Retrospective analysis of palliative metronomic chemotherapy in head and neck cancer

Oral Metronomic Chemotherapy in Advanced and Metastatic Oral Squamous Cell Carcinoma: A Need of the Hour

Aim

The present review article aims to compile the best available evidence-based data on oral metronomic chemotherapy (OMCT) including its mechanism of action, its utility, and future directions.

Methods

A systematic search was carried out in PubMed database for available English literature from last 10 years between 2011 and 2021. Keyword combinations used were 'Oral Metronomic chemotherapy for oral cancer, mechanism of action of OMCT, Oral metronomic chemotherapy in India, OMCT in recurrent and palliative treatment of oral cancers.'

Results

Multitudes of studies have been published recently stating the role of OMCT in head and neck squamous cell carcinoma (HNSCC), but the studies with the category of level of evidence required to advocate OMCT as a recognized therapy are still scarce. On careful stratification of these studies, we found that OMCT has a lot to offer in palliative settings, recurrent, and metastatic HNSCC. There is some limited evidence of its role in adjuvant therapy as maintenance and in neoadjuvant setting.

Conclusion

With current evidence, there is a definite role of OMCT in treatment of oral SCC. OMCT can be an alternative in patients who are not tolerable or affordable for standard palliative chemotherapy and also an option for patient who are waiting for surgery. However, results of ongoing and future studies on exact mechanism, indications, and implications of this drug regimen would help in integration OMCT in current standard of therapy.

Graphical abstract

Comparison of survival between palliative surgery and no surgery for advanced tongue squamous cell carcinoma: an analysis of SEER data

The aim of this study was to investigate the survival effect of palliative surgery in advanced tongue squamous cell carcinoma (TSCC). A retrospective analysis of data in the SEER database for 6151 patients with stage III/IV TSCC (American Joint Committee on Cancer (AJCC) staging), diagnosed between 2004 and 2015, was performed. The patients were divided into two groups: palliative surgery and no surgery. Kaplan-Meier and Cox proportional hazards regression analyses were applied to determine risk factors for overall survival (OS) and cancer-specific survival (CSS). A further analysis was performed using 1:1 propensity score matching (PSM) to balance 13 patient variables (sex, age at diagnosis, race, marital status, primary tumour site, SEER stage, AJCC stage, pathological differentiation grade, tumour size, lymph node metastasis, previous lymph node removal, radiotherapy, and chemotherapy). Among the 6151 patients, 706 underwent palliative surgery; the other 5445 did not undergo any kind of surgery. Those who underwent palliative surgery had a higher 5-year survival rate. After PSM, 1274 patients were included in the matched cohort. Multivariate Cox regression analysis showed that patients who underwent palliative surgery had a lower risk of death than those who did not (OS: hazard ratio 0.58, 95% confidence interval 0.49-0.69, P < 0.001; CSS: hazard ratio 0.60, 95% confidence interval 0.49-0.74, P < 0.001). In this comparative study it was found that compared with no surgery, palliative surgery has a positive impact on the survival rate of patients with advanced TSCC.

Long term outcomes of phase I/II study of palliative triple metronomic chemotherapy in platinum-refractory/early failure oral cancer

Background

Triple metronomic chemotherapy is one of the options of treatment in platinum-refractory/early failure oral cancer. However, long term outcomes with this regimen are unknown.

Methods

Adult patients with platinum-refractory/early-failure oral cancer were enrolled in the study. Patients were administered triple metronomic chemotherapy ie erlotinib 150 mg once daily celecoxib 200 mg twice daily and methotrexate weekly (phase 1 in variable dose 15-6 mg/m² & 9 mg/m² in phase 2), all taken orally till progression of disease or development of intolerable adverse events. The primary objective was to estimate the long-term overall survival and factors impacting it. The Kaplan Meier method was used for time-to-event analysis. Cox proportional hazard model was used to identify factors impacting overall survival (OS) and progression-free survival (PFS). The factors included in the model were age, sex, Eastern Cooperative Oncology Group - performance status (ECOG PS), tobacco exposure and a subsite of primary and circulating endothelial cell levels at baseline. A p-value of 0.05 was considered significant. Clinical trials information: CTRI/2016/04/006834.

Results

A total of 91 patients were recruited (15 in phase 1 & 76 in phase 2), the median follow-up was 41 months and 84 events of death had occurred. The median OS was 6.7 months (95% CI 5.4-7.4). The 1-year, 2-years and 3-year OS' were 14.1% (95% CI 7.8-22.2), 5.9% (95% CI 2.2-12.2) and 5.9% (95% CI 2.2-12.2) respectively. The only factor favorably impacting OS was the detection of circulating endothelial cells at baseline (HR = 0.46; 95% CI 0.28-0.75, P = 0.0020). The median PFS was 4.3 months (95% CI 4.1-5.1) and the 1-year PFS was 13.0% (95% CI 6.8-21.2). The factors with statistically significant impact on PFS were detection of circulating endothelial cells at baseline (HR = 0.48; 95% CI 0.30-0.78, P = 0.0020) and no tobacco exposure at baseline (HR = 0.51; 95% CI 0.27-0.94, P = 0.030).

Interpretation

The long-term outcomes with triple oral metronomic chemotherapy ie erlotinib, methotrexate and celecoxib are unsatisfactory. Detection of circulating endothelial cells at baseline is a biomarker predicting efficacy of this therapy.

Funding

The study was funded by an intramural grant from Tata Memorial Center Research Administration Council (TRAC) and Terry Fox foundation.

Toxicity profile, adverse drug reactions and drug-drug interactions among geriatric cancer patients under metronomic chemotherapy in a South Indian tertiary care hospital

OBJECTIVE

The study aims to examine the toxicity profile, pattern of adverse drug reactions (ADRs) and drug-drug interactions (DDIs) in geriatric cancer patients receiving metronomic chemotherapy.

PATIENTS AND METHODS

Patients were followed after each cycle till 12 weeks. Haematological parameters such as complete blood count, liver function test and renal function test were recorded from the baseline to the final visit. The Common Terminology Criteria for Adverse Events (CTCAE) scale was used to characterise the toxicity profile. ADRs that the patients had were documented and assessed for its causality, severity and preventability. The Lexicomp drug interaction checker was used to grade DDIs.

RESULTS

Of 129 patients, according to CTCAE grading, haemoglobin indicated grade 1 toxicity, while other haematological parameters revealed no toxicity. Although there was a statistically significant difference in ALT, alkaline phosphate, serum creatinine and potassium (p < 0.05), it was not clinically significant. A total of 226 ADRs were documented. Anaemia was the most frequently occurred ADR (14%) and Capecitabine caused the highest number of ADRs. Assessments of causality showed that the majority of cases are "possible" (63%). In evaluating the severity of ADRs, 99% ADRs were "mild" and 61% of ADRs were "probably" preventable. Upon assessing the DDIs, 82% of the prescriptions had "no known interaction".

CONCLUSION

Metronomic chemotherapy in geriatric cancer patients exhibited grade 1 toxicity for haemoglobin. Anemia was the most common ADRs. The majority of cases were "possible" in causality, "mild" in severity, and "probably" preventable. The majority of the prescriptions have no known DDIs.

Dermal metastases in oral cancer after curative treatment: a single institution cohort study

Dermal metastasis (DM) is, by definition, the involvement of the skin by cancer cells that originate from cancer elsewhere in the body. The skin is considered a rare site of distant failure in head and neck cancer and DM is the bearer of a poor outcome. Literature about it is limited so this study was undertaken to analyse the factors associated with its incidence and outcomes. A prospectively maintained database on operated cases of oral cancer at a tertiary cancer centre was analysed, and patients who developed dermal metastases during follow up were evaluated. Factors that contributed to early DM and predicted survival after its development were studied. A total of 68 patients (2.8%) had DM as the first presentation of recurrence after a median disease-free period of five months. Early DM was significantly associated with skin involvement by the primary tumour at the time of presentation (p=0.06), extracapsular extension of nodes (p=0.004), and with those who required adjuvant chemotherapy in view of aggressive histology (p=0.021). Median (range) survival after the detection of DM was 97 (5-328) days (3.25 months). Surgical excision of isolated cases was associated with significantly increased survival after detection (p=0.05). Whenever it is feasible without too much morbidity, solitary DM should be excised.

Making the Best of Limited Resources: Improving Outcomes in Head and Neck Cancer

The overwhelming majority of head and neck cancers and related deaths occur in low- and middle-income countries, which have challenges related to burden of disease versus access to care. Yet the additional health care burden of the COVID-19 pandemic has also impacted access to care for patients with head and neck cancer in the United States. This article focuses on challenges and innovation in prioritizing head and neck cancer care in Sub-Saharan Africa, the Indian experience of value-added head and neck cancer care in busy and densely populated regions, and strategies to optimize the management of head and neck cancer in the United States during the COVID-19 pandemic.

Low-cost oral metronomic chemotherapy versus intravenous cisplatin in patients with recurrent, metastatic, inoperable head and neck carcinoma: an open-label, parallel-group, non-inferiority, randomised, phase 3 trial

BACKGROUND

Regimens for palliation in patients with head and neck cancer recommended by the US National Comprehensive Cancer Network (NCCN) have low applicability (less than 1-3%) in low-income and middle-income countries (LMICs) because of their cost. In a previous phase 2 study, patients with head and neck cancer who received metronomic chemotherapy had better outcomes when compared with those who received intravenous cisplatin, which is commonly used as the standard of care in LMICs. We aimed to do a phase 3 study to substantiate these findings.

METHODS

We did an open-label, parallel-group, non-inferiority, randomised, phase 3 trial at the Department of Medical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, India. We enrolled adult patients (aged 18-70 years) who planned to receive palliative systemic treatment for relapsed, recurrent, or newly diagnosed squamous cell carcinoma of the head and neck, and who had an Eastern Cooperative Oncology Group performance status score of 0-1 and measurable disease, as defined by the Response Evaluation Criteria In Solid Tumors. We randomly assigned (1:1) participants to receive either oral metronomic chemotherapy, consisting of 15 mg/m² methotrexate once per week plus 200 mg celecoxib twice per day until disease progression or until the development of intolerable side-effects, or 75 mg/m² intravenous cisplatin once every 3 weeks for six cycles. Randomisation was done by use of a computer-generated randomisation sequence, with a block size of four, and patients were stratified by primary tumour site and previous cancer-directed treatment. The primary endpoint was median overall survival. Assuming that 6-month overall survival in the intravenous cisplatin group would be 40%, a non-inferiority margin of 13% was defined. Both intention-to-treat and per-protocol analyses were done. All patients who completed at least one cycle of the assigned treatment were included in the safety analysis. This trial is registered with the Clinical Trials Registry-India, CTRI/2015/11/006388, and is completed.

FINDINGS

Between May 16, 2016, and Jan 17, 2020, 422 patients were randomly assigned: 213 to the oral metronomic chemotherapy group and 209 to the intravenous cisplatin group. All 422 patients were included in the intention-to-treat analysis, and 418 patients (211 in the oral metronomic chemotherapy group and 207 in the intravenous cisplatin group) were included in the per-protocol analysis. At a median follow-up of 15·73 months, median overall survival in the intention-to-treat analysis population was 7·5 months (IQR 4·6-12·6) in the oral metronomic chemotherapy group compared with 6·1 months (3·2-9·6) in the intravenous cisplatin group (unadjusted HR for death 0·773 [95% CI 0·615-0·97, p=0·026]). In the per-protocol analysis population, median overall survival was 7·5 months (4·7-12·8) in the oral metronomic chemotherapy group and 6·1 months (3·4-9·6) in the intravenous cisplatin group (unadjusted HR for death 0·775 [95% CI 0·616-0·974, p=0·029]). Grade 3 or higher adverse events were observed in 37 (19%) of 196 patients in the oral metronomic chemotherapy group versus 61 (30%) of 202 patients in the intravenous cisplatin group (p=0·01).

INTERPRETATION

Oral metronomic chemotherapy is non-inferior to intravenous cisplatin with respect to overall survival in head and neck cancer in the palliative setting, and is associated with fewer adverse events. It therefore represents a new alternative standard of care if current NCCN-approved options for palliative therapy are not feasible.

FUNDING

Tata Memorial Center Research Administration Council.

TRANSLATIONS

For the Hindi, Marathi, Gujarati, Kannada, Malayalam, Telugu, Oriya, Bengali, and Punjabi translations of the abstract see Supplementary Materials section.

Beyond conventional chemotherapy, targeted therapy and immunotherapy in squamous cell cancer of the oral cavity

The focus of this review article is to throw light on non-conventional systemic chemotherapy that affects the tumour microenvironment and potentially has a favourable impact on the management of squamous cell cancer of the oral cavity. A metronomic combination of weekly methotrexate and celecoxib seems equally effective to single agent cisplatin in the palliative setting, but needs phase III testing. The same metronomic combination seems inferior to paclitaxel-cetuximab. Triple drug metronomic chemotherapy (methotrexate, celecoxib, and erlotinib) is still under development with promising data from pilot studies. Metronomic chemotherapy also seems beneficial in the curative setting but results of confirmatory studies are eagerly awaited. The low rate of adverse events and low cost make this regimen an attractive alternative. Both in vivo and in-vitro data suggests that numerous drugs like anthelmintics, DMARDs, antimalarials can be repurposed for Head and Neck Cancers. However, there is a dearth of clinical studies reported till date.

Palliative chemotherapy in head and neck cancer: balancing between beneficial and adverse effects

Introduction: Head and neck squamous cell cancer (HNSCC) is the sixth most common cancer in the world. Almost 2/3rds of patients have recurrent or metastatic (R/M) HNSCC. Treatment options for R/M HNSCC have evolved, with relatively little change in survival. Thus, it is imperative that management decisions must balance efficacy with toxicity and emphasize the importance of maintaining the patient's quality of life (QOL).Areas covered: We cover the various chemotherapeutic options available for R/M HNSCC including single agent chemotherapy, platinum-based doublets and triplet options. The role of cetuximab, immunotherapy and oral metronomic chemotherapy (OMCT) is also reviewed. We discuss the management of patients with platinum-refractory disease.Expert opinion: In all patients with R/M HNSCC, we recommend assessment of extent of disease, patient symptomatology, performance status, affordability and availability of logistic and social support. In patients with PD-L1 CPS =/> 20, pembrolizumab is an option. In patients with PD-L1 CPS < 20, pembrolizumab/cisplatin/5FU or cisplatin/5FU/cetuximab (EXTREME) may be considered based on affordability and availability. Options available that have a lower toxicity and can help to maintain the patient's QOL include; single agent chemotherapy, carboplatin/paclitaxel combination chemotherapy, sequential combination chemotherapy followed by cetuximab, replacing 5FU with docetaxel (TPEx regime) and OMCT.

Metronomic Chemotherapy: A Systematic Review of the Literature and Clinical Experience

Metronomic chemotherapy, continuous and dose-dense administration of chemotherapeutic drugs with lowered doses, is being evaluated for substituting, augmenting, or appending conventional maximum tolerated dose regimens, with preclinical and clinical studies for the past few decades. To date, the principle mechanisms of its action include impeding tumoral angiogenesis and modulation of hosts' immune system, affecting directly tumor cells, their progenitors, and neighboring stromal cells. Its better toxicity profile, lower cost, and easier use are main advantages over conventional therapies. The evidence of metronomic chemotherapy for personalized medicine is growing, starting with unfit elderly patients and also for palliative treatment. The literature reviewed in this article mainly demonstrates that metronomic chemotherapy is advantageous for selected patients and for certain types of malignancies, which make it a promising therapeutic approach for filling in the gaps. More clinical studies are needed to establish a solidified role for metronomic chemotherapy with other treatment models in modern cancer management.