Nasopharyngeal carcinoma (NPC) SACT

Scottish Cancer Network: Clinical Management Pathways
NHS National Services Scotland
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This consensus document is not a rigid constraint on clinical practice, but a concept of good practice against which the needs of the individual patient should be considered. It therefore remains the responsibility of the individual clinician to interpret the application of the Clinical Management Pathway (CMP), taking into account local service constraints and the needs and wishes of the patient. It is not intended that these consensus documents are applied as rigid clinical protocols.

Testing for variants in the gene associated with dihydropyrimidine dehydrogenase (DPYD) activity is recommended for all patients due to begin treatment with a fluoropyrimidine (fluorouracil, capecitabine, tegafur)

SACT regimens for Epstein-Barr Virus (EBV) related nasopharyngeal carcinoma (NPC)

 

NPC Induction SACT

Cisplatin/Gemcitabine 

Preferred first line

Cisplatin 80mg/m2 IV Day1 

Gemcitabine 1000mg/m2 IV Day 1 and 8 

 

Every 21 days, for 2-3 cycles. 

 

In cases of concern over renal/cardiac function or patient factors, can replace Cisplatin with Carboplatin AUC5 

Refer to regional or local protocols for carboplatin prescribing advice

TPF

Docetaxel 60mg/m2 IV Day 1 

Cisplatin 60mg/m2  IV Day 1 

5FU 3000mg/m2 IV Day 1 over 5 days  

 

Every 21 days for 2-3 cycles 

 

Alternative regimen:  

Docetaxel 75mg/m2 IV Day 1 

Cisplatin 75mg/m2 IV Day 1 

5FU 4000mg/m2 IV Day 1 over 4-5 days    

 

Every 21 days for 2-3 cycles 

Cisplatin/Fluorouracil  

Cisplatin 80mg/m2 IV Day 1  

5FU 4000mg/m2 IV Day 1 over 4-5 days  

 

Every 21 days for 2-3 cycles

 

Option to replace Fluorouracil with: 

Capecitabine 1000mg/m2 BD PO D1-14 (if oral route assessed as appropriate route of administration) 

 

In cases of concern over renal/cardiac function or patient factors, can replace cisplatin with carboplatin AUC5 

Refer to regional or local protocols for carboplatin prescribing advice

NPC Concurrent SACT with radiotherapy

Cisplatin

Cisplatin 100mg/m2 IV Week 1 and week 4 of Radiotherapy  

For 2-3 cycles* 

(maximum dose of surface area (SA)=2.00/m2) 

*For patients receiving 7 weeks of radiotherapy, a third cycle can also be considered on week 7 (day 43) 

 

Alternative regimen 

Cisplatin 40mg/m2 IV Week 1 of radiotherapy then weekly during radiotherapy for 6-7 cycles 

 

In cases of concern over renal/cardiac function or patient factors, switch Cisplatin to Carboplatin AUC5

Refer to regional or local protocols for carboplatin prescribing advice 

Carboplatin

Carboplatin AUC5 IV Week 1 and week 4 of Radiotherapy  

For 2-3 cycles  

 

For patients receiving 7 weeks of radiotherapy, a third cycle can also be considered on week 7 (day 43)  

 

Alternative regimen 

Carboplatin AUC 1.5 weekly for 6-7 cycles throughout radiotherapy 

 

Only consider if cisplatin not suitable  

Refer to regional or local protocols for carboplatin prescribing advice 

NPC Adjuvant SACT

Treatment options as per NPC Induction SACT section if no prior induction/neo-adjuvant treatment.  

Induction preferred option due to improved tolerability.

For treatment options refer to NPC Induction SACT section.

For adjuvant radiotherapy in combination with SACT refer to the NPC Concurrent SACT with Radiotherapy section.

 

NPC First-line non-curative SACT

Cisplatin/Gemcitabine 

Preferred first line

Cisplatin 80mg/m2 IV Day1 

Gemcitabine 1000mg/m2 IV Day 1 and 8 

 

Every 21 days, for 6-8 cycles. 

 

In cases of concern over renal/cardiac function or patient factors, can replace cisplatin with carboplatin AUC5 

Refer to regional or local protocols for carboplatin prescribing advice 

Cisplatin/Fluorouracil  

Cisplatin 80mg/m2 IV Day 1  

5FU 4000mg/m2 IV Day 1 over 4-5 days  

 

Every 21 days for 6-8 cycles

 

Option to replace Fluorouracil with: 

Capecitabine 1000mg/m2 BD PO D1-14 (if oral route assessed as appropriate route of administration) 

 

In cases of concern over renal/cardiac function or patient factors, can replace cisplatin with carboplatin AUC5 

Refer to regional or local protocols for carboplatin prescribing advice 

Carboplatin/PaclitaxelCarboplatin AUC 5 IV D1 

Paclitaxel 175mg/m2 IV D1 

 

Every 21 days for 6 cycles 

Refer to regional or local protocols for carboplatin prescribing advice 

NPC Second-line+ non-curative SACT

Nivolumab

Nivolumab 240mg IV every 2 weeks or Nivolumab 480mg IV every 4 weeks for up to 2 years 

 

In patients who have not received prior immunotherapy treatment for HNSCC (PD-L1 status not required) 

SMC1261/17 external link Nivolumab as monotherapy, for the treatment of squamous cell cancer of the head and neck (SCCHN) in adults progressing on or after platinum-based therapy. Nivolumab is subject to a two-year stopping rule.

Re-challenge with first-line SACT

Refer to the NPC First-line non-curative SACT section

Gemcitabine

Gemcitabine 1000mg/m2 IV Day 1, 8 and 15 every 28 days 

Until progression or unacceptable toxicity 

 

Alternative regimen 

Gemcitabine 1250mg/m2 IV Day 1 and 8 every 21 days 

Until progression or unacceptable toxicity 

Paclitaxel 

Paclitaxel 175mg/m2 IV Day 1  

Every 21 days, for 4-6 cycles  

 

Alternative regimen 

Paclitaxel 80mg/m2, IV, Day 1 

Every 7 days for 12-18 cycles

Methotrexate

Methotrexate 40mg/m2 IV day 1 every 7 days until progression or unacceptable toxicity 

Cetuximab

Cetuximab Loading dose 400mg/m2 IV then 250mg/m2 IV weekly until progression or unacceptable toxicity 

Docetaxel

Docetaxel 75mg/m2 IV every 21 days for up to 6 cycles  

 

Alternative regimen 

Docetaxel 30mg/m2 IV every 7 days for up to 18 cycles

Vinorelbine

Vinorelbine 30mg/m2 IV days 1, 8 and 15 every 21 days for up to 6 cycles or until progression or unacceptable toxicity

Regional SACT protocols

Links to Regional Guidance/Protocols where available (access to local intranet may be required):

NCA

NHS Highland 

NHS Grampian

(For Tayside protocols refer to Chemocare)

SCAN

WoSCAN