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| LETTER TO EDITOR |
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| Year : 2020 | Volume
: 3
| Issue : 2 | Page : 339-340 |
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Authors' reply to Somashekhar et al. and Rath et al.
Sampada Dessai1, Ankita Nachankar2, Pritam Kataria3, Anuja Abhyankar4
1 Department of Surgical Oncology, Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India
2 Department of Radiation Oncology, Gunma University, Gunma, Japan
3 Department of Medical Oncology, Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India
4 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| Date of Submission | 10-May-2020 |
| Date of Decision | 11-May-2020 |
| Date of Acceptance | 11-May-2020 |
| Date of Web Publication | 19-Jun-2020 |
Correspondence Address:
Sampada Dessai
Prarthana Samaj, Raja Rammohan Roy Rd., Charni Road East, Khetwadi, Girgaon, Mumbai, Maharashtra - 400 004, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/CRST.CRST_188_20
How to cite this article:
Dessai S, Nachankar A, Kataria P, Abhyankar A. Authors' reply to Somashekhar et al. and Rath et al. Cancer Res Stat Treat 2020;3:339-40 |
We would like to thank Somashekhar et al.[1] and Rath and Parab [2] for taking interest in our article titled, “Management of patients with gynecological cancers during the COVID-19 pandemic”[3] and another article published in the same issue by Goel.[4] Ours was a review article written on the basis of existing evidence. The two articles have been separately written by different authors. We are glad to know that the review of the literature on the same topic by the other author has led to similar interpretations. As is seen in most well-constructed guidelines, recommendations appear similar and repetitive. For example, the recommendations for the management of the gestational trophoblastic neoplasm (GTN) are the same in both the National Comprehensive Cancer Network and European Society for Medical Oncology guidelines.
We have recommended against systemic paraaortic lymph node dissection. The reason is that the results of the randomized study showed the futility of this procedure in clinically node-negative patients.[5] We agree on the intraoperative assessment of the pelvic and paraaortic nodes and their removal if they are enlarged. We also agree on the non-inferiority of three cycles of chemotherapy versus six cycles, which has been shown in the Gynecologic Oncology Group 157 trial.[6] However, it is vital to remember that in this study, paclitaxel and carboplatin combination was used in both the arms. Even three cycles of this regimen in the study were associated with granulocytopenia of grade 2 or above in 87.6% (185 out of 211) of the patients. The risk of COVID-19-related infections and complications is closely related to myelosuppression.[6],[7] No study has compared carboplatin with paclitaxel–carboplatin in early-stage ovarian cancer. This explains our preference for single-agent carboplatin.[8] We thank Somashekhar et al. for raising the fundamentally important, but largely neglected, issue of starting treatment early in patients with gestational trophoblastic disease. Unfortunately, in today's molecular era, the basic principles of chemotherapy based on the seminal works of many authors are largely overlooked, even by medical oncologists. In accordance with the Gompertzian curve and resistance kinetics, in fast-growing tumors such as GTN, there is an increase in kinetic resistance as the size increases. Further, in accordance with the Goldie–Coldmann hypothesis, the larger the size of the tumor, the higher is the probability of developing resistance to a single chemotherapeutic drug.[9]
We have recommended the use of chemoradiation with weekly cisplatin in this pandemic. This recommendation is based on the overall survival (OS) advantage shown with this drug when added to radiation. In a pivotal study reported from the Tata Memorial Hospital in stage IIIB squamous cell tumors of the uterine cervix, the addition of cisplatin led to around 10% absolute improvement in both the 5-year disease-free survival (DFS) and OS. The relative proportional improvements were approximately 20% and 17% in the DFS and OS, respectively. These results were achieved with a 2.6% risk of grade 3 or above neutropenia with weekly cisplatin.[10] Further, in a community setting prospective study reported by Nandakumar et al. in locally advanced cervical cancers involving 1753 patients (Stages IIB–IVA), there was an improvement in the 5-year OS from 47.3% to 70.2% with the addition of cisplatin.[11] We believe that the significant survival benefits with minimal risk of grade 3 or above side effects justify the need for weekly cisplatin. While making our recommendations, we had considered the OS and the interventions impacting it. Unfortunately in carcinoma endometrium, in multiple randomized studies, neither external beam radiation nor vaginal brachytherapy were shown to be associated with an improvement in the OS.[12],[13] Hence, we recommend against radiation therapy for endometrial cancers, which has no survival benefit and leads to grade 2 and above lymphocytopenia rate of 10%.[12],[14]
This review was written at the time when the pandemic was still in its infancy in India; certainly, the decisions will have to be individualized in accordance with the situation and institute preferences in a particular area. We need to evolve over time, learn from our short-term experiences by auditing our data during the COVID era,[15] evaluate our adaptability to situations, and then develop our own long-term guidelines.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Somashekhar SP, Ahuja V, Olawaiye AB. Gynecological cancer care in the COVID-19 era: Shifting focus from short term to the long term. Cancer Res Stat Treat 2020;3:335-7.  [Full text] |
| 2. | Rath S, Parab P. Impact of COVID-19 on gynecological cancer patients. Cancer Res Stat Treat 2020;3:338-9. |
| 3. | Dessai S, Nachankar A, Kataria P, Abyankar A. Management of patients with gynecological cancers during the COVID-19 pandemic. Cancer Res Statist Treat 2020;3 Suppl S1:40-8. |
| 4. | Goel A. Management of cancer during the COVID pandemic: Treatment of gynecological malignancies. Cancer Res Statist Treat 2020;3 Suppl S1:106-9. |
| 5. | Harter P, Sehouli J, Lorusso D, Reuss A, Vergote I, Marth C, et al. A Randomized Trial of Lymphadenectomy in Patients with Advanced Ovarian Neoplasms. N Engl J Med 2019;380:822-32. |
| 6. | Bell J, Brady MF, Young RC, Lage J, Walker JL, Look KY, et al. Randomized phase III trial of three versus six cycles of adjuvant carboplatin and paclitaxel in early stage epithelial ovarian carcinoma: A Gynecologic Oncology Group study. Gynecol Oncol 2006;102:432-9. |
| 7. | Bansal N, Ghafur A. COVID-19 in oncology settings. Cancer Res Stat Treat 2020;3 Suppl S1:13-4. |
| 8. | Sapkota S, Abhyankar A, Dessai S. Ovarian cancer practice survey from the South Asian Association for Regional Cooperation (SAARC) Nations. Cancer Res Stat Treat 2019;2:158-62. [Full text] |
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| 10. | Shrivastava S, Mahantshetty U, Engineer R, Chopra S, Hawaldar R, Hande V, et al. Cisplatin chemoradiotherapy vs. Radiotherapy in FIGO stage IIIB squamous cell carcinoma of the uterine cervix: A randomized clinical trial. JAMA Oncol 2018;4:506-13. |
| 11. | Nandakumar A, Kishor Rath G, Chandra Kataki A, Poonamalle Bapsy P, Gupta PC, Gangadharan P, et al. Concurrent chemoradiation for cancer of the cervix: Results of a multi-institutional study from the setting of a developing country (India). J Glob Oncol 2015;1:11-22. |
| 12. | Nout RA, van de Poll-Franse LV, Lybeert ML, Wárlám-Rodenhuis CC, Jobsen JJ, Mens JW, et al. Long-term outcome and quality of life of patients with endometrial carcinoma treated with or without pelvic radiotherapy in the post operative radiation therapy in endometrial carcinoma 1 (PORTEC-1) trial. J Clin Oncol 2011;29:1692-700. |
| 13. | Nout RA, Smit VT, Putter H, Jürgenliemk-Schulz IM, Jobsen JJ, Lutgens LC, et al. Vaginal brachytherapy versus pelvic external beam radiotherapy for patients with endometrial cancer of high-intermediate risk (PORTEC-2): An open-label, non-inferiority, randomised trial. Lancet 2010;375:816-23. |
| 14. | de Boer SM, Powell ME, Mileshkin L, Katsaros D, Bessette P, Haie-Meder C, et al. Adjuvant chemoradiotherapy versus radiotherapy alone for women with high-risk endometrial cancer (PORTEC-3): Final results of an international, open-label, multicentre, randomised, phase 3 trial. Lancet Oncol 2018;19:295-309. |
| 15. | Patil VM, Srikanth A, Noronha V, Joshi A, Dhumal S, Menon N, Prabhash K. The pattern of care in head-and-neck cancer: Comparison between before and during the COVID-19 pandemic. Cancer Res Stat Treat 2020;3 Suppl S1:7-12. |
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