Up until the present, there are no predictive biomarkers or indicators for guiding the HNSCC treatment. A survey report on precision medicine entitled, “Global Precision Medicine Market – Analysis and Forecast, 2017–2026” from BIS research registered $43.59 billion in 2016. It is estimated to reach $141.70 billion by 2026, with an annual growth rate of 11.23%. The Personalized Medicine Coalition for diagnostic and targeted agents was $25 billion in 2015.
Dr Hemantkumar Nemade
Consultant Head and Neck Oncologist
The biomarkers for precision medicine drugs (in numbers) were 5 in 2008 and went up to 132 in
2016. According to a survey by The Tufts Centre for Drug Development. 42% of drugs are in the
pipeline plan and will be considered soon. Global investments in the next 5 years are likely to
increase by 33% for precision medicine drugs, and immunotherapy drugs. There is a surge in the
global market where the growth was $108 billion in 2016 and is nearly estimated to be $200 billion
by 2021. The objective in HNSCC patients for cancer treatment are:
● Minimal morbidity
● Preservation and restoration of organ function
● Improvement of quality of life
However, the guidelines to treat patients are hugely based on the region of carcinoma and the TMN stages, (i.e) Tumor size, lymph nodal involvement, and presence or absence of metastasis. Subsequently, the major guidelines are as follows:
- The National Comprehensive Cancer Network (NCCN)
- The European Society for Medical Oncology (ESMO).
Certainly, both provide the professional database and protocols on how the cancers should be treated. In addition, it involves the methodologies that are to be practiced, and recommendations to help patients with the best care options. Most of the countries prefer NCCN guidelines, along with the Institution based protocols.
Treatments and Therapies:
Cancer surgery primarily aims to remove the tumor as much as possible, as it helps to get rid of the disease. The most preferred surgeries are:
- Laser surgery (beams of light)
- Lymph node or neck dissection
- Electro-surgery (electric currents)
- Reconstructive (plastic) surgery
- Cryosurgery (very cold temperatures to freeze cancer cells)
These surgeries are equipped with harmonics and gamma knife practices. The Radiation technique is used to treat cancer cells and Radioactive Iodine I-131 is used in systemic radiation therapy for thyroid cancer. Meanwhile, the side effect of radiation therapy is that it not only kills but also hinders cancer cells growth along with healthy cells. Other radiation techniques include:
- Intensity Modulated Radiation Therapy (IMRT)
- Image-guided radiation therapy (IGRT)
- Rapid arc
In 2012, Paclitaxel (PTX) was incorporated for clinical trials. Chemotherapy was the first-line treatment (Indian guidelines) in 2014 CTX with platinum-based treatment . Subsequently, these all reported a response rate above 45%. Henceforth, the combinations of these drugs are preferred and currently are used in palliative Chemotherapy. Approximately, every treatment costs a minimum of INR 75,000.
Survival, Recurrence and what if treatment fails?
Dr. Hemantkumar Nemade points out that drug are used to increase the survival rate, and this survival rate is truly based on the stages in which the person is up to.
Survival rates are increased through drugs, and this survival rate is truly based on the stages in which the person is up to. Say in the early stage like stage 1 the survival rate is 80%, stage 2 is 70-60% and stage 3, 4 is 50% and below. The effectiveness of salvage is very predominant for stage I/II patients with 70% disease-free survival for 2 years and 60% stable wellbeing have been reported. For stages 3 and 4, the cancer is loco-regionally advanced. Above all, with innovations in science and technology, a significant percentage of this cancer recurs. India should focus on
- Reduction in toxicity related treatment
- General health
- Social and economic support
Cancer occurs with no symptoms and is labelled as no evidence of disease. Recurrent cancer are the ones that return after original treatment and it of three types namely
- local recurrence
- regional recurrence
- distant recurrence
A special psychological session should be conducted to make the patients feel comfortable. However, the worst condition is when cancer can’t be controlled and is known as advanced or terminal stage as the life expectancy would be less than 6months and hospice care will be provided.
India needs to work on:
- The goal of increasing 5-year survival, which is 30% in India, and 60% in West
- The technical ability, infrastructure, and recently-equipped machines are a must in a Cancer Center along with professional oncologists to deliver the best treatment.
- To promote healthy lifestyles, Oral hygiene, reduced tobacco use, improvement of cancer registries, and mass screening for some cancers frequent awareness and education campaigns need to be conducted
- Clinical governance is the desperate need of the hour. Most importantly, in both the private and public sector
Cost-effective care: Diagnostic tests, cancer drugs, and end-of-life care are expensive due to inadequate facilities and privatization. Therefore, the government should come up with the indigenization of diagnostic tests, expensive equipment and start a window of public-private partnership, as this would reduce the expenses.
Prevention of Cancer:
- Rehabilitation centres, campaigns, and health care focus on Smoking/tobacco cessation as it prevents 40% of tobacco-related cancers.
- Quit tobacco attempts use FDA-approved first-line pharmacotherapies. For instance, for nicotine replacement such as nicotine patch, gum, lozenge, nasal spray or oral inhaler and two non-nicotine oral medications, bupropion and varenicline
- HPV vaccines: These were developed to prevent HPV-positive HNSCC, based on placebo-controlled trials and estimating the burden of anogenital HPV infections, the effectiveness against oral HPV infection has been analysed. In India a quadrivalent vaccine (GardasilTM marketed by Merck) and a bivalent vaccine (CervarixTM marketed by GlaxoSmithKline) are available.
- However, another strategy is training health workers to screen the population-based on symptoms. For Eg, Say VIA/vinegar test for the rural population to screen for cervical cancer, ENT care may serve the need.
HNSCC patients are complicated. A survey for HNSCC says that mortality rate may increase to 40–50% in cancer patients, if untreated. The focus on Oncology based Centres with latest machinery and to manufacture anti-cancer drugs at low cost. Anti-smoking campaigns must be conducted. Moreover, special care in rehabilitation centres for tobacco and other chewing habits must be given prior importance, thus reducing the HNSCC. In addition, the drive to improve the quality of services across the private and public sector provides a major opportunity to improve cancer outcomes but it needs to be practically implemented as laid out above.