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

ABSTRACT

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.

KEYWORDS:

• Recurrent and metastatic head and neck squamous cell carcinoma
• HNSCC
• palliative chemotherapy
• quality of life
• R/M HNSCC

Declaration of interest

Kumar Prabhash has received funding for research from Dr Reddy’s Laboratory Inc, Fresenius Kabi, Alkem Lab, NATCO, BDR, and Roche. Vanita Noronha has received funding from AMGEN, Sanofi India Ltd, Dr Reddy’s Laboratory Inc, Intas pharamaceuticals and Astrazenca Pharma India Ltd. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Article Highlights

• Treatment of Recurrent/Metastatic Head and Neck Squamous cell carcinoma has evolved over the past few years with relatively small change in survival

• Treatment decisions must always weigh the benefit of the treatment with the quality of life the patient needs to endure with the treatment

• These patients must be classified into two subgroups – cisplatin sensitive(no prior exposure to cisplatin or exposure before 6 months) and cisplatin resistant(exposure to cisplatin in the past 6 months)

• In the Cisplatin sensitive group, EXTREME regime is the established standard of care

• In patients with PD-L1 CPS =/> 20, Pembrolizumab monotherapy and Pembrolizumab/chemotherapy combination is an option based on the recently published Keynote −048

• In the resource poor setting, single agent cisplatin, substitution of carboplatin (in combination with paclitaxel), sequential combination chemotherapy followed by cetuximab, replacing 5FU with docetaxel (‘TPEx’ regime) and double OMCT must be considered

• In the Cisplatin refractory group, Nivolumab and Pembrolizumab are the standard of care

• Triple OMCT is an exciting option for the cisplatin refractory setting which needs to further evaluated through randomized trial

Additional information

Funding

This paper received no funding.