1Consultant Medical Oncologist
Jaslok Hospital and Bombay Hospital
Email ID: bharatsinghbhosale@gmail.com
The health care system all across the globe has been overwhelmed by COVID-19 pandemic. The systems are trying to recover from the enormous strain. Not only low- and middle-income countries but developed countries also have been badly affected. There are challenges with respect to providing adequate hospital resources to non-COVID patients. This scenario is changing for the better slowly, as most of the countries are trying to strengthen their healthcare systems for the better care of both COVID and non-COVID patients. This reform will take some time. Cancer care in low- and middle-income countries like India has been facing many challenges as even basic cancer care is also not possible in some remote parts of India. [1]
Head and neck cancer is one of the most common and preventable cancers in terms of incidence and mortality in India. Recent decade has seen evolution in cancer care in terms of discoveries of targeted therapies and immunotherapies in most of the cancers including head and neck cancer. As per international guidelines recommendation, the standard of care for advanced / recurrent / metastatic head and neck cancer in non-curative setting is a combination of targeted therapies and chemotherapy or immunotherapy alone or in combination with chemotherapy. The biggest hurdle for the recommended standard of care by international guidelines, is accessibility and financial constraints for a country like ours. Even patients from affluent societies to some extent cannot afford the cost of immunotherapy and targeted therapy. In India, most of the patients of head and neck cancer in palliative setting end up receiving single agent platinum or taxanes or in combination and rarely a toxic regimen like Docetaxel, Cisplatin and Fluorouracil (DCF) is used. Many patients cannot afford the cost of chemotherapy and supportive care especially in rural areas. [1,2] The government of India is trying hard to address these issues through various schemes but the problem remains unsolved. We are far from offering standard of care for majority of the patients with head and neck cancer patients. Another challenge, is palliative care access and pain management for advanced cases. Expert palliative and pain management specialists are not available to all patients; this is also a huge challenge. To increase availability of such specialists, postgraduate teaching program has been introduced by institutes like Tata Hospital. This can be seen as the initial welcome step, but there is still a long way to go. There has been an unmet need to address the above-mentioned issues.
Oral Metronomic therapy (OMT) has been utilized in many cancers including head and neck. So far there was no clear high-level evidence to back it up as a standard of care. Only those patients for whom standard treatment was not feasible used to opt for the OMT. Dr Banavali (our teacher and director at Tata Memorial Hospital) has been one of the pioneers and proponents of OMT. He has successfully utilized OMT for different cancers in rural cancer center at Dervan. There is scarcity of healthcare facilities to deal with oncological emergencies at Dervan. Hence, OMT by virtue of limited toxicities can be of great help in providing cancer care. So subsequent attempts started at Tata Memorial Hospital with retrospective study and phase 2 followed by phase 3 trial of metronomic therapy in head and neck cancer patients in palliative setting. Important milestone of OMT is recent article by Vijay Patil et. This is phase 3 randomized non inferiority trial with standard chemotherapy arm as control and all patients in standard arm received single agent Cisplatin. This is not only the greatest achievement but it is one of the inventions which actually address the need of Indian patients suffering from head and neck cancer who cannot have access to recommended standard of care treatment comprising of Targeted therapy or Immunotherapy combinations. In the last few decades, the only modalities which improved overall survival in head and neck cancer patients in palliative settings apart from intravenous chemotherapy are Immunotherapy and Cetuximab; it’s known that more than 95% parent of Indian patients and patients from low- and middle-income country can’t afford these costly therapies. Hence it is an important milestone which has shown affordable therapy accessible to all which can also give as good results as intravenous chemotherapy. [4.5.6]
Courtesy - Indian Journal of Medical and Paediatric Oncology (IJMPO)
Editor-in-Chief - Dr. Padmaj Kulkarni
Section Editor - Dr. Sneha Bothra
Editorial Assistant - Devika Joshi