|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 2 | Page : 398
Authors' reply to Banavali et al., Bansal et al. and Viswanathan et al.
Kiran Kumar, Venkatraman Radhakrishnan
Department of Medical Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
|Date of Submission||07-Apr-2020|
|Date of Acceptance||11-Apr-2020|
|Date of Web Publication||19-Jun-2020|
Department of Medical Oncology, Cancer Institute, Adyar, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumar K, Radhakrishnan V. Authors' reply to Banavali et al., Bansal et al. and Viswanathan et al. Cancer Res Stat Treat 2020;3:398
We would like to thank Banavali et al., Bansal  and Viswanathan et al. for showing interest in our work and  the accompanying editorial  and providing valuable comments and suggestions.
We agree with Bansal about the need to test the efficacy of oral metronomic chemotherapy (OMC) under more stringent conditions in a clinical trial. A randomized controlled trial done by Pramanik et al. did not show the benefit of OMC when compared with best supportive care. However, we need to look at efficacy in specific cancers rather than clubbing all tumors together. Our study shows the real-world picture of treating relapsed/refractory pediatric malignancies where all options of standard chemotherapy have been exhausted or are not available due to cost. Ours is a retrospective study and we did not look at specific cancers as the numbers are small. In response to Bansal we have not substituted OMC for standard chemotherapy in responsive malignancies and have used this strategy only in the palliative intent setting.
We agree with Banavali et al. that OMC must be given in a continuous low dose fashion. The major issue we face with continuous dosing is the lack of pediatric formulations of etoposide and cyclophosphamide. We found it difficult to give drugs continuously without toxicity. We provided drug holidays in between for the counts to recover. As seen in our trial, patients on OMC did develop neutropenia.
We would like to thank Viswanathan et al. for sharing data from their institute. They have used mercaptopurine (6MP) in refractory acute myeloid leukemia (AML). Even in our study, patients with AML did not fare well and there is a need to study the optimal regimen for this population. There is no standard regimen for these patients and no evidence that multiple drugs are better than one or two.
The use of OMC in hematological malignancies like Hodgkin's lymphoma and leukemias needs to be explored further as most studies are done in solid tumors. Collaborative studies including various centers across India need to be done and data from the Indian Pediatric Oncology Group would be the first step towards understanding the practice and outcomes of the use of OMC in the pediatric population.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Kumar K, Radhakrishnan V, Dhanushkodi M, Kalaiyarasi JP, Mehra N, Kumar AR, et al
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