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Repurposing Drugs for Cancer Treatment in Very Remote and Low Resource Areas

By Sandeep Saluja | 05 Jun, 2015

Friends,
May I please take the liberty of seeking your esteemed views on a question which has been engaging my mind as a clinician for quite some time? I have volunteered to work in very remote and low resource areas. What is the best course of action when confronted with a cancer patient in such places? Many of us may believe that we need to refer such patients to speciality centres or at least the district hospital.However, does the patient really benefit from such an exercise? For one, we may only be able to provide him with resources to reach such a place but his ordeal does not end there. For the patient and the caregivers from such areas to land up in a city with not much in their pockets does nothing to end their misery. We only feel light because we have got the burden off our shoulders without doing much good to the patient or the community.
Do we therefore, only offer palliative care to all such patients? Palliative care is surely important but even palliation is not well done unless accompanied by some degree of anti cancer therapy. Conventional chemotherapy is not really difficult to administer and may sometimes not be very expensive either but the biggest challenge is to monitor for and manage associated adverse effects in such places.
Over the past few years, there has been much effort in the scientific world to repurpose drugs (generally used for other indications) for cancer therapy. Interesting such examples include metformin, chloroquine, mebendazole, clioquinol etc.The beauty is that these agents are not very expensive, easily available for other indications, devoid of major adverse effects and most clinicians are comfortable with their use.Further, many of them seem to work on many different cancer types and thus could be useful even if a very precise diagnosis of the kind and origin of cancer is not feasible.
Of course, none of these agents are as of today licensed for use in this indication and at the current pace this could take a long time because:
a) No pharmaceutical industry would find it lucrative to invest in them
b)Even if a trial is done they would be compared with current standard of care and the trial may thus not be positive.However,if the comparator standard of care is what is actually available to patients in these areas, the results could be very different.
I therefore wonder would it not be in the interest of such communities to urgently conduct clinical trials on these repurposed drugs in such settings where the comparator arm is the reality of life today.

Replies

 

Irene Chidothe Replied at 4:42 AM, 7 Jun 2015

This is an interesting question drawing different view points and echoing
an all too familiar situation as far as health care stands in many LMIC.

Whilst I may not have an answer on such clinical trials and understanding
the duration they need to answer such a question; momentarily one could
explore such things as:

. mobile oncology clinics by specialists to such remote areas
. community mobilisation to contribute regularly to some form of supportive
fund for these situations
. Some therapies are less toxic and can be delivered with some level of
safety in peripheral care facilities as long as there is close linking with
specialists.

There is no one answer to this but each case I suppose ought to be
considered individually keeping in mind curative potential of some cancers
so as not to deny them this chance. Additionally patient decision after
presenting the facts also is important.

Sandeep Saluja Replied at 5:12 AM, 7 Jun 2015

Thanks Irene for reminding us of some very important issues though of course,I had raised a slightly different point from a clinician's perspective.I would possibly need your valued inputs in organising the clinical services.

Rajan Dewar Replied at 7:54 AM, 7 Jun 2015

Sandeep,
I work at one of the teaching hospitals of Harvard Med School. Professor Vikas Sukhatme (Chief Academic Officer) and his wife have been campaigning for exactly what you're advocating (add aspirin to your list). They formed a non-profit called 'global-cures' - trying to repurpose existing low cost medicines that will never have the support of pharma because of non-existent profit margins.

https://www.global-cures.org/about/our-mission

Thank you for posting this very important question,
- Rajan Dewar MD PhD

Nilesh Mahale Replied at 9:22 AM, 7 Jun 2015

Nice post
I'm using methotrexate and celecoxib for Palliation in advanced Head and
Neck Cancer

Sandeep Saluja Replied at 10:03 AM, 7 Jun 2015

Thanks Nilesh!

What dose methotrexate do you use?
Like many other cancers,hedgehog signalling is important in head and neck cancer and it would be worth studying the role of mebendazole in this situation though most of the work on that molecule has so far focussed on medulloblastomas.
You may also like to see http://www.oraloncology.com/article/S1368-8375(15)00008-1/abstract which discusses metformin in this context.
Curcumin and spirulina may also be good and adverse effect free add ons not only for thier anti cancer effects but also their role in influencing the immune system especially dendritic cells.To reduce costs,one can consider using turmeric in place of curcumin though one may have to use large quantity for equivalent effect.

Nilesh Mahale Replied at 6:04 AM, 8 Jun 2015

I use MTX 15mg per m2 per week

Sandeep Saluja Replied at 7:10 AM, 8 Jun 2015

At that dose level,generally,one would not have major adverse effects and sounds good.

Useful information and good learning for me.

Maryam Shafaee Replied at 3:58 PM, 9 Jun 2015

Hi Mahale,

Do you have extensive experience on using MTX in this group of patients?
Do you have a database with outcome of the therapy measured?

Ignacio De Gabriel Hernández Replied at 6:25 PM, 9 Jun 2015

hola Irene..Saludos desde Huatusco,Ver. Soy médico cirujano ya de 57 años de edad,con una clínica muy pequeña(un quirófano,3habitaciones,un endoscopio y la misión mia es ofrecer estudios de escrutinio mas tempranos a los pacientes con riesgo de Cáncer gastrointestinal..lamentablemente vienen cuando la patología está fuera de todo tipo de tratamiento curativo..só lo para ofrecer tratamientos paliativos..Por otro lado quisiera saber sí tienes algún contacto donde pudiera recibir un entrenamiento bien formal en endoscopia de tubos disgestivo al menos que sea diagnóstica.. gracias por tus comentarios

Nilesh Mahale Replied at 7:48 PM, 9 Jun 2015

Dear Maryam
I don't have extensive experience as I occasionally get such patients where
intravenous standard chemo is not possible
But there is ample evidence to support mtx

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