An effective and well-tolerated strategy in recurrent and/or metastatic head and neck cancer: successive lines of active chemotherapeutic agents

Abstract

BackgroundThe combination platinum, 5-fluorouracil (5-FU) and cetuximab is the standard first-line regimen of recurrent and/or metastatic head and neck squamous cell carcinoma (HNSCC). Due to the toxicity of this treatment, alternative therapies are often offered to patients. The aim of this study was to evaluate the overall survival obtained with a first line chemotherapy adapted to patients functional status and the administration of all active drugs within successive lines of chemotherapy.MethodsThis series included a total of 194 patients with recurrent and/or metastatic HNSCC treated from 2006 to 2011 in a single institution where the administration of successive lines of chemotherapies has been the standard clinical approach. Treatment was administered according to clinical practice guidelines.ResultsMost patients received at least two treatment lines. Only 11 patients (6%) were treated with a combination of cisplatin, 5-FU and cetuximab in front line, but most patients received at least one platinum-based regimen (n = 154 patients, 78%); 162 (82%) received taxanes, 36 (18%) received 5-FU, 27 (14%) received capecitabine, 67 (34%) received methotrexate and 134 (68%) received cetuximab. The median overall survival was 9.8 months (95% CI: 8.1-11.4 months) and reached 13.1 months among the subgroup of 131 patients eligible for inclusion in a clinical trial.ConclusionThe survival outcomes of patients treated in the first-line setting with chemotherapy regimens adapted to their functional status, followed by several subsequent regimens were comparable with published outcomes of patients treated by platinum, 5-FU and cetuximab.

Palliative treatment standards for head and neck squamous cell carcinoma

“…At the same time, local institutional standards may help the treating physicians to choose an adequate protocol for their particular patients, even if not one standard regimenbut a varietyofprotocols are provided to choose from. A group from Lyon has published their strategy for successive palliative treatment lines at their institution, which nicely depicts how institutional treatment guidelines can help to standardize palliative treatment while at the same time allowing for individualization [9]. For each line of treatment a variety of protocols to choose from is provided and translated into an easily readable flow chart.…”

“…The reason for the choice of standards different from the EXTREME protocol cannot be elicited in this survey. The reasons may include cost-effectiveness considerations [4] as well as obligations regarding the toxicity of the protocol in relation to the overall life time gained by the treatment [9]. Péron et al advocate the succession of the most important substance classes (platin compounds, taxanes, anti-metabolites, EGFR inhibitors) throughout different lines of palliative treatment for patients with low tumor HNO burden, medium intensity of symptoms, with a good compliance, and the willingness to be closely monitored during therapy instead of a highly intensive combination therapy.…”

“…Overall we found no clear differences in the perception of whether palliative therapy is possible comparing certified cancer centers with noncertified centers, university with nonuniversity hospitals, or centers with ≥75 newly diagnosed patients per year and centers with <75 newly diagnosed cases per year. In the report by Péron et al, among their whole cohort of 198 patients, only 74 (37 %) received one line of palliative therapy, 47 (24 %) received two lines, 44 (22 %) received three lines, and 33 (17 %) received more than three successive lines of palliative therapy [9].…”

“…Thus, clinical trials may not reflect the majority of patients being treated in the second line of palliation. In the dataset of Péron et al, 131 of 198 patients (66.2 %) were deemed to be eligible for a clinical trial [9].…”

“…Although generally described as a well-tolerated treatment combination, some head and neck oncologists argue that many patients who would require palliative treatment are not fit to undergo the protocol as recommended [9]. Alternatives for patients with a reduced performance status or for patients in whom first-line palliative chemotherapy failed are not well-standardized.…”