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Table of Contents
LETTER TO EDITOR
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 396-397

Conservative salvage ideas – Can metronomic therapy improve the quality of life and prolong survival?


Department of Pediatric Oncology, Kidwai Cancer Institute, Bengaluru, Karnataka, India

Date of Submission09-Mar-2020
Date of Decision09-Mar-2020
Date of Acceptance10-Mar-2020
Date of Web Publication19-Jun-2020

Correspondence Address:
Prakruthi S Kaushik
Department of Pediatric Oncology, Kidwai Cancer Institute, D. H. Marigowda Road, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_77_20

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How to cite this article:
Viswanathan A, Kaushik PS, Appaji L. Conservative salvage ideas – Can metronomic therapy improve the quality of life and prolong survival?. Cancer Res Stat Treat 2020;3:396-7

How to cite this URL:
Viswanathan A, Kaushik PS, Appaji L. Conservative salvage ideas – Can metronomic therapy improve the quality of life and prolong survival?. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Sep 19];3:396-7. Available from: http://www.crstonline.com/text.asp?2020/3/2/396/287267



Kumar et al. have highlighted the benefits of oral metronomic chemotherapy (OMC) in low and middle income countries and have also shown that partial responses can be attained in certain progressive cancers. As illustrated by their results, metronomic therapy can prolong survival in some cancers.[1] Ours is a tertiary care cancer institute in South India that caters to approximately 500 children with cancers every year. Therefore, we would like to share our experience with OMC over the past 12 months. The commonly used drugs were cyclophosphamide and etoposide with celecoxib; additionally, temozolomide/methotrexate were added on a case-by-case basis. A total of 8 children, 3 with acute myeloid leukemia (AML), 3 with Ewing's sarcoma, 1 with adrenocortical carcinoma, and 1 with anaplastic ependymoma, were started on OMC. Two children with AML succumbed to the disease within 2 weeks, whereas the third child is alive with progressive symptoms in week 6 of OMC. On the other hand, the five children with solid tumors have had stable disease for a median duration of 6.4 months (range, 4–9 months). Four of these five children had received second-line chemotherapy prior to OMC, and three out of four showed progression on salvage chemotherapy. Currently, all the five children are asymptomatic with stable disease. Although low-dose chemotherapy is insufficient to clear the disease in hematological malignancies, it can make the patients prone to significant side effects, probably because of the diseased marrow status. Febrile neutropenia was observed in two out of three children with AML, whereas none of the children with solid tumors on OMC developed any grade 3 or 4 toxicity or required admission. Prospective studies are required to determine whether regimen modification will benefit patients with hematological malignancies, as some studies have shown that mercaptopurine benefits patients with refractory AML.[2] The role of maintenance therapy in rhabdomyosarcoma has been established by the European pediatric Soft Tissue Sarcoma Study Group; however, only those in complete remission (CR) were considered for the study.[3],[4] In view of the promising results observed for metronomic therapy in rhabdomyosarcoma[5] as shown by Kumar et al., a trial of maintenance metronomic therapy for cases in which CR is not achieved might prove to be beneficial.

As aptly pointed out by Amegan-Aho in the editorial, it would be interesting to know the conventional treatment given to the patients in Kumar et al.'s study before starting metronomic therapy,[6] as some of our pediatric patients who progressed to develop metastasis on second-line chemotherapy had stabilized with metronomic therapy. This would help us decide between metronomic therapy at the first sign of progression and a trial of second-line chemotherapy, which may add to the toxicity without much benefit. Before advocating for metronomic therapy, we also need to know its clinical benefits and its effect on the quality of life of children and caregivers through prospective studies.

It is certainly a cost-effective option in settings with limited resources, where many of our patients cannot afford a transplant.[7] Knowing the poor salvage rates in such cases of early progression, whether to advocate transplant in these children shall remain an ethical dilemma. Does OMC prolong the survival or suffering? We think that they are two sides of the same coin!

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kumar K, Radhakrishnan V, Dhanushkodi M, Kalaiyarasi JP, Mehra N, Kumar AR, et al. Oral etoposide and cyclophosphamide: A low-cost palliative metronomic chemotherapy in advanced pediatric cancers. Cancer Res Stat Treat 2020;3:64.  Back to cited text no. 1
  [Full text]  
2.
SIOP PODC Adapted Risk Stratification and Treatment Guidelines: Recommendations for Acute Myeloid Leukemia in Resource - Limited Settings - Bansal - Pediatric Blood and amp; Cancer - Wiley Online Library. Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/pbc. 28087. [Last accessed on 2020 Mar 06].  Back to cited text no. 2
    
3.
Editors CN. New Role for Maintenance Chemo in Rhabdomyosarcoma?. Cancer Network. 2018; Available from: https://www.cancernetwork.com/article/new-role-maintenance-chemo-rhabdomyosarcoma. [Last accessed on 2020 Mar 06].  Back to cited text no. 3
    
4.
Parambil BC, Ramanathan S. Improving outcomes in Rhabdomyosarcoma -The way ahead. Cancer Res Stat Treat 2019;2:69-71.  Back to cited text no. 4
  [Full text]  
5.
Bhaskar Bhuvan L P, Radhakrishnan V, Raja A, Ganesarajah S, Sagar TG. Outcomes in rhabdomyosarcoma: Experience from a tertiary cancer center in India. Cancer Res Stat Treat 2019;2:4-9.  Back to cited text no. 5
    
6.
Amegan-Aho KH. Surviving on less. Cancer Res Stat Treat 2020;3:87-8.  Back to cited text no. 6
  [Full text]  
7.
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. 7
  [Full text]  




 

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