A Clinical and Biological Umbrella Protocol for Smoker or Non-smoker Patients With OPML or HNSCC (UMBRELLA)

The long-term goal of this study is to reduce the incidence of HNSCC which may impact as well other smoking-related cancers. It may be interesting to foster excellent translational research towards the target of reducing the incidence of HNSCC by developing a global and personalized approach for prevention and treatment of HNSCC. The only way to reach this goal is to develop an ambitious program that coordinates the efforts of experts from various fields (surgeons, medical oncologists and addictologists, scientists, sociologists and economists) that will work together toward the same goal.

This study intends to gather a large scale clinical, sociological, psychological data gathering combined to a unique set of biospecimens collected prospectively including oral preneoplastic disease and resectable HNSCC. This represents a unique setting to develop multidisciplinary studies including a translational research component (validation and discovery of biomarkers, high throughput molecular studies to understand the dynamics of molecular changes and identify new strategies for prevention), a sociopsychological component and an addiction component that aim to increase the percentage of patients entering a process of weaning, as well as a medico-economics component that intend to evaluate the impact of new approaches that may emerge from our work.

In summary, this study proposes to prospectively collect clinical, sociopsychological, medico-economics data and biospecimens in patients included in 3 different cohorts. Cohort A will include patients with OPML, either from smokers/drinkers (S/D) or non-smokers/non-drinkers (NS/ND), while cohort B and C will include patients with HNSCC eligible to upfront surgical resection. Patients in cohort B will be included in an interventional randomized clinical trial evaluating an intensive and sustained smoking cessation program.

In patients with OPML, no standard workup and treatment plan is recommended. OPMLs biopsy is important to identify patients with high grade dysplasia and in situ carcinoma who should undergo surgical resection of the OMPLs if possible. Although LOH status in OPML biopsies or buccal brushes has been evaluated in this population as a biomarker of risk to develop oral cancer, it is not routinely performed. More studies are required to validate their value as a biomarker of risk in a prospective setting and to identify the best set of biomarkers. In smokers and/or excessive alcohol drinkers, it is critical to counsel and help patients quit and it should be part of the standard of care. Unfortunately, this is not always the case. Studies of chemopreventive agents have not resulted in the development of an intervention that can be considered as standard of care.

Despite the accumulated knowledge, no comprehensive molecular characterization of OPML is available. Identification of new targets for prevention and therapy, mainly with genomic, epigenomic and immune characterization of OPML is critical. Cohort A will allow to prospectively collect clinical information and biospecimens (biopsies, buccal brushes and saliva). These unique resources will allow to confirm the value of LOH as a biomarker of risk and develop standardized procedures for sample processing that can be transferred in the routine setting, validate or identify other biomarkers and improve risk assessments beyond LOH, to understand the spatial and temporal dynamics of molecular changes that may help predicting oral cancer risk, identify relevant targets and suggest new chemoprevention strategies including immunoprevention interventions. Furthermore, patients included in this cohort will benefit from standardized care plans and state of the art smoking and alcohol cessation programs according to current recommendations, and will be given the opportunity to participate in future chemoprevention studies that may be embedded in the near future in the umbrella protocol.

In patients with resectable HNSCC (cohorts B and C), smoking and alcohol cessation is one important step in the management. They allow reducing treatment-related morbidity and improving radiation and chemoradiation efficacy. It is tempting to believe that they may also improve patients' quality of life as in the general population, and reduce the risk of second primary tumor (SPT). Available data focusing on patients with HNSCC and smoking cessation is scarce. Although the diagnosis and treatment of patients with HNSCC favors smoking cessation, a significant proportion of former smokers are actively smoking during follow-up despite having completed treatments associated with substantial morbidity. The literature review shows that the range of patients that continue to smoke at one year is in the range of 21-41%. Of note, those smoking quit rates at one year are based on patient self-reporting without biological confirmation in the majority of the cases, which clearly overestimates quit rates. Smoking cessation programs currently available lead to disappointing results. HNSCC patients with smoking addiction harbor the highest risk of SPTs. In this vulnerable population, beyond early management of nicotine dependence, new strategies / innovative interventional approaches are warranted. Preliminary results from a monocentric study indicate that an active intervention in this challenging population may lead to encouraging results in motivated patients. Furthermore, an intensive smoking cessation program implemented during radiation therapy is feasible in this population of patients. In cohort B, the efficacy of an intensive and sustained smoking cessation program in a randomized cohort of these patients at highest risk with potentially curable HNSCC (cohort B) will be evaluated, with the hypothesis that an intensive and sustained smoking cessation program led by an addictologist or a tobacco treatment specialist (TTS) during radiation therapy may improve the 6- and 12-month quite-rate compared with a minimal tobacco cessation intervention. Among secondary objectives of this trial, medico-economics information will be gathered to provide an initial assessment of the cost-effectiveness of the experimental versus standard arms.

Cohort C will allow prospective collection of clinical information and biospecimens (biopsies, buccal brushes and saliva) only. Patients will benefit from state of the art smoking and alcohol cessation programs according to current recommendations.

Well-annotated cohorts of patients with HNSCC are scarce. Information and biospecimens collected in cohorts B and C will provide unique resources to identify biomarkers of risk of recurrence and SPT.

Having access to large scale information and to biospecimens in patients with preneoplastic disease (cohort A) who may or may not develop smoking/alcohol related cancers, and with HNSCC (cohorts B and C) who may develop disease recurrence or SPT, represent a unique opportunity to understand the dynamics of molecular changes and their interaction with smoking cessation and/or alcohol withdrawal.