Efficacy of Oncoxin-Viusid on the Reduction of Adverse Reactions to Chemotherapy and Radiotherapy in Patients Diagnosed with Cervical Cancer and Endometrial Adenocarcinoma

Introduction: Oncoxin-Viusid (OV) has shown antioxidant, immunomodulatory and anti-tumour capabilities in experimental studies on humans and animal subjects. Acute toxicity of Radiation Therapy (RT) and Chemotherapy (CT) in patients with cervical cancer and endometrial adenocarcinoma impact quality of life and, therefore, outcomes of these therapies. Objective: To identify Oncoxin-Viusid’s efficacy in reducing acute toxicity produced by onco-specific treatments in patients with cervical cancer and endometrial adenocarcinoma. Materials and Methods: A controlled, randomised dou-ble-blind phase II clinical trial was performed with a sample size of 63 patients distributed into 2 groups: one receiving the standard treatment plus the Oncoxin-Viusid nutritional supplement (OV group) and another receiving the standard treatment and placebo (P group). The primary efficacy variable is the proportion of secondary disruptions to acute adverse reactions produced by RT and CT. Results: The number of patients suffering adverse events from chemotherapy was 20.6% less in the OV group (70.0%) than in the placebo group (90.6%) (p = 0.04). We recorded consistently normal values of haemoglobin (−6.2 OV quality of life (QLQ-30) was registered in the OV group with a large effect size on such issues as emotional and social function (Cohen’s d = 0.9), as well as in the reduction of symptoms like dyspnea 60%, insomnia 15% and anorexia 30% (item CX-2), (Cohen’s d = 0.98), which were higher than the placebo group. Conclusions: OV administration reduces onco-specific adverse events and improves quality of life in patients diagnosed with cervical cancer and endometrial adenocarcinoma undergoing radiation therapy and chemotherapy.


Introduction
Cervical cancer constitutes the fourth most prevalent malignancy in women worldwide in terms of incidence, with approximately 569,847 new cases diagnosed in 2018 according to the World Health Organization (WHO). It is the fourth leading cause of cancer related deaths in women with 311,365 deaths in 2018 [1]. Of these cases, 85% were diagnosed in developing countries [2] [3]. In Cuba, cervical cancer ranked fourth in malignant tumours among women in 2015, with 1438 cases at a crude rate of 25.5 cases per 100,000 women. A total of 548 deaths were recorded in 2018 due to this cause, for a crude rate of 9.7 per 100,000 women [4].
Malignant tumours of the uterine corpus rank sixth among malignant neoplasms affecting women in Cuba. It is most common in postmenopausal women and reached 700 cases and a rate of 12.4 cases per 100,000 women by 2015.
Uterine corpus tumours were the fourth leading cause of death for women, with 622 deaths in 2018 and a rate of 11.0 deaths per 100,000 women [4].
Randomised clinical studies have shown that concurrent radiotherapy (RT) and chemotherapy (CT) with cisplatin (cis-diamminedichloroplatinum II, CDDP) as a radiosensitizer is the "gold standard" in treating locally progressive cervical and endometrial carcinoma [5]. It is an alkylating agent [6], which induces cell death by damaging DNA. However, it has adverse side effects such as gastrointestinal, renal, bone marrow toxicity and ototoxicity [7], typically induced by oxidative stress from the strong electrophilic nature of activated cisplatin [8] [9].
Acute RT-derived side effects are exacerbated when given concurrently with CT due to tissue damage and manifest as acute and chronic inflammatory symptoms arising from repair, leading to dystrophies, atrophy, fibrosis, necrosis, and torpid ulcers [10].
Oxidative stress has been linked to a series of diseases, in term of pathogenesis, including cancer [11] [12], due to an imbalance in pro-oxidant and antioxidant levels [13]. The body has a defence mechanism to prevent free radical-induced cell  [15].
Studies such as those carried out by Lamson and Brignall suggest increased effectiveness of onco-specific treatments and a decrease in their adverse effects on patients, when administered simultaneously with antioxidants (micro-nutrients, vitamins and natural substances) or even an increase in survival rates [16] [17].
Pre-clinical and clinical studies have been performed with the Oncoxin-Viusid (OV) nutritional supplement from Laboratorios Catalysis in Spain, demonstrating its anti-tumour effects: the supplement limits the angiogenetic process, blocks growth factor signal transduction and inhibits cellular proliferation and blocks metastasis; inhibits the urokinase enzyme found in malignant tumours; induces apoptosis in tumour cells; has a synergistic effect with chemotherapy due to an increase in the anti-tumour effects of some cytostatics; and acts as a radiosensitiser in malignant cells with cytoprotection of healthy tissues [18] [19] [20].
OV is formulated with antioxidants that prove effective as anticarcinogens, being treated with a molecular activation process that increases their biological activity, among which the following are noteworthy: Green tea polyphenols, epigallocatechin gallate with antimutagenic and anticarcinogenic activity due to TNF-a receptor blocking, NFkB activation due to nuclear translocation and inhibition of COX-2 expression. The supplement inhibits protein expression such as VEGF (vascular endothelial growth factor) and cellular migration using ephrin-A1; stops the release and expression process for cellular matrix metalloproteinases (MMPs) 2 and 9, related to the invasive process of tumour cells. In addition, it restores apoptosis in tumour cells by stopping the cellular cycle and inducing the expression of the p53, caspase-3 and Bax pro-apoptotic proteins and inhibiting the anti-apoptotic protein Bcl-2 [21] [22].
In several clinical studies, OV's anti-tumour effect has been investigated through various tumour models, including HER2 positive breast cancer [23], acute myeloid leukaemia [24] and hepatocellular carcinoma [25]. The dual action of the drug that inhibited cell cycle progression and also stimulated cell death may provide a therapeutic advantage to traditional pharmacological agents used in small cell lung cancer therapy [26].
Its clinical relevance and improvement in the patients' quality of life has also been shown in chemoradiotherapy treatment of epidermoid carcinomas of the head and neck [27], as well as an enhancer in chemotherapy with irinotecan in the metastatic progression of colorectal cancer to the liver [28].
Our objective in the study was to evaluate the impact of the Oncoxin-Viusid nutritional supplement on chemotherapy and radiotherapy associated toxicity among patients with a histological diagnosis of cervical cancer and endometrial adenocarcinoma.

Materials and Methods
A controlled, randomised double-blind phase II clinical trial was performed,

Patients Included in This Study Were Treated as Follows
Patients with cervical cancer were administered teletherapy using Co60 for a total dosage of 40 -50 Gy, divided into 1.8 -2 Gy daily, for 5 days a week during 6 weeks and Cisplatin 40 mg/m 2 IV weekly in 5 cycles as a radiosensitizer. After completing the treatment, a two-week course of high-dose brachytherapy was administered in three 800 cGy applications, for a total of 8 weeks of treatment, if the patient did not present any further complications requiring discontinuation of the treatment. The control group received a placebo oral solution and the experimental group received Oncoxin Viusid (oral solution), in similar 75 ml daily doses, divided into 25 ml every 8 hours from the beginning of the onco-specific treatment and up to 3 weeks after its completion. Follow-up was conducted during the treatment and each month for 3 months to assess for efficacy and safety. The randomised list was created automatically via a computer using the ASAL system at Catalysis Laboratories. Table 1 displays chemical composition of OV.

Clinical, Laboratory and Quality of Life Parameters Assessment
The following parameters were systematically determined or assessed in all participants at the enrollment visit and some of them at the end of follow-up: demographic factors including age and sex, the presence of comorbidities, laboratory tests including white and red blood cells, histological diagnosis and clinical stages of gynaecological cancers, ECOG performance status, and specific health-related quality of life (HRQoL) questionnaires, including EORTC QLQ-30 [29] and EORTC QLQ-CX24 [30].

Sample size
To obtain the sample size, the ratio of patients that presented adverse reactions requiring interruption of radiotherapy and/or chemotherapy treatment to the number of patients included in the study was considered. In the institution, this figure is close to 45% (ones who successfully avoided interruption at 55%).
A Flemming stage design was used (no early stop rules) given this deal with a dietary supplement, with a large amount of information on product safety. Let us suppose that the Oncoxin-Viusid product was definitively declared to be ineffective (maximum inefficacy), if the proportion of patients that presented no adverse reactions to both chemotherapy and radiotherapy requiring treatment interruption was equal to or less than 55% (p 0 )-i.e. maximum success level, below which the product showed no signs of efficacy (this study does not guarantee further research), while taking 75% as the value of p 1 , where p 1 is the maximum level of efficacy required for the product to be declared effective. Assuming a 5% α error rate (probability of rejecting the null hypothesis when it is true) and a 10% β error rate (probability of rejecting the alternative hypothesis when it is true) (the strength of the test: 1 − β = 80%), we determined a maximum recruitment of 66 subjects.
The trial tests null hypothesis H 0 : p ≤ p 0 against the alternate hypothesis: H 1 : p ≥ p 1 . While a is set at = 30, where a is the number of responses (that do not undergo treatment interruption) at a level equal to or less than the number with which the product would be declared ineffective (H 0 is acceptable). And r = a + 1 is the cut-off point, that is, the number of responses where the generated efficiency level guarantees moving to a phase III study. In this case, we would hope for ≥31 successes.
A single analysis was conducted at the conclusion of the study when all study participants had received 6 months follow-up. The analysis of quantitative variables used both measures of central tendency and dispersion such as mean, standard deviation and range, for absolute and relative frequencies for qualitative variables. Analysis of the demographic data and baseline patient characteristics was conducted by means of a descriptive analysis corresponding to either the quantitative or qualitative variable type.
The primary response variable was to determine the number and percentage of interruptions in oncological treatment due to severe chemotherapy and radiotherapy induced toxicity reactions. Safety parameters were evaluated and classified according to the NCI's CTC-CAE (version 4), with the investigated product and as per the adverse event's severity.
Statistical tests were used to compare the treatment groups with respect to the efficacy variables, by means of: the Chi-square homogeneity test for qualitative variables, the paired samples t-test (for before and after) to compare the quantitative variables within the groups, the Student t-test (independent samples) to compare the quantitative variables between the groups and to calculate the effect size of Cohen's d. Statistical significance level: 0.05. Data will be stored in Excel 2010 and processed in SPSS version 21.0.

Patient Characteristics
The study included 63 female patients with locally advanced cervical cancer and endometrial adenocarcinoma, in compliance with the established protocol sample size. Statistical analysis was performed on 33 patients included in the placebo group and 30 in the group receiving the Oncoxin-Viusid treatment ( Table 2).
We excluded a patient with inclusion number 29, a 45 year-old individual with endocervix carcinoma in the control group who died from cardiopulmonary arrest due to a bronchial asthma crisis 3 weeks after being admitted to the study, having started the combined RT + CT + OV treatment. Therefore, this patient only appears in the baseline table (analysis by ITT). The mean age of patients was 59.3 years, ranging from 33 to 81 years old. No significant differences  When comparing the study groups, it was possible to observe that in the OV group, the percentage of women who were able to carry out normal unrestricted physical activity in their daily lives was 10% lower than those included in the placebo group. However, in the statistical analysis, no significant differences were found in the degree of ECOG between the groups.

Treatments Administered
A total of 55 patients were administered teletherapy using Co60 with a total dosage of 40 -50 Gy and cisplatin 40 mg/m 2 weekly as a radiosensitizer. After completing the treatment, a two-week course of high-dose brachytherapy was administered in three courses of 800 cGy, for a total of 8 weeks of treatment, if the patient did not present any further complications requiring discontinuation of the treatment (  Gy. When concluded, high-dose rate local brachytherapy was applied intravaginally using 3 courses of 800 cGy or 4 applications of 600 cGy twice a week for two weeks. A total of 8 weeks of similar treatment was completed with the remaining patients.
Of these, 5 did not receive CT treatment, only receiving cisplatin 40 mg/m 2 weekly. Two of these patients, one from the control group who needed a transfusion due to haematological toxicity before starting RT and another patient from the OV group, who tolerated 3 cycles of TC without haematological complications, followed by 5 cycles of cisplatin. In each cycle, these patients received twice as many cytostatic doses as their counterparts. These individuals were in stages IIIA and IIIB of the disease, with an ECOG of between 1 and 2. Therefore, their prognosis was worse, as was their overall condition, which was more compromised.
The control group received a Placebo oral solution and the experimental group received Oncoxin Viusid (oral solution), in similar 75 ml daily doses, divided into 25 ml every 8 hours from the beginning of the onco-specific treatment and up to a month post-treatment.

Treatment Interruptions
No statistically significant differences were found between the OV and placebo doses of cytostatics per interruption. It can therefore be argued that the OV group required 4 more doses than the placebo group per treatment interruption due to cytotoxicity, which would be equivalent to 2 rounds of taxol and carboplatin or 4 rounds of cisplatin, indicating that treatment with the OV increased patients' tolerance to onco-specific treatment.

Adverse Events (AE)
A mean of 80.6% of patients included in the study experienced some kind of adverse reaction. In the OV group, 70.0% of the patients suffered some adverse reaction, 10.6% less than among the total number of patients and 20% less than in the placebo group. The analysis showed that the number of patients suffering from chemotherapy related adverse effects was significantly higher in the placebo group compared to the OV group (Chi-squared test [1 df] with a 4220 statistical significance and a p = 0.04 value). More than 20% more patients were affected in the placebo group than in the OV group (Table 4).
The most prevalent adverse event was anaemia, which affected 10 patients in each study group. No significant differences were found between these groups.  the exception of neutropenia and thrombocytopenia. These events occurred in the OV group and were associated with the administration of the neoadjuvant taxol + carboplatin, which entailed greater haematological toxicity.
On average, 6.5% were mild reactions, 38.7% were moderate, 32.2% were considered severe as they required treatment and interruption of onco-specific therapy. Meanwhile, only two cases showed severe reactions, both of which were radiotherapy related. Adverse events in both groups occurred due to onco-specific treatment, except for two cases in the OV group and one in the control group, which were disease related. Hospitalisations occurred in both groups, six in the OV group and two in the control group. In all cases, patients recovered without any sequelae.

Screening of Haematological Variables
Both groups showed a decrease in haemoglobin levels, platelet and leukocyte counts. However, such decreases were significantly lower in the OV group than in the placebo group, despite the fact that the former was exposed to increased toxicity, as explained above. At the beginning of the trial, patients in the placebo However, the reduction in haemoglobin levels was significant in the placebo group, whereas in the OV group it was average. Thus, at the end of the research, no significant differences were found between the haemoglobin levels of the two groups ( Table 5).
As far as the platelet and leukocyte counts were concerned, the opposite transpired. At the beginning of the research, no significant differences were found between the two groups' values. However, in the end, both the platelet and leukocyte count of the OV group declined significantly less than those of the placebo group. A lower percentage reduction was found in the Oncoxin-Viusid treatment group, which means that the drug reduced chemotherapy toxicity.

Quality of Life
The EORTC QLQ 30 (version 3) and QLQ-CX 24 questionnaires were conducted on patients at the beginning and six months after they were included in the study to measure quality of life. At baseline, the study groups showed no significant differences. After 6-month retesting and comparing these values with the initial values within each group, a statistically significant increase in overall quality of life was observed in both groups. However, it should be noted that for the OV group, a large increase was observed with a Cohen's d of 0.9, which implies a greater patient outcome from the clinical point of view, compared to the average effect achieved in the placebo group following the usual onco-specific treatment ( Table 6).
The OV group showed an increase in all the functions on the scale, with the emotional and social function being particularly significant and showing average clinical effects, which were higher than those of the placebo group. In terms of symptoms, pain and fatigue were significantly reduced with average and high effect size, respectively. Other symptoms, such as dyspnoea, fell by 60%, insomnia by 15% and anorexia by 30% compared to initial values. The OV group experienced a substantial drop in financial impact, with an average effect.
When comparing mean values for EORTC CX-24 survey items between the OV and placebo groups, no significant differences were found at baseline and at    (Table 7).
Sexual activity in the placebo group was significantly reduced from the baseline, unlike the OV group where no change was recorded. Items corresponding to sexual/vaginal function and sexual activity displayed decreased standardised values in both groups. However, they were not included in the mean comparisons as sharp differences emerged between those who responded to the initial survey and those who responded to the final one. Nevertheless, it is worth noting that the percentage of women who answered these questions at six months in-

Response to Treatment
Among the OV group, 86.7% of patients experienced a full response to treatment, 11.7% more than in the placebo group. No statistically significant differences were found between the two groups in terms of response to treatment, despite the fact that the OV group predominantly comprised patients with advanced stage endometrial carcinoma and a worse overall health status at inclusion ( Table 8).
The p associated with Fisher's exact test was insignificant in terms of treatment response, and patients with full response versus those who did not respond were grouped together.

Discussion
Cervical cancer is a preventable tumour through routine screening and treatment of pre-cancerous lesions [31]. However, an estimated 35% of cervical tumours, worldwide, are diagnosed as locally advanced disease (stage IB2-IIB) with an estimated 5-year overall survival rate of 60%. In developing countries, an estimated 70% of cases were diagnosed in advanced stages [32].
Multiple authors suggest an enhanced efficacy of onco-specific treatments, as well as reduced adverse effects, when administered simultaneously with antioxidants (micro-nutrients, vitamins and natural substances). In this regard, Lamson and Brignall concluded that the combination of antioxidants has shown to have a synergistic anti-tumour effect "in vivo" and that their use in conjunction with Chemotherapy and Radiotherapy reduces toxicity in patients or even increases survival [33].
In a study conducted at the National Institute of Oncology in Cuba, Chon et al. used OV concurrently with RTP in patients with epidermoid carcinoma of the head and neck, where they found that OV, the investigated product, proved safe to administer, as no adverse reactions were recorded for the nutritional supplement. A significant improvement in quality of life occurred in the OV group when comparing the initial and final stages of RT with significant reductions in major symptoms such as asthenia, nausea, vomiting and pain, which allowed for improved tolerance of radiation therapy in this experimental treatment arm. Although the largest percentage of AEs were reported as being moderate, 38.7% and 32.2% were considered severe, being related to onco-specific treatment, while others were associated with neoplastic disease. The overall quality of life in both groups was significant. However, it should be noted that a large increase was observed in the OV group with a Cohen's d of 0.9, which implies a greater patient outcome from the clinical point of view, compared to the average effect achieved in the placebo group following the usual onco-specific treatment [27].
Diaz-Rodriguez et al. evaluated the anti-tumour effect and safety profile of Oncoxin-Viusid in SCLC (small cell lung cancer) using OOS in combination with commonly used clinical treatments such as cisplatin, docetaxel or vincristine. Treatment with OOS slowed tumour growth while showing no serious toxicity issues [26].
On colon cancer treatment, Hernandez UI et al. found that oral Oncoxin, as an adjunct therapy to irinotecan chemotherapy in colorectal cancer in metastatic progression to the liver, improves the overall well-being of patients with metastatic CRC by reducing side effects and therefore improving their quality of life [28].

Quality of Life Analysis
Treating patients suffering from cervix cancer should not only focus on reducing disease mortality, but also on improving survival without compromising people's QoL [34]. According to Schwartzmann, assessing an individual's QoL re- with radiotherapy (p = 0.014), and decreased with age in those treated with chemotherapy plus radiotherapy (p = 0.001 respectively) [36].
As per physical performance, Hsu et al. compared QoL by treatment type (surgery or radiotherapy) in women affected by early stage cervical cancer and found that despite significant differences in side effects, the long-term post-treatment quality of life was very similar to that observed in our study [37].

Conclusion
The nutritional supplement Oncoxin-Viusid (oral solution) administered concurrently with radiotherapy and chemotherapy in patients with locally advanced epidermoid carcinoma of the cervix and endometrial adenocarcinoma showed no significant difference between the groups in the number of interruptions.
However, patients in the Oncoxin-Viusid group tolerated higher doses of cytostatics without interruptions due to onco-specific treatment acute toxicity. The average interruption period lasted two days less and no adverse effects were recorded for Oncoxin-Viusid. Oncoxin-Viusid significantly reduced the number of patients who suffered adverse events to onco-specific treatment and stopped haemoglobin levels, and platelet and leukocyte counts from falling compared to patients receiving traditional treatment. Overall well-being for the QLQ 30 questionnaire showed significant increases in the OV group with a large effect size (Cohen's d = 0.9), exceeding the placebo group where the effect was average in nature.