Head & neck: Oropharynx — de-intensification and trial enrolment

A 47-year-old never-smoker has a p16-positive, low-stage oropharyngeal squamous cell carcinoma. At the multidisciplinary team meeting a colleague proposes reducing the radiotherapy dose and omitting concurrent cisplatin outside any study, reasoning that HPV-positive tumours respond very well and that this will spare late toxicity. What is the most appropriate position to take?

1. AOffer surgery alone, as transoral resection always avoids the need for any adjuvant treatment in HPV-positive disease
2. BReplace cisplatin with cetuximab to de-intensify while preserving the radiosensitiser
3. CProceed with the reduced-dose, chemotherapy-free regimen as routine care because HPV-positive disease justifies de-intensification
4. DReduce only the nodal dose while maintaining the primary-site dose, as a compromise outside a trial
5. EDo not offer de-intensification of curative treatment outside a clinical trial; treat with standard radical chemoradiotherapy or enrol in a de-escalation study