Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

stage 1 (T1, N0, M0)

1st line – radiation therapy

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ACUTE
|
stage 1 (T1, N0, M0)
1st line – 

radiation therapy

Radiation therapy without concurrent chemotherapy is the recommended treatment for patients with stage 1 disease.[2][19]​​​​​​​​​ In patients with clinically and radiographically undetectable nodal metastases (N0), reducing the nodal elective radiation therapy target volume to exclude level IV (low neck) can be considered.[30] 

Radiation therapy is the mainstay of treatment for nonmetastatic nasopharyngeal cancer (NPC) given that it is a radiosensitive tumor and typically in a location that limits complete surgical resection.[1][2]​​​[19]​​ The goal of treatment is cure for patients with nonmetastatic NPC.[2]

Conformal external beam radiation therapy (EBRT) techniques, including intensity-modulated radiation therapy (IMRT) and volumetric modulated arc therapy, are considered the standard of care.[1][2]​​ 

stage 2 (T2, N0, M0)

1st line – radiation therapy

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ACUTE
|
stage 2 (T2, N0, M0)
1st line – 

radiation therapy

Radiation therapy is the recommended treatment for patients with low-risk stage 2 disease (N0 and pretreatment plasma Epstein-Barr virus DNA <4000 copies/mL).[1][19]​​​​ In patients with clinically and radiographically undetectable nodal metastases (N0), reducing the nodal elective radiation therapy target volume to exclude level IV (low neck) can be considered.[1][30]​​​ 

Radiation therapy is the mainstay of treatment for nonmetastatic nasopharyngeal cancer (NPC) given that it is a radiosensitive tumor and typically in a location that limits complete surgical resection.[1][2]​​​[19]​​ The goal of treatment is cure for patients with nonmetastatic NPC.[2] 

Conformal external beam radiation therapy (EBRT) techniques, including intensity-modulated radiation therapy (IMRT) and volumetric modulated arc therapy, are considered the standard of care.[1][2]​​​​

Consider – chemotherapy

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ACUTE
|
stage 2 (T2, N0, M0)
Consider – 

chemotherapy

Treatment recommended for SOME patients in selected patient group

Use concurrent chemotherapy if high-risk features are present (such as bulky tumor volumes or high EBV DNA copy number).[1][19]​​

Cisplatin should be considered as the standard concurrent chemotherapy agent.[1][2]​​[19]​​ For patients who cannot tolerate cisplatin (e.g., if there is preexisting chronic kidney disease or hearing impairment), carboplatin is a reasonable alternative.[1][19]

Recommended chemotherapy regimens are based on NCCN guidelines and are preferred regimens.[19]​ Other alternative regimens are also recommended and you should consult your local guidelines for more information.

See local specialist protocol for dosing guidelines.

Primary options

cisplatin

Secondary options

carboplatin

stage 2 (T0 (EBV+)-T2, N1, M0)

1st line – chemoradiation

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ACUTE
|
stage 2 (T0 (EBV+)-T2, N1, M0)
1st line – 

chemoradiation

National Comprehensive Cancer Network (NCCN) guidelines recommend concurrent chemotherapy and radiation therapy.[19]

Radiation therapy is the mainstay of treatment for nonmetastatic nasopharyngeal cancer (NPC) given that it is a radiosensitive tumor and typically in a location that limits complete surgical resection.[1][2]​​​[19]​​ The goal of treatment is cure for patients with nonmetastatic NPC.[2]

Conformal external beam radiation therapy (EBRT) techniques, including intensity-modulated radiation therapy (IMRT) and volumetric modulated arc therapy, are considered the standard of care.[1][2]​​

Cisplatin should be considered as the standard concurrent chemotherapy agent.[1][2]​​[19]​ For patients who cannot tolerate cisplatin (e.g., if there is preexisting chronic kidney disease or hearing impairment), carboplatin is a reasonable alternative.[1][19]​ Recommended chemotherapy regimens are based on NCCN guidelines and are preferred regimens.[19]​ Other alternative regimens are also recommended and you should consult your local guidelines for more information. 

See local specialist protocol for dosing guidelines.

Primary options

cisplatin

Secondary options

carboplatin

Consider – induction or adjuvant chemotherapy

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ACUTE
|
stage 2 (T0 (EBV+)-T2, N1, M0)
Consider – 

induction or adjuvant chemotherapy

Treatment recommended for SOME patients in selected patient group

The addition of induction chemotherapy (prior to the radiation therapy) or of adjuvant chemotherapy is generally not recommended but could be considered after multidisciplinary discussion in select patients with large tumor burden or very high pretreatment Epstein-Barr virus DNA copy number.[1][19]​​

Preferred induction regimens include gemcitabine plus cisplatin, or docetaxel plus cisplatin plus fluorouracil. Preferred adjuvant regimens include cisplatin (or carboplatin if cisplatin ineligible or intolerant) plus fluorouracil.[19] 

Recommended chemotherapy regimens are based on NCCN guidelines and are preferred regimens.[19]​ Other alternative regimens are also recommended and you should consult your local guidelines for more information.

See local specialist protocol for dosing guidelines.

Primary options

Induction regimen

gemcitabine

and

cisplatin

OR

Induction regimen

docetaxel

and

cisplatin

and

fluorouracil

OR

Adjuvant regimen

cisplatin

or

carboplatin

-- AND --

fluorouracil

stage 3 (T3, N0, M0)

1st line – chemoradiation

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ACUTE
|
stage 3 (T3, N0, M0)
1st line – 

chemoradiation

Discuss the treatment strategy with the multidisciplinary team for patients with advanced nasopharyngeal cancer (NPC).[2]

Use radiation therapy plus concurrent chemotherapy for patients with stage 3 (T3, N0, M0) disease.[1][2]​​[19]

Cisplatin should be considered as the standard concurrent chemotherapy agent.[1][2]​​[19]​​ For patients who cannot tolerate cisplatin (e.g., if there is preexisting chronic kidney disease or hearing impairment), carboplatin is a reasonable alternative.[1][19]

Recommended chemotherapy regimens are based on NCCN guidelines and are preferred regimens.[19]​ Other alternative regimens are also recommended and you should consult your local guidelines for more information.

See local specialist protocol for dosing guidelines.

Primary options

cisplatin

Secondary options

carboplatin

Consider – induction or adjuvant chemotherapy

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ACUTE
|
stage 3 (T3, N0, M0)
Consider – 

induction or adjuvant chemotherapy

Treatment recommended for SOME patients in selected patient group

The addition of induction chemotherapy (prior to the radiation therapy) or of adjuvant chemotherapy to chemoradiation is generally not recommended for these patients with a more extensive primary tumor without nodal metastases, but could be considered after multidisciplinary discussion in select patients with large tumor burden or very high pretreatment EBV DNA levels.[19]

Preferred induction regimens include gemcitabine plus cisplatin, or docetaxel plus cisplatin plus fluorouracil. Preferred adjuvant regimens include cisplatin (or carboplatin if cisplatin ineligible or intolerant) plus fluorouracil.[19]

Recommended chemotherapy regimens are based on NCCN guidelines and are preferred regimens.[19]​ Other alternative regimens are also recommended and you should consult your local guidelines for more information.

See local specialist protocol for dosing guidelines.

Primary options

Induction regimen

gemcitabine

and

cisplatin

OR

Induction regimen

docetaxel

and

cisplatin

and

fluorouracil

OR

Adjuvant regimen

cisplatin

or

carboplatin

-- AND --

fluorouracil

stage 3-4A (T3, N1-3, M0; OR T4, N0-3, M0; OR T0 (EBV+)-2, N2-3, M0)

1st line – induction chemotherapy + chemoradiation

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ACUTE
|
stage 3-4A (T3, N1-3, M0; OR T4, N0-3, M0; OR T0 (EBV+)-2, N2-3, M0)
1st line – 

induction chemotherapy + chemoradiation

​Discuss the treatment strategy with the multidisciplinary team for patients with advanced nasopharyngeal cancer (NPC).[2]

Induction chemotherapy is recommended for the majority of patients with stage 3-4A NPC (excluding T3, N0, M0).[1][19]​​​​ Gemcitabine plus cisplatin, or docetaxel plus cisplatin plus fluorouracil are the preferred induction regimens.[1][19]​​​[34]

Concurrent chemoradiation is recommended for the majority of patients.[1][19]​​

Cisplatin should be considered as the standard concurrent chemotherapy agent.[1][2]​​[19]​ For patients who cannot tolerate cisplatin (e.g., if there is preexisting chronic kidney disease or hearing impairment), carboplatin is a reasonable alternative.[1][19]

Recommended chemotherapy regimens are based on NCCN guidelines and are preferred regimens.[19]​ Other alternative regimens are also recommended and you should consult your local guidelines for more information.

See local specialist protocol for dosing guidelines.

Primary options

Induction regimen

gemcitabine

and

cisplatin

OR

Induction regimen

docetaxel

and

cisplatin

and

fluorouracil

OR

Concurrent chemoradiation regimen

cisplatin

OR

Concurrent chemoradiation regimen

carboplatin

Consider – clinical trial

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ACUTE
|
stage 3-4A (T3, N1-3, M0; OR T4, N0-3, M0; OR T0 (EBV+)-2, N2-3, M0)
Consider – 

clinical trial

Treatment recommended for SOME patients in selected patient group

Stage 3-4A (excluding T3, N0, M0) nasopharyngeal cancer is a particularly heterogeneous category. As such, participation in clinical trials is especially encouraged to better select subgroups of patients for more intensive treatments and other subgroups for less intensive treatments.[19]

2nd line – chemoradiation + adjuvant chemotherapy

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ACUTE
|
stage 3-4A (T3, N1-3, M0; OR T4, N0-3, M0; OR T0 (EBV+)-2, N2-3, M0)
2nd line – 

chemoradiation + adjuvant chemotherapy

Discuss the treatment strategy with the multidisciplinary team for patients with advanced nasopharyngeal cancer.[2]

For patients who are ineligible for induction chemotherapy, adjuvant chemotherapy (cisplatin plus fluorouracil) is recommended after completion of concurrent chemoradiation.[1][19]​​​ Cisplatin should be considered as the standard concurrent chemotherapy agent.[1][2]​​[19]​ For patients who cannot tolerate cisplatin (e.g., if there is preexisting chronic kidney disease or hearing impairment), carboplatin is a reasonable alternative.[1][19]

Recommended chemotherapy regimens are based on NCCN guidelines and are preferred regimens.[19]​ Other alternative regimens are also recommended and you should consult your local guidelines for more information.

See local specialist protocol for dosing guidelines.

Primary options

Concurrent chemoradiation regimen

cisplatin

OR

Concurrent chemoradiation regimen

carboplatin

OR

Adjuvant regimen

cisplatin

or

carboplatin

-- AND --

fluorouracil

Consider – clinical trial

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ACUTE
|
stage 3-4A (T3, N1-3, M0; OR T4, N0-3, M0; OR T0 (EBV+)-2, N2-3, M0)
Consider – 

clinical trial

Treatment recommended for SOME patients in selected patient group

Stage 3-4A (excluding T3, N0, M0) nasopharyngeal cancer is a particularly heterogeneous category. As such, participation in clinical trials is especially encouraged to better select subgroups of patients for more intensive treatments and other subgroups for less intensive treatments.[19]

metastatic disease

1st line – chemotherapy + supportive care

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ACUTE
|
metastatic disease
1st line – 

chemotherapy + supportive care

Discuss the treatment strategy with the multidisciplinary team for patients with advanced nasopharyngeal cancer (NPC).[2]

The preferred first-line treatment for patients with metastatic NPC who have no surgery or radiation therapy options is toripalimab (a programmed cell death protein 1 [PD-1] inhibitor) plus cisplatin plus gemcitabine.[19]

Other recommended first-line options include: cisplatin plus gemcitabine; cisplatin plus gemcitabine plus tislelizumab; cisplatin plus gemcitabine plus pembrolizumab or nivolumab; cisplatin plus fluorouracil; cisplatin or carboplatin plus docetaxel or paclitaxel; carboplatin plus cetuximab; and gemcitabine plus carboplatin.[19]

See local specialist protocol for dosing guidelines.

Supportive care can include speech and swallowing therapy, nutritional support, and psychosocial support. Provide pain management and consider how to control any bleeding.

Primary options

toripalimab

and

cisplatin

and

gemcitabine

OR

cisplatin

and

gemcitabine

OR

cisplatin

and

gemcitabine

and

tislelizumab

OR

cisplatin

and

gemcitabine

-- AND --

pembrolizumab

or

nivolumab

OR

cisplatin

and

fluorouracil

OR

cisplatin

or

carboplatin

-- AND --

docetaxel

or

paclitaxel

OR

carboplatin

and

cetuximab

OR

gemcitabine

and

carboplatin

ONGOING

locoregional nasopharyngeal and/or neck nodal recurrence

1st line – surgery ± adjuvant radiation therapy or chemoradiation

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ONGOING
|
locoregional nasopharyngeal and/or neck nodal recurrence
1st line – 

surgery ± adjuvant radiation therapy or chemoradiation

Discuss the treatment strategy with the multidisciplinary team for patients with advanced nasopharyngeal cancer (NPC).[2]

Salvage nasopharyngectomy and/or neck dissection should be considered for small locoregional recurrences amenable for surgical resection.[2] Radical, modified radical, or selective neck dissection can be used for nodal neck recurrence.[2] The NCCN classifies cervical lymphadenectomy as either comprehensive or selective.[19]

Adjuvant radiation or chemoradiation is frequently offered after salvage surgery. There are limited data supporting the practice, but reradiation therapy after salvage surgery is supported by consensus guidelines.[36]

Cisplatin or carboplatin plus paclitaxel is an example of a regimen that may be considered for chemoradiation.[19]​ However, chemotherapy for recurrences is highly specialized and local protocols should be followed for choice of regimen.

See local specialist protocol for dosing guidelines.

Primary options

cisplatin

or

carboplatin

-- AND --

paclitaxel

2nd line – reradiation therapy ± induction chemotherapy

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ONGOING
|
locoregional nasopharyngeal and/or neck nodal recurrence
2nd line – 

reradiation therapy ± induction chemotherapy

Discuss the treatment strategy with the multidisciplinary team for patients with advanced nasopharyngeal cancer.[2]

For unresectable locoregional recurrence, consider reradiation therapy before a chemotherapy-only approach. Reradiation therapy is challenging since many organs at risk have already been exposed to near maximal safe doses of radiation from the first course of radiation therapy and careful patient selection is needed.[2] International recommendations generally favor reradiation therapy after at least 12 months latency between courses of radiation therapy to allow normal tissues to recover from the initial course of radiation therapy.[36] Unlike the first course of radiation therapy that includes targeting subclinical disease, reradiation therapy targets gross recurrent tumor only.

Intensity-modulated radiation therapy (IMRT)/volumetric modulated arc therapy (VMAT) is viewed as an appropriate modality for reradiation therapy though if particle therapy such as proton therapy is available, it could be considered as well and may be preferred for select recurrences.[36]

For bulky recurrences, induction with concurrent chemotherapy is favored among experts with reradiation therapy.

Cisplatin or carboplatin plus gemcitabine is an example of a regimen that may be considered (if not received in the previous 6 months).[19]​ However, chemotherapy for recurrences is highly specialized and local protocols should be followed for choice of regimen.

See local specialist protocol for dosing guidelines.

Primary options

cisplatin

or

carboplatin

-- AND --

gemcitabine

Plus – chemotherapy

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ONGOING
|
locoregional nasopharyngeal and/or neck nodal recurrence
Plus – 

chemotherapy

Treatment recommended for ALL patients in selected patient group

Chemotherapy is typically offered with concurrent re-irradiation.

Cisplatin plus fluorouracil is an example of a regimen that may be considered (if not received within the previous 6 months).[19]​ However, chemotherapy for recurrences is highly specialized and local protocols should be followed for choice of regimen.

See local specialist protocol for dosing guidelines.

Primary options

cisplatin

and

fluorouracil

3rd line – palliative chemotherapy + supportive care

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ONGOING
|
locoregional nasopharyngeal and/or neck nodal recurrence
3rd line – 

palliative chemotherapy + supportive care

Discuss the treatment strategy with the multidisciplinary team for patients with advanced nasopharyngeal cancer (NPC).[2]

Locoregional recurrence not amenable for salvage surgery or reradiation therapy is treated with palliative chemotherapy. Palliative chemotherapy is highly specialized and local protocols should be followed for choice of agent.

Toripalimab (a programmed cell death protein 1 [PD-1] inhibitor) plus cisplatin plus gemcitabine is recommended as first-line option for patients with recurrent NPC who have no surgery or radiation therapy options.[19]

Other recommended first-line options include: cisplatin plus gemcitabine; cisplatin plus gemcitabine plus tislelizumab; cisplatin plus gemcitabine plus pembrolizumab or nivolumab; cisplatin plus fluorouracil; cisplatin or carboplatin plus docetaxel or paclitaxel; carboplatin plus cetuximab; and gemcitabine plus carboplatin.[19]​  

See local specialist protocol for dosing guidelines.

Supportive care can include speech and swallowing therapy, nutritional support, and psychosocial support. Provide pain management and consider how to control any bleeding.

Primary options

toripalimab

and

cisplatin

and

gemcitabine

OR

cisplatin

and

gemcitabine

OR

cisplatin

and

gemcitabine

and

tislelizumab

OR

cisplatin

and

gemcitabine

-- AND --

pembrolizumab

or

nivolumab

OR

cisplatin

and

fluorouracil

OR

cisplatin

or

carboplatin

-- AND --

docetaxel

or

paclitaxel

OR

carboplatin

and

cetuximab

OR

gemcitabine

and

carboplatin

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer