Indian Journal of Cancer Home 

MINI SYMPOSIUM - EDITORIAL
[Download PDF]
Year : 2011  |  Volume : 48  |  Issue : 2  |  Page : 145--147

Cetuximab in head and neck cancer

PM Parikh1, GS Bhattacharyya2, A Vora3,  
1 Indian Cooperative Oncology Network, Mumbai, India
2 Department of medical oncology, AMRI, Kolkata, India
3 Max Hospitals, New Delhi, India

Correspondence Address:
P M Parikh
Indian Cooperative Oncology Network, Mumbai
India




How to cite this article:
Parikh P M, Bhattacharyya G S, Vora A. Cetuximab in head and neck cancer.Indian J Cancer 2011;48:145-147


How to cite this URL:
Parikh P M, Bhattacharyya G S, Vora A. Cetuximab in head and neck cancer. Indian J Cancer [serial online] 2011 [cited 2020 Aug 5 ];48:145-147
Available from: http://www.indianjcancer.com/text.asp?2011/48/2/145/82871


Full Text

Squamous cell carcinoma of head and neck (SCCHN) region is the largest group of cancers seen in India and many countries with limited resources. [1] In patients with advanced disease, outcome still remains poor. Yet, the subgroup of patients who do not have distant metastases, can be offered potentially curative therapy in the form of chemoradiotherapy. This translates into an absolute survival benefit of 6.5% at 5 years for concurrent chemoradiotherapy as per the MACH-NC collaborative group meta-analysis. [2] The best results have been with cisplatin- and carboplatin-based chemotherapy combined with radiotherapy, the survival being prolonged by 16.8 and 6.7 months, respectively. [3]

Unfortunately, this benefit is not delivered to significant number of eligible patients - toxicity prevents this in as many as 30% of cases. [1] Results can be improved by one of the following approaches: (1) use of more tolerable chemotherapy combinations, (2) integration of molecular targeted drugs, and (3) application of modern radiotherapy technology.

SCCHN is associated with overexpression of epidermal growth factor receptors (EGFR) and contributes to the natural history of the disease. Cetuximab is a large molecule monoclonal antibody that binds to the extracellular domain of EGFR, inhibits intracellular phosphorylation, and blocks further downstream signaling. It has been shown to block cell cycle, promote apoptosis as well as potentiate the effects of chemotherapy and radiotherapy. [4]

This issue of the Indian Journal of Cancer has two original articles on the concomitant use of cetuximab with radiation therapy for patients with advanced SCCHN. [5],[6] Agarwal JP have reported the retrospective evaluation of 37 cases, whereas Dattatreya and Goswami document the outcome in 19 patients with locally advanced SCCHN treated prospectively at two centers.

Before we discuss their data, let us get an understanding of the background.

In the landmark Bonner trial, the median improvement in OS was 30 months (vs RT alone). [7] Such a dramatic improvement in patients with advanced SCCHN was not reported till this data was presented. The results were reaffirmed when other trials also confirmed the median OS benefit (of 25 months).

In the meantime, our medical knowledge has moved on and the new standard of care for locally advanced SCCHN became chemoradiotherapy (CRT). [1] The impression is that CRT has more data. So let us understand the truth about chemotherapy (CT) in SCCHN patients. CT can have significant toxicity when combined with RT - in fair number of patients. If separated from RT and used in the neoadjuvant setting, its toxicity has the potential to compromise subsequent RT. For instance it is well documented that only 40% of the patients are able to maintain dose intensity for the concomitant segment due to toxicity of neoadjuvant CT. [8] To specify further, recent data from Tata Hospital presented at the annual American Head and Neck Society meeting (April 2011), showed that the incidence of febrile neutropenia was as high as 50%. [9] Finally if one looks at the long term (5 year) overall survival for advanced SCCHN, it remains in the range of 30 to 40 % even with the most effective chemotherapy molecule (cisplatin). [1]

Hence, it is reasonable to evaluate the role of monoclonal antibodies (MoAb) like cetuximab - be it concomitant, neoadjuvant, or adjuvant setting. [10]

In fact the data of benefit of cetuximab in SCCHN is so compelling that various regulatory authorities had no choice but to approve its use. Yet the path taken by various countries is interesting. We will take just two examples to make our point. With the regulatory approval of cetuximab by US FDA, its use has become widespread. [11] On the other hand, its use in UK and Canada continues to be limited. [12],[13] In these countries, the initial approval was only if cisplatin was contraindicated (later broadened to all non elderly patients - since the elderly subgroup analysis failed to show benefit in the elderly).

The original data of concomitant cetuximab and RT from India is therefore crucial and needs to be understood well. Whereas Agarwal has studied this in unfit patients, Dattatreya and Goswami were able to document its benefit in fit patients. [5],[6]

In fit patients, the overall response rate (ORR) was 68.42% and the overall survival at 2 year was 84%. This compares favourably with the data presented by Bonner et al (loco-regional control of 47% and overall survival of 55%). [6],[14] This was achieved with minimal toxicity, permitting good dose intensity in the majority of patients. In fact, other than the solitary patient who developed Progressive disease (PD) while on therapy, dose intensity was more than 90% in all of them. The concern that this combination leads to significant toxicity was unfounded in fit Indian patients enrolled on this study. There was no grade 3 or 4 toxicity.

Among unfit patients, the median age was 59 years. [5] Cisplatin could not be used as concurrent chemotherapy due to major co-morbidities (renal impairment being the most common) or advanced age. Even in this group of 37 patients, dose intensity was maintained in 80% of cases. At the median follow-up of 16 months, the projected 2-year loco-regional control was 35.5% after initial primary treatment (increasing to 40.7% with the use of salvage surgery) and the overall survival was 44.4%. For patients not fit to receive the most successful concomitant chemotherapy, this data demonstrated the ability to combine cetuximab with RT with tolerable toxicity.

In the Bonner study, at two years, the locoregional control with combined therapy was 50% and ultimately resulted in a 32% reduction in the risk of locoregional progression with addition of cetuximab. [14] Survival at two years was 62 % with RT plus cetuximab. This is not dissimilar from the two studies from India.

But there is scope for improvement by personalising therapy to optimise benefit. Bonner has shown that patients with oropharyngeal cancers, early T stage, concomitant boost RT, higher N stage, higher performance status, male sex, and younger age were associated with a higher benefit from cetuximab. [14] On the other hand, we also know that cetuximab does not work in patients with EGFR mutation type III. [15] Another study has shown an overall survival advantage (24.5 vs. 14.8 months) in the post operative salvage setting without a significant increase in grade 3/4 toxicities. [16] There is also least preclinical evidence that RT induced a strong and very significant increase in tumour angiogenesis, which was reversed when combined with erlotinib and bevacizumab. [17] Finally, the triple combination of cetuximab, chemotherapy, and RT will be reported at ASCO this year. [18] We should evaluate whether these (or other) parameters can help us positively select to improve outcomes.

While doing this we must also remember what is not going to change. With concomitant cetuximab and RT, the incidence of distant metastases (16%) or second primary cancers (8%) remains unchanged at two years follow-up. [14] So we should not expect cetuximab to help control distant spread and we should dispel the fear of higher risk of second malignancies.

The bottom line is that in palliative setting in SCCHN, use of cetuximab is the only intervention that has improved survival in last 30 years (by almost 36% - from 7 to 10 months) and should be considered in all eligible patients. [19]

References

1Jain P, Kumar P, Pai VR, Parikh PM. Neoadjuvant chemotherapy or chemoradiotherapy in head and neck cancer. Indian J Cancer 2008;45:83-9.
2Pignon JP, le Maitre A, Maillard E, Bourhis J. Meta-Analysis of Chemotherapy in Head and Neck Cancer (MACH-NC): An update on 93 randomised trials and 17,346 patients. Radiother Oncol 2009;92:4-14.
3Goel AK, SinghD. Radiosensitization of head and neck cancer by targeting the epidermal growth factor receptor Indian J Med Paediatr Oncol 2009;30:92-4.
4Nicolatou-Galitis O, Sarri T, Dardoufas K, Kouloulias V, Vakalis X, Polychronopoulou A, Demenagas, D., Sotiropoulou-Lontou, A.: Oral mucositis, pain and xerostomia in patients with head and neck cancer who received chemoradiotherapy with or without cetuximab. Open Clin Cancer J 2010;4:6-14.
5Agarwal JP, Gupta T, Kalyani N, Budrukkar A, Laskar SG, Murthy V, et al. Cetuximab with radiotherapy in patients with loco-regionally advanced squamous cell carcinoma of head and neck unsuitable or ineligible for concurrent platinum-based chemo-radiotherapy: Ready for routine clinical practice? Indian J Cancer 2011; 48;148-53
6Dattatreya S, Goswami C. Cetuximab plus radiotherapy in patients unresectable locally advanced squamous carcinoma of head and neck region labelled single arm phase II study. Indian J Cancer 2011; 48;154-7
7Bonner JA, Harari PM, Giralt J, Azarnia N, Shin DM, Cohen RB, et al. Radiotherapy plus cetuximab for squamous-cell carcinoma of the head and neck. N Engl J Med 2006;354:567-78.
8Budach W, Hehr T, Budach V, Belka C, Dietz K. A meta-analysis of hyperfractionated and accelerated radiotherapy and combined chemotherapy and radiotherapy regimens in unresected locally advanced squamous cell carcinoma of the head and neck. BMC Cancer 2006;6:28.
9Dabkara D, Prabhash K, Noronha V, DCruz A, Chaukar D, Chaturvedi P, et al. Induction chemotherapy in locally advanced oral cavity cancer. Proceedings of Annual Conference of American Head Neck Society, April 2011S029 . p. 43.
10Blick SK, Scott LJ. Cetuximab: A review of its use in squamous cell carcinoma of the head and neck and metastatic colorectal cancer. Drugs 2007;67:2585-607.
11Available from: http://www.cancer.gov/cancertopics/druginfo/fda-cetuximab [Last accessed on 2011 June 14].
12Available from: http://guidance.nice.org.uk/TA145/CostingTemplate/xls/English [Last accessed on 2011 June 14].
13Available from: http://www.hc-sc.gc.ca/dhp-mps/prodpharma/sbd-smd/phase1-decision/drug-med/sbd_smd_2007_erbitux_088225-eng.php [Last accessed on 2011 June 14].
14Bonner JA, Harari PM, Giralt J, Cohen RB, Jones CU, Sur RK, et al. Radiotherapy plus cetuximab for locoregionally advanced head and neck cancer: 5-year survival data from a phase 3 randomised trial, and relation between cetuximab-induced rash and survival. Lancet Oncol 2010;11:21-8.
15Pedersen MW, Meltorn M, Damstrup L, Poulsen HS. The type III epidermal growth factor receptor mutation - Biological significance and potential target for anti-cancer therapy. Ann Oncol 2001;12:745-60.
16Heron DE, Rwigema JC, Gibson MK, Burton SA, Quinn AE, Ferris RL. Concurrent cetuximab with stereotactic body radiotherapy for recurrent squamous cell carcinoma of the head and neck: a single institution matched case-control study. Am J Clin Oncol 2011;34:165-72.
17Bozec A, Sudaka A, Fischel JL, Brunstein MC, Etienne-Grimaldi MC, Milano G. Combined effects of bevacizumab with erlotinib and irradiation: A preclinical study on a head and neck cancer orthotopic model. Br J Cancer 2008;99:93-9.
18RTOG 0522: A randomized phase III trial of concurrent accelerated radiation and cisplatin versus concurrent accelerated radiation, cisplatin, and cetuximab [followed by surgery for selected patients] for Stage III and IV head and neck carcinomas. Available form: ( http://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0522 ) [Last accessed on 2011 June 14].
19Vermorken JB, Mesia R, Rivera F, Remenar E, Kawecki A, Rottey S, et al. Platinum-Based Chemotherapy plus Cetuximab in Head and Neck Cancer. N Engl J Med 2008;359:1116-27.