Letter re: The efficacy of immunotherapy combined with capecitabine versus immunotherapy alone as maintenance therapy in patients with de novo metastatic nasopharyngeal carcinoma: a retrospective propensity score matching study

Letter re: The efficacy of immunotherapy combined with capecitabine versus immunotherapy alone as maintenance therapy in patients with de novo metastatic nasopharyngeal carcinoma: a retrospective propensity score matching studyWe read with great interest the recent study by He et al., 1 investigating the combination of immune checkpoint inhibitors (ICIs) and capecitabine as maintenance therapy in patients with de novo metastatic nasopharyngeal carcinoma (mNPC).The authors report that the addition of capecitabine to maintenance ICIs significantly prolongs progression-free survival (PFS), particularly in patients with polymetastatic disease and detectable Epstein-Barr virus (EBV) DNA after initial therapy.However, several points merit further discussion.Firstly, the rationale for this study appears to rely heavily on prior data from Liu et al., 2 which demonstrated the benefits of capecitabine maintenance in patients who had previously received triplet chemotherapy regimens containing capecitabine or 5-fluorouracil as part of their induction therapy.However, it is important to highlight that, in clinical practice, the combination of gemcitabine and cisplatin has emerged as the established first-line induction chemotherapy for patients with mNPC. 3 More recently, ICIs with anti-programmed cell death protein 1 antibodies combined with gemcitabine and cisplatin have become the new standard of care in the first-line setting, demonstrating further improvements in PFS. 4 In contrast, in the present study, more than half of the patients did not receive an induction regimen containing fluoropyrimidines.Consequently, the maintenance approach evaluated in this study does not represent a true continuation of the initial induction chemotherapy backbone.Rather, it involves introducing a new treatment agent, capecitabine, solely in the maintenance setting, raising concerns about the biological plausibility and clinical relevance of this approach.For a