What is an appropriate second-line regimen for recurrent endometrial cancer? Ancillary analysis of the SGSG012/GOTIC004/Intergroup study

Exposure to select PFAS and PFAS mixtures alters response to platinum-based chemotherapy in endometrial cancer cell lines

BACKGROUND

Exposure to per- and poly-fluoroalkyl substances (PFAS) has been associated with significant alterations in female reproductive health. These include changes in menstrual cyclicity, timing of menarche and menopause, and fertility outcomes, as well as increased risk of endometriosis, all of which may contribute to an increased risk of endometrial cancer. The effect of PFAS on endometrial cancer cells, specifically altered treatment response and biology, however, remains poorly studied. Like other gynecologic malignancies, a key contributor to lethality in endometrial cancer is resistance to chemotherapeutics, specifically to platinum-based agents that are used as the standard of care for patients with advanced-stage and/or recurrent disease.

OBJECTIVES

To explore the effect of environmental exposures, specifically PFAS, on platinum-based chemotherapy response and mitochondrial function in endometrial cancer.

METHODS

HEC-1 and Ishikawa endometrial cancer cells were exposed to sub-cytotoxic nanomolar and micromolar concentrations of PFAS/PFAS mixtures and were treated with platinum-based chemotherapy. Survival fraction was measured 48-h post-chemotherapy treatment. Mitochondrial membrane potential was evaluated in both cell lines following exposure to PFAS ± chemotherapy treatment.

RESULTS

HEC-1 and Ishikawa cells displayed differing outcomes after PFAS exposure and chemotherapy treatment. Cells exposed to PFAS appeared to be less sensitive to carboplatin, with instances of increased survival fraction, indicative of platinum resistance, observed in HEC-1 cells. In Ishikawa cells treated with cisplatin, PFAS mixture exposure significantly decreased survival fraction. In both cell lines, increases in mitochondrial membrane potential were observed post-PFAS exposure ± chemotherapy treatment.

DISCUSSION

Exposure of endometrial cancer cell lines to PFAS/PFAS mixtures had varying effects on response to platinum-based chemotherapies. Increased survival fraction post-PFAS + carboplatin treatment suggests platinum resistance, while decreased survival fraction post-PFAS mixture + cisplatin exposure suggests enhanced therapeutic efficacy. Regardless of chemotherapy sensitivity status, mitochondrial membrane potential findings suggest that PFAS exposure may affect endometrial cancer cell mitochondrial functioning and should be explored further.

Understanding Characteristics, Treatment Patterns, and Clinical Outcomes for Individuals with Advanced or Recurrent Endometrial Cancer in Alberta, Canada: A Retrospective, Population-Based Cohort Study

Endometrial cancer (EC) incidence has increased in recent decades. However, population-based outcomes data are limited. In this retrospective cohort study, we examined characteristics, treatment patterns, and clinical outcomes, including time to next treatment (TNNT) and overall survival (OS), among advanced/recurrent (A/R) EC patients between 2010 and 2018 in Alberta, Canada. Kaplan-Meier statistics evaluated TTNT and OS, stratified by patient (A/R) and treatment. A total of 1053 patients were included: 620 (58.9%) advanced and 433 (41.1%) recurrent. A total of 713 (67.7%) patients received first-line therapy: 466 (75.2%) advanced and 247 (57.0%) recurrent. Platinum-based chemotherapy (PBCT) was the most common first-line regimen (overall: 78.6%; advanced: 96.1%; recurrent: 45.3%). The median TTNT and OS from first-line therapy were 19.9 months (95% confidence interval [CI]: 17.5-23.5) and 35.9 months (95% CI: 31.5-53.5), respectively. Following first-line PBCT, the median OS from second-line chemotherapy (N = 187) was 10.4 months (95% CI: 8.9-13.3) and higher for those rechallenged with PBCT (N = 72; 38.5%) versus no rechallenge (N = 115; 61.5%) (13.3 months [95% CI: 11.2-20.9] vs. 6.4 months [95% CI: 4.6-10.4; p < 0.001]). The findings highlight poor outcomes in A/R EC, particularly following first-line therapy, and that additional tolerable therapeutic options are needed to improve patient outcomes.

Looking beyond carboplatin and paclitaxel for the treatment of advanced/recurrent endometrial cancer

Endometrial cancer incidence and mortality are rising among all ethnic groups. Carboplatin plus paclitaxel is the established frontline treatment for advanced/recurrent disease; however, subsequent treatment with traditional cytotoxic chemotherapy is challenging. The molecular characterization of endometrial cancer has provided important insights into the biological drivers of carcinogenesis, which has allowed for the development of newer precision immunotherapies and targeted therapies, including pembrolizumab, dostarlimab, and lenvatinib. Until recently, platinum rechallenge was often considered at the time of recurrence, given the lack of other available therapeutic options; however, "platinum sensitivity" in endometrial cancer is subjective and largely based on expert opinion and/or practitioner experience. Small retrospective studies have tried to provide guidance on the utility of platinum rechallenge, but they are limited by variable patient characteristics and small sample sizes. The applicability of these retrospective studies to contemporary clinical practice is difficult in the setting of changing patient demographics, a better understanding of endometrial cancer drivers, and the recent approvals of immune checkpoint inhibitors and the combination of lenvatinib plus pembrolizumab in the second-line setting. The primary focus of this review is to distill the available data regarding platinum-doublet chemotherapy rechallenge and highlight recent pivotal developments in endometrial cancer treatment, as well as future directions.

Previously treated recurrent or advanced endometrial cancer in England: A real-world observational analysis

OBJECTIVES

In patients with recurrent/advanced endometrial cancer who have progressed after first-line treatment, there are a lack of real-world data on treatment patterns, characteristics, and survival outcomes. A novel study was conducted to determine real-world treatment patterns and outcomes in England.

METHODS

This non-interventional study used routine, administrative health data from the National Cancer Registration and Analysis Service in England to identify patients diagnosed with recurrent/advanced endometrial cancer between 1 January 2013 and 31 December 2018, inclusive. A cohort of patients who progressed to second-line treatment were identified as the 'immune checkpoint inhibitor-eligible second-line' cohort. The co-primary objectives were to summarise baseline demographics, disease characteristics, treatments received, and depict overall survival and time-to-next-treatment (a proxy for progression-free survival) from the start of second-line therapy using Kaplan-Meier methodology.

RESULTS

Overall, 12,058 patients were diagnosed with recurrent/advanced endometrial cancer; 999 patients were included in the immune checkpoint inhibitor-eligible second-line cohort and 77.9% (778 of 999) had advanced disease (Stage III/IV). The most common treatments received at second-line were carboplatin plus paclitaxel (27.9%), carboplatin plus liposomal doxorubicin (14.1%), liposomal doxorubicin monotherapy (13.0%), and paclitaxel monotherapy (11.6%). From initiation of second-line therapy, median (95% confidence interval) overall survival was 10.3 months (9.2-11.1), and median time-to-next-treatment was 7.7 months (7.1-8.2).

CONCLUSIONS

Treatments received in the relapsed setting were variable and survival outcomes poor at second-line, highlighting the need for standard of care guidance and innovative therapies to improve patient outcomes in England and in countries with similar treatment patterns.

FUNDING

GSK.

Endometrial cancer

Although endometrial cancer management remains challenging, a deeper understanding of the genetic diversity as well as the drivers of the various pathogenic states of this disease has led to development of divergent management approaches in an effort to improve therapeutic precision in this complex malignancy. This comprehensive review provides an update on the epidemiology, pathophysiology, diagnosis and molecular classification, recent advancements in disease management, as well as important patient quality-of-life considerations and emerging developments in the rapidly evolving therapeutic landscape of endometrial cancers.

Prognostic factors determining survival after extrapelvic recurrence in endometrioid type endometrial cancer

OBJECTIVE

To define the factors that determine survival after extrapelvic recurrence in patients with endometrioid type endometrial cancer (EC).objective MATERIALS AND METHODS: Clinicopathological and survival data of surgically treated endometrioid type EC patients who recurred outside pelvis were reviewed. Patients who had non-endometrioid tumor, sarcomatous component in the final pathology and synchronous tumor were excluded. The period from surgery to recurrence was defined as time to recurrence (TTR) and the period from recurrence to death or last visit was defined as post-recurrence survival (PRS).

RESULTS

Sixty-six patients with extrapelvic recurrence were included in the study. No residual disease was achieved in all patients at initial surgery. Median TTR was 18 months (range, 2-84). Recurrence developed within 1 year in 24 (36.4%) patients and between 13 and 24 months in 22 (33.3%) patients. Fifty-three of 66 patients (80.3%) had extraabdominal recurrence. The 2-year PRS of the all cohort with extrapelvic recurrence was 56%. In the univariate analysis, advanced FIGO stage, lymph node metastasis, adnexal metastasis and short TTR were associated with diminished PRS (p < 0.05). The salvage chemotherapy for recurrence had a tendency to be associated with improved PRS in the univariate analysis. Two-year survival was 81% and 37% in the patients who received chemotherapy and radiotherapy, respectively (p = 0.057).

CONCLUSION

Almost half of the patients with extrapelvic recurrence died of disease within 2 years. Chemotherapy seemed to be more effective than radiotherapy as the salvage therapy of extrapelvic recurrences.

A Personalized Neoantigen Vaccine in Combination with Platinum-Based Chemotherapy Induces a T-Cell Response Coinciding with a Complete Response in Endometrial Carcinoma

Endometrial cancer (EC) is a common gynecological malignancy and the fourth most common malignancy in European and North American women. Amongst EC, the advanced serous, p53-mutated, and pMMR subtypes have the highest risk of relapse despite optimal standard of care therapy. At present, there is no standard of care maintenance treatment to prevent relapse among these high-risk patients. Vaccines are a form of immunotherapy that can potentially increase the immunogenicity of pMMR, serous, and p53-mutated tumors to render them responsive to check point inhibitor-based immunotherapy. We demonstrate, for the first time, the feasibility of generating a personalized dendritic cell vaccine pulsed with peptide neoantigens in a patient with pMMR, p53-mutated, and serous endometrial adenocarcinoma (SEC). The personalized vaccine was administered in combination with systemic chemotherapy to treat an inoperable metastatic recurrence. This treatment association demonstrated the safety and immunogenicity of the personalized dendritic cell vaccine. Interestingly, a complete oncological response was obtained with respect to both radiological assessment and the tumor marker CA-125.

Real-world database analysis of the characteristics and treatment patterns of patients with endometrial cancer in Japan

OBJECTIVE

The aim was to identify the characteristics and treatment patterns of early and advanced stage endometrial cancer patients using real-world data.

METHODS

Patients' data extracted from a Japanese health insurance claims database were analyzed.

RESULTS

Of the 12,449 endometrial cancer patients, 74.4% were in stage I, 5.1% in stage II, 12.0% in stage III, and 8.4% in stage IV. Their median age was 60.5 years, higher in advanced stages (III/IV) than in early stages (I/II). Overall, 11,055 patients (88.8%) underwent surgery, and 4977 patients (40.0%) received post-surgery treatment, including chemotherapy (4441: 35.7%), chemoradiation therapy (379: 3.0%), and radiation therapy (157 patients: 1.3%); 1394 patients (11.2%) were not treated by surgery, and 742 patients (6.0%) received other treatment, with chemotherapy (548: 4.4%), radiation therapy (105: 0.8%), and chemoradiation therapy (89: 0.7%). The rate of patients undergoing surgery decreased, and that receiving chemotherapy increased significantly as cancer stage progressed. Paclitaxel/carboplatin was the most frequent first-line regimen (85.4% of patients), whereas various combination and monotherapy regimens were used as second- and third-line regimens. The most frequent second-line monotherapy was paclitaxel. The rate of monotherapy increased as the treatment line progressed (first-line 3.5%, second-line 22.0%, and third-line 36.4%).

CONCLUSIONS

The characteristics and treatment patterns of endometrial cancer patients differed between early and advanced stages, as did the chemotherapy regimens among first-, second-, and third-lines. Since various regimens were used for second- and third-line chemotherapies, development of appropriate second- and third-line chemotherapy regimens is warranted. A real-world analysis of cancer patients using a nationwide claims database may be a valuable approach to identifying unmet medical needs.

Retreatment with carboplatin and paclitaxel for recurrent endometrial cancer: A retrospective study of the Memorial Sloan Kettering Cancer Center experience

Women with endometrial cancer (EC) frequently receive adjuvant paclitaxel and carboplatin (PC) chemotherapy. There is no standard first line chemotherapy at disease recurrence. Data extrapolated from ovarian cancer has suggested that patients with recurrent EC may benefit from further platinum-based chemotherapy. We performed a retrospective analysis of patients who were retreated with PC chemotherapy for recurrent EC at Memorial Sloan Kettering Cancer Center between January 2000 and December 2014. The median progression free survival (PFS) and overall survival (OS) were estimated using the Kaplan Meier method. Twenty patients were included in the analysis. Patients were re-treated with PC a median of 25 (8-79) months from their original PC. There were no complete responses, 10 (50%) patients had partial response (PR), 3 (15%) had stable disease, 2 (10%) had progression at best response and 5 (20%) were not evaluable by RECIST. A median of 6 cycles of PC were administered (2-9). Four patients (20%) transitioned to paclitaxel only due to carboplatin allergy. At the data cut off, one patient continued PC, and another was off therapy with PR. The remainder (N = 18, 90%) received a median of 2.5 (1-6) further lines of treatments. Median PFS and OS from re-treatment were 10 and 27 months respectively. Median OS from original diagnosis was 74 months. In this small retrospective study, selected patients with recurrent EC who are >6 months from completion of PC derive benefit from retreatment with PC with a response rate of 50%.

Significance of Monocyte Counts at Recurrence on Survival Outcome of Women With Endometrial Cancer

OBJECTIVE

Tumor-associated macrophages (TAMs) are known to have adverse effects on the survival of women with endometrial cancer. Because monocytes function as progenitors of macrophages, this study examined the association between monocyte count at the first recurrence/progression of endometrial cancer and survival time after recurrence/progression (SAR).

METHODS

This is a retrospective study evaluating 141 consecutive cases of recurrent endometrial cancer after surgical staging (n = 114) and progression after nonsurgical management (n = 27). Complete blood cell counts with cell differentiation at the time of the first recurrence/progression were correlated to SAR.

RESULTS

Median time of SAR was 7.8 months, and there were 97 (68.8%) patients who died from endometrial cancer with 1-, 2-, and 5-year SAR rates being 51.0%, 32.9%, and 14.2%, respectively. Median monocyte counts at recurrence/progression were 0.5 × 10/L. The strongest correlation to monocyte counts was seen in neutrophil counts (r = 0.57, P < 0.01) followed by platelet counts (r = 0.43, P < 0.01). An elevated monocyte count at recurrence/progression was significantly associated with decreased SAR (hazard ratio per unit, 3.97; 95% confidence interval, 2.00-7.90; P < 0.01). On multivariate analysis controlling for patient demographics, complete blood cell counts, tumor factors, and treatment types for recurrent/progressed disease, higher monocyte counts at recurrence/progression remained an independent predictor for decreased SAR (hazard ratio per unit, 3.12; 95% confidence interval, 1.52-6.67; P < 0.01).

CONCLUSIONS

Our study demonstrated that the increased monocyte counts at recurrence/progression may be a useful biomarker for predicting decreased survival outcome of women with endometrial cancer.

Is repeated high-dose medroxyprogesterone acetate (MPA) therapy permissible for patients with early stage endometrial cancer or atypical endometrial hyperplasia who desire preserving fertility?

Objective

Reports on the repeated administration of medroxyprogesterone acetate (MPA) for intrauterine recurrence after fertility-preserving therapy for atypical endometrial hyperplasia (AEH) and early grade 1 endometrioid carcinoma (G1) are lacking. We aimed to clarify the outcomes of repeated MPA therapy in cases of intrauterine recurrence after fertility-preserving therapy with MPA against AEH/early G1.

Methods

Patients with AEH or stage IA well-differentiated endometrioid carcinoma without myometrial invasion who underwent first-line MPA therapy for primary lesions or intrauterine recurrence were divided into initial treatment and repeated treatment groups (162 and 82 patients, respectively). Oral MPA administration (400−600 mg/day) was continued until pathological tumor disappearance. Data regarding clinicopathological factors, adverse events, and outcomes following the initial and repeated hormonal treatments were extracted from medical records and analyzed.

Results

Complete response rates in the initial and repeated treatment groups were 98.5% and 96.4%, respectively, among patients with AEH, and were 90.7% and 98.1%, respectively, among patients with G1. In the initial treatment group, 5-year recurrence-free survival (RFS) rates were 53.7% and 33.2% among patients with AEH and G1, respectively. In the repeated treatment group, RFS rates were 14.0% and 11.2% among patients with AEH and G1, respectively. Among patients with AEH, the pregnancy rate tended to be lower in the repeated treatment group than in the initial treatment group (11.1% vs. 29.2%; p=0.107), while no significant group difference was observed among patients with G1 (20.8% vs. 22.7%).

Conclusion

Repeated treatment is sufficiently effective for intrauterine recurrence after hormonal therapy for AEH/early G1.

Treatment strategies for endometrial cancer: current practice and perspective

PURPOSE OF REVIEW

Endometrial cancer incidence is increasing in North America and is a major cause of morbidity and mortality in women. We review recent literature published on treatment of endometrial cancer and highlight areas of active interest.

RECENT FINDINGS

There has been movement toward minimal invasive surgery at diagnosis; lymph node staging remains controversial and continues to be investigated. Progress has been made to establish consensus on endometrial cancer risk classification to promote consistency for future trial design. Molecular characterization of endometrial cancer and its integration into clinicopathological profiling to develop predictive biomarkers for treatment selection are active areas of research. Optimal adjuvant treatment strategy in high-risk endometrial cancer remains to be defined with recognition of treatment-related toxicity. Despite encouraging results in drug development for treatment of advanced/recurrent endometrial cancer, no targeted therapies beyond hormonal therapy are approved. There is an urgent need for scientifically validated therapy with predictive biomarkers.

SUMMARY

Our understanding of endometrial cancer has evolved through improvements in molecular biology, allowing improved definition of target-specific therapies. The precise role and sequence of conventional and targeted therapies, including immunotherapy, will require careful attention to the design of clinical trials with translational emphasis to allow the discovery, validation, and implementation of predictive biomarkers into clinical care.