Chemotherapy for symptom control in recurrent squamous cell carcinoma of the head and neck

Cost-effectiveness of Molecular Profile Patient Selection for First-line Treatment of Recurrent/Metastatic Head and Neck Cancer

PURPOSE

Patients with recurrent and/or metastatic head and neck squamous cell cancer are offered platinum-based chemotherapy plus cetuximab; however, this strategy is not cost-effective. We evaluated the cost-effectiveness of a hypothetical predictive molecular test to identify and treat only patients potentially responsive to cetuximab (C) added to platinum-fluorouracil (PF) (PF + C POS) versus the administration of PF + C to all patients (PF + C ALL).

METHODS

A Markov model has been developed to estimate health outcomes (quality-adjusted life years [QALYs]; life years [LYs]) and costs of the 2 strategies on a time horizon of 3 years from the Italian health care perspective. For the response to treatment, a definition, including partial or complete response, has been applied. In the base-case scenario, molecular test sensitivity, specificity, and cost have been assumed equal to 85%, 70%, and €4000, respectively.

FINDINGS

The model estimated 0.5285 QALYs (0.9245 LYs) and 0.5666 QALYs (0.9949 LYs) for PF + C POS and PF + C ALL, respectively. The incremental cost-utility ratio of PF + C ALL versus PF + C POS was €112,462/QALY, suggesting the administration of PF + C only to patients who would be responsive to it.

IMPLICATIONS

The use of cetuximab with chemotherapy could be a cost-effective choice in first-line recurrent and/or metastatic head and neck squamous cell cancer if based on a molecular selection able to identify which patients will achieve partial or complete response to the treatment. The developed model may be usefully applied to new emerging treatments, such as immunotherapeutic agents in the same setting.

Retrospective analysis of chronomodulated chemotherapy versus conventional chemotherapy with paclitaxel, carboplatin, and 5-fluorouracil in patients with recurrent and/or metastatic head and neck squamous cell carcinoma

BACKGROUND

Chronomodulated chemotherapy has emerged as a new therapy as a result of recent studies focusing on the biological clock. It has been demonstrated that combination chronomodulated chemotherapy of platinum-based drugs and 5-fluorouracil (5-Fu) can significantly improve efficacy and reduce the incidence of adverse events in patients with metastatic colorectal cancer, as compared with conventional chemotherapy. However, the results may be different in different tumors. Recurrent and metastatic head and neck squamous cell carcinoma (HNSCC) is very difficult to treat, with an extremely unfavorable prognosis. So far, no report is available on chronomodulated chemotherapy for HNSCC.

METHODS

Retrospective analyses were made on 49 patients with local recurrent and/or metastatic HNSCC who underwent palliative treatments with paclitaxel, carboplatin, and 5-Fu. The patients were divided into a chronomodulated chemotherapy group (28 patients) and a conventional chemotherapy group (21 patients) according to their administration times. The two groups were compared for tumor objective response rate, overall survival (OS), progression-free survival (PFS), and the incidence of adverse events.

RESULTS

The tumor objective response rate and patients' OS were significantly higher and longer in the chronomodulated chemotherapy group than in the conventional chemotherapy group (71.43% versus 42.86%, respectively, P<0.05; and median OS 15.3 months versus 10.6 months, respectively, P<0.05). However, PFS was similar statistically (median PFS 11.6 months versus 7.2 months, P>0.05). The global incidence of adverse events in the chronomodulated chemotherapy group was significantly lower than that in the conventional chemotherapy group (46.43% versus 76.19%, P<0.05), with significantly lower incidence of grade 3-4 adverse events (7.14% versus 33.33%, P<0.05).

CONCLUSION

Chronomodulated chemotherapy with paclitaxel, carboplatin, and 5-Fu may be a new and effective therapy for patients with recurrent and/or metastatic HNSCC as compared with conventional chemotherapy.

Analysis of the EGFR mutation status in head and neck squamous cell carcinoma before treatment with Gefitinib

BACKGROUND

The efficacy of chemotherapy in metastatic and recurrent squamous cell carcinomas of the head and neck (HNSCC) remains unsatisfactory. Gefitinib offers a new therapeutic option with comparable results and better tolerability than chemotherapy. We conducted this study to see if mutations in the epidermal growth factor receptor (EGFR) might predict the therapeutic benefit in HNSCC patients.

PATIENTS AND METHODS

In a pilot trial, 8 patients with metastatic or recurrent HNSCC were treated palliatively with gefitinib (500 mg/day orally). Forceps biopsies were taken to confirm tumor recurrence and to perform an EGFR mutation analysis.

RESULTS

The EGFR status could be determined in 6 of the 8 patients. 5 patients had no EGFR gene mutation, and 1 patient showed a silent guanine-to-adenosine mutation in position 2607. Even without any relevant mutation in the EGFR, we observed partial remission in 3 of 6 patients treated with gefitinib. We also observed that an additional 4 patients had stable disease for at least 10 weeks. The median progression-free survival was 6.25 months, and the median overall survival was 7.39 months.

CONCLUSION

In HNSCC, there are tumor responses to gefitinib without protein-altering mutations in the EGFR gene.

Rapid palliation of symptoms with platinum-based chemotherapy plus cetuximab in recurrent oral cancer: a case report

Background

Symptom control is an important consideration in the choice of treatment for patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck (SCCHN). Patients who demonstrate objective tumour responses to platinum-based chemotherapy are more likely to have symptom relief than those who do not have such responses. A phase III trial (EXTREME) showed that adding the epidermal growth factor receptor (EGFR)-targeting IgG1 monoclonal antibody cetuximab to first-line platinum-based chemotherapy significantly prolongs progression-free and overall survival and increases response rate compared with platinum-based chemotherapy alone. We report here the case of a 60-year old female with recurrent squamous cell carcinoma of the gum who had rapid palliation of symptoms and reduction of facial disease mass following treatment with a combination of carboplatin/5-fluorouracil (5-FU) and cetuximab.

Case presentation

The patient was diagnosed with T4N0 M0 disease of the oral cavity in November 2006 and underwent surgery, with R0 resection, followed by adjuvant radiotherapy and concomitant cisplatin chemotherapy. Around 3 months later, the disease recurred and the patient had severe pain (9/10 on a visual pain scale), marked facial oedema and a palpable facial mass of 89 mm. The patient received 4 21-day cycles of carboplatin (AUC 5), 5-FU (1,000 mg/m²/day for 4 days) and cetuximab (400 mg/m² initial dose followed by subsequently weekly doses of 250 mg/m²), with continuation of cetuximab monotherapy at the end of this time, and pain relief with topical fentanyl and oral morphine. After 7 days of treatment, pain had reduced to 2/10, with discontinuation of morphine after 4 days, and the facial mass had reduced to 70 mm. After 2 cycles of treatment, the facial mass had decreased to 40 mm. After 3 cycles of treatment, pain and facial oedema had resolved completely and a cervical computed tomography scan showed a marked reduction in tumour mass. Cetuximab monotherapy was continued uninterrupted for 7 months.

Conclusion

This case illustrates the rapid reduction of tumour mass and disease-associated pain and oedema that can be achieved with a combination of platinum-based chemotherapy and cetuximab in recurrent and/or metastatic SCCHN.

Treatment of Advanced Head and Neck Cancer with Cetuximab

Cetuximab is a monoclonal antibody targeting the transmembrane receptor HER-1 (epidermal growth factor receptor, EGFR). In theory, inhibition of EGFR may influence tumor behavior since the receptor regulates many important tumor cell activities including tumor growth, angiogenesis, and inhibition of the apoptotic response to chemotherapy and radiotherapy. Available experimental data suggest that cetuximab may enhance the activity of chemotherapy and radiotherapy, reverse resistance to some anticancer drugs, and has itself anticancer activity. Early clinical data support the experimental results. This paper reviews the published findings on cetuximab in the treatment of advanced head and neck cancer and points out the future objectives of the clinical research on this drug.

A Retrospective Analysis of the Outcome of Patients with Recurrent and/or Metastatic Squamous Cell Carcinoma of the Head and Neck Refractory to a Platinum-based Chemotherapy

AIMS

Recurrent and/or metastatic squamous cell carcinoma of the head and neck (SCCHN) develops in around 72,000 people in Europe every year. Treatment options are limited, mainly consisting of platinum-based palliative chemotherapy, with median overall survival times of only 6-8 months. No standard second-line treatment after progression on platinum-based chemotherapy is available. Few data have reported the efficacy of these treatments and the outcome of the patients. In an effort to generate such data, this retrospective study analysed clinical records from 151 patients with SCCHN refractory to platinum-based chemotherapy treated between 1990 and 2000 at seven different centres around Europe.

MATERIALS AND METHODS

Most patients (45%) received only best supportive care (BSC), and had a median survival of 56 days. A total of 28.5% of the patients received second-line chemotherapies: 16.6% radiotherapy and 9.9% chemoradiotherapy.

RESULTS

No objective response was observed with the various second-line chemotherapies. The overall median survival was 103 days (95% confidence interval [CI]: 77-126 days) for the whole cohort. The overall objective response rate (ORR) to second-line treatment in this population was calculated to be 2.6%.

CONCLUSION

These results highlight the need for additional treatment options for this disease. Similar, if not superior, response rates have already been observed in initial clinical studies of novel, targeted anti-cancer agents.

Chemotherapy in the management of squamous-cell carcinoma of the head and neck

Previously reserved for palliation, chemotherapy is now also a central component of several curative approaches to the management of patients with advanced-stage head and neck cancer. Here we review the results of both induction chemotherapy and chemoradiotherapy trials in patients with curable disease, and chemotherapy trials in patients with recurrent and metastatic disease, and we highlight current areas of investigation. Compared with traditional treatment modalities, chemotherapy given on induction schedules to patients with advanced laryngeal cancer allows greater organ preservation without compromise to survival; when given concomitantly with radiotherapy to patients with resectable or unresectable advanced disease, chemotherapy again improves survival.

Phase II study of docetaxel and cisplatin in patients with recurrent or disseminated squamous-cell carcinoma of the head and neck

BACKGROUND

Results with docetaxel as single drug in squamous-cell head and neck cancer have been encouraging. The purpose of the present phase II study is to evaluate the antitumour efficacy and toxicity of the combination of docetaxel and cisplatin in patients with recurrent or disseminated squamous-cell carcinoma of the head and neck (SCCHN) for whom no curative therapy is available.

PATIENTS AND METHODS

Eligibility criteria included: written informed consent; WHO performance status < or = 2; age 18-70 years; adequate bone marrow, liver, and renal function; measurable or evaluable disease; no previous systemic chemotherapy (prior radiotherapy and/or surgery were allowed), no other previous or concurrent malignancy; no peripheral neuropathy. Treatment consisted of docetaxel 75 mg/m2 in a one-hour infusion after pre-treatment with prednisolone, followed by cisplatin 75 mg/m2 in a half-hour infusion preceded and followed by hydration. Treatment was repeated every three weeks for a maximum of eight cycles.

RESULTS

Twenty-five patients (median age 52 years, range 33-66) entered the trial, all were evaluable for survival, twenty-four for response and toxicity. Twenty-four patients had undergone prior radiotherapy and seventeen had also had surgery. Nineteen had local-regional recurrence only, three had local-regional disease and distant metastases, and three had distant metastases only. Patients received a median of 5 treatment cycles (range 2-8). Overall response rate was 33% (8 of 24) of patients; complete response rate was 8% (2 of 24) of patients, lasting 2.2 and 17.1 months, respectively; partial response rate was 25% (6 of 24) of patients, lasting for a median of 4.9 months (range 1.7-11.6 months). Median survival was 11 months. Toxicity was relatively well tolerated. However, one patient died of probable toxicity (neutropenia and infection) and three patients discontinued treatment because of toxicity (massive oedema, myocardial infarction, persistent thrombocytopenia). The most frequent moderate-to-severe toxicity (75% of patients) was grade 3-4 neutropenia, transient in all but one patient. Grade 3 neuropathy occurred in one patient, none had grade 4. Grade 3 oral mucositis occurred in three patients, none had grade 4. Grade 2-3 hypomagnesaemia occurred in 10 patients requiring magnesium infusion.

CONCLUSIONS

Docetaxel and cisplatin is an active combination in patients with recurrent or disseminated SCCHN. Remissions are however fairly short. Toxicity is significant, but generally manageable.

Salvage surgery for patients with recurrent squamous cell carcinoma of the upper aerodigestive tract: when do the ends justify the means?

OBJECTIVES/HYPOTHESES

Salvage surgery is widely viewed as a "double-edged sword." It is the best option for many patients with recurrent cancer of the upper aerodigestive tract, especially when original therapy included irradiation, yet it may provide only modest benefit at high personal cost to the patient. The stakes are high because alternatives are of limited value. The primary objective of this study was to fully assess the value of salvage surgical procedures in the treatment of local and regional recurrence. The following hypotheses were developed to focus the study design and data analysis. 1) The efficacy of salvage surgery correlates recurrent stage, recurrent site, and time to presalvage recurrence. 2) The economic and noneconomic costs of salvage surgery increase with higher recurrent stage. 3) Information relating the value of salvage surgery to recurrent stage and recurrent site will be useful to these patients and the physicians who treat them.

STUDY DESIGN

Two complimentary methods of investigation were used: a meta-analysis of the published literature and a prospective observational study of patients undergoing salvage surgery for recurrent cancer of the upper aerodigestive tract.

METHODS

The meta-analysis combined 32 published reports to obtain an estimate of average treatment effect for salvage surgery with regard to survival, disease-free survival, surgical complications, and operative mortality. The prospective observational study included detailed data in 109 patients who underwent salvage surgery. In addition to parameters studied in the meta-analysis, we obtained baseline and interval quality of life data (Functional Living Index for Cancer [FLIC] scores), baseline and interval performance status evaluations (Performance Status Scale for Head and Neck Cancer Patients [PSS head and neck scores]), length of hospital stay, and hospital and physician charges, and related this data primarily to recurrent stage, recurrent site, and time to presalvage recurrence.

RESULTS

The weighted average of 5-year survival in the meta-analysis was 39% in 1,080 patients from 28 different institutions. In the prospective study, median disease-free survival was 17.9 months in 109 patients, and this correlated strongly with recurrent stage, weakly with recurrent site, and not at all with time to presalvage recurrence. Noneconomic costs for patients and economic costs correlated with recurrent stage, but not with site. Baseline FLIC and PSS head and neck scores correlated with recurrent stage, but not with site. After salvage surgery the percentage of patients reaching or exceeding baseline was 51% for FLIC scores, and this differed significantly with recurrent stage. Postoperative interval "success" in PSS head and neck subscale scores for diet and eating in public also correlated with recurrent stage.

CONCLUSIONS

Overall, the expected efficacy for salvage surgery in patients with recurrent head and neck cancer was surprisingly good, but success was limited and costs were great in stage III and, especially, in stage IV recurrences. A strong correlation of efficacy and noneconomic costs with recurrent stage allowed the creation of expectation profiles that may be useful to patients. Additional systematic clinical research is needed to improve results. In the end, the decision to undergo salvage surgery should be a personal choice made by the patient after honest and compassionate discussion with his or her surgeon.

Lipophilization of somatostatin analog RC-160 with long chain fatty acid improves its anti-proliferative activity on human oral carcinoma cells in vitro

Oral cancer which comprises about 40% of total cancers in India, has one of the lowest relative survival rates of all cancers. Epidermal growth factor (EGF) has been known to play a role in the proliferation/malignant transformation of oral neoplasms. Since, the somatostatin analog RC-160 is reported to be a potent inhibitor of EGF stimulated cell proliferation, its anti-proliferative activity in the human oral carcinoma cell line KB was investigated, in this study. RC-160 was found to potently inhibit EGF-induced proliferation in KB cells in vitro, suggesting a therapeutic potential of the same in oral carcinoma. However, the therapeutic potential of RC-160 is limited by its short serum half life. To overcome this limitation, fatty acids namely butanoic acid and myristic acid individually were coupled to RC-160. The lipophilized derivatives of RC-160 were synthesized, purified and characterized. The anti-proliferative activity of lipophilized derivatives of RC-160 on KB cells was evaluated in vitro. Myristoyl-RC-160 (0.75 nM) inhibited the growth of KB cells at a 10-fold lower concentration relative to RC-160 (8.8 nM) and at a 100-fold lower concentration relative to butanoyl-RC-160 (0.83 microM) (p<0.001). The affinity of RC-160 towards somatostatin receptors remains unaltered by lipophilization. The signaling pathways underlying the antineoplastic activity of these lipopeptides are similar to RC-160, and do not involve the stimulation of a protein tyrosine phosphatase or a serine threonine phosphatase 1A and 2A. The anti-proliferative activity of the lipopeptides was found to be mediated by somatostatin receptors and correlates with the inhibition of protein tyrosine kinase activity and decrease in intracellular cAMP levels. Myristoyl-RC-160 displayed significantly greater resistance towards trypsin and serum degradation than RC-160 (p<0.01). These findings demonstrate that RC-160 can inhibit the growth of oral cancer cells in vitro. Lipophilization of RC-160 with long chain fatty acids like myristic acid improves its stability and anti-proliferative activity, in human oral carcinoma cells in vitro, thereby enhancing the scope of improving its therapeutic index.

[Docetaxel in treatment of other solid tumors]

PHASE-II-STUDIES: Docetaxel (Taxotere; Rhône-Poulenc Rorer) was evaluated in the treatment of a wide range of tumors in the early nineties. This overview relates mainly to the results of 32 phase-II-studies from Europe, North America and Japan including the following malignancies: head and neck cancer, cancer of the ovary and cervix uterus, soft tissue sarcomas, gastrointestinal cancers, renal and transitional cell cancer as well as melanoma and glioma. Results of recent studies also revealed a high activity of combination chemotherapy with cisplatinum in untreated head and neck cancer as well as ovarian cancer.

RESULTS

A remarkable single agent activity was observed in the palliative treatment after recurrence of head and neck tumors (ORR 27 to 42%) and as salvage chemotherapy after failure of platinum compounds in ovarian cancer, where Docetaxel appeared to be similarly active as Paclitaxel and Topotecan. Remarkable activity was also observed in the treatment of gastric, pancreatic and urothelial cancer as well as melanoma.

CONCLUSION

Docetaxel ist a new cytotoxic drug with a broad range of activity in various solid tumors. The place of this compound in relation to established regimens and its value its value in combination chemotherapy warrants further investigation.