De-escalation for Human Papillomavirus-Positive Oropharyngeal Cancer: A Look at the Prospective Evidence.

Purpose of review: Although it is now firmly established that the presence of human papillomavirus (HPV) expression in oropharyngeal cancer is associated with a favorable prognosis, the implications with respect to treatment remain uncertain. However, the recognition that HPV-positive oropharyngeal cancer is exquisitely sensitive to radiation and chemotherapy has raised questions regarding the appropriateness of historical treatment paradigms, and clinical trials have been conducted to assess whether patients can be treated with less intensive regimens. The fundamental goal of de-escalation is to preserve the high rates of cure and survival from traditional approaches while reducing the incidence of both short- and long-term side effects. However, the data reporting on de-escalation is relatively limited.

Recent findings: While the evidence to date has been promising, the heterogeneity of the published studies particularly with trial design, de-escalation approach, inclusion criteria, and treatment selection has made drawing definitive conclusions difficult. The use of differing endpoints related to disease control and quality of life have also complicated the comparison of trials across the literature. Multiple uncertainties continue to exist with respect to the current state of de-escalation for HPV-positive oropharyngeal cancer, and how to consider the growing evidence in the context of clinical decision-making in the future is the subject of this review.