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Head & neck: Oropharynx — definitive concurrent chemoRT (HPV-positive)

Free question published 02 August 2026

Head & neckOropharynx — definitive concurrent chemoRT (HPV-positive)

A 49-year-old never-smoker has a p16-positive squamous cell carcinoma of the base of tongue with bilateral small-volume nodal disease, staged as locally advanced and suitable for definitive non-surgical treatment. He has normal renal function, no significant hearing loss and an ECOG performance status of 0. He has read online that cetuximab is 'gentler' than chemotherapy and asks whether he can have radiotherapy with cetuximab instead of cisplatin. What is the most appropriate concurrent systemic agent to recommend with his radical radiotherapy?

  1. ACarboplatin, as it is non-inferior to cisplatin and avoids the need to compare with cetuximab
  2. BRadiotherapy alone, since HPV-positive oropharyngeal disease has excellent prognosis without concurrent or adjuvant systemic therapy
  3. CCetuximab, as it achieves equivalent survival with less toxicity in HPV-positive disease
  4. DCetuximab followed by adjuvant cisplatin to combine the benefits of both
  5. EHigh-dose cisplatin as cetuximab shows inferior survival and locoregional control in HPV-positive cancer

Why E is correct

Both the De-ESCALaTE HPV and RTOG 1016 randomised trials showed that substituting cetuximab for cisplatin in HPV-positive oropharyngeal cancer produced inferior overall survival and worse locoregional control without a meaningful reduction in severe toxicity. The 2020 EHNS-ESMO-ESTRO guideline and UK practice therefore retain high-dose cisplatin as the standard concurrent agent for platinum-eligible patients.

And why the others are not

  • AWrong — carboplatin was not the comparator in these trials and is not established as non-inferior to cisplatin in this definitive setting; cisplatin remains standard for a fit patient.
  • BWrong — de-intensification including omitting concurrent chemotherapy is not standard care and, per NICE NG36, should only occur within a clinical trial.
  • CWrong — cetuximab gave inferior survival and was not less toxic for severe (grade 3-5) events in De-ESCALaTE, so it is not equivalent.
  • DWrong — this sequence is not an evidence-based regimen; the standard is concurrent high-dose cisplatin with radiotherapy.

Source De-ESCALaTE HPV — radiotherapy plus cisplatin or cetuximab in low-risk HPV-positive oropharyngeal cancer — Mehanna H, Robinson M, Hartley A, et al. Lancet 2019;393(10166):51-60. DOI 10.1016/S0140-6736(18)32752-1.

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