This study aimed to compare the efficacy between neoadjuvant chemotherapy (NACT) plus intensity-modulated radiotherapy (IMRT) and NACT plus concurrent chemoradiotherapy (CCRT) in patients with nasopharyngeal carcinoma (NPC).
Data from 603 patients with ascending (T4 and N0-1) or descending (T1-2&N3) NPC who were treated at Sun Yat-sen University Cancer Center between October 2009 and February 2012 were retrospectively analyzed. These patients were divided into two groups: NACT+IMRT (n = 302) and NACT+CCRT (n = 301). The primary endpoint was overall survival (OS), which was analyzed using the Kaplan-Meier method, log-rank test, Cox proportional hazards model, and landmark analysis.
In univariate analysis, there was no significant difference in 5-year OS between the NACT+IMRT and NACT+CCRT groups (hazard ration [HR]: 0.69; 95% confidence interval [CI]: 0.47-1.01; P = 0.057). However, after adjustment for age (<45 years, ≥45 years), gender, histological stage (I/II, III), T stage (1/2, 3, 4), and N stage (0/1, 2/3), NACT+IMRT was more effective in improving OS, with a 33% decrease in the risk of death than NACT+CCRT (HR: 0.67; 95%CI: 0.45-0.99). Furthermore, landmark analysis indicated that patients in the NACT+IMRT group had higher OS rates within 24 months (HR: 1.83; 95%CI: 1.00-3.34), whereas those treated with NACT+CCRT had higher OS rates after 24 months (HR, 0.47; 95% CI, 0.29-0.77). We also found significant survival benefits of NACT+IMRT regimen in patients younger than 45 years old (HR: 0.27; 95%CI: 0.14-0.49), and in those at stage T3 (HR: 0.50; 95%CI: 0.27-0.93) and stage N2/3 (HR: 0.52; 95%CI: 0.32-0.83).
Patients with ascending or descending NPC who are treated with NACT+IMRT may have better long-term survival outcomes than those treated with NACT+CCRT, especially the patients younger than 45 years old or in stage T3/N2/N3. Additionally, NACT+IMRT may be a better option than NACT+CCRT in patients within the first 24 months.

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