Repurposing pantoprazole in combination with systemic therapy in advanced head and neck squamous cell carcinoma: a phase I/II randomized study

Pantoprazole decreases the acidity of the tumor microenvironment by inhibiting proton pumps on the cancer cell. This possibly leads to increased sensitivity to cytotoxic therapy. We conducted a phase I/II randomized controlled trial in adult patients with head and neck squamous cell carcinoma (HNSCC) planned for first-line palliative chemotherapy. Patients were randomized to chemotherapy + / - intravenous (IV) pantoprazole. The primary endpoint in phase I was to determine the maximum safe dose of intravenous pantoprazole, whereas it was progression-free survival (PFS) in phase II. The dose of IV pantoprazole established in phase I was 240 mg. Between Nov'18 and Oct'20, we recruited 120 patients in phase II, 59 on pantoprazole and 61 on the standard arm. Median age was 51 years (IQR 43-60), 80% were men. Systemic therapy was IV cisplatin in 22% and oral-metronomic-chemotherapy (OMC) in 78%. Addition of pantoprazole did not prolong PFS, which was 2.2 months (95% CI 2.07-3.19) in the pantoprazole arm and 2.5 months (95% CI 2.04-3.81, HR, 1.14; 95% CI 0.78-1.66; P = 0.48) in the standard arm. Response rates were similar; pantoprazole arm 8.5%, standard arm 6.6%; P = 0.175. Overall survival was also similar; 5.6 months (95% CI 4.47-8.51) in the pantoprazole arm and 5.4 months (95% CI 3.48-8.54, HR 1.06; 95% CI 0.72-1.57; P = 0.75) in the standard arm. Grade ≥ 3 toxicities were similar. Thus, pantoprazole 240 mg IV added to systemic therapy does not improve outcomes in patients with advanced HNSCC.

Low-Dose Immunotherapy in Head and Neck Cancer: A Randomized Study

PURPOSE

The regimens approved for the treatment of advanced head and neck squamous cell carcinoma are accessible to only 1%-3% of patients in low- and middle-income countries because of their cost. In our previous study, metronomic chemotherapy improved survival in this setting. Retrospective data suggest that a low dose of nivolumab may be efficacious. Hence, we aimed to assess whether the addition of low-dose nivolumab to triple metronomic chemotherapy (TMC) improved overall survival (OS).

METHODS

This was a randomized phase III superiority study. Adult patients with recurrent or newly diagnosed advanced head and neck squamous cell carcinoma being treated with palliative intent with an Eastern Cooperative Oncology Group performance status of 0-1 were eligible. Patients were randomly assigned 1:1 to TMC consisting of oral methotrexate 9 mg/m² once a week, celecoxib 200 mg twice daily, and erlotinib 150 mg once daily, or TMC with intravenous nivolumab (TMC-I) 20 mg flat dose once every 3 weeks. The primary end point was 1-year OS.

RESULTS

One hundred fifty-one patients were randomly assigned, 75 in TMC and 76 in the TMC-I arm. The addition of low-dose nivolumab led to an improvement in the 1-year OS from 16.3% (95% CI, 8.0 to 27.4) to 43.4% (95% CI, 30.8 to 55.3; hazard ratio, 0.545; 95% CI, 0.362 to 0.820; P = .0036). The median OS in TMC and TMC-I arms was 6.7 months (95% CI, 5.8 to 8.1) and 10.1 months (95% CI, 7.4 to 12.6), respectively (P = .0052). The rate of grade 3 and above adverse events was 50% and 46.1% in TMC and TMC-I arms, respectively (P = .744).

CONCLUSION

To our knowledge, this is the first-ever randomized study to demonstrate that the addition of low-dose nivolumab to metronomic chemotherapy improved OS and is an alternative standard of care for those who cannot access full-dose checkpoint inhibitors.

Audit of screen failure in 15 randomised studies from a low and middle-income country

Background

Growth and development in patient management occurs via randomised studies. Screen failure is a significant hurdle while conducting randomised studies. There is limited data available from low and middle-income countries about factors resulting in screen failure. Hence, this audit was performed to identify the proportion of patients who screen failed and to elucidate reasons for the same.

Methods

This was an audit of 15 randomised studies performed by medical oncology solid tumour unit II of Tata Memorial Centre. The screening logs of these studies were acquired. From the screening logs, data regarding the number of patients who had screen failed & reason for the same were obtained. Descriptive statistics were performed.

Results

A total of 7,481 patients were screened for 15 randomised clinical studies. Out of these, 3,666 (49.0%) patients were enrolled into trials and 3,815 (51.0%) screen failed. The most common reason for screen failure was 'not meeting inclusion criteria' (54.9%) followed by declining to take treatment (22.2%). Other factors that affect enrolment were 'not willing to stay in the locality of the trial site' (6.2%), being recruited in other studies (3.7%), poor performance status (PS) (3.4%), non-compliance (2.2%), meeting exclusion criteria (0.9%) and 'other' (6.5%).

Conclusion

The commonest causes of screen failure in lower and middle-income countries are non-meeting of inclusion criteria followed by declining to take treatment, not willing to stay in locality of trial site, recruited into other studies, poor PS, non-compliance, meeting exclusion criteria & 'other'. This information would help analysing and hence planning of newer strategies to decrease the rate of screen failure.

Phase 3 randomised study evaluating the addition of low-dose nivolumab to palliative chemotherapy in head and neck cancer

LBA6016

Background: The regimens approved for the treatment of advanced head and neck squamous cell carcinoma (HNSCC) are accessible to only 1-3% of patients in low and middle-income countries due to cost. In our previous study, metronomic chemotherapy (MC) improved survival in this setting. Retrospective data suggest that a low dose of nivolumab may be efficacious. Hence, we aimed to assess whether the addition of low dose nivolumab to MC improved the overall survival. Methods: This was a randomised phase 3 superiority open-label study. Adult patients with relapsed -recurrent or newly diagnosed advanced HNSCC being treated with palliative intent with ECOG PS 0-1 were eligible. Patients were randomised 1:1 to MC consisting of methotrexate 15 mg/m2 PO weekly, celecoxib 200 mg PO daily and erlotinib 150 mg PO daily, or MC with intravenous nivolumab 20 mg flat dose once-every-3-weeks. Therapy was continued until disease progression or intolerable adverse events. Response assessment (RECIST version 1.1) was performed every 2 months. The primary endpoint was 1-year overall survival (OS) and this was a pre-specified interim analysis with the nominal p-value for efficacy being 0.006. Results: 151 patients were randomised, 75 in MC and 76 in the MC-I arm respectively. The addition of low dose nivolumab led to an improvement in the 1-year overall survival from 16.3% (95%CI 7.95-27.4) to 43.4% (95% CI 30.8-52.3) [Hazard ratio-0.545; 95%CI 0.362-0.82; P=0.00358]. The median overall survival in MC and MC-I arms was 6.7 months (95%CI 5.83 -8.07) and 10.1 months (95%CI 7.37-12.63) respectively (P=0.0052). The median progression-free survival in MC and MC-I arms was 4.57 months (95%CI 4.2 -5.3) and 6.57 months (95%CI 4.43-8.9) respectively (P=0.0021). Response rate in MC and MC-I arm were 49.3% (95% CI 37.8-60.8) and 65.2% (95%CI 53.4-75.4) respectively (P=0.085). The rate of grade 3 and above adverse events was 50% and 46.1% in MC and MC-I arm respectively (P=0.744). Conclusions: In this first-ever randomised study, the addition of low dose nivolumab led to improved overall survival and is an alternative standard of care for those who cannot access full dose nivolumab. Clinical trial information: CTRI/2020/11/028953.

Five years survival outcomes of head and neck cancer patients treated with palliative metronomic chemotherapy

e18009

Background: Palliative metronomic chemotherapy improved overall survival over intravenous chemotherapy in head and neck cancers. However, there is no data available about the 5-year outcomes with this regimen. Methods: This was a single-arm prospective study that enrolled head and neck squamous cell carcinoma patients warranting palliative chemotherapy. The chemotherapy administered was methotrexate 15 mg/m2 per oral weekly and celecoxib 200 mg per oral daily till the development of intolerable side effects or progression. Kaplan Meier method was used for estimation of OS and factors impacting the same were sought. A p-value of 0.05 was considered significant. Results: 200 patients were enrolled with a median age was 49.5 years (Range 22-85 years) and preponderance of male gender (175, 87.5%). The predominant site of malignancy was oral cavity in 144 patients (72.2%). Prior chemotherapy exposure was present in 78 patients (39%). The median FACT trial outcome index score was 43.7 (16.7-80.7). The median OS was 194 days (95%CI 181.7-206.3) . The 1-year, 3-years and 5-years OS were 17 %(Standard error-2.8%), 7.9% (Standard error-2.5%), and 3.9% (Standard error- 2%) respectively. The details of factors impacting OS are given in Table. Conclusions: Oral metronomic chemotherapy leads to a small proportion of patients having long term survival with metronomic chemotherapy. Clinical trial information: CTRI/2015/11/006392. [Table: see text]

Real world data of neoadjuvant and adjuvant chemotherapy in head neck osteosarcoma: Experience from a tertiary care center in India

e18012

Background: The head and neck (HN) region is a rare sub-site of osteosarcoma(OGS), with less than 10% of all cases of osteosarcoma and < 1% of all the head and neck malignancies . The evidence pertaining to the treatment of OGS of the head & neck region is limited. The role of adjuvant chemotherapy is evolving and research in this field is limited by the rarity of this tumour. However, in multiple small series, adjuvant or neoadjuvant chemotherapy has been found to be beneficial in head and neck OGS. To this end, we have audited our practice of the last 10 years to see the pattern of care, outcomes and advancements in the chemotherapy of HN OGS. Methods: We maintain a record at our outpatient department of patients receiving neoadjuvant and adjuvant chemotherapy. We conducted a database search spanning the data from 2010 to 2020, using the keywords: osteosarcoma, osteogenic sarcoma, OGS and head neck region, maxilla, skull base. Any adult patients who received chemotherapy in the adjuvant or neoadjuvant setting were selected for this study. The baseline demographics, patterns of chemotherapy administration and outcomes were documented. We analysed the data using SPSS descriptive statistical analysis. Survival analysis for progression-free survival and overall survival was done using the Kaplan-Meyer method. Results: 30 patients of HN OGS were treated with neoadjuvant chemotherapy (NACT) or adjuvant chemotherapy (ACT) at our centre from 2010 to 2020. The median age was 25 years, with a male preponderance (n = 21, 70%). The sites of disease were maxilla- 15(50%), mandible- 11 (37%), alveolus- 2 (6.6 %), orbit- 1 (3.3%), masticator space - 1 (3.3%). Out of the study population, 18 patients (60%) received NACT, 17 patients (56%) received ACT, 5(16%) patients received both NACT and ACT. 23 patients (76.6 %) underwent surgical resection, with R0 resection achieved in 17 (56.6%) and R1 in 3 patients(10%). 16 patients (53.3%) received adjuvant radiotherapy. Median progression-free survival was 16.10 months (95% CI: 10.30-21.89). Median overall survival (OS) was 22.56 months (95%CI: 11.16-33.96). 2 years OS was 49.1% (standard error 9.6). Conclusions: The patterns of use of neoadjuatnt and adjuvant chemotherapy in HN OGS are variable. Overall, the outcomes of HN OGS remain unsatisfactory. Further efforts are warranted in this direction to standardise an algorithm for chemotherapy. Further intensification of therapy may be required to improve patient outcomes.