Progress in the comprehensive treatment of nasopharyngeal carcinoma: a review for risk-stratified management strategies

Abstract Purpose A “one-size-fits-all” treatment recommendation is not advisable for nasopharyngeal carcinoma (NPC). This article aims to review the risk-stratified strategies and propose future directions in NPC. Results For low-risk NPC patients, a review of literature shows that de-escalation approaches can be generally categorized into de-escalating systemic therapy and de-escalating radiotherapy. Studies have explored the exemption of concurrent chemotherapy in stage II and T3N0M0 NPC patients, as well as sparing concurrent chemotherapy after induction chemotherapy in selected low-risk patients,changing the cisplatin-based chemotherapy schedules, and doses. De-escalation of radiotherapy involves a reduction in dose and clinical treatment volume (CTV). For high-risk patients, increasing treatment intensity is commonly used, including selecting appropriate patients to receive induction or adjuvant chemotherapy or adding targeted therapy to standard chemo-radiotherapy to improve survival. In many instances, these risk-stratified approaches are guided by the measurement of Epstein-Barr virus DNA levels and various image-based modalities. Immunotherapy has shown initial efficacy in recurrent or metastatic NPC patients. The treatment advances of ICIs monotherapy in Locoregionally advanced NPC have remained scarce, and several phase II and III anti-PD-1/PD-L1 monoclonal antibody clinical trials are currently underway. Conclusions Various strategies for the risk-stratified treatment of NPC have been investigated and remain highly effective in most approaches. Optimization of patient selection is still critical, and both long-term oncological outcomes and late complications remain to be determined. More prospective, multi-institutional researches are needed to elucidate how best to individualize the treatment of NPC.