Long-term results of dose-dense paclitaxel and carboplatin versus conventional paclitaxel and carboplatin for treatment of advanced epithelial ovarian, fallopian tube, or primary peritoneal cancer (JGOG 3016): a randomised, controlled, open-label trial

Incidence of Hypersensitivity Reactions to Carboplatin or Paclitaxel in Patients With Ovarian, Fallopian Tube, or Primary Peritoneal Cancer With or Without BRCA1 or BRCA2 Mutations

The association of BRCA mutation status with hypersensitivity reactions (HSRs) to carboplatin has gained interest in recent years, particularly in patients with ovarian, fallopian tube, and primary peritoneal cancer. The primary objective of this study is to determine whether the presence of BRCA mutations increased the likelihood of HSRs to carboplatin. The incidence of HSRs to paclitaxel and symptom grade based on the Common Terminology Criteria for Adverse Events, version 4.0, were explored as secondary endpoints. A retrospective chart review of patients with ovarian, fallopian tube, or primary peritoneal cancer at the University of Arizona Cancer Center who underwent treatment with carboplatin-containing regimens and received genetic testing was performed. Institutional review board approval was obtained for this study. Fisher's exact test was used to analyze the primary outcome. Out of 167 initial patients, 62 with germline test results constituted the evaluable sample. 15 of 62 (24.2%) BRCA-tested patients were treated with carboplatin monotherapy, while 44 of 62 (71.0%) patients were treated with paclitaxel-containing regimens. Hypersensitivity reactions occurred in 4 of 13 (30.8%) BRCA-mutated patients and 22 of 49 (44.9%) BRCA wild-type patients (p = .5291). Hypersensitivity reactions to paclitaxel occurred in 1 of 13 (7.7%) BRCA-mutated patients and 26 of 49 (53.1%) BRCA wild-type patients (p = .0039). Overall, there were 11 grade 1 reactions, 14 grade 2 reactions, and 16 grade 3 reactions to carboplatin. All reactions to carboplatin in BRCA-mutated patients were grade 1. All paclitaxel reactions manifested as grade 2. The sample size was the main study limitation. The presence of BRCA mutations was not statistically significantly associated with a higher incidence of HSRs to carboplatin, but was statistically significant with regards to paclitaxel.

Weekly versus 3-weekly paclitaxel in combination with carboplatin in advanced ovarian cancer: which is the optimal adjuvant chemotherapy regimen?

The 3-weekly regimen of carboplatin and paclitaxel is the backbone of first line adjuvant chemotherapy for advanced ovarian cancer. The landmark Japanese Gynaecologic Oncology Group (JGOG) 3016 study demonstrated significant improvements in progression-free survival and overall survival with dose dense weekly administration of paclitaxel in combination with 3-weekly carboplatin. However, efforts to replicate these benefits have failed in subsequent phase III trials. Weekly paclitaxel is purported to have enhanced antitumor activity, with stronger anti-angiogenic effects, and yet is better tolerated. In this review, we explore the rationale for dose dense weekly paclitaxel, and compare the relevant trials as well as quality of life considerations. Possible reasons for the difference in outcomes between the JGOG 3016 and other studies are reviewed, with a focus on how the addition of bevacizumab, the variations between histological and molecular subtypes of epithelial ovarian cancers, and ethnic pharmacogenetic differences may potentially affect the efficacy of dose dense paclitaxel.

Differences in presentation and survival of Asians compared to Caucasians with ovarian cancer: An NRG Oncology/GOG Ancillary study of 7914 patients

PURPOSE

To compare patient/tumor characteristics and outcomes of Asians to Caucasian patients with epithelial ovarian cancer.

METHODS

Ancillary data were pooled and analyzed from ten prospective randomized front-line Gynecologic Oncology Group clinical trials from 1996 to 2011. Demographic, clinicopathologic features, disease-specific and all-cause survival were analyzed.

RESULTS

Of 7914 patients, 7641 were Caucasian and 273 Asian. When compared to Caucasians, Asians were younger at trial enrollment, had a better performance status, earlier-stage cancers (17.2% vs. 8.1% with stage I; p < 0.001), and were more likely to be of clear cell (15.8% vs. 6.2%, p < 0.001) and mucinous (3.3% vs. 1.9%, p < 0.001) histology. Asians had an improved 5-year disease-specific survival of 54.1% compared to 46.1% for Caucasians, p = 0.001. In multivariate analysis, the Asian race remained a significant prognostic factor for all-cause survival (HR: 0.84; 95% CI: 0.72-0.99; p = 0.04). Other factors predictive of improved survival included younger age, better performance status, optimal cytoreduction, earlier stage, non-clear cell histology, and lower grade tumors.

CONCLUSION

Asians enrolled into phase III ovarian cancer clinical trials were younger, with better performance status, earlier-stage of disease, and have a greater number of clear cell and mucinous tumors. After adjusting for these prognostic factors, Asians have a better survival compared to Caucasians.

Advanced Epithelial Ovarian Cancer: Do More Options Mean Greater Benefits?

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors’ suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

A healthy 51-year-old woman presented with increasing abdominal and pelvic pain. Computed tomography imaging of the abdomen and pelvis showed an 11.6-cm pelvic mass, retroperitoneal lymphadenopathy, right hydronephrosis, and mesenteric tumor deposits ( Fig 1A ). A serum CA-125 was elevated at 1,149 U/mL. She underwent primary surgical cytoreduction including hysterectomy, bilateral salpingo-oophorectomy, appendectomy, resection of pelvic tumor, omentectomy, and low anterior resection with colorectal anastomosis. Intraoperatively, she was noted to have bilateral ovarian masses, pelvic and para-aortic lymphadenopathy, and a 4-cm omental tumor; in addition, both the uterus and rectosigmoid colon had adherent tumor deposits. All gross tumor was resected during the procedure. Final pathology confirmed high-grade serous carcinoma of ovarian origin ( Fig 1B ) that was determined to be stage IIIC as a result of upper abdominal involvement with greater than 2-cm tumor deposits, as well as retroperitoneal lymph node involvement. She underwent germline genetic testing, which did not identify a mutation in the BRCA1, BRCA2, BRIP1, RAD51C, or RAD51D genes. She presented for adjuvant chemotherapy after an optimal (R0) resection.

Randomized Trial of Intravenous Versus Intraperitoneal Chemotherapy Plus Bevacizumab in Advanced Ovarian Carcinoma: An NRG Oncology/Gynecologic Oncology Group Study

PURPOSE

To evaluate the impact of two different intraperitoneal (IP) chemotherapy regimens on progression-free survival (PFS) among women with newly diagnosed advanced ovarian carcinoma.

METHODS

Eligible patients were randomly assigned to six cycles of IV paclitaxel 80 mg/m2 once per week with intravenous (IV) carboplatin area under the curve 6 (IV carboplatin) versus IV paclitaxel 80 mg/m2 once per week with IP carboplatin area under the curve 6 (IP carboplatin) versus once every 3 weeks IV paclitaxel 135 mg/m2 over 3 hours day 1, IP cisplatin 75 mg/m2 day 2, and IP paclitaxel 60 mg/m2 day 8 (IP cisplatin). All participants received bevacizumab 15 mg/kg IV every 3 weeks in cycles 2 to 22.

RESULTS

A total of 1,560 participants were enrolled and had 84.8 months of follow-up. The median PFS duration was 24.9 months in the IV carboplatin arm, 27.4 months in the IP carboplatin arm, and 26.2 months in the IP cisplatin arm. For the subgroup of 1,380 patients with stage II/III and residual disease of 1 cm or less, median PFS was 26.9 (IV-carboplatin), 28.7 (IP-carboplatin), and 27.8 months (IP cisplatin), respectively. Median PFS for patients with stage II/III and no residual disease was 35.9, 38.8, and 35.5 months, respectively. Median overall survival for all enrolled was 75.5, 78.9, and 72.9 months, respectively, and median overall survival for stage II/III with no gross residual disease was 98.8 months, 104.8 months, and not reached. Mean patient-reported Functional Assessment of Cancer Therapy neurotoxicity scores (Gynecologic Oncology Group) were similar for all arms, but the mean Trial Outcome Index of the Functional Assessment of Cancer Therapy-Ovary scores during chemotherapy were statistically worse in the IP cisplatin arm.

CONCLUSION

Compared with the IV carboplatin reference arm, the duration of PFS was not significantly increased with either IP regimen when combined with bevacizumab and was better tolerated than IP cisplatin.

Wanna Get Away? Maintenance Treatments and Chemotherapy Holidays in Gynecologic Cancers

Epithelial ovarian cancer has a very high rate of relapse after primary therapy; historically approximately 70% of patients with a complete clinical response to surgery and adjuvant chemotherapy will relapse and die of the disease. Although this number has slowly improved, cure rates remain less than 50%. As such, maintenance therapy with the aim of preventing or delaying disease relapse and the goal of improving overall survival has been the subject of intense study. Numerous earlier studies with agents ranging from radioactive phosphorus to extended frontline therapy or to monthly taxol administration demonstrated encouraging improvements in progression-free survival (PFS) only to find, disappointingly, no benefit in overall survival. In addition, the PFS advantage of maintenance therapy was associated with disconcerting side effects such that maintenance therapy was not adapted as standard of care. Studies with bevacizumab and PARP inhibitors have demonstrated a PFS advantage with a manageable side-effect profile. However, an overall survival advantage remains unclear, and the use of these approaches thus remains controversial. Furthermore, in recurrent disease, the length of chemotherapy and benefits of extended chemotherapy is unclear. Thus, additional trials assessing maintenance strategies in ovarian and other gynecologic malignancies are needed.

Efficacy and safety of TC dose-dense chemotherapy as first-line treatment of epithelial ovarian cancer: a single-institution retrospective cohort study

BACKGROUND

The optimal first-line therapy of advanced ovarian cancer still remains questionable: standard paclitaxel-carboplatin (TC), dose-dense TC, intraperitoneal chemotherapy or TC plus bevacizumab. In this study, we present the real-life results of dose-dense treatment of the single-institution on Caucasian population.

METHODS

A retrospective cohort study was used on consecutive samples of 74 patients treated with the conventional 3-weekly TC protocol (2008-11) and on 70 treated with TC dose-dense protocol (2012-16). The primary endpoint of this study was overall survival (OS). Secondary endpoints were progression free-survival (PFS) and toxicity. We made adjustments for age, pathohistological type, tumor grade, stage and postoperative residual disease by Cox regression.

RESULTS

After adjustment for pre-planned clinical and sociodemographic factors, patients treated with dose-dense protocol showed a significantly lower hazard for dying from any cause, than patients treated with conventional protocol (HR = 0.50; 95% CI 0.26-0.98; P = 0.042). Median OS, at 60 months follow-up had not been reached in the dose-dense group, while in the standard treatment group was 48 months (95% CI 33-62). Unadjusted PFS was significantly longer in the dose-dense group (HR = 0.58; 95% CI 0.38-0.88; P = 0.011), but not after the adjustment (P = 0.096). Generally, the level of toxicity was similar in both groups of patients. The need for blood transfusions and usage of filgrastim was significantly higher in the TC dd group. The incidence of neutropenia and thrombocytopenia Grade 3 or 4 were not significantly different in both regimens.

CONCLUSIONS

Our retrospective study has shown the superior efficacy and comparable toxicity of dose-dense chemotherapy regimen over the conventional regimen in treatment of ovarian cancer on Caucasian population at a single-institution.

ESMO-ESGO consensus conference recommendations on ovarian cancer: pathology and molecular biology, early and advanced stages, borderline tumours and recurrent disease

The development of guidelines is one of the core activities of the European Society for Medical Oncology (ESMO) and European Society of Gynaecologial Oncology (ESGO), as part of the mission of both societies to improve the quality of care for patients with cancer across Europe. ESMO and ESGO jointly developed clinically relevant and evidence-based recommendations in several selected areas in order to improve the quality of care for women with ovarian cancer. The ESMO-ESGO consensus conference on ovarian cancer was held on April 12-14, 2018 in Milan, Italy, and comprised a multidisciplinary panel of 40 leading experts in the management of ovarian cancer. Before the conference, the expert panel worked on five clinically relevant questions regarding ovarian cancer relating to each of the following four areas: pathology and molecular biology, early-stage and borderline tumours, advanced stage disease and recurrent disease. Relevant scientific literature, as identified using a systematic search, was reviewed in advance. During the consensus conference, the panel developed recommendations for each specific question and a consensus was reached. The recommendations presented here are thus based on the best available evidence and expert agreement. This article presents the recommendations of this ESMO-ESGO consensus conference, together with a summary of evidence supporting each recommendation.

ESMO-ESGO consensus conference recommendations on ovarian cancer: pathology and molecular biology, early and advanced stages, borderline tumours and recurrent disease†

The development of guidelines recommendations is one of the core activities of the European Society for Medical Oncology (ESMO) and European Society of Gynaecologial Oncology (ESGO), as part of the mission of both societies to improve the quality of care for patients with cancer across Europe. ESMO and ESGO jointly developed clinically relevant and evidence-based recommendations in several selected areas in order to improve the quality of care for women with ovarian cancer. The ESMO-ESGO consensus conference on ovarian cancer was held on 12-14 April 2018 in Milan, Italy, and comprised a multidisciplinary panel of 40 leading experts in the management of ovarian cancer. Before the conference, the expert panel worked on five clinically relevant questions regarding ovarian cancer relating to each of the following four areas: pathology and molecular biology, early-stage and borderline tumours, advanced stage disease and recurrent disease. Relevant scientific literature, as identified using a systematic search, was reviewed in advance. During the consensus conference, the panel developed recommendations for each specific question and a consensus was reached. The recommendations presented here are thus based on the best available evidence and expert agreement. This article presents the recommendations of this ESMO-ESGO consensus conference, together with a summary of evidence supporting each recommendation.

Feasibility of initial treatment in elderly patients with ovarian cancer in Japan: a retrospective study

PURPOSE

The purpose of this study was to evaluate the real world situation and clarify the problem in initial treatment for elderly patients with ovarian cancer in Japan.

METHODS

We used the ovarian cancer database, containing all patients diagnosed and treated with International Federation of Gynecology and Obstetrics Stage I-IV ovarian cancer at the National Cancer Center Hospital in Japan from June 2008 to April 2013. Patients were stratified into two groups based on age: an elderly group, aged 70 years or older, and a younger group, aged below 70 years. We retrospectively assessed the rate of receiving standard therapy, and the feasibility and safety of chemotherapy compared with younger patients.

RESULTS

In total, 244 patients (elderly group, 36 patients; younger group, 208 patients) were analyzed. A significantly lower proportion of elderly patients than younger patients received standard therapy (15.7% vs. 32.5%, p = 0.026). Even for the elderly group, 95% patients underwent surgery in our institution. Conversely the rate of patients receiving nonstandard chemotherapy in the elderly group was significantly higher than in the younger group (30.5% vs. 9.6%, p = 0.01).

CONCLUSIONS

This study clarified the type of treatment being performed in the field, and the proportion of elderly ovarian cancer patients receiving standard therapy compared with younger patients in Japan. In addition, the actual situation of elderly patients in Japan might be different from that in Western countries. We need to evaluate the appropriate treatment for elderly patients in Japan.

Angiogenesis Inhibitors for the Treatment of Ovarian Cancer: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials

Supplemental digital content is available in the text.

Background

Angiogenesis inhibitors showed activity in ovarian cancer, but preliminary data could not accurately reflect the survival benefit. We thus did a systematic review and meta-analysis of randomized controlled trials to reassess the efficacy and safety of angiogenesis inhibitors combined with chemotherapy for ovarian cancer.

Methods

We searched PubMed, EMBASE, Cochrane, and ClinicalTrials.gov for randomized controlled trials comparing angiogenesis inhibitors containing therapy with conventional chemotherapy alone or no further treatment. Our main outcomes were the progression-free survival (PFS), overall survival (OS), and common adverse events.

Results

Fifteen trials were included (N = 8721 participants). For newly diagnosed ovarian cancer, combination treatment with angiogenesis inhibitors and chemotherapy yielded a lower risk of disease progression (hazard ratio [HR], 0.83; 95% confidence interval (CI), 0.71–0.97) and no improved OS (HR, 0.95; 95% CI, 0.86–1.05). In the high-risk progression subgroup, the addition of bevacizumab significantly improved PFS (HR, 0.72; 95% CI, 0.65–0.81) and OS (HR, 0.84; 95%CI, 0.74–0.96). In recurrent patients, the combined HR was 0.58 (95% CI, 0.52–0.65) for PFS, and for OS, the combined HR was 0.86 (95% CI, 0.79–0.94). We found no significant improvement for either PFS (HR, 0.80; 95% CI, 0.63–1.01) or OS (HR, 1.06; 95% CI, 0.88–1.28) in the pure maintenance therapy.

In the overall population, angiogenesis inhibitors increased the incidence of gastrointestinal perforation (risk ratio [RR], 2.57; 95% CI, 1.66–3.97), hypertension (RR, 7.60; 95% CI, 2.79–20.70), arterial thromboembolism (RR, 2.27; 95% CI, 1.34–3.84), proteinuria (RR, 4.31; 95% CI, 2.15–8.64), and complication of wound healing (RR, 1.72, 95% CI, 1.12–2.63).

Conclusions

Combination treatment with angiogenesis inhibitors and chemotherapy significantly improved PFS and OS in both patients with high-risk of progression and recurrent ovarian cancer, with an increased incidence of common adverse events. Conversely, we detected no statistically significant survival benefit in the pure maintenance setting. The main limitation of the review is clinical heterogeneity across the studies.

Epithelial ovarian cancer

Epithelial ovarian cancer generally presents at an advanced stage and is the most common cause of gynaecological cancer death. Treatment requires expert multidisciplinary care. Population-based screening has been ineffective, but new approaches for early diagnosis and prevention that leverage molecular genomics are in development. Initial therapy includes surgery and adjuvant therapy. Epithelial ovarian cancer is composed of distinct histological subtypes with unique genomic characteristics, which are improving the precision and effectiveness of therapy, allowing discovery of predictors of response such as mutations in breast cancer susceptibility genes BRCA1 and BRCA2, and homologous recombination deficiency for DNA damage response pathway inhibitors or resistance (cyclin E1). Rapidly evolving techniques to measure genomic changes in tumour and blood allow for assessment of sensitivity and emergence of resistance to therapy, and might be accurate indicators of residual disease. Recurrence is usually incurable, and patient symptom control and quality of life are key considerations at this stage. Treatments for recurrence have to be designed from a patient's perspective and incorporate meaningful measures of benefit. Urgent progress is needed to develop evidence and consensus-based treatment guidelines for each subgroup, and requires close international cooperation in conducting clinical trials through academic research groups such as the Gynecologic Cancer Intergroup.

Tailoring Ovarian Cancer Treatment: Implications of BRCA1/2 Mutations

High grade serous ovarian cancer (HGSOC) is the most common epithelial ovarian cancer, harbouring more than 20% germline or somatic mutations in the tumour suppressor genes BRCA1 and BRCA2. These genes are involved in both DNA damage repair process via homologous recombination (HR) and transcriptional regulation. BRCA mutation confers distinct characteristics, including an increased response to DNA-damaging agents, such us platinum chemotherapy and poly-ADP ribose polymerase inhibitors (PARPi). However, several mechanisms of resistance to these agents have been described, including increased HR capacity through reverse BRCA mutations, non-homologous end-joint (NHEJ) repair alterations and drug efflux pumps. Current treatments of ovarian cancer including surgery, chemotherapy, targeted treatment and maintenance strategies, as well as resistance mechanisms will be reviewed, focusing on future trends with respect to BRCA mutation carriers.

Tailoring Ovarian Cancer Treatment: Implications of BRCA1/2 Mutations

High grade serous ovarian cancer (HGSOC) is the most common epithelial ovarian cancer, harbouring more than 20% germline or somatic mutations in the tumour suppressor genes BRCA1 and BRCA2. These genes are involved in both DNA damage repair process via homologous recombination (HR) and transcriptional regulation. BRCA mutation confers distinct characteristics, including an increased response to DNA-damaging agents, such us platinum chemotherapy and poly-ADP ribose polymerase inhibitors (PARPi). However, several mechanisms of resistance to these agents have been described, including increased HR capacity through reverse BRCA mutations, non-homologous end-joint (NHEJ) repair alterations and drug efflux pumps. Current treatments of ovarian cancer including surgery, chemotherapy, targeted treatment and maintenance strategies, as well as resistance mechanisms will be reviewed, focusing on future trends with respect to BRCA mutation carriers.

Tailoring Ovarian Cancer Treatment: Implications of BRCA1/2 Mutations

High grade serous ovarian cancer (HGSOC) is the most common epithelial ovarian cancer, harbouring more than 20% germline or somatic mutations in the tumour suppressor genes BRCA1 and BRCA2. These genes are involved in both DNA damage repair process via homologous recombination (HR) and transcriptional regulation. BRCA mutation confers distinct characteristics, including an increased response to DNA-damaging agents, such us platinum chemotherapy and poly-ADP ribose polymerase inhibitors (PARPi). However, several mechanisms of resistance to these agents have been described, including increased HR capacity through reverse BRCA mutations, non-homologous end-joint (NHEJ) repair alterations and drug efflux pumps. Current treatments of ovarian cancer including surgery, chemotherapy, targeted treatment and maintenance strategies, as well as resistance mechanisms will be reviewed, focusing on future trends with respect to BRCA mutation carriers.

Ovarian Cancer: Clinical Trial Breakthroughs and Impact on Management

Ovarian cancer treatment continues to evolve. Despite aggressive surgery and chemotherapy, most women will ultimately die from disease. Improvement in disease control are due to the incorporation of molecular targeted agents and the adoption of maintenance therapy. Maintenance therapy has been shown to enhance progression-free survival. Recent surgical trials have evaluated the role of neoadjuvant chemotherapy versus primary debulking at the time of diagnosis in advanced stage ovarian cancer. The role of lymph node dissection and secondary cytoreductive surgeries have also been evaluated. This article reviews contemporary trials of maintenance therapy and novel drug development.

The mesenchymal transition subtype more responsive to dose dense taxane chemotherapy combined with carboplatin than to conventional taxane and carboplatin chemotherapy in high grade serous ovarian carcinoma: A survey of Japanese Gynecologic Oncology Group study (JGOG3016A1)

OBJECTIVE

Recently, we established new histopathological subtypes of high-grade serous ovarian cancer (HGSOC) that include the mesenchymal transition (MT) type, the immune reactive (IR) type, the solid and proliferative (SP) type and the papillo-glandular (PG) type. Furthermore, we identified that the mesenchymal transcriptome subtype might be sensitive to taxane. We investigated whether these different histopathological subtypes of HGSOC require individualized chemotherapy for optimal treatment.

METHODS

We conducted the Japanese Gynecologic Oncology Group (JGOG) 3016A1 study, wherein we collected hematoxylin and eosin slides (total n = 201) and performed a histopathological analysis of patients with HGSOC registered in the JGOG3016 study, which compared the efficacy of conventional paclitaxel and carboplatin (TC) and dose-dense TC (ddTC). We analyzed the differences in progression-free survival (PFS) and overall survival (OS) among the four histopathological subtypes. We then compared the PFS between the TC group and the ddTC group for each histopathological subtype.

RESULTS

There were significant differences in both PFS and OS among the four histopathological subtypes (p = 0.001 and p < 0.001, respectively). Overall, the MT subtype had the shortest PFS (median 1.4 y) and OS (median 3.6 y). In addition, the MT subtype had a longer PFS in the ddTC group (median 1.8 y) than in the TC group (median 1.2 y) (p = 0.01). Conversely, the other types had no significant difference in PFS when the two regimens were compared.

CONCLUSIONS

The MT type of HGSOC is sensitive to taxane; therefore, the ddTC regimen is recommended for this histopathological subtype.

Asian Society of Gynecologic Oncology International Workshop 2018

The Asian Society of Gynecologic Oncology International Workshop 2018 on gynecologic oncology was held in the Ajou University Hospital, Suwon, Korea on the 24th to 25th August 2018. The workshop was an opportunity for Asian doctors to discuss the latest findings of gynecologic cancer, including cervical, ovarian, and endometrial cancers, as well as the future of fertility-sparing treatments, minimally invasive/radical/debulking surgery, radiotherapy, chemotherapy, targeted therapy, and immunotherapy. Clinical guidelines and position statement of Asian countries were presented by experts. Asian clinical trials for gynecologic cancers were reviewed and experts emphasized the point that original Asian study is beneficial for Asian patients. In Junior session, young gynecologic oncologists presented their latest research on gynecologic cancers.

Diagnosis and Treatment of Ovarian Cancer

Epithelial ovarian cancer classically presents with vague persistent gastrointestinal, urologic, or nonacute abdominal/pelvic symptoms (bloating, early satiety, discomfort). Ultimately, a pelvic examination or imaging identifies an adnexal mass typically with accompanied advanced peritoneal dissemination. Management involves aggressive cytoreductive surgery in combination with platinum and taxane chemotherapy. Over the last 20 years, optimal resection and mode and timing of chemotherapy have evolved. The authors review the initial diagnosis and management and present the available data and recommendations to guide the decision tree of when to use neoadjuvant, intraperitoneal, HIPEC, dose-dense, and maintenance chemotherapy in the front-line treatment of epithelial ovarian cancer.

Final report on serial phase II trials of all-intraperitoneal chemotherapy with or without bevacizumab for women with newly diagnosed, optimally cytoreduced carcinoma of Müllerian origin

BACKGROUND

Intraperitoneal (IP) chemotherapy can improve outcomes for women with optimally cytoreduced epithelial ovarian cancer but toxicities are a concern. We conducted 2 phase 2 trials of an IV/IP regimen using carboplatin and paclitaxel without (Trial A) and with bevacizumab (Trial B).

METHODS

Both trials consisted of carboplatin AUC 6 day 1, and paclitaxel 60 mg/m² on days 1,8, 15 of a 21-day cycle; in Trial B, patients received IV bevacizumab 15 mg/kg every cycle starting cycle 2. Chemotherapy was administered IV for cycle 1 and then IP for all subsequent cycles. Primary objectives included safety and tolerability, pathologic CR rate (Trial A), and the rate of completion of IP cycles of therapy (Trial B). Progression-free (PFS), overall survival (OS), and pharmacokinetic analysis were secondary endpoints.

RESULTS

81 patients were treated on both trials (n = 40 and 41 in trials A and B, respectively). Median age for trials A and B was 59 (range, 36-76) and 55 (range, 19-69) years, respectively. 68% and 85% of patients, respectively for A and B, completed at least 4 cycles of treatment in both trials. Treatment with bevacizumab resulted in higher rates of grade 3 fatigue (37 versus 33%) and grade 3-4 diarrhea (22 versus 8%). Median PFS was 23.5 (95%CI 16.2-35.3) and 25 (95%CI 16.4-42.7) months, respectively; median OS was 68 (95%CI 49.5-NR) and 79.7 (95%CI 59.0-79.7) months, respectively for Trial A and B.

CONCLUSIONS

Weekly administered IP carboplatin and IP paclitaxel is tolerable and safe with similar activity with and without concommittant bevacizumab in these 2 trials.

Therapeutic advances in hormone-dependent cancers: focus on prostate, breast and ovarian cancers

Hormonal cancers affect over 400,000 men and women and contribute collectively to over 100,000 deaths in the United States alone. Thanks to advances in the understanding of these cancers at the molecular level and to the discovery of several disease-modifying therapeutics, the last decade has seen a plateauing or even a decreasing trend in the number of deaths from these cancers. These advanced therapeutics not only effectively slow the growth of hormonal cancers, but also provide an insight on how these cancers become refractory and evolve as an altogether distinct subset. This review summarizes the current therapeutic trends in hormonal cancers, with focus on prostate, breast and ovarian cancers. The review discusses the clinical drugs being used now, promising molecules that are going through various stages of development and makes some predictions on how the therapeutic landscape will shift in the next decade.

ZNF671 DNA methylation as a molecular predictor for the early recurrence of serous ovarian cancer

Serous ovarian cancer is the most frequent type of epithelial ovarian cancer. Despite the use of surgery and platinum‐based chemotherapy, many patients suffer from recurrence within 6 months, termed platinum resistance. Currently, the lack of relevant molecular biomarkers for the prediction of the early recurrence of serous ovarian cancers is linked to the poor prognosis. To identify an effective biomarker for early recurrence, we analyzed the genome‐wide DNA methylation status characteristic of early recurrence after treatment. The patients in The Cancer Genome Atlas (TCGA) dataset who showed a complete response after the first therapy were categorized into 2 groups: early recurrence serous ovarian cancer (ERS, recurrence ≤12 months, n = 51) and late recurrence serous ovarian cancer (LRS, recurrence >12 months, n = 158). Among the 12 differently methylated probes identified between the 2 groups, we found that ZNF671 was the most significantly methylated gene in the early recurrence group. A validation cohort of 78 serous ovarian cancers showed that patients with ZNF671 DNA methylation had a worse prognosis (P < .05). The multivariate analysis revealed that the methylation status of ZNF671 was an independent factor for predicting the recurrence of serous ovarian cancer patients both in the TCGA dataset and our cohort (P = .049 and P = .021, respectively). Functional analysis revealed that the depletion of ZNF671 expression conferred a more migratory and invasive phenotype to the ovarian cancer cells. Our data indicate that ZNF671 functions as a tumor suppressor in ovarian cancer and that the DNA methylation status of ZNF671 might be an effective biomarker for the recurrence of serous ovarian cancer after platinum‐based adjuvant chemotherapy.

Phase Ib with expansion study of olaparib plus weekly (Metronomic) carboplatin and paclitaxel in relapsed ovarian cancer patients

OBJECTIVE

Our goals were to: establish the maximum-tolerated dose of olaparib tablets combined with metronomic carboplatin and paclitaxel in patients with relapsed high-grade serous ovarian cancer; evaluate dose-limiting toxicities; and evaluate efficacy at the maximum tolerated dose.

METHODS

In this open-label, single-arm, investigator-initiated trial (ClinicalTrials.gov NCT01650376), patients with high-grade serous ovarian cancer who failed primary platinum and taxane therapy received oral olaparib tablets twice daily days 1-3 each week combined with fixed-dose metronomic carboplatin AUC2 and paclitaxel 60 mg/m² weekly for 3 out of 4 weeks. A 3 × 3 design was used to determine the olaparib maximum tolerated dose. Combination therapy continued until disease progression, but patients with partial or complete response were transitioned to olaparib maintenance therapy. All patients were included in the analysis.

RESULTS

The maximum tolerated dose of olaparib tablets was 150 mg twice daily with metronomic carboplatin and paclitaxel. 54 women were enrolled, 14 in phase Ib and 40 in the expansion phase. The median number of prior therapeutic regimens was 3. Response included 13 complete remission (24%) and 16 partial remission (30%) per Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST 1.1) for an overall response rate of 54% (95% CI 40% to 67%). Of 47 patients who underwent BRCA testing, 23 were BRCA mutation (BRCAm) and 24 B RCA wild type (BRCAwt). Progression-free survival for BRCAm was 12.1 months versus 4.8 for BRCAwt (p=0.0001). Median overall survival for BRCAm was 24.1 months versus 10.4 months for BRCAwt (p=0.02). 42 patients (78%) experienced grade 3-4 toxicities with combination therapy; the most common were hematologic. There were no treatment related deaths. Among 14 patients who received maintenance therapy, 7 experienced grade 1-2 non-hematologic toxicities.

CONCLUSIONS

Olaparib 150 mg tablet twice daily can be safely administered in combination with metronomic carboplatin and paclitaxel in pre-treated relapsed ovarian cancer with 24% complete remission. BRCAm patients had statistically significant longer progression-free survival and overall survival than BRCAwt.

TRIAL REGISTRATION NUMBER

NCT01650376.

The Evolving Landscape of Chemotherapy in Newly Diagnosed Advanced Epithelial Ovarian Cancer

The treatment of women with advanced-stage epithelial ovarian cancer (EOC) is aggressive surgical cytoreduction and a combination of platinum plus taxane chemotherapy. The timing and extent of surgery has direct implications on the selection of subsequent treatment as well as the prognosis of patients with EOC. Frontline chemotherapeutic regimens have evolved through a series of large multi-institutional randomized clinical trials that focused on targeted agents as maintenance therapy. On June 13, 2018, the U.S. Food and Drug Administration (FDA) approved adding bevacizumab to adjuvant intravenous chemotherapy followed by maintenance based on the results of Gynecologic Oncology Group protocol 218. Maintenance olaparib was FDA-approved on December 19, 2018, for frontline maintenance among those with advanced EOC who respond to frontline chemotherapy and harbor a germline or somatic BRCA1 or BRCA2 mutation. This was based on the results of SOLO-1. Despite a strong rationale and extensive study, intraperitoneal chemotherapy has not been adopted in clinical practice. Alternatively, heated intraperitoneal chemotherapy has shown promise as a more tolerable and technically feasible method of regional therapy, but widespread application will require more evidence. Significant strides have also been made in understanding the biology of EOC, resulting in a personalized approach to first-line therapy. One approach calls for recognizing differences in histologic subtypes and molecular alterations, which may open up alternative therapeutic interventions.

Cancer of the ovary, fallopian tube, and peritoneum

The Gynecologic Oncology Committee of FIGO in 2014 revised the staging of ovarian cancer, incorporating ovarian, fallopian tube, and peritoneal cancer into the same system. Most of these malignancies are high-grade serous carcinomas (HGSC). Stage IC is now divided into three categories: IC1 (surgical spill); IC2 (capsule ruptured before surgery or tumor on ovarian or fallopian tube surface); and IC3 (malignant cells in the ascites or peritoneal washings). The updated staging includes a revision of Stage IIIC based on spread to the retroperitoneal lymph nodes alone without intraperitoneal dissemination. This category is now subdivided into IIIA1(i) (metastasis ≤10 mm in greatest dimension), and IIIA1(ii) (metastasis >10 mm in greatest dimension). Stage IIIA2 is now "microscopic extrapelvic peritoneal involvement with or without positive retroperitoneal lymph node" metastasis. This review summarizes the genetics, surgical management, chemotherapy, and targeted therapies for epithelial cancers, and the treatment of ovarian germ cell and stromal malignancies.

A new promising way of maintenance therapy in advanced ovarian cancer: a comparative clinical study

Background

There is an urgent need for more novel and efficacious therapeutic agents and strategies for the treatment of ovarian cancer - one of the most formidable female malignancies. These approaches should be based on comprehensive understanding of the pathobiology of this cancer and focused on decreasing its recurrence and metastasis. The aim of this study was to evaluate the efficacy of five-year maintenance therapy with indole-3-carbinol (I3C) as well as I3C and epigallocatechin-3-gallate (EGCG) conducted before, during, and after combined treatment compared with combined treatment alone in advanced ovarian cancer.

Methods

Patients with stage III-IV serous ovarian cancer were assigned to receive combined treatment plus I3C (arm 1), combined treatment plus I3C and EGCG (arm 2), combined treatment plus I3C and EGCG plus long-term platinum-taxane chemotherapy (arm 3), combined treatment alone without neoadjuvant platinum-taxane chemotherapy (control arm 4), and combined treatment alone (control arm 5). Combined treatment included neoadjuvant platinum-taxane chemotherapy, surgery, and adjuvant platinum-taxane chemotherapy. The primary endpoint was overall survival (OS). Secondary endpoints were progression-free survival (PFS) and rate of patients with recurrent ovarian cancer with ascites after combined treatment.

Results

After five years of follow-up, maintenance therapy dramatically prolonged PFS and OS compared to control. Median OS was 60.0 months (95% CI: 58.0–60.0 months) in arm 1, 60.0 months (95% CI: 60.0–60.0 months) in arms 2 and 3 while 46.0 months (95% СI: 28.0–60.0 months) in arm 4, and 44.0 months (95% СI: 33.0–58.0 months) in arm 5. Median PFS was 39.5 months (95% СI: 28.0–49.0 months) in arm 1, 42.5 months (95% СI: 38.0–49.0 months) in arm 2, 48.5 months (95% СI: 39.0–53.0 months) in arm 3, 24.5 months (95% СI: 14.0–34.0 months) in arm 4, 22.0 months (95% СI: 15.0–26.0 months) in arm 5. The rate of patients with recurrent ovarian cancer with ascites after combined treatment was significantly less in maintenance therapy arms compared to control.

Conclusions

Long-term usage of I3C and EGCG may represent a new promising way of maintenance therapy in advanced ovarian cancer patients, which achieved better treatment outcomes.

Trial registration

Retrospectively registered with ANZCTR number: ACTRN12616000394448. Date of registration: 24/03/2016.

Risk of selected gastrointestinal toxicities associated with poly (ADP-ribose) polymerase (PARP) inhibitors in the treatment of ovarian cancer: a meta-analysis of published trials

Aims

We aimed to comprehensively assess the risk of gastrointestinal toxicities associated with poly (ADP-ribose) polymerase inhibitors (PARPis) in the treatment of ovarian cancer patients.

Materials and methods

We searched several databases for relevant trials. Eligible studies included prospective Phase II and III trials of ovarian cancer patients on the four PARPis (olaparib, veliparib, niraparib and rucaparib), describing events of nausea, vomiting, diarrhea, and constipation. Summary incidence, relative risk (RR), and 95% CIs were calculated employing fixed- or random-effects models.

Results

A total of 2,286 ovarian cancer patients from 12 trials were included for analysis. Our results showed that summary incidences of all-grade gastrointestinal events in ovarian cancer patients were nausea 68.8% (95% CI, 63.5%–73.6%), vomiting 36.2% (95% CI, 30.9%–41.8%), diarrhea 25.3% (95% CI, 21.2%–29.8%), and constipation 25.3% (95% CI, 17.9%–34.5%). The RRs of all-grade nausea, vomiting, diarrhea, and constipation were 2.00 (95% CI: 1.79–2.24; P<0.001), 2.12 (95% CI: 1.75–2.58; P<0.001), 1.20 (95% CI: 1.01–1.44; P=0.044), and 1.20 (95% CI: 0.88–1.80; P=0.21); respectively. While, the RRs of high-grade nausea, vomiting, diarrhea, and constipation were 3.74 (95% CI: 1.50–9.36; P=0.005), 2.81 (95% CI: 1.17–6.74; P=0.02), 0.56 (95% CI: 0.22–1.43; P=0.23), 0.92 (95% CI: 0.34–2.49, P=0.87); respectively.

Conclusion

Our study suggests that the risk of all-grade gastrointestinal toxicities associated with PARPis, excepting constipation, is significantly increased in ovarian cancer patients. And the use of PARPis significantly increased the risk of developing high-grade nausea and vomiting, but not for diarrhea and constipation. Close clinical monitoring is recommended when administering these drugs.

Alternating Magnetic Field-Triggered Switchable Nanofiber Mesh for Cancer Thermo-Chemotherapy

We have developed a smart anti-cancer fiber mesh that is able to control tumor-killing activity against lung adenocarcinoma precisely. The mesh is capable of carrying large loads of chemotherapeutic drug, paclitaxel (PTX), as well as magnetic nanoparticles (MNPs). The mesh generates heat when the loaded MNPs are activated in an alternating magnetic field (AMF). The mesh is thermo-responsive, so the heat generated can be also used to trigger PTX release from the mesh. An electrospinning method was employed to fabricate the mesh using a copolymer of N-isopropylacrylamide and N-hydroxymethylacrylamide, the phase transition temperature of which was adjusted to the mild-hyperthermia temperature range around 43 °C. In vitro anti-tumor studies demonstrated that both MNP- and PTX-loaded mesh killed about 66% of cells, whereas only PTX-loaded mesh killed about 43% of cells. In a mouse lung cancer model, the thermo-chemotherapy combo displayed enhanced anti-tumor activity and the systemic toxic effects on mice were eliminated due to local release of the chemotherapeutic agents. The proposed fiber system might provide a blueprint to guide the design of the next generation of local drug delivery systems for safe and effective cancer treatment.

Improved survival in ovarian cancer, with widening survival gaps of races and socioeconomic status: a period analysis, 1983-2012

Introduction: Ovarian cancer is the first leading cause of cancer-related deaths among gynecologic malignancies, and the 7th most common female cancer worldwide. However, previous studies on changes in the long-term survival of ovarian cancer were limited.

Methods: Our data were extracted from Surveillance, Epidemiology, and End Results (SEER) registries to assess the incidence and relative survival changes of patients with ovarian cancer during 1983-2012. Patients with ovarian cancer were stratified by age, race, and socioeconomic status (SES). Cox regression analysis and Spearman rank correlation analysis were performed by STATA 12 software.

Results: The overall incidence of ovarian cancer per 100,000 decreased from 13.7 to 12.4 to 10.8 over three decades with peak incidence occurring in the 70+ age group at 47.6, 45.7 and 40.2 in each respective decade. Median survival improved from 34 months to 46 months to 52 months over three decades, with the 5-year relative survival rate (RSR) increasing from 39.3% to 43.4% to 45.4% (p < 0.0001). However, Whites showed higher median survival (34 months) than Blacks (27 months) in the first decade, and the survival difference significantly increased to 16 months in the third decade. Additionally, the median survival difference between the low-poverty group and high poverty group increased from 4 months to 12 months in the three decades.

Discussion: This study demonstrated the decreasing incidence of ovarian cancer with an observed improvement in relative survival over three decades in a large sample. However, the survival gaps among races and SESs significantly widened over the three decades.

Tumor progression and metastatic dissemination in ovarian cancer after dose-dense or conventional paclitaxel and cisplatin plus bevacizumab

The efficacy of therapeutic regimens incorporating weekly or every-3-weeks paclitaxel (PTX) for ovarian cancer is debated. We investigated the addition of bevacizumab in regimens of chemotherapy with different PTX doses and schedules in preclinical models. Treatments were cisplatin (DDP) with weekly PTX (conventional), or dose-dense-equi (every other day to the conventional cumulative dose), or dose-dense-high (total dose 1.5 times higher), with or without bevacizumab. Treatment efficacy was evaluated analyzing tumor growth in different time-windows in two patient-derived ovarian cancer xenografts with different sensitivity to cisplatin. Tumor progression, metastasis and survival were studied in ovarian cancer models growing orthotopically and disseminating in the mouse peritoneal cavity. Short-term effects on cell cycle, tumor cell proliferation/apoptosis and vasculature were evaluated by flow cytometry and immunohistochemistry. PTX dose-dense (with/without DDP) was superior to the conventional scheme in a dose-dependent manner; the high efficacy was confirmed by the lower ratio of tumor to normal cells. All schemes benefited from bevacizumab, which reduced tumor vessels. However, DDP/PTX dose-dense-high (only chemotherapy) was at least as active as DDP/PTX conventional plus bevacizumab. DDP/PTX dose-dense-high plus bevacizumab was the most effective in delaying tumor progression, though it did not prolong mouse survival and the continuous treatment with bevacizumab was associated with a malignant disease. These findings indicate that the effect of bevacizumab in combination with chemotherapy may depend on the schedule-dose of the treatment and help to explain the unclear benefits after bevacizumab.

Bevacizumab with dose-dense paclitaxel/carboplatin as first-line chemotherapy for advanced ovarian cancer

Phase III trials have shown improved survival in ovarian cancer patients when the anti-vascular endothelial growth factor (VEGF) therapy bevacizumab is added to first-line chemotherapy. However, further evidence is needed regarding bevacizumab when used with dose-dense paclitaxel/carboplatin chemotherapy in advanced ovarian cancer patients. This single-arm trial enrolled 184 advanced-stage (III-IV) epithelial ovarian cancer patients following primary debulking. Enrollees were treated with dose-dense paclitaxel/carboplatin chemotherapy with bevacizumab administered on the first day of cycles 2 through 6. Thereafter, maintenance bevacizumab was continued for 12 months in patients exhibiting persistent disease. The primary endpoint was the tumor response rate. The secondary endpoints were overall survival (OS), progression-free survival (PFS), and adverse effects. VEGF-associated serum markers and VEGFA/B lymphoma Mo-MLV insertion region 1 homolog (BMI1) pathway proteins in tumor-derived ovarian epithelial cancer cells were analyzed. Of the enrollees with residual disease that completed at least four cycles, 56.6% had a complete response and 3.7% had a partial response. OS and PFS were significantly different between optimally debulked and suboptimally debulked patients (P < 0.05). The most common grade 3/4 adverse event was neutropenia. Patients with progressive disease showed greater basal serum VEGFA and ovarian VEGFA/BMI1 pathway protein expression relative to patients with stable disease and responsive disease (P < 0.05). In conclusion, bevacizumab plus dose-dense paclitaxel/carboplatin shows efficacy and tolerability in advanced ovarian cancer patients, especially in those having received optimal resection. Our evidence also suggests a prognostic relationship between serum VEGFA levels and a worse prognosis in ovarian cancer patients with measurable disease.

Ex vivo expanded tumour-infiltrating lymphocytes from ovarian cancer patients release anti-tumour cytokines in response to autologous primary ovarian cancer cells

Epithelial ovarian cancer (EOC) is the leading cause of gynaecological cancer-related death in Europe. Although most patients achieve an initial complete response with first-line treatment, recurrence occurs in more than 80% of cases. Thus, there is a clear unmet need for novel second-line treatments. EOC is frequently infiltrated with T lymphocytes, the presence of which has been shown to be associated with improved clinical outcomes. Adoptive T-cell therapy (ACT) using ex vivo-expanded tumour-infiltrating lymphocytes (TILs) has shown remarkable efficacy in other immunogenic tumours, and may represent a promising therapeutic strategy for EOC. In this preclinical study, we investigated the efficacy of using anti-CD3/anti-CD28 magnetic beads and IL-2 to expand TILs from freshly resected ovarian tumours. TILs were expanded for up to 3 weeks, and then subjected to a rapid-expansion protocol (REP) using irradiated feeder cells. Tumours were collected from 45 patients with EOC and TILs were successfully expanded from 89.7% of biopsies. Expanded CD4⁺ and CD8⁺ subsets demonstrated features associated with memory phenotypes, and had significantly higher expression of key activation and functional markers than unexpanded TILs. Expanded TILs produced anti-tumour cytokines when co-cultured with autologous tumour cells, inferring tumour cytotoxicity. Our findings demonstrate that it is possible to re-activate and expand tumour-reactive T cells from ovarian tumours. This presents a promising immunotherapy that could be used sequentially or in combination with current therapeutic strategies.

Experimental animal study of docetaxel combined with carboplatin in the treatment of retinoblastoma

The synergistic effects of docetaxel (DTX) combined with carboplatin in the treatment of retinoblastoma (RB) was explored in mouse RB xenografts compared with carboplatin alone and DTX alone groups. Retinoblastoma Y-79 cells (4.0×10⁷/ml) were injected into the vitreous body of the right eye of mice to establish the mouse model of RB xenografts. Then the mice were randomly divided into 4 groups (n=30): DTX combined with carboplatin group (group A), carboplatin group (group B), DTX group (group C) and blank control group (group D). The changes in tumors, the survival time of mice, and the synergistic effects of DTX combined with carboplatin were observed and analyzed. The diameters and weight of the right eyeballs of the Institute for Cancer Research (ICR) mice were significantly larger and higher than those of the left eyeballs in each group, respectively (P<0.05). The diameters and weight in group A were significantly shorter and lighter than those in the other three groups, respectively (P<0.05), and there was no significant difference compared with that of normal eyeballs (P>0.05). There was no difference in diameter and weight between group B and group C (P>0.05), but the diameters and weight were shorter and lighter than those in group D, respectively (P<0.05). The survival time of ICR mice in groups A, B and C was significantly longer than that in group D (P<0.05). The survival time in group A was significantly longer than that in groups B and C (P<0.05). There was no significant difference in the survival time between the group B and group C (P>0.05). DTX, carboplatin and the combination of the two have significant inhibitory effects on RB; however, DTX combined with carboplatin has a better therapeutic effect on RB.

Metastatic gynecologic malignancies: advances in treatment and management

Gynecologic cancers comprise of mostly uterine, ovarian, and cervical malignancies and are responsible for 95,000 new cases annually in the United States. Uterine cancer is the most common and the number of new cases and mortality has been increasing. Cervical cancer has decreased due to screening, early detection, and treatment of pre-invasive cancers. However, ovarian cancer remains the most lethal because of advanced stage at diagnosis and drug resistance. The metastatic spread pattern differs amongst these cancers, with uterine and cervical cancer found mostly in the primary organ and ovarian cancer disseminating throughout the peritoneum and upper abdomen at presentation. The primary treatment of ovarian cancer typically involves surgery followed by systemic therapy for more advanced disease. Previously, systemic chemotherapy with platinums, taxanes, doxorubicin, topotecan, and gemcitabine has been the standard in either upfront or recurrent setting. With molecular and genetic breakthroughs, we now have over eight new indications and five novel biologic therapies including antiangiogenics, poly ADP ribose polymerase inhibitors, and immunotherapies approved over the last 3 years. In this review, we will examine the biology of gynecologic cancer metastasis and focus on new treatment options for these cancers with a focus on ovarian cancer.

Front-line therapy of advanced ovarian cancer: new approaches

Background

The 5-year survival of ovarian cancer has slowly increased but to date much of this has been due to the use of more lines of treatment rather than better first-line therapy. In this setting, there has been little improvement over the past 15 years. The introduction of new treatments to extend time to first progression and overall survival remains a key objective of clinical research.

Design

The focus of research in the previous decade has been on the incorporation of anti-angiogenic therapy or dose-dense scheduling of paclitaxel (Taxol) to improve outcome. The new trials being conducted build on the knowledge gained and are focussing on two new areas of research, the use of PARP (poly-ADP ribose polymerase) inhibitors and immunotherapy.

Results

Ongoing randomised trials using PARP inhibitors or immune checkpoint inhibits are reviewed and the potential benefits and challenges of using these agents are discussed.

Conclusions

Improvements in outcome from some of the many open trials may present challenges; interpretation of the outcome data needs to be taken in the context of clinical benefit and a health-economic assessment. The latter is becoming ever-more important as the cost of trials with combinations of targeted therapy is very great.

The role of neoadjuvant chemotherapy in ovarian cancer

INTRODUCTION

Ovarian cancer is mostly diagnosed at advanced stage. Better survival is achieved through complete debulking surgery and chemotherapy. Historically, neoadjuvant chemotherapy (NAC) has been introduced for unresectable disease to decrease tumor load and perform a unique complete surgery. Four randomized control trials have compared primary debulking surgery to NAC, but there is still controversy about the use of neoadjuvant chemotherapy and questions about its modalities. Areas covered: We made a review of knowledge on benefits of NAC compared to primary debulking chemotherapy, in terms of survival and morbidity, methods of administration, new drugs in early and late phase trials, the selection of patients. Similar survival was observed after NAC and interval debulking surgery or primary debulking surgery. Morbidity of surgery was decreased after interval debulking compared primary debulking surgery. Conventional drugs are carboplatin and paclitaxel. Safety of bevacizumab was evaluated in phase 2 trials associated with conventional drugs. Immunotherapy trials are enrolling patients in phase 1 study. Expert commentary: NAC followed by debulking surgery is the best treatment for patients with advanced ovarian cancer.

Efficacy of weekly administration of paclitaxel and carboplatin for advanced ovarian cancer patients with poor performance status

OBJECTIVE

The aim of this study was to reveal the efficacy of weekly administration of paclitaxel and carboplatin for advanced ovarian cancer patients with poor performance status (PS).

METHODS

FIGO stage III/IV ovarian cancer or fallopian tube cancer patients who underwent interval debulking surgery (IDS) followed by neoadjuvant chemotherapy (NAC) were analyzed retrospectively. Patients were divided into two groups based on NAC: weekly paclitaxel and carboplatin (W-TC) and 3 weeks of paclitaxel and carboplatin (TW-TC). Toxicity, efficacy of NAC, surgery outcome, and prognosis were assessed by comparing the two groups.

RESULTS

Twenty patients treated with W-TC and 18 patients treated with TW-TC were analyzed. All of the W-TC patients were poor PS (PS ≥ 2), and all of the TW-TC patients were good PS (PS ≤ 1). The overall clinical response rates were 70% in W-TC and 83.4% in TW-TC. In the W-TC group, Grade 3/4 anemia and thrombocytopenia and greater than grade 2 neuropathy were significantly reduced compared to TW-TC patients. A frequency of treatment delay greater than 7 and 14 days, G-CSF support, blood transfusion, and dose reduction or regimen change were also significantly reduced in the W-TC group. The rate of IDS, optimal debulking surgery, complications during operation, and blood transfusion were similar between the W-TC and TW-TC groups. Progression-free survival and overall survival were also similar between the two groups.

CONCLUSION

Our study suggested that NAC with W-TC for poor PS patients with non-treated ovarian cancer reduced the toxicity of chemotherapy and had the same efficacy as TW-TC.

Carboplatin (every 21 days) and divided-dose paclitaxel (days 1, 11): rationale and tolerance in chemotherapy naïve women with high-grade epithelial cancers of Mullerian origin

PURPOSE

We report here on the tolerance of a carboplatin-'divided dose' paclitaxel (given on days 1 and 11) regimen in chemotherapy-naïve patients with resected and staged endometrial epithelial neoplasms deemed at high-risk of recurrence or early stage epithelial high-grade serous tubo-ovarian adenocarcinomas after risk-reducing surgery. More recently, we applied this regimen as neoadjuvant chemotherapy for advanced ovarian cancer presentations.

METHODS

A retrospective chart review of patients receiving this day 1, 11 paclitaxel regimens in combination with carboplatin at AUC 6 every 3 weeks since 2004 was carried out by the second author with subsequent updates by the first and third authors. Tolerance over the first three cycles was analyzed.

RESULTS

A total of 27 women were treated with at least three cycles of this paclitaxel 'divided dose' schedule combined with carboplatin: 6 had endometrial adenocarcinoma, 9 had early stage ovarian cancer, and 12 received it as part of neoadjuvant therapy prior to undergoing cytoreductive surgery. Only 14 of 27 patients required dose reductions to complete the first three cycles of treatment.

CONCLUSIONS

A median of three cycles of divided dose paclitaxel (D1, D11) concurrent with carboplatin dosed every 3 weeks was found to be safe and feasible as adjuvant to surgery in early endometrial and ovarian cancers or as neoadjuvant treatment in chemotherapy-naive women with ovarian cancer.

Dose-dense weekly chemotherapy in advanced ovarian cancer: An updated meta-analysis of randomized controlled trials

OBJECTIVE

The use of dose-dense weekly chemotherapy in the management of advanced ovarian cancer (OC) remains controversial. The aim of this meta-analysis was to evaluate the efficacy of dose-dense regimen to improve clinical outcomes in OC patients with the inclusion of new trials.

METHODS

For this updated meta-analysis, PubMed Medline and Scopus databases and meeting proceedings were searched for eligible studies with the limitation of randomized controlled trials, comparing dose-dense chemotherapy versus standard treatment. Trials were grouped in two types of dose-dense chemotherapy: weekly dose-dense (both paclitaxel and carboplatin weekly administration) and semi-weekly dose-dense (weekly paclitaxel and three weekly carboplatin administration). Data were extracted independently and were analyzed using RevMan statistical software version 5.3 (http://www.cochrane.org). Primary end-point was progression-free survival (PFS).

RESULTS

Four randomized controlled trials comprising 3698 patients were identified as eligible. Dose-dense chemotherapy had not a significant benefit on PFS (HR 0.92, 95% CI 0.81-1.04, p = 0.20). When the analysis was restricted to both weekly and semi-weekly dose-dense data, a no significant interaction between dose-dense and standard regimen was confirmed (HR 1.01, 95% CI 0.93-1.10 and HR 0.82, 95% CI 0.63-1.08, respectively).

CONCLUSIONS

In the absence of PFS superiority of dose-dense schedule, three weekly schedule should remain the standard of care for advanced OC.

Weekly versus three weeks chemotherapy for advanced ovarian cancer: a meta-analysis

Aim

Three weeks paclitaxel and carboplatin has been considered the standard of care for primary treatment of ovarian cancer (OC). Whether weekly therapy will further improve the clinical outcomes or not is still unclear. We conducted a meta-analysis to compare the two regimens.

Method

Articles were selected with a systematic approach, using PubMed databases. Trials concerning comparison between carboplatin plus weekly paclitaxel (dose-dense regimen) and carboplatin plus paclitaxel every 3 weeks were considered. Outcomes included overall survival (OS), progression free survival (PFS) and severe acute toxicity.

Results

Dose-dense regimen was associated with significant improvement of PFS compared with standard schedule, with HR of 0.73 (95% CI 0.61-0.88, p = 0.001). There was no difference in OS between treatment regimens (HR 0.95, 95% CI 0.77-1.16, p=0.06), as well as in term of severe acute toxicity.

Conclusion

Dose-dense regimen is superior to standard schedule in terms of PFS. Further studies are necessary to firmly confirm this evidence in advanced OC treatment.

Bevacizumab combined with chemotherapy for ovarian cancer: an updated systematic review and meta-analysis of randomized controlled trials

BACKGROUND

This meta-analysis was updated with results from a new trial and final data to reassess the efficacy and safety of bevacizumab combined with chemotherapy in ovarian cancer (OC).

METHODS

Randomized controlled trials (RCTs) were searched in PubMed, EMBASE, Cochrane clinical trials, Web of Science and clinicaltrial.gov databases. Outcomes included the progression-free survival (PFS), overall survival (OS), objective response rate (ORR) and common adverse events. The hazard ratio (HR), risk ratio (RR) and odds ratio (OR) were pooled when the meta-analysis was performed.

RESULTS

Five RCTs with 4994 patients were included. In overall newly diagnosed OC, bevacizumab combined with chemotherapy did not significantly improve PFS (HR 0.85, 95%CI 0.70-1.02) or OS (HR 0.94, 95%CI 0.84-1.05). In the high-risk progression subgroup, the addition of bevacizumab significantly improved PFS (HR 0.76, 95%CI 0.68-0.84) and OS (HR 0.85, 95%CI 0.74-0.96). In recurrent OC, the addition of bevacizumab to chemotherapy significantly extended PFS (HR 0.53, 95%CI 0.45-0.63) and OS (HR 0.87, 95%CI 0.77-0.99). The ORR was improved (OR 2.37, 95%CI 1.99-2.82) in the overall population. Bevacizumab increased the incidence of hypertension (RR 21.27, 95%CI 9.42-48.02), proteinuria (RR 4.77, 95%CI 2.15-10.61), bleeding (RR 3.16, 95%CI 1.59-6.30), GI perforations (RR 2.76, 95%CI 1.51-5.03), arterial thrombosis events (RR 2.39, 95%CI 1.39-4.10) and venous thrombosis events (RR 1.43, 95%CI 1.04-1.96).

CONCLUSIONS

Bevacizumab combined with chemotherapy significantly improved PFS and OS in both patients with high-risk of progression and patients with recurrent OC, with an increased incidence of common adverse events. However, no statistically significant survival benefit was identified in the front-line settings.

Gynecologic cancer in HIV-infected women: treatment and outcomes in a multi-institutional cohort

OBJECTIVE

To evaluate gynecologic cancer treatments in HIV-infected women for adherence to National Comprehensive Cancer Network (NCCN) guidelines and to describe survival by adherence to guidelines.

DESIGN

Beyond cervical cancer, there are little data on treatment and outcomes for these women. This is a retrospective cohort study of HIV-infected women with gynecologic cancers.

METHODS

HIV-infected women with gynecologic cancers from 2000 to 2015 were identified at two urban, comprehensive cancer centers. Chart reviews extracted demographic, HIV, and cancer-related variables. Cancer treatment was evaluated for adherence to NCCN guidelines. Overall survival was compared between those who received NCCN adherent and nonadherent cancer care.

RESULTS

Fifty-seven women were identified; 15 vulvar (26%), 26 cervical (46%), nine ovarian (16%), and seven endometrial (12%) cancers. Median time from HIV to cancer diagnosis was 8.5 years, and 88% of women were black. Thirty patients (53%) had stage I, and 27 (47%) had stage II-IV disease. Overall, 28 women (49%) received NCCN-adherent care; 22 of 30 stage I (73%) and six of 27 stage II-IV patients (22%). Among 29 women not receiving NCCN-adherent care, 69% were due to patient-related factors or toxicity. Among women with II-IV cancers, 48-month survival was higher in women who received NCCN-adherent care than those who did not (60 versus 28%).

CONCLUSION

Most HIV-infected women with advanced gynecologic cancers did not receive NCCN-adherent care and had worse survival compared to those who did. Focus on treatment-related toxicities and patient-related barriers to cancer care are necessary in this population.

Efficacy and safety of dose-dense paclitaxel plus carboplatin as neoadjuvant chemotherapy for advanced ovarian, fallopian tube or peritoneal cancer

Objective

Interval debulking surgery (IDS) after neoadjuvant chemotherapy (NAC) is currently one of the preferred treatment options for advanced ovarian, fallopian tube or peritoneal cancer. This study was conducted to evaluate the clinical efficacy and safety of dose-dense paclitaxel plus carboplatin therapy (ddTC therapy) as NAC for these cancers.

Patients and methods

A retrospective study was conducted in 25 patients with Stage III/IV ovarian, fallopian tube or peritoneal cancer who received ddTC therapy as NAC. For ddTC therapy, paclitaxel (80 mg/m2) was administered intravenously on Days 1, 8 and 15 and carboplatin (AUC 6.0 mg/ml × min) was administered intravenously on Day 1 every 3 weeks. IDS was performed after three cycles of ddTC therapy, and ddTC therapy was also continued after surgery.

Results

With ddTC therapy as NAC, the response rate was 92% and disease progression did not occur in any patient. Grade 4 hematologic toxicity and ≥Grade 3 non-hematologic toxicity both occurred in 8% of the patients, but no patient discontinued NAC because of adverse events. When IDS was performed, the complete surgery rate was 64% and the optimal surgery rate was 96%. ≥Grade 3 perioperative complications occurred in 16% of the patients, but there were no perioperative deaths. Median overall survival was 35.7 months and median progression-free survival was 17.7 months.

Conclusion

This study showed that ddTC therapy was considerably effective and tolerable as NAC. The complete surgery rate was high with IDS, and perioperative complications were acceptable.