A randomized study of inpatient versus outpatient continuous infusion chemotherapy for patients with locally advanced head and neck cancer

National expert consensus on home-administered oncologic therapies in Spain

The diagnosis and treatment of cancer impose a significant emotional and psychological burden on patients, families, and caregivers. Patients undergo several interventions in a hospital setting, and the increasing number of patients requiring extended care and follow-up is driving the demand for additional clinical resources to address their needs. Hospital at Home (HaH) teams have introduced home-administered oncologic therapies that represent a new model of patient-centered cancer care. This approach can be integrated with traditional models and offers benefits to both patients and healthcare professionals (HCPs). Home-administered treatment programs have been successfully piloted globally, demonstrated as a preferred option for most patients and a safe alternative that could reduce costs and hospital burden. The document aims to establish the minimum recommendations for the home administration of oncologic therapies (ODAH) based on a national expert agreement. The expert panel comprised seven leading members from diverse Spanish societies and three working areas: clinical and healthcare issues, logistical and administrative issues, and economic, social, and legal issues. The recommendations outlined in this article were obtained after a comprehensive literature review and thorough discussions. This document may serve as a basis for the future development of home-administered oncologic therapy programs in Spain. .

Comparison of chemotherapy treatment administration via venous port and peripheral vascular access in terms of quality of life and costs

PURPOSE

In this study, it was aimed to compare the administration of chemotherapy drugs via venous port catheter and peripheral vein in metastatic colon cancer patients in terms of quality of life and treatment costs.

METHODS

The research was carried out in a university hospital in Turkey. The population of the study consists of 130 patients with metastatic colon cancer who were treated with chemotherapy. The sample of the study consists of 103 participants. During the data collection phase of the study, three data collection tools were used: demographic information form, EOTC QLQ-30 quality of life scale and invoices for treatments. Data were analyzed using Microsoft Office Excel and IBM SPSS 20 package programs.

RESULTS

In the study, 71.8% of the participants received chemotherapy with a venous port catheter, 65% for more than 3 months, 56.3% in the day unit. As a result of the study, it was found that there were no significant differences in the quality of life (except social function) according to the chemotherapy method. In addition, when the research results are examined in terms of cost, statistically significant differences were found in the treatment cost (except total costs excluding drugs) according to the chemotherapy application method.

CONCLUSION

In line with these results, it is thought that when choosing the chemotherapy application method, factors such as the treatment duration of the patients, the ease of opening the vascular access, and the patient's psychological state should be taken into consideration.

Evaluation of the use of non-formulary oncology medications restricted to outpatient use in hospitalized patients after implementation of a criteria-for-use algorithm

OBJECTIVE

To decrease the number of orders and total hospital spend for inpatient use of antineoplastic drugs of interest, while evaluating each case for urgent or emergent need for administration.

METHODOLOGY

This study is a multicenter, retrospective, cost-evaluation, cohort study performed in five Ascension Seton hospitals in the Austin, Texas area between 1 January 2013 and 31 December 2018. Patients were identified via a dispense analysis report for the antineoplastic drugs of interest.

RESULTS

An overall reduction of 56% was seen in orders processed with a 62% decrease in annual hospital spending after implementation of the criteria-for-use algorithm. When results were evaluated without including rituximab orders, a reduction of 17% was seen in orders processed with a 21% decrease in annual hospital spending.

DISCUSSION AND CONCLUSION

The decreases in our primary outcomes were primarily driven by a reduction in the use of one drug, rituximab. Overall, implementation of a criteria-for-use algorithm was effective in reducing both overall number of orders and hospital spending for restricted antineoplastic agents.

A pharmacokinetic-pharmacodynamic study on carboplatin administered in prolonged continuous infusion regimens with synchronous radiotherapy

A clinical and pharmacokinetic study was conducted on an outpatient basis in which carboplatin was administered by continuous infusion (20, 25, or 30 mg/d X 5 days X 4 weeks) with synchronous radio therapy. Responses were obtained in 8 of 15 patients, and dose-limiting toxicity was not reached. Leukope nia (grade 1 or 2) occurred in 8 patients, nausea (grade 1 or 2) in 2 patients, and no other toxicity was evident. AUC (area under plasma concentration X time curve) and elimination half-life (1.68 to 2.97 hours) data were similar to values obtained for the rapid intravenous (IV) infusion of carboplatin at an equivalent dose in previous studies. Values of volume of distribution at steady-state (Vdss) were higher following continuous infusion administration as com pared with rapid IV infusion. This was consistent with results from other studies and may possibly be ex plained by altered drug distribution and disposition following continuous infusion therapy. Data were fitted to a mono-exponential elimination curve that was also in agreement with previous reports on carboplatin pharmacokinetics. Relationships between pharmacokinetic variables and pharmacodynamic variables (haematological toxicity) were investigated in order to explore the possibility of developing pharmacokinetically guided dosage schemes for car boplatin given by continuous infusion in a combined modality treatment. A linear correlation (r = 0.71) was evident between the percentage decrease in platelets (at the nadir 4 weeks after the start of infusion) and AUC X normalised radiation field area. Wtih further studies, it is possible that a formula could be derived from this relationship for dose individual isation in patients receiving carboplatin by continu ous infusion with synchronous radiotherapy.

A multi-method review of home-based chemotherapy

This study summarises research- and practice-based evidence on home-based chemotherapy, and explores existing delivery models. A three-pronged investigation was conducted consisting of a literature review and synthesis of 54 papers, a review of seven home-based chemotherapy programmes spanning four countries, and two case studies within the Canadian province of Ontario. The results support the provision of home-based chemotherapy as a safe and patient-centred alternative to hospital- and outpatient-based service. This paper consolidates information on home-based chemotherapy programmes including services and drugs offered, patient eligibility criteria, patient views and experiences, delivery structures and processes, and common challenges. Fourteen recommendations are also provided for improving the delivery of chemotherapy in patients' homes by prioritising patient-centredness, provider training and teamwork, safety and quality of care, and programme management. The results of this study can be used to inform the development of an evidence-informed model for the delivery of chemotherapy and related care, such as symptom management, in patients' homes.

Modified weekly cisplatin-based chemotherapy is acceptable in postoperative concurrent chemoradiotherapy for locally advanced head and neck cancer

BACKGROUND

Triweekly cisplatin-based postoperative concurrent chemoradiotherapy (CCRT) has high intolerance and toxicities in locally advanced head and neck cancer (LAHNC). We evaluated the effect of a modified weekly cisplatin-based chemotherapy in postoperative CCRT.

METHODS

A total of 117 patients with LAHNC were enrolled between December 2007 and December 2012. Survival, compliance/adverse events, and independent prognostic factors were analyzed.

RESULTS

Median follow-up time was 30.0 (3.1-73.0) months. Most patients completed the entire course of postoperative CCRT (radiotherapy ≥ 60 Gy, 94.9%; ≥ 6 times weekly chemotherapy, 75.2%). Only 17.1% patients required hospital admission. The most common adverse effect was grade 3/4 mucositis (28.2%). No patient died due to protocol-related adverse effects. Multivariate analysis revealed the following independent prognostic factors: oropharyngeal cancer, extracapsular spread, and total radiation dose. Two-year progression-free survival and overall survival rates were 70.9% and 79.5%, respectively.

CONCLUSION

Modified weekly cisplatin-based chemotherapy is an acceptable regimen in postoperative CCRT for LAHNC.

Circadian variation in plasma 5-fluorouracil concentrations during a 24 hour constant-rate infusion

Background

Varying the rate of continuous intravenous infusions of 5-fluorouracil (5FU) chemotherapy over a 24-hour period has been reported to improve patient outcomes. It has been hypothesized that circadian variation in drug disposition is a contributing factor. We analyzed 5-FU concentrations during a 24-hour continuous 5-FU infusion.

Methods

Sixty-four subjects with advanced malignancies including pancreatic, hepatocellular, colorectal as well as other epithelial malignancies and either abnormal hepatic or renal function were treated on a phase I and pharmacokinetic study of weekly 24-hour intravenous infusions of 5-FU and leucovorin. No other concomitant anticancer therapy was administered. Blood samples were collected every three hours from 61 subjects for measurement of plasma 5-FU during the first two weekly infusions.

Results

After adjusting for differences in dose, elapsed time from start of infusion and infusion number (2 versus 1), mean 5-FU concentration was highest at 6 am and lowest at 3 pm, with an overall change in the mean from 3 pm to 6 am of +20 percent (95% CI = 12–28%). However, this variation in mean concentration associated with time of day was comparable in magnitude to the between-patient differences, within-patient differences between infusions, and the residual variation within infusion (coefficient of variation = 21%).

Conclusions

Our data show systematic variation by time of day in plasma concentrations of 5-FU administered at a constant rate over 24 hours, but it is small compared to the total variation in plasma concentration contributed by other sources. Circadian variation in men was more pronounced than in women.

Home administration of maintenance pemetrexed for patients with advanced non-squamous non-small cell lung cancer: rationale, practicalities and phase II feasibility study design

BACKGROUND

Home-based care in oncology is mainly reserved for patients at the end of life. Regulations regarding home delivery of cytotoxics differ across Europe, with a notable lack of practice guidelines in most countries. This has led to a lack of data addressing the feasibility of home-based administration of cytotoxic chemotherapy. In advanced non-squamous non-small cell lung cancer, pemetrexed is approved as maintenance therapy after first-line chemotherapy. In this setting, patients have the potential to be treated long-term with maintenance therapy, which, in the absence of unacceptable toxicity, is continued until disease progression. The favourable safety profile of pemetrexed and the ease of its administration by 10-minute intravenous infusion every 3 weeks make this drug a suitable candidate for administration in a home setting.

METHODS

Literature and regulations relevant to the home-based delivery of cytotoxic therapy were reviewed, and a phase II feasibility study of home administration of pemetrexed maintenance therapy was designed. At least 50 patients with advanced non-squamous non-small cell lung cancer, Eastern Cooperative Oncology Group performance status 0-1 and no progressive disease after four cycles of platinum-based first-line therapy are required to allow investigation of the feasibility of home-based administration of pemetrexed maintenance therapy (500 mg/m(2) every 3 weeks until progressive disease or unacceptable toxicity). Feasibility is being assessed as adherence to the home-based administration process (primary endpoint), patient safety, impact on patients' quality of life, patient and physician satisfaction with home care, and healthcare resource use and costs. Enrolment of patients from the UK and Sweden, where home-based care is relatively well developed, commenced in December 2011.

DISCUSSION

This feasibility study addresses an important aspect of maintenance therapy, that is, patient comfort during protracted home-based chemotherapy. The study design requires unusual methodology and specific logistics to address outcomes relevant to the home-delivery approach. This article presents a study design that offers a novel and reproducible model for home-based chemotherapy, and provides an up-to-date overview of the literature regarding this type of treatment.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01473563.

Randomized cross-over trial comparing inpatient and outpatient administration of high-dose cisplatin

BACKGROUND/AIMS

Treatment with high-dose cisplatin (HDC) previously required inpatient (IP) admission with overnight hospitalization, but recently practice has shifted to outpatient (OP) therapy. We aimed to determine whether it is preferable to give HDC as an IP or OP using a two-period cross-over trial.

METHODS

Eligible patients were starting chemotherapy with ≥2 cycles of HDC (≥100 mg/dose) and were suitable for OP treatment. All patients received an IP cycle and OP cycle: the order was randomly allocated. Pre-hydration, anti-emetics and chemotherapy were identical for IP and OP. Post-hydration varied by group (3 L normal saline (NS) for IP, 2 L NS for OP). The primary outcome was patient preference for IP versus OP treatment. Secondary outcomes included aspects of health-related quality of life, adverse events (dose delays and reductions, elevated creatinine and unplanned readmissions) and resource use.

RESULTS

Fifty-nine patients were randomized, 53 completed two cycles of HDC. Most patients preferred OP treatment (36 vs 13, P = 0.002). There were no significant differences in patients' ratings of nausea, vomiting, fatigue, anxiety, depression or overall quality of life. Adverse events were few and unrelated to IP versus OP treatment. Nursing time was longer for IP than OP (163 vs 104 min, P < 0.001).

CONCLUSION

OP treatment was preferred by most patients, appeared safe and used less resources.

Reducing cancer costs and improving quality through collaboration with payers: a proposal from the Florida society of clinical oncology

One of Florida's largest private payers has retained an outside consulting firm to develop a program to reduce cancer care spending, which could seriously limit the ability of oncology practices in Florida to provide quality care to their patients.

The cost-effectiveness of community-based screening for oral cancer in high-risk males in the United States: a Markov decision analysis approach

OBJECTIVE

The 2004 US Preventative Services Task Force (USPSTF) guidelines do not recommend routinely screening adults for oral cancer given no proven mortality reduction. A large cluster-randomized controlled screening trial in Kerala, India, in 2005, however, reported a significant reduction in mortality for screened male tobacco and/or alcohol users. In the United States, office-based screening efforts targeting males of high risk (regular use of tobacco and/or alcohol) have been unsuccessful due to poor attendance. Given the newfound screening mortality benefit to this high-risk subpopulation, we sought to ascertain the cost-effectiveness threshold of a yearly, community outreach screening program for males more than 40 years regularly using tobacco and/or alcohol.

STUDY DESIGN

Markov decision analysis model; societal perspective.

METHODS

A literature search was performed to determine event probabilities, health utilities, and cost parameters to serve as model inputs. Screen versus No-Screen strategies were modeled using assumptions and published data. The primary outcome was the difference in costs and quality-adjusted life-years (QALYs) between the two cohorts, representing the potential budget for a screening program. One-way sensitivity analysis was performed for several key parameters.

RESULTS

The No-Screen arm was dominated with an incremental cost of $258 and an incremental effectiveness of -0.0414 QALYs. Using the $75,000/QALY metric, the maximum allowable budget for a screening program equals $3,363 ($258 + $3,105) per screened person over a 40-year time course.

CONCLUSION

Given the significant health benefits and financial savings via early detection in the screened cohort, a community-based screening program targeting high-risk males is likely to be cost-effective.

Ambulatory high-dose methotrexate administration among pediatric osteosarcoma patients in an urban, underserved setting is feasible, safe, and cost-effective

BACKGROUND

We describe the safety, feasibility, and provide a cost-estimate of outpatient high-dose methotrexate administration (HDMTX) among an urban, underserved population.

PROCEDURE

A retrospective analysis of ambulatory HDMTX administration among osteosarcoma patients, at Montefiore Medical Center's Children's Hospital (Bronx, NY) was performed. HDMTX (12 g/m(2)) was given intravenously (IV) over 4 hr after urine alkalinization. Patients were discharged home to continue IV hydration and alkalinization delivered via a home infusion pump. Families were instructed to monitor urine pH overnight and management was adjusted according to our institution's treatment algorithm until MTX level ≤ 0.1 µmol/L. A cost estimate was performed to assess the difference in costs for outpatient versus hypothetical inpatient administrations.

RESULTS

Of the 97 ambulatory HDMTX administrations, 99% were successfully completed. One patient failed outpatient administration secondary to home infusion pump malfunction. This patient successfully completed subsequent courses as an outpatient. Most patients (72%) had a MTX level of < 10 µmol/L at 24 hr post-HDMTX. No patients were found to have a MTX level of > 50 µmol/L at 24 hr. About 26% of courses were associated with grade III or IV neutropenia, 4% were associated with grade III or IV thrombocytopenia and 1% were associated with grade III/IV leukopenia. Compared to a hypothetical hospital inpatient stay, the hospital costs for ambulatory HDMTX were an average of $1400 less per cycle.

CONCLUSION

Ambulatory HDMTX administration among an underserved, urban population is safe, feasible, and cost-effective.

Home infusions of biphosphonate in cancer patients: a prospective study

The objective of the study was to determine outcome and satisfaction of cancer patients treated by home-infusions of biphosphonates. 107 patients entered the study and 97 of them chose to receive infusions of zoledronic acid (Z) in the home setting. Patient satisfaction and quality of care (QoC) were assessed by a 22-item questionnaire. Changes from baseline were determined for bone pain using a 0-10 cm visual analogue scale pain score (VAS). Patients expressed a high level of satisfaction specifically with regard to nursing care. Seventy patients experienced a significant decrease in the median pain score during the home-therapy phase not due to an increased use of analgesic therapy (P = 0.03). Z was well tolerated with no major adverse events. The authors conclude that home infusions of biphosphonates, on the condition that the supportive care team is well-organized, is a safe procedure that could be advantageous for patients by increasing satisfaction and compliance with treatment.

Methotrexate, Cisplatin, and Fluorouracil (MPF Regimen) for Head and Neck Cancer

The increasing complexity of cancer chemotherapy heightens the requirement that pharmacists be familiar with these highly toxic agents. This column will review various issues related to preparation, dispensing, and administration of cancer chemotherapy. It will also serve as a review of various agents, both commercially available and investigational, used to treat malignant diseases.

Phase I and pharmacokinetic study of 24-hour infusion 5-fluorouracil and leucovorin in patients with organ dysfunction

BACKGROUND

Patients with hepatic or renal dysfunction are often treated with 5-fluorouracil (5-FU), but there are few data to confirm the safety of this practice.

PATIENTS AND METHODS

Patients with solid tumors were eligible if they were able to fit into one of three organ dysfunction cohorts: I, creatinine >1.5 but < or =3.0 mg/dl and normal bilirubin; II, bilirubin >1.5 but <5.0 mg/dl with normal creatinine; or III, bilirubin > or =5.0 mg/dl with normal creatinine. 5-FU doses were escalated separately within each of the three cohorts. Leucovorin (LV) dosage was fixed at 500 mg/m(2). 5-FU was given as a 24-h infusion at 1000, 1800 or 2600 mg/m(2), and plasma concentrations were measured every 3 h during the first two infusions for each patient.

RESULTS

Sixty-four patients were treated. Toxicities did not appear to be related to organ dysfunction cohort. A weekly dose of of 5-FU 2600 mg/m(2) produced dose-limiting toxicity (DLT) in six of 20 evaluable patients. These DLTs included grade 3 fatigue (n = 3), grade 2 neutropenia precluding weekly dosing (n = 1), grade 3 thrombocytopenia (n = 1) and grade 3 mental status changes (n = 1). There was no relationship between serum bilirubin or serum creatinine and 5-FU clearance.

CONCLUSIONS

Patients with elevated bilirubin may be safely started on a weekly regimen of 5-FU 2600 mg/m(2) with leucovorin 500 mg/m(2) as a 24-h continuous infusion.

A randomized crossover trial assessing patient preference for two different types of portable infusion-pump devices

BACKGROUND

A variety of anticancer agents are better tolerated and more effective if given as continuous compared to bolus administration. Portable pump devices are needed to allow outpatient continuous infusion. Different types of portable pumps are available and we tested patient preference in a randomized crossover design.

PATIENTS AND METHODS

Patients on continuous infusion fluorouracil were randomly assigned to start treatment with an elastomeric infusor (Baxter) or a mechanical, electronically controlled pump (CADD-1, Pharmacia) and crossed over to the alternative model after three weeks. After exposure to both pump types patients were asked to indicate their preferred device.

RESULTS

After 10 patients the study was closed because all study participants preferred the elastomeric pump (P < 0.01). Reasons were pump weight (100%), smaller pump size (89%), interference with daily activities (89%), user friendliness (56%), impact on sleep (44%), and lack of technical problems (22%). Although the mechanical pump required more handling time for the first two refillings, the learning curve suggested about equal time requirement thereafter.

CONCLUSION

In the interest of patient comfort, the disposable elastomeric infusor is an acceptable alternative to the more accurate electronically controlled pumps especially for drugs with a short half-life and a favorable toxicity profile.

The Home Infusion Therapy/Relative Benefit Index: summary of an analysis using insurance claims data

OBJECTIVES

The cost of providing services is the traditional criteria used by payers in making selective contracting decisions regarding home care providers in general, and home infusion therapy (HIT) vendors specifically for this analysis. This approach assumes comparable health outcomes, for which adequate measures often are unavailable. In practice, poor quality can result in a need for remedial services. The objective of this research is to develop a method to use health insurance claims data to incorporate the hidden costs of adverse outcomes into an analysis of the costs of a vendor's HIT.

METHODS

The Home Infusion Therapy/Relative Benefit Index (HIT/RBI) model incorporates measures of both the cost of providing HIT services as well as the cost of remedial treatment for the adverse outcomes that may result from HIT care, eg, emergency room visits. The data source for the analysis is the health care claims for a sample of managed care patients of national insurer for the period 1990 to 1994.

RESULTS

The analysis confirms that adverse clinical outcomes can lead to additional demand for remedial health care with resultant negative financial consequences. When the cost of the adverse outcomes is incorporated into the analysis, vendors who appeared to be low cost on the basis of HIT services, in fact were higher cost vendors, whereas vendors with a high cost of services but with few adverse events were low cost vendors.

CONCLUSIONS

Payers should consider both the clinical and economic consequences of providing care into account in selecting vendors. The HIT/RBI model is a useful tool for incorporating the cost of adverse outcomes into a comprehensive comparison of the cost multiple vendors of HIT services.

A prospective analysis of 949 long-term central venous access catheters for ambulatory chemotherapy in patients with gastrointestinal malignancy

We present a prospective analysis of the insertion complications and longevity of 949 cuffed, tunnelled central venous catheters used for ambulatory chemotherapy. Mean catheter life span was 121.8 days, 13.4% had complications at insertion, 17.7% had complications not necessitating removal and 18.6% had complications requiring removal. The more experienced operators had fewer complications inserting catheters (P < 0.0001). Late-onset shoulder pain occurred in 4.8% and was associated with an increased incidence of venous thrombosis (P < 0.0001) and infection (P = 0.06). Complications necessitating removal were not predicted by patient' age, site of insertion or malignancy, chemotherapy regimen, insertion platelet and fibrinogen counts, insertion complications, leucocyte count or cuff distance from the exist site. Catheters inserted with their tip in the superior vena cava were more at risk of removal (2.57 times) than those in the right atrium (P = 0.003).

Treatment of recurrent and/or metastatic squamous cell head and neck carcinoma with a combination of vinorelbine, cisplatin, and 5-fluorouracil: a multicenter phase II trial

PURPOSE

Vinorelbine has been demonstrated to be active against squamous cell carcinomas of the head/neck (SCHNC) and lung. This multicenter phase II trial was carried out to evaluate the activity and tolerability of the combination of vinorelbine, cisplatin, and 5-fluorouracil given on an outpatient schedule in a series of 80 patients with recurrent SCHNC.

PATIENTS AND METHODS

Eighty patients with recurrent and/or metastatic SCHNC were treated with a combination of CDDP 80 mg/m2on day 1, 5-FU 600 mg/m2 as a 4-hour infusion on days 2-5, and vinorelbine 25 mg/m2 on days 2 + 8. This cycle was repeated every 28 days. Most patients had oral cavity, larynx, or oropharynx carcinoma (88%). Forty-seven had previously received surgery alone, two radiotherapy alone, and 31 surgery plus radiotherapy. Seventy-two patients had locoregional recurrency, and eight had distant metastases.

RESULTS

According to an intent-to-treat analysis, complete response (CR) of a mean duration of 12.7+ months was achieved in 13% of cases (95% CI 5%-21%), and partial response of 8.3+ months in 45% of patients (95% CI 33%-56%), for an overall response rate of 55% (95% CI 43%-65%). Nine patients (11%) showed no change, and 22 (28%) progressed. Five patients were not evaluable for response and toxicity. CR were seen more frequently in patients pretreated with only surgery than in those who had also received radiotherapy (15% vs. 9%; p = 0.7). No statistically significant differences in response rate according to site of primary tumor were found (p = 0.8, NS). The received dose intensities of 5-FU, CDDP, and VNR were 90%, 92%, and 82%, respectively. The overall survival of the series as a whole was 9.7+ months (range 4-27). Toxicity was generally acceptable. Grades 3 and 4 leukopenia were recorded in 11% and 5% of patients, respectively. Noteworthy was the occurrence of pain at the tumor site after vinorelbine administration in 5 patients.

CONCLUSION

The combination regimen of CDDP, 5-FU and vinorelbine is quite active in the treatment of metastatic and/or recurrent SCHNC. This regimen should be tested as initial treatment in previously untreated patients and compared to a standard regimen in recurrent SCHNC.

A clinical trial of continuous cisplatin-fluorouracil induction chemotherapy and supracricoid partial laryngectomy for glottic carcinoma classified as T2

BACKGROUND

Vertical partial laryngectomy (VPL) and radiation therapy (RT) are the recommended conventional conservative options for glottic carcinoma classified as T2. In series presenting more than 100 patients with a minimum 3-year follow-up, however, local recurrence rates were reported as 22-43.5%. The authors' experience with a new strategy based on continuous cisplatin-fluorouracil induction chemotherapy (IC) and supracricoid partial laryngectomy with cricohyoepiglottopexy (CHEP) is presented.

METHODS

A retrospective analysis of 67 patients who presented with untreated moderately to well differentiated invasive glottic carcinoma classified as T2, managed from 1983 to 1991 with IC and CHEP, was conducted. Statistical analysis of survival, local control, nodal control, distant metastasis, and metachronous second primary tumor incidence was based on the Kaplan-Meier actuarial method. Univariate analysis was performed to analyze the relationships between various factors and survival, local recurrence, and nodal recurrence. Clinical response, histologic response, IC toxicity and postoperative course were reported.

RESULTS

The Kaplan-Meier 5-year survival, local recurrence, nodal recurrence, distant metastasis, and metachronous second primary tumor estimate were 92.3%, 5.6%, 1.5%, 1.8%, and 5.6%, respectively. Overall laryngeal preservation was achieved in 65 patients (97%). Ultimate local control was achieved in all patients but one. Nodal recurrence was statistically more likely in patients presenting with a local recurrence. Analysis of the specimens demonstrated complete histologic response to IC in 25 (37.3%) patients. A strong statistical relation (P < 0.0001) was noted between complete clinical response after IC and complete histologic response.

CONCLUSIONS

The change from the prevailing treatment modalities of RT and VPL to a new multimodal strategy (IC+CHEP) did not decrease survival and allowed for an increase in laryngeal preservation rate. The high rate (37.3%) of complete histologic response suggests that IC deserves further consideration in the management of patients with glottic carcinoma classified as T2. The favorable results achieved in this series, when compared with historic controls, should stimulate prospective clinical trials comparing the two surgical procedures (CHEP vs. VPL with or without IC) for resection of Stage II glottic carcinoma.

Costs and benefits of outpatient therapy

In recent years, much of the care traditionally rendered in hospitals has been shifted to ambulatory settings. This change has been fueled as much by changing patterns of reimbursement as by rapid developments in medicine and technology. The current climate of health-care reform suggests that this trend will continue for the near future. Unfortunately, there are few studies that systematically evaluate the cost effectiveness or benefits of ambulatory care. Among the few such studies published to date, the results are not overwhelmingly positive. While the monetary costs of ambulatory care are generally far lower than inpatient management, several studies suggest that family and household disruption are prominent features of outpatient strategies. Thus, the measurement of the direct and indirect costs and benefits of ambulatory treatment presents a significant challenge to researchers. Development of methodologies to support such studies must be among our highest priorities.

Plasma 5-fluorouracil and alpha-fluoro-beta-alanin accumulation in lung cancer patients treated with continuous infusion of cisplatin and 5-fluorouracil

This study was undertaken to investigate the day-to-day pharmacokinetic variability of 5-fluorouracil (5FU) given as a continuous i.v. infusion concomitantly with cisplatin. Ten lung cancer patients were investigated during the first course of chemotherapy. All patients had advanced, previously untreated, inoperable non-small-cell lung cancer. They received continuous infusions of cisplatin given at 100 mg/m2 over 5 days and of 5FU given at 1 g/m2 daily from day 2 to day 5. Both drugs were infused i.v. for 24 h/day at a constant rate with a volumetric pump. Blood samples were drawn from day 2 to day 5, every 4 h from 8 a.m. to 8 p.m. and every 2 h during the night (8 p.m. to 8 a.m.). Plasma 5FU and FBAL concentrations were determined simultaneously by gas chromatography-mass spectrometry. Plasma 5FU concentrations varied widely over the 4-day treatment course for each patient. Despite continuous constant-rate 5FU administration, plasma 5FU concentrations were significantly lower between 8 a.m. and 8 p.m. than during the night. Mean plasma concentrations of 5FU and FBAL increased significantly from the 1st day (0.42 and 1.19 micrograms/ml for 5FU and FBAL, respectively) to the 4th day of 5FU infusion (0.67 and 1.78 micrograms/ml for 5FU and FBAL, respectively). Further study is warranted to elucidate the mechanisms of the observed increase in plasma 5FU concentrations as well as its relationship with cisplatin coadministration and to assess the clinical relevance of this plasma 5FU accumulation.

Bioavailability and feasibility of subcutaneous 5-fluorouracil

Continuous intravenous (i.v.) infusion of 5-fluorouracil (5-FU) has been shown to be superior to bolus regimens in terms of response rates and toxicity. However, a continuous infusion is more expensive and prone to complications such as thromboembolism and infections. A way to circumvent these problems would be to administer 5-FU subcutaneously (s.c.). To assess feasibility and bioavailability of s.c. 5-FU, eight patients with advanced cancer received 250 mg 5-FU as an infusion over 90 min either intravenously (i.v.) or s.c. into the abdominal wall. The mean +/- s.d. bioavailability of s.c. 5-FU was 0.89 +/- 0.23. The interpatient variability for the area under the plasma concentration-time curve was 48% for the s.c. and 36% for the i.v. infusion. No local side effects were observed. To test the local tolerance of a more prolonged administration three patients received 930-1,000 mg m-2 5-FU by 24-h continuous s.c. infusion. The steady-state plasma levels were comparable to i.v. infusion. One patient developed a painless skin pigmentation at the s.c. infusion site. However, the same reaction was observed at the forearm after i.v. infusion. We conclude that at the dose studied s.c. 5-FU has an almost complete bioavailability and is well tolerated. Further work will show, whether prolonged s.c. infusion can be used as a safe and economical alternative to i.v. infusion.

Evolving role of surgery after induction chemotherapy and primary site radiation in head and neck cancer

Chemotherapy, as preliminary treatment before surgery and/or radiation for advanced squamous cell carcinoma of the head and neck, is no longer novel. In prospective trials to date, however, multiple agent induction chemotherapy has yet to demonstrate the initial presumptive promise of improved rates of cure. As an alternate goal, there has emerged a renewed attentiveness toward limiting treatment morbidity, several strategies for which may be considered. Extirpative, often radical, surgery on the primary site of disease usually represents the most significant threat to life quality. Various ways of limiting surgical morbidity will be considered by way of introduction. The trends of head and neck cancer treatment over the decades, leading into the era of induction chemotherapy and refined radiation techniques, will be described. At the combined Dana-Farber/New England Deaconess Head and Neck Oncology Clinic, an experience with over 300 patients receiving induction chemotherapy for advanced head and neck cancer has been analyzed with an emphasis on the postulate of lessening the extent of surgery in appropriately selected patients. In a comparison between trials initiated in 1980 and 1987, improved complete response rates from 26 to 57% were documented. Survival rates were identical, but the use of planned primary site ablative surgery was decreased from 47 to 14%. While some increase in local failure has been noted in patients treated by primary site radiation alone, surgical salvage appeared to be more effective. The implication of these trends for patterns of failure and surgical salvage and data concerning the need for neck dissection in this group of patients will be briefly summarized. Other trials addressing organ-preservation strategies will also be referenced and the dichotomy between survival-based studies and morbidity-limiting studies illustrated. Independent trends in radiation technique as a potential substitute for traditional surgical practice will be reviewed.

High-dose folinic acid and 5-fluorouracil plus cisplatin on a weekly schedule in the treatment of advanced cancer of the head and neck

A group of 60 patients with advanced head/neck cancer were treated with high-dose folinic acid (500 mg/m-2/week-1) plus 5-fluorouracil (400 mg/m-2/week-1 on day 1, and cisplatin (20 mg/m-2/week-1) 24 h after folinic acid infusion was completed. Out of 55 evaluable patients, 10 patients (18%) experienced a complete response with a mean duration of 11.4+ months, 25 patients had a partial response (45%) of 6.7+ months, 6 patients (11%) showed a stabilization of 4.8+ months, and 14 (25%) progressed. The overall response rate was 63.6% (95% confidence limits 56.5%-69.5%). Patients pretreated with radiotherapy had a 67% overall response rate, while those pretreated with chemotherapy showed a 54% overall response rate. All patients with cancer of the oropharynx had a major response, while patients with cancer of the oral cavity had the lowest response rate. The mean survival of patients who attained a complete response was 14.5+ months. Partial responders had a mean survival of 10.6+ months, while patients who progresses survived a mean of 3.6+ months. The treatment has been very well tolerated with few cases of grade 3 gastrointestinal toxicity. Grade 1-2 leukopenia was recorded in 64% of cases, grade 1-2 nausea/vomiting in 85%. In one case therapy was stopped because of persistent diarrhoea.

Subcutaneous continuous infusion of ifosfamide and cyclophosphamide in ambulatory cancer patients: bioavailability and feasibility

The oxazaphosphorines ifosfamide (IFO) and cyclophosphamide (CTX) are standard alkylating agents. Both drugs show an increased therapeutic index when given as a fractionated dosage over several days. Maximal fractionation is achieved by continuous infusion. We have studied the feasibility and bioavailability of a subcutaneously (s.c.) administered isotonic and neutral (pH 7) solution of IFO (10 h up to 5 days infusion) and CTX (12-24 h infusion) in patients with advanced cancer. A portable disposable gas-driven infusor syringe was used for ambulatory patients. Our results show 90%-100% bioavailability of s.c. IFO and CTX. The isotonic solution of IFO and CTX (pH 7) showed no significant local toxicity (one local infection in 51 cycles) during or after s.c. administration of 33 cycles with IFO and 18 with CTX. Haematotoxicity of both drugs was equal after s.c. and i.v. application. For IFO-treated patients no uro- or neurotoxicity was observed. We conclude that this novel continuous s.c. oxazaphosphorine infusion over a prolonged period is a rational, well-tolerated and economic way of delivering this drug on an outpatient basis.

Bioavailability of subcutaneous ifosfamide and feasibility of continuous outpatient application in cancer patients

The oxazaphosphorine prodrug Ifosfamide (IFO) in conjunction with the uroprotective agent Mesna is becoming a standard alkylating agent. It has an increased therapeutic index when given as a fractionated dosage over 3-5 days. Maximal fractionation is achieved by continuous infusion over several days and has been shown to be less emetic and neurotoxic than regimens with bolus infusions. We have studied in patients with advanced cancer the feasibility and bioavailability of a subcutaneously administered isotonic and neutral (pH 7) IFO solution given continuously over 10 h for up to 5 days. A portable disposable gas-driven infusor syringe was used. Our results show 90-100% bioavailability of sc administered IFO. The isotonic solution of IFO (pH 7) showed no significant local toxicity during or after sc administration. Haematotoxicity was equal for sc and iv application. No uro- or neurotoxicity has been observed in 24 sc cycles. We conclude that this novel continuous sc IFO infusion over several days is a rational, well-tolerated and economical way of delivering this drug on an outpatient basis.