I am bringing this post back up as the sentiment it expresses has been raised elsewhere by others which could potentially undermine the faith of an individual with an HPV+ve tumour in their doctor who has recommended Erbitux (cetuximab) as their treatment.

I think this topic requires a bit more discussion and a little less blind acceptance.

I finally got around to reading the article that Charm refers to in this post and discovered it was a panel of doctors discussing a case of a 46 year old male with a recurrent HPV+ve tumour.

http://oralcancernews.org/wp/locore...ous-cell-carcinoma-of-the-head-and-neck/

The reference to cetuximab was a discussion point and was not part of the patient's treatment.

The quote that started this post is a point made by Dr Jimeno in response to a question about whether or not HPV status changes treatment decisions. Dr Jimeno refers to the study done at Memorial Sloan-Kettering and makes the comment that Erbitux was found to be inferior to cisplatin in HPV+ve tumours.

Because this comment flew in the face of my previous reading, I went looking for the study and discovered it has some serious shortcomings.

1. It is a retrospective study which also appears to be observational. This is pretty much the weakest level of evidence you can get with the exception of a case study.
2. The cisplatin group had 125 patients and the cetuximab group had 49. Such a disparity screams a warning. The obvious first thought is the cetuximab group was likely to have been selected for that treatment because they already had health issues which would preclude them from usual treatment of cisplatin. This makes them generally a "sicker" group to start with.
3. The cetuximab group were older and had a decreased creatinine clearance. This is proof that there are indeed issues as outlined in point 2.

Now this doesn't sound like much but it is a very big deal. This tells someone who can read a trial (and some doctors can't) that the results are only useful to indicate future research topics and then the paper should be used to rest one's coffee cup on to avoid rings on the desk.

I was only able to access the abstract or summary of this trial so cannot get to the details, but the abstract doesn't even mention HPV+ve positive tumours.

The study can be found in: Int J Radiat Oncol Biol Phys. 2011 Nov 15;81(4):915-22. Epub 2010 Oct 13.

So here's my point (finally). I notice that there are a number of people who are now suggesting that cetuximab is not a good treatment for HPV+ve tumours and as far as I can tell, it is based on this one study that has been quoted over and over elsewhere. I have been unable to find any other studies that suggest this and in fact, have found the opposite. The original trial that put cetuximab on the map for oral cancer was the trial by Bonner et al. Whilst his group didn't look at HPV status, there were a large proportion of oropharyngeal cancers and one would assume a percentage of them were HPV+ve. The oropharyngeal group did well on cetuximab which suggests that this is a viable treament for HPV+ve tumours as well.

I think that a "logical leap" has been made that cetuximab targets EGFR so is more effective when EGFR is over-expressed. This is flawed reasoning. EGFR over-expression correlates with a poor response to treatment and it doesn't matter which one, as they are all less effective in this setting.

Does anyone know of any work that has been done to suggest cetuximab is inferior for HPV+ve tumours?

For the record, Alex and I also rejected cetuximab as a adjunct but mainly because of lack of data at the time and because, as Charm has already pointed out, when cetuximab fails it does so spectacularly well. As Alex was young and relatively fit at the time, we felt he could cope with the cisplatin toxicities and the preference was to go with the drug with the proven track record.