Evaluation of the Tolerance of Afatinib in Combination With Docetaxel and Cisplatin in LAHNSCC Induction Chemotherapy (TAPIS)

Cancers of the upper aerodigestive tract correspond in the Western countries about 5% of cancers. They are treated by surgery, radiotherapy, and chemotherapy. Although progress in radio chemotherapy have reduced mortality and increase the rates of organ preservation in patients with locally advanced head and neck cancers, they have metastatic risk or particularly high local recurrence. The induction chemotherapy is a first-line treatment of cancer in which the patient receives doses of chemotherapy allowing to obtain a significant reduction in tumor size, and thus to avoid the surgery and to treat the tumor then by radiotherapy alone or combine by certain drugs. The standard treatment of induction chemotherapy currently used for the carcinoma of aerodigestive tract is TPF compose of 3 drugs: the docetaxel (or Taxotere®, T), the cisplatin (P) and the 5-fluorouracil (or 5FU, F). Despite of the relative efficacy of this treatment, which provides a survival benefit, it is necessary to find a combination of induction to be more effective and less toxic. That is why this study intended to check if a new combination called TPA in which the fluorouracil (F) is replaced by the afatinib (A), will be more beneficial. The afatinib is a powerful and irreversible inhibitor of the EGFR (human Epidermal Growth Factor Receptor type 1), HER2 and HER 4. The EGFR is associated with a pejorative prognosis and resistance to the treatments through its role in the proliferation (multiplication of tumoral cells), the cell survival and replication and angiogenesis (process of growth of new blood-vessels, vital in the growth of the malignant tumors). Afatinib has proved effective in patients in with local recurrence or metastatic squamous cell carcinoma of the head and neck after first line cisplatin based and tolerance is correct.

The rational of this study is based on the following elements:

• Cisplatin and docetaxel on the one hand and the afatinib on the other hand have proved effectiveness in head and neck cancers. The tolerance of their association is not known.
• In addition, several broad randomized trials have shown that it is possible to improve the effectiveness of induction chemotherapy in locally advanced head and neck carcinoma by the addition of Taxotere® to the cisplatin-5FU.
• Independently, it has been shown in carcinoma of the upper aerodigestive tract with recurrence or metastatic, that an anti-EGFR targeted therapy by cetuximab could improve the effectiveness of chemotherapy with cisplatin-5FU More recently, Taxotere® and Cisplatin + Cetuximab (or Erbitux®) combination for the treatment of head and neck squamous cell carcinoma has been tested in a broad study of phase II showing the good feasibility of this combination and a particularly high rate of tumoral response.
• Finally a comparative study of cetuximab versus afatinib showed an advantage in terms of tumoral response in support of afatinib.

From all these observations, the investigators can hypothesize that the addition of afatinib to the docetaxel and the cisplatin could be an induction treatment for locally advanced carcinoma both innovating and promising. Indeed, this regimen appears optimized in terms of efficiency, incorporating both the combination of the most active cytotoxic agents, Taxotere® and the cisplatin, but also potentially more effective than Erbitux®.

The purpose of the study is to determine the Maximum Tolerated Dose (MTD) of afatinib administrated in combination with docetaxel (Taxotere®) and cisplatin in induction chemotherapy of locally advanced head and neck carcinoma in order to move to a phase II, allowing the comparison with standard induction chemotherapy TPF.

It is a multicentric, national, opened, not-randomized phase Ib. Three doses of the afatinib (20, 30 and 40 Mg per day) will be studied in combination with the fixed standard doses of the docetaxel and the cisplatin. For each dose level, beginning with smallest (20 Mg per day of afatinib), 3 to 6 patients will be treated at maximum, i.e. 3 cycles of three weeks treatment each one (9 weeks on the whole). The next dose level will be studied only if the previous dose is well tolerated for the period of the first 4 weeks observation of the treatment (1st cycle and first week of the 2nd cycle). Once the MTD is determine, four additional patients will be treated with this dose. A maximum of 22 patients should be included in this study. The total duration of the study is estimated at 18 months. In case of major safety problems, the study may be stopped earlier. In short, the preclinical data, pharmacological and clinical on afatinib indicate that the benefit-risk ratio can be regarded as positive and that the association of afatinib with cisplatin and docetaxel could be effective in patients with head and neck squamous cell carcinoma potentially resulting in an extension of time to progression.