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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 608-609

Palliative oral triple metronomic chemotherapy in a patient with head-and-neck cancer during the COVID-19 pandemic in India: A case report

Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Submission17-Jun-2020
Date of Decision22-Jul-2020
Date of Acceptance23-Jul-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Kumar Prabhash
Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/CRST.CRST_220_20

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How to cite this article:
Dhumal SB, Noronha V, Kurup AR, Patil V, Joshi A, Menon N, Prabhash K. Palliative oral triple metronomic chemotherapy in a patient with head-and-neck cancer during the COVID-19 pandemic in India: A case report. Cancer Res Stat Treat 2020;3:608-9

How to cite this URL:
Dhumal SB, Noronha V, Kurup AR, Patil V, Joshi A, Menon N, Prabhash K. Palliative oral triple metronomic chemotherapy in a patient with head-and-neck cancer during the COVID-19 pandemic in India: A case report. Cancer Res Stat Treat [serial online] 2020 [cited 2021 May 7];3:608-9. Available from: https://www.crstonline.com/text.asp?2020/3/3/608/295549

Pembrolizumab is the standard immunotherapeutic agent used in the palliative setting for the treatment of head-and-neck cancers in the first line.[1] Patil et al. reported that their preferred pattern of care in the palliative setting amid the current coronavirus disease 2019 (COVID-19) pandemic is oral metronomic chemotherapy.[2] In developing countries like India, less than 1% of the patients can afford immunotherapy. Patil et al. recommended the use of an oral, less toxic metronomic chemotherapeutic regimen that can be taken at home and requires a minimum number of hospital visits.[3] Compared to intravenous chemotherapy, metronomic chemotherapy has been reported to be cost-effective and well-tolerated in patients with recurrent/metastatic head-and-neck cancers.[4]

COVID-19 cases are on the rise in India. As of July 20, 2020, the total number of active cases were 3,90,459, cured/discharged cases were 7,00,086, and reported deaths were 27,497.[5] In response to the pandemic, the Government of India had imposed a nationwide lockdown until May 17, 2020.[6] This created logistic issues in continuing cancer-related care, especially for those who had to travel to a different state to avail treatment during this time. To continue cancer-related care, as an institutional strategy, we resorted to contacting patients telephonically. Here, we present the follow-up of one of our patients whose treatment was ongoing during these difficult times.

On September 20, 2019, a 54-year-old man presented at our hospital with complaints of change in voice and a large swelling in the neck. A histopathological examination of the left pyriform sinus performed on September 25, 2019, was suggestive of a squamous cell carcinoma. The baseline positron emission tomography scan performed on October 3, 2019, showed a soft-tissue lesion involving the left pyriform sinus and the left aryepiglottic fold, with metastatic bilateral cervical and left upper paratracheal nodes and a suprasternal notch deposit. The case was discussed in the head-and-neck oncology multidisciplinary clinic, and the patient was planned for palliative chemotherapy. The option for standard immunotherapy was offered to the patient, but he could not afford it. Therefore, on October 9, 2019, he was started on palliative oral metronomic chemotherapy with celecoxib 200 mg orally twice daily and oral methotrexate 15 mg/m2. On January 6, 2020, a radiologic disease progression was observed [Figure 1], in view of this, tablet erlotinib 150 mg was added to the existing oral metronomic chemotherapy regimen on January 7, 2020. The patient was called back for reassessment after 3 months. He was contacted telephonically, and the clinical response was assessed using photographs taken by the patient on April 27, 2020, which were then compared with the baseline clinical photograph available in our records. This revealed a good clinical response [Figure 2]. During treatment, the patient developed an erlotinib-induced rash, which was managed with doxycycline capsules and Lacto Calamine lotion. He was last contacted telephonically on June 7, 2020, and he reported that he was feeling better. Based on this, he was advised to continue the oral triple metronomic chemotherapy. [Figure 3] depicts the timeline of the historical and current clinical events of the patient.
Figure 1: Before chemotherapy

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Figure 2: After chemotherapy

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Figure 3: Timeline of historical and current information

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Triple metronomic chemotherapy with celecoxib, methotrexate, and erlotinib is a good option in the palliative setting for early failure advanced-stage head-and-neck cancers.[7] Our report highlights the importance of triple metronomic chemotherapy during such a critical time.

Declaration of patient consent

We state that we have taken patient consent for publication of his images in both online and printed formats. The patient's consent is uploaded on the journal's website.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Burtness B, Harrington KJ, Greil R, Soulières D, Tahara M, de Castro G Jr, et al. Pembrolizumab alone or with chemotherapy versus cetuximab with chemotherapy for recurrent or metastatic squamous cell carcinoma of the head and neck (KEYNOTE-048): A randomised, open-label, phase 3 study. Lancet 2019;394:1915-28.  Back to cited text no. 1
Patil VM, Srikanth A, Noronha V, Joshi A, Dhumal S, Menon N, et al. 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.  Back to cited text no. 2
Patil V, Noronha V, Chaturvedi P, Talapatra K, Joshi A, Menon N, et al. COVID-19 and head and neck cancer treatment. Cancer Res Stat Treat 2020;3, Suppl S1:15-28.  Back to cited text no. 3
Patil VM, Noronha V, Joshi A, Muddu VK, Dhumal S, Bhosale B, et al. A prospective randomized phase II study comparing metronomic chemotherapy with chemotherapy (single agent cisplatin), in patients with metastatic, relapsed or inoperable squamous cell carcinoma of head and neck. Oral Oncol 2015;51:279-86.  Back to cited text no. 4
Available from: https://www.mohfw.gov.in/pdf/FAQ.pdf. [Last cited on 2020 Jul 20].  Back to cited text no. 5
India Virus Lockdown Extended by Two Weeks. BBC News; 2020. Available from: https://www.bbc.com/news/world-asia-india-52505436. [Last cited on 2020 May 23].  Back to cited text no. 6
Patil VM, Noronha V, Joshi A, Dhumal S, Mahimkar M, Bhattacharjee A, et al. Phase I/II study of palliative triple metronomic chemotherapy in platinum-refractory/early-failure oral cancer. J Clin Oncol 2019;37:3032-41.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3]


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