Low Dose, Low Cost Immunotherapy In Head And Neck Cancers

Head and neck cancers are very common in India due to frequent habit of chewing tobacco and betel quids. The outcome of advanced head and neck squamous cell carcinoma (HNSCC) is particularly poor and these patients are usually recommended expensive targeted therapies and immunotherapies which are standard of care in today’s practice. Financial hardship caused by cancer care is far more common than we think. There is growing evidence of financial problems among people with cancer.

A study from tertiary cancer hospital from India has found that an ultra-low dose of the immunotherapy drug nivolumab in combination with metronomic therapy can more than double the number of patients still alive 1 year later. It is potentially more affordable because the dose used here is 6 % of what is typically use as per guidelines which decreases the cost of therapy to 5% to 9% of the cost of full-dose immunotherapy regimens.

The results have larger implications: the potential to put the expensive immunotherapy drug within reach of many more people with different kind of cancer.

This phase 3 clinical trial which included 151 people with advanced and metastatic HNSCC either upfront or recurrent setting. The patients were randomised in 1:1 fashion to receive methotrexate, erlotinib and celecoxib with or without low-dose nivolumab. The dose of nivolumab in the immunotherapy group was 20 mg 3 weekly, instead of 240 mg which is the typical dose used as per guidelines. 43% of patients in the immunotherapy group and 16% in the standard treatment group were still alive at 1 year. Median survival of patients in the immunotherapy group was 10 months, compared with 7 months for those in the standard treatment group. This is pretty remarkable as the magnitude of survival benefit has occurred with 6% of the FDA – approved dose of nivolumab. The overall response rate in immunotherapy group was 59% as against 45% in the standard treatment group.

Although the direct comparision of low dose and the full dose of nivolumab is not available but, the survival benefit of the low dose is similar to what’s been seen in studies of the full dose.

This new study also raises the possibility that lower doses of other immunotherapeutic agents could be effective for HNSCC as well as other kinds of cancer. The same idea could even be applied to other kinds of cancer therapy. With lower doses and lower costs more patients could be benefited and many deaths prevented.

Dr. Manish Sharma
Consultant – Medical Oncology
RGCIRC, Niti Bagh, South Delhi