Phase II clinical trial of local use of GM-CSF for prevention and treatment of chemotherapy- and concomitant chemoradiotherapy-induced severe oral mucositis in advanced head and neck cancer patients: an evaluation of effectiveness, safety and costs

In the present open non-randomized phase II study we looked for effectiveness, safety, tolerability and costs of locally applied GM-CSF in preventing or treating mucositis in patients receiving chemotherapy or chemoradiotherapy for head and neck cancer. In addition to clinical mucositis scoring system, the effects of treatment with GM-CSF were evaluated by its impact on patient quality of life and by laboratory immunological assays such as serum proinflammatory cytokines, IL-2 and leptin. The trial was designed to assess the effectiveness of local GM-CSF treatment in two different settings: i) prophylaxis of mucositis; ii) treatment of mucositis. Prophylaxis was chosen for chemoradiotherapy treatments of high mucosatoxic potential, while curative treatment was reserved for chemotherapy or chemoradiotherapy treatments of lesser potential of inducing mucositis. From January 1998 to December 2001, 68 patients entered the study. The great majority of patients of both groups had head and neck cancer, were stage IV, PS ECOG 0-1, were habitual smokers and were treated with chemotherapy and concomitant (or sequential) chemoradiotherapy. Forty-six patients were included in the ‘prophylactic’ setting and 22 patients in the ‘curative’ setting. The main findings of our study are: only 50% of patients included in the ‘prophylactic’ setting developed mucositis; the duration of oral mucositis from appearance until complete remission was significantly shorter in the ‘prophylactic’ than in the ‘curative’ setting; the mean grade of oral mucositis at baseline, on day 3 of therapy and on day 6 of therapy was significantly lower in the ‘prophylactic’ than in the ‘curative’ setting; 24 (55.82%) patients in the ‘prophylactic’ setting had grade 3/4 oral mucositis at baseline compared to 25 (80.60%) patients in the ‘curative’ setting (p=0.048). Thirteen (30.23%) patients in the ‘prophylactic’ setting had grade 3/4 oral mucositis on day 3 of therapy compared to 19 (61.29%) patients in the ‘curative’ setting (p=0.015); ‘prophylactic’ setting was able to shorten grade 3/4 oral mucositis to grade 0/1 more effectively than the ‘curative’ one on day 6 of therapy (p=0.05). The present clinical trial is to date by far the largest study assessing the effectiveness of topical GM-CSF and it is the first study comparing the efficacy of topical GM-CSF in the ‘prophylactic’ setting, i.e., with the aim to prevent the chemoradiotherapy-induced oral mucositis, with that in the ‘curative’ treatment, i.e., the therapy for established oral mucositis. The topical application of GM-CSF was demonstrated to be effective for oral mucositis induced by chemotherapy and chemoradiotherapy regimens. Moreover, the ‘prophylactic’ setting was demonstrated to be more effective than the ‘curative’ one.