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LETTER TO EDITOR
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 129-130

Primum non nocere


Department of Medical Oncology, Father Muller Medical College, Mangalore, Karnataka, India

Date of Submission10-Jan-2020
Date of Acceptance10-Jan-2020
Date of Web Publication24-Feb-2020

Correspondence Address:
Hemanth Kumar
Department of Medical Oncology, Father Muller Medical College, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_17_20

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How to cite this article:
Kumar H, Shetty N. Primum non nocere. Cancer Res Stat Treat 2020;3:129-30

How to cite this URL:
Kumar H, Shetty N. Primum non nocere. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Apr 10];3:129-30. Available from: http://www.crstonline.com/text.asp?2020/3/1/129/279096



The incidence of esophageal cancer is on the rise. This malignancy is associated with significant morbidity and poor quality of life (QOL) as the vital necessity needed for survival, i.e., 'intake of food' is hampered. Treatment in this setting has to strike a balance with the survival benefit against the possible toxicities and deterioration of QOL.

The article by Simha et al.[1] begins with an important question – “Does palliative chemotherapy prolong overall survival in esophageal cancer?” The systematic review by Janmaat et al.[2] found a statistically significant benefit of 1 month in survival for the addition of a cytotoxic/targeted therapy to the control arm, and a benefit of 0.5 month when compared to supportive care alone. Despite being statistically significant, this does not translate to a meaningful benefit in outcomes. Hence, the question arises as to how well to use the possible therapeutic options to improve outcomes in terms of survival and QOL.[3]

The article explores the possible therapeutic options, response rates to single agent chemotherapeutic agents, benefits and toxicities of combination chemotherapy. With the addition of each additional drug, the possible response rates increase but this improvement comes with significant added toxicity. Most of these trials were done in ideal settings in patients with good performance status. However, real-life scenarios are very different. In a country like India, where many patients have poor nutritional status and general condition, the article by Joshi et al.[4] highlighted the benefit of metronomic weekly paclitaxel as an option in poor performance state individuals which not only showed a decent survival advantage but also improved the QOL in the context of an ability to forego nasogastric tube in 72% of these patients. As the FLOT (docetaxel, oxaliplatin, leucovorin, and 5-fluorouracil) chemotherapy regimen is more often used in the neoadjuvant setting currently, we will be restricted by options in the second line setting.

Newer agents are being tested in esophageal/gastro-esophageal junction cancers. Ramucirumab was approved by the Food and Drug Administration in the second-line setting which only showed a survival benefit of 1.4 months, with a hazard ratio of 0.776 (95% confidence [CI], 0.603–0.998; P = 0.047). On the European Society of Medical Oncology – Magnitude of clinical benefit scale, ramucirumab resulted in negligible benefit.[5] Approval of such drugs results in lack of innovation and creativity and poses a significant cost implication in the treatment of cancer.[6]

Studies in which QOL is the primary objective in patients with esophageal cancers undergoing palliative chemotherapy are few. A qualitative study of life and perspectives by Laursen et al.[7] revealed how these patients metaphorically end up at a 'table in the corner.' The Hippocratic Oath binds every physician to “Primum non nocere,” i.e., “First, do no harm.” To improve the survival in these patients by few days or months, one should not forget the possible harm that may be done to these patients. The current article gives an opportunity for future studies focusing on QOL in these patients.[8]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Simha V, Patil V, Joshi A, Prabhash K, Noronha V. Role of palliative chemotherapy and targeted therapy in advanced esophageal and gastroesophageal junction cancers. Cancer Res Stat Treat 2019;2:172-81.  Back to cited text no. 1
  [Full text]  
2.
Janmaat VT, Steyerberg EW, van der Gaast A, Mathijssen RH, Bruno MJ, Peppelenbosch MP, et al. Palliative chemotherapy and targeted therapies for esophageal and gastroesophageal junction cancer. Cochrane Database Syst Rev 2017;11:CD004063.  Back to cited text no. 2
    
3.
Asthana S, Bhatia S, Dhoundiyal R, Labani SP, Garg R, Bhatnagar S. Quality of life and needs of the Indian advanced cancer patients receiving palliative care assessment of the quality of life, problems, and needs of the advanced cancer patient receiving palliative care. Cancer Res Stat Treat 2019;2:138-44.  Back to cited text no. 3
  [Full text]  
4.
Joshi A, Noronha V, Pandey A, Patil V, Samar A, Mahajan A, et al. Outcomes with palliative weekly paclitaxel in advanced, recurrent, and metastatic esophageal cancer – Real world experience. Indian J Med Paediatr Oncol 2018;39:46-51.  Back to cited text no. 4
  [Full text]  
5.
Cherny NI, Dafni U, Bogaerts J, Latino NJ, Pentheroudakis G, Douillard JY, et al. ESMO-magnitude of clinical benefit scale version 1.1. Ann Oncol 2017;28:2340-66.  Back to cited text no. 5
    
6.
Philip CC, Mathew A, John MJ. Cancer care: Challenges in the developing world. Cancer Res Stat Treat 2018;1:58-62.  Back to cited text no. 6
  [Full text]  
7.
Laursen L, Schønau MN, Bergenholtz HM, Siemsen M, Christensen M, Missel M. Table in the corner: A qualitative study of life situation and perspectives of the everyday lives of oesophageal cancer patients in palliative care. BMC Palliat Care 2019;18:60.  Back to cited text no. 7
    
8.
Noronha V. Making a case for cancer research in India. Cancer Res Stat Treat 2018;1:71-4.  Back to cited text no. 8
  [Full text]  




 

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