The first 60 days: Locoregionally advanced nasopharyngeal carcinoma (stage III to IVA)
Locoregionally advanced nasopharyngeal carcinoma is nasopharyngeal cancer, the Epstein-Barr-virus-driven cancer behind the nose, that has grown into nearby structures or neck lymph nodes but not further. It is treated without surgery, by precise radiotherapy with cisplatin, usually after gemcitabine and cisplatin chemotherapy and in recent trials with PD-1 immunotherapy; most patients are cured. Below, week by week, is what OnCo's record of Locoregionally advanced nasopharyngeal carcinoma (stage III to IVA) says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
MRI of the nasopharynx and neck, PET-CT or CT of chest and abdomen with bone scan, plasma EBV DNA, dental and audiological assessment.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- RadiologistNamed in the standard of care for: Staging, Follow-up.
- Medical oncologistNamed in the standard of care for: Stage III to IVA, standard, After chemoradiotherapy, Immunotherapy in the curative setting.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Stage III to IVA, standard, Immunotherapy in the curative setting, Follow-up.
- Palliative and supportive care teamNamed in the standard of care for: Follow-up.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
- 1.Stage III to IVA, standardCSCO/ASCO guideline on nasopharyngeal carcinoma 2021; NCCN Head and Neck Cancers
Induction gemcitabine and cisplatin for three cycles followed by intensity-modulated radiotherapy (70 Gy) with concurrent cisplatin; TPF induction as an alternative.
- 2.After chemoradiotherapyCSCO/ASCO guideline on nasopharyngeal carcinoma 2021; NCCN Head and Neck Cancers
Metronomic capecitabine for one year in high-risk patients; EBV DNA-directed adjuvant therapy in trials (NRG-HN001).
- 3.Immunotherapy in the curative settingCSCO/ASCO guideline on nasopharyngeal carcinoma 2021; NCCN Head and Neck Cancers
PD-1 antibody (sintilimab in CONTINUUM; toripalimab and camrelizumab in trials) added to induction and chemoradiotherapy in high-risk disease, adopted in China.
Plasma EBV DNA, MRI and nasopharyngoscopy; management of xerostomia, hearing loss, hypothyroidism and hypopituitarism.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example Plasma EBV DNA, EBER in situ hybridisation on biopsy, TNM stage on MRI of the nasopharynx and neck and PET-CT, Response to induction chemotherapy on MRI, PD-L1), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include Stage III nasopharyngeal carcinoma, Stage IVA nasopharyngeal carcinoma, Non-keratinising undifferentiated EBV-associated nasopharyngeal carcinoma.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Staging
- For my situation (staging), which of the standard options do you recommend and why?Guideline options include: MRI of the nasopharynx and neck, PET-CT or CT of chest and abdomen with bone scan, plasma EBV DNA, dental and audiological assessment.
Stage III to IVA, standard
- For my situation (stage iii to iva, standard), which of the standard options do you recommend and why?Guideline options include: Induction gemcitabine and cisplatin for three cycles followed by intensity-modulated radiotherapy (70 Gy) with concurrent cisplatin; TPF induction as an alternative.
- Am I a candidate for Gemcitabine + cisplatin, Cisplatin, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
After chemoradiotherapy
- For my situation (after chemoradiotherapy), which of the standard options do you recommend and why?Guideline options include: Metronomic capecitabine for one year in high-risk patients; EBV DNA-directed adjuvant therapy in trials (NRG-HN001).
- Am I a candidate for Capecitabine, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Immunotherapy in the curative setting
- For my situation (immunotherapy in the curative setting), which of the standard options do you recommend and why?Guideline options include: PD-1 antibody (sintilimab in CONTINUUM; toripalimab and camrelizumab in trials) added to induction and chemoradiotherapy in high-risk disease, adopted in China.
- Am I a candidate for Camrelizumab, Toripalimab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of A Study of YL201 in Combination With Toripalimab and With or Without Cisplatin in Nasopharyngeal Carcinoma. apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Follow-up
- For my situation (follow-up), which of the standard options do you recommend and why?Guideline options include: Plasma EBV DNA, MRI and nasopharyngoscopy; management of xerostomia, hearing loss, hypothyroidism and hypopituitarism.
Any stage
- Are there clinical trials I could join, for example of Toripalimab, Camrelizumab, Proton therapy, A Study of YL201 in Combination With Toripalimab and With or Without Cisplatin in Nasopharyngeal Carcinoma.?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “Which patients can safely have less chemotherapy or radiotherapy is being defined trial by trial”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Late toxicities of skull-base radiotherapy last for life”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Locoregionally advanced nasopharyngeal carcinoma (stage III to IVA): the full pageLocoregionally advanced nasopharyngeal carcinoma is nasopharyngeal cancer, the Epstein-Barr-virus-driven cancer behind the nose, that has grown into nearby structures or neck lymph nodes but not further. It is treated without surgery, by precise radiotherapy with cisplatin, usually after gemcitabine and cisplatin chemotherapy and in recent trials with PD-1 immunotherapy; most patients are cured.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- Plasma EBV DNA: Fragments of Epstein-Barr virus DNA in the blood that measure nasopharyngeal carcinoma: used to screen healthy people in endemic regions, to stage, to decide who needs extra treatment after radiotherapy, and to detect relapse.
- Head and neck subsites (oral cavity, oropharynx, larynx): Head and neck cancer is really several cancers named by exact location: mouth (oral cavity), back of the throat (oropharynx, where HPV cancers arise), voice box (larynx), lower throat (hypopharynx) and behind the nose (nasopharynx).
- Epstein-Barr virus (EBV) in cancer: The common glandular-fever virus, carried lifelong by most adults, which in a minority of people drives nasopharyngeal cancer, some stomach cancers and several lymphomas.
- Chemoradiation (chemoradiotherapy, CRT): Radiotherapy given at the same time as chemotherapy, which sensitises the cancer to radiation.
Every term links to the glossary.