 mmol/L despite intervention to normalize levels Note:
             Patients with an initial magnesium < 0.5 mmol/L (1.2 mg/dl) may receive corrective
             magnesium supplementation but should continue to receive either prophylactic weekly
             infusion of magnesium and/or oral magnesium supplementation (eg, magnesium oxide) at
             the investigator's discretion.
          -  No prior severe infusion reaction to a monoclonal antibody
          -  Written informed consent must be obtained from all patients prior to beginning
             therapy. Patients should have the ability to understand and the willingness to sign a
             written informed consent document.
          -  Informed consent must be obtained from all patients prior to beginning therapy,
             including consent for mandatory tissue submission for ERCC1 staining (and p16 staining
             if not locally conducted). Patients should have the ability to understand and the
             willingness to sign a written informed consent document.
          -  No unstable angina or myocardial infarction within the prior 6 months; no symptomatic
             congestive heart failure; no serious cardiac arrhythmia requiring medication; no
             cerebrovascular ischemia or stroke within the past 6 months.
          -  No uncontrolled intercurrent illness including active infection, uncontrolled
             diabetes, uncontrolled hypertension, or uncontrolled psychiatric illness which in the
             investigator's opinion would limit compliance with study requirements or compromise
             patient safety.
          -  Women must not be pregnant or breast feeding because chemotherapy and/or cetuximab may
             be harmful to the fetus or the nursing infant. Pregnant women are excluded from this
             study because chemotherapy and/or cetuximab have the potential for teratogenic or
             abortifacient effects.
          -  Women of child-bearing potential and men must agree to use adequate contraception
             (hormonal or barrier method of birth control) prior to study entry and for the
             duration of study participation. Should a woman become pregnant or suspect she is
             pregnant while in this study, she should inform her treating physician immediately.
             All females of childbearing potential must have a blood test or urine study within 14
             days of registration to rule out pregnancy.
          -  HIV-positive patients receiving combination anti-retroviral therapy are excluded from
             the study because of possible drug interactions with study drugs. Appropriate studies
             will be undertaken in patients receiving combination anti-retroviral therapy when
             indicated. Note: HIV testing is not required for entry into this protocol.
          -  Patients may not be receiving any other anti-neoplastic investigational agents.