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  Table of Contents  
Year : 2021  |  Volume : 58  |  Issue : 3  |  Page : 476-478

News from the world of oncology

Date of Submission03-Sep-2021
Date of Decision03-Sep-2021
Date of Acceptance07-Sep-2021
Date of Web Publication22-Sep-2021

Correspondence Address:
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijc.ijc_1064_21

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How to cite this article:
. News from the world of oncology. Indian J Cancer 2021;58:476-8

How to cite this URL:
. News from the world of oncology. Indian J Cancer [serial online] 2021 [cited 2021 Oct 28];58:476-8. Available from: https://www.indianjcancer.com/text.asp?2021/58/3/476/326417

Can sentinel node biopsy–guided neck dissection be an alternative to elective neck dissection in early-stage oral cavity squamous cell carcinoma?

According to GLOBOCAN 2020, India reports more than 135,000 oral cavity cancers (OCCs) every year. Excision of tumor with concomitant neck dissection (ND) is the standard treatment for OCC. A large randomized trial led by D'cruz et al. was published in the New England Journal of Medicine in 2015 (Elective versus therapeutic neck dissection in node-negative oral cancer. https://www.nejm.org/doi/full/10.1056/nejmoa1506007). It concluded that elective neck dissection (END) in OCC decreases the chances of recurrence by 23%. The strategy of prophylactic ND is based on the premise of approximately 30% occult node metastasis in early-stage OCC. However, END is associated with poor quality of life (QOL) and debilitating shoulder morbidity. Over time, ND has evolved from radical to a more selective ND conserving the internal jugular vein, sternocleidomastoid nerve, and spinal accessory nerve. This conservative approach improved the QOL without compromising oncological safety. Another conservative step is sentinel lymph node biopsy (SLNB). SLNB identifies the first echelon node without the need to undergo dissection of additional neck levels. SLNB is well established as a standard of care in breast cancer and melanoma. However, this procedure does have considerable false-negative rates in the head and neck cancers because of the wide variation in the neck anatomy, leading to higher chances of second-stage surgery.

A randomized, controlled, multicenter (16 centers), Japanese trial led by Yasuhisa Hasegawa was recently published in the Journal of Clinical Oncology in 2021 (Neck dissections based on sentinel lymph node navigation versus elective neck dissections in early oral cancers: A randomized, multicenter, and noninferiority trial. DOI: https://doi.org/10.1200/JCO.20.03637. This study included 275 treatment-naïve, early (T1, T2) OCC patients with clinicoradiologically node-negative neck, except T1 tumors with a depth of invasion of less than 4 mm. About 97.1% of the patients underwent ND in the END arm compared with 39.5% in the SLNB arm. The sentinel node detection rate was 98.5%. There was no significant difference in the 3-year overall survival between the END (86.6%) and the SLNB groups (87.9%). Disease-free survival was also noninferior in the SLNB group (78.7% versus 81. 3%). The neck dissection rates in the SLNB arm were reduced by 57.6%. The QOL in terms of the range of motion, stiffness, pain, constriction, numbness, shoulder drop, reach above, and arm abduction test was significantly better in the SLNB arm. It is important to note that frozen section analysis with immunohistochemistry was applied in this study to improve the efficacy to diagnose intraoperative metastasis. The authors were able to detect nine isolated tumor cells and 20 micrometastasis out of 54 positive sentinel nodes improving its efficacy.

This study does have its limitations. Indication of concomitant chemotherapy and treatment protocol for positive margins varied in different centers depending on the institutional practice. Second-stage surgery was required in 30% of the node-positive cases. False-negative rates (defined as neck recurrences) were higher for the SLNB group (15.1% versus 10. 5%). Also, noninferiority margins could have been narrower for accurate application of the results. Similar evidence from OCC-ridden countries would consolidate its application in a real-world setting. In spite of the pitfalls, this study does provide some evidence to support the use of SLNB in selected OCC patients without conceding the oncological outcomes while improving the QOL.

Hitesh R. Singhavi

ORCID iD: https://orcid.org/0000-0001-8191-0951

Impact of antibiotic use on efficacy of immunotherapy in lung cancer patients

Immune checkpoint inhibitors (ICIs) are being increasingly utilized across various malignancies. As more and more data are emerging, some very interesting and astonishing facts are coming to light about this newer class of drugs. The use of antibiotics is fairly common in clinical practice for various indications. Apart from therapeutic indications, the use of prophylactic antibiotics is also not uncommon in cancer patients. Especially in the Indian scenario, with frequent intercurrent infections and chronic obstructive pulmonary disease in the background of cancer-related immunocompromise, many patients visiting the hospital receive antibiotics for treatment or prophylaxis.

In a recently published retrospective study in the European Journal of Cancer by Ochi et al. in 2021 (The effects of antibiotics on the efficacy of immune checkpoint inhibitors in patients with non-small cell lung cancer differ based on PD-L1 expression. DOI: https://doi.org/10.1016/j.ejca.2021.02.040, the researchers found a negative impact of antibiotics use in patients with non–small-cell lung cancer (NSCLC) and PD-L1 (programmed death-ligand 1) expression >50% but not in those with PD-L1 expression <50%. The authors reviewed the data of 531 NSCLC patients who received ICIs from nine cancer institutions in Japan and selected those patients who received antibiotics 2 months before to 1 month after the start of ICIs. Among the 98 such selected patients, the ones with exposure to antibiotics had significantly shorter overall survival (OS) compared with the ones with nonexposure (11.7 months in the antibiotics group versus 16.1 months in the nonantibiotics group; P = 0.028). However, the difference in progression-free survival (PFS) was not significant. In the subgroup of 265 patients, in whom PD-L1 testing was done, significant difference was not detected in the median OS or PFS between patients with NSCLC and PD-L1 expression <50% receiving antibiotics and those not receiving antibiotics. Conversely, patients with NSCLC and PD-L1 expression >50% receiving antibiotics showed significantly shorter median PFS and OS (PFS: 4.2 versus 9.4 months, P = 0.012; OS: 11.9 versus 28.4 months, P = 0.011).

This discovery is interesting and could be practice changing. It would be challenging to have any such data from prospective studies. However, it needs demonstration in bigger studies for practical recommendations. Nevertheless, avoiding excessive use of antibiotics is doable and must be borne in mind.

HS Darling

ORCID iD: https://orcid.org/0000-0001-7557-0292

Olaparib: A wonder drug to reduce recurrence in early BRCA-positive breast cancers?

According to the GLOBOCAN 2020 data, breast cancer (BC) is the most common cancer in women worldwide and in India. According to a review and meta-analysis conducted by Sandhu et al. in the Journal of Global Oncology in 2016 (Prevalence of triple-negative breast cancer in India: Systematic review and meta-analysis. DOI: https://doi.org/10.1200/JGO.2016.005397), the prevalence of triple-negative BC (TNBC) was 31% in the Indian population, which is higher compared with the Western population. Young age at diagnosis, positive familial history, and TNBC are known to be associated with germline mutations in BC genes 1 and 2 (BRCA1 and BRCA2). These patients may benefit from genetic testing. Olaparib is an oral poly ADP-ribose polymerase (PARP) inhibitor. Inhibition of PARP is known to benefit patients with BRCA-mutated cancers, including breast and ovarian cancers.

An interim analysis of a double-blind, randomized, controlled trial (OlympiA) was recently published in the New England Journal of Medicine by Tutt et al. in 2021 (Adjuvant olaparib for patients with BRCA1- or BRCA2-mutated breast cancer. DOI: https://www.nejm.org/doi/full/10.1056/NEJMoa2105215). This study randomized 1,836 patients, who underwent surgery and received either neoadjuvant or adjuvant chemotherapy, and who had HER-2 (human epidermal growth factor)-negative disease and had tested positive for BRCA1 and/or BRCA2 germline pathogenic variant, to either receive olaparib (921) or placebo (915). The experimental arm received 300 mg of olaparib twice daily for 52 weeks.

This study showed significant improvement in invasive disease-free survival (iDFS) in favor of olaparib (85.9% versus 77.1%) with an absolute improvement of 8.8%. The 3-year distant disease-free survival was also higher (87.5% versus 80.4%; hazard ratio: 0.57, 95% confidence interval: 0.39–0.83) in the olaparib group. Although 27 fewer deaths were observed with olaparib, the difference in 3-year overall survival was not statistically significant (92% versus 88.3%).

Adverse events (AEs) were more common with olaparib, although serious AEs were similar in both groups. Anemia was the commonest Grade 3 AE associated with olaparib seen in 8.7% compared with 0.3% in the placebo arm, with 5.8% of patients requiring transfusion. In addition, 10 patients experienced Grade 4 AEs (decreased neutrophil count, anemia, fatigue). The study did not show any increase in the incidence of myelodysplastic syndrome or acute myeloid leukemia as previously reported with the use of olaparib by Morice et al. in The Lancet Haematology in 2021 (Myelodysplastic syndrome and acute myeloid leukaemia in patients treated with PARP inhibitors: A safety meta-analysis of randomised controlled trials and a retrospective study of the WHO pharmacovigilance database. DOI: https://doi.org/10.1016/S2352-3026(20)30360-4). However, the median follow-up of this study is only 2.5 years, and a longer follow-up would be necessary to understand any long-term side effects. Dose reduction was required in 25% and treatment discontinuation in 9.9% of patients in the olaparib arm compared with 5.2% dose reductions in the placebo group. It would be interesting to know if the patients who permanently discontinued olaparib were also a part of the survival analysis. The study fails to mention the compliance rate of patients and its difference among the olaparib or placebo group.

This trial is promising since olaparib significantly improved the iDFS when used in the adjuvant settings for early high-risk BC. The final survival analysis and late effects of olaparib on BC survivors are eagerly awaited.

Jinesh R. Singhavi

ORCID iD: https://orcid.org/0000-0002-6923-9736


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