Mature results of a prospective randomized trial comparing a three-weekly with an accelerated weekly schedule of cisplatin in advanced ovarian carcinoma

Progression-free survival as a surrogate endpoint for overall survival in modern ovarian cancer trials: a meta-analysis

Background

Progression-free survival (PFS) has been adopted as the primary endpoint in many randomized controlled trials, and can be determined much earlier than overall survival (OS). We investigated whether PFS is a good surrogate endpoint for OS in trials of first-line treatment for epithelial ovarian cancer (EOC), and whether this relationship has changed with the introduction of new treatment types.

Methods

In a meta-analysis, we identified summary data [hazard ratio (HR) and median time] from published randomized controlled trials. Linear regression was used to assess the association between treatment effects on PFS and OS overall, and for subgroups defined by treatment type, postprogression survival (PPS) and established prognostic factors.

Results

Correlation between HRs for PFS and OS, in 26 trials with 30 treatment comparisons comprising 24,870 patients, was modest (r² = 0.52, weighted by trial sample size). The correlation diminished with recency: preplatinum/paclitaxel era, r²= 0.66; platinum/paclitaxel, r²= 0.44; triplet combinations, r²= 0.22; biologicals, r²= 0.30. The median PPS increased over time for the experimental (P_trend = 0.03) and control arms (P_trend = 0.003). The difference in median PPS between treatment arms strongly correlated with the difference in median OS (r² = 0.83). In trials where the control therapy had median PPS of less than 18 months, correlation between PFS and OS was stronger (r² = 0.64) than where the median PPS was longer (r² = 0.48).

Conclusions

In EOC, correlation in the relative treatment effect between PFS and OS in first-line platinum-based chemotherapy randomized controlled trials is moderate and has weakened with increasing availability of effective salvage therapies.

Dose-dense paclitaxel in advanced ovarian cancer

Carboplatin and paclitaxel, delivered on a 3-weekly basis, is the historical standard for the management of advanced epithelial ovarian cancers (EOC). Increased dose intensity, the inclusion of additional active cytotoxic agents and lengthening treatment duration have failed to improve the outcomes seen with standard doses of carboplatin and paclitaxel in the treatment of EOC. Dose-dense (i.e. weekly) delivery of paclitaxel may exploit anticancer mechanisms such as anti-angiogenesis and the induction of apoptosis. Tumour regrowth may be more effectively impaired by the dose-dense delivery of paclitaxel. Non-randomised studies of dose-dense chemotherapy in EOC have been promising, particularly in heavily pretreated and platinum-resistant disease, with reported response rates as high as 60%. Dose-dense paclitaxel also seems to be well tolerated. These observations led to a number of comparative trials of dose-dense paclitaxel chemotherapy, three have been reported and four are ongoing. This review explores the rationale behind dose-dense delivery of paclitaxel and evaluates the results of completed phase III trials.

Update on first-line treatment of advanced ovarian carcinoma

Despite the high response rate to first-line treatment of advanced ovarian cancer, the vast majority of patients relapse. Maximal debulking surgery and chemotherapy with a platinum doublet have remained the standard of care for many years and new approaches are imperative. Recent clinical trials have given grounds for hope. Neoadjuvant chemotherapy, intraperitoneal delivery, and dose-dense strategies have all shown promising results, as has the targeting of angiogenesis. A greater understanding of the molecular landscape of ovarian cancer is helping to identify new treatment options. In this review, we will highlight the key trials and recent progress in these areas.

Discovering cytokines as targets for chemotherapy-induced painful peripheral neuropathy

Chemotherapy-induced peripheral neuropathy (CIPN), a dose-limiting neurotoxic effect of chemotherapy, is the most common reason for early cessation of cancer treatment. This can result in an increased risk of recurrence and decreased survival rate. Inflammatory cascade activation, proinflammatory cytokine upregulation, and neuro-immune communication pathways play essential roles in the initiation and progression of CIPN. Most notably, TNF-α, IL-1β, IL-6, and CCL2 are involved in neuropathic pain. Further elucidation of the role of these cytokines could lead to their development and use as biomarkers for predicting the onset of painful peripheral neuropathy and early axonal damage. In this review, we provide evidence for the involvement of cytokines in CIPN, the possible underlying mechanisms, and their use as potential therapeutic targets and biomarkers to prevent and improve the painful peripheral neuropathy related to chemotherapeutic agents.

Dose-dense therapy is of benefit in primary treatment of ovarian cancer: contra

Several studies in the past have tried to improve the prognosis of ovarian cancer by increasing the dose intensity of platinum. Only 2 out of 12 randomized studies showed survival benefit at the cost of significant long-term toxicity. Dose-dense induction therapy with combined weekly paclitaxel (at a dose of 90 mg/m(2)) and weekly carboplatin [at an area under the curve (AUC) of 4 mg·ml/min] followed by 3-weekly paclitaxel/carboplatin was very effective in platinum-resistant patients (response 58%, progression-free survival 10 months). In first-line, however, no survival benefit was found with the same dose-dense weekly paclitaxel/carboplatin regimen over standard-dosed 3-weekly paclitaxel/carboplatin in a randomized study. Very recently, the Japanese Gynecologic Oncology Group (JGOG) study no. 3016, randomizing patients in first-line between dose-dense weekly paclitaxel 80 mg/m(2) plus 3-weekly carboplatin AUC 6 and 3-weekly paclitaxel/carboplatin, showed a significant increase in progression-free survival (median 28 versus 17.2 months in the control arm; hazard ratio for progression, 0.71; 95% confidence interval, 0.58-0.88; P=0.0015). The 3-year overall survival was 72% versus 65% (P=0.03), respectively. The hematologic toxicity was substantial in both arms and substantially higher than observed with the weekly paclitaxel/carboplatin induction regimen. Many patients had treatment delays, dose reductions and stopped treatment prematurely. The JGOG 3016 study is the only dose-dense study with such a significant survival benefit. It is also the only dose-intensity study performed in Asian patients. Genotypes and phenotypes are thought to represent important determinants of drug efficacy in ovarian cancer. Therefore, confirmatory studies with this JGOG regimen together with translational research are needed in both Caucasian and Asian patients.

Vascularization of the dorsal root ganglia and peripheral nerve of the mouse: implications for chemical-induced peripheral sensory neuropathies

Although a variety of industrial chemicals, as well as several chemotherapeutic agents used to treat cancer or HIV, preferentially induce a peripheral sensory neuropathy what remains unclear is why these agents induce a sensory vs. a motor or mixed neuropathy. Previous studies have shown that the endothelial cells that vascularize the dorsal root ganglion (DRG), which houses the primary afferent sensory neurons, are unique in that they have large fenestrations and are permeable to a variety of low and high molecular weight agents. In the present report we used whole-mount preparations, immunohistochemistry, and confocal laser scanning microscopy to show that the cell body-rich area of the L4 mouse DRG has a 7 fold higher density of CD31+ capillaries than cell fiber rich area of the DRG or the distal or proximal aspect of the sciatic nerve. This dense vascularization, coupled with the high permeability of these capillaries, may synergistically contribute, and in part explain, why many potentially neurotoxic agents preferentially accumulate and injure cells within the DRG. Currently, cancer survivors and HIV patients constitute the largest and most rapidly expanding groups that have chemically induced peripheral sensory neuropathy. Understanding the unique aspects of the vascularization of the DRG and closing the endothelial fenestrations of the rich vascular bed of capillaries that vascularize the DRG before intravenous administration of anti-neoplastic or anti-HIV therapies, may offer a mechanism based approach to attenuate these chemically induced peripheral neuropathies in these patients.

The “Leuven” dose-dense paclitaxel/carboplatin regimen in patients with recurrent ovarian cancer

OBJECTIVE

The purpose of this study was to evaluate the "Leuven" dose-dense regimen in recurrent ovarian cancer.

METHODS

Six courses of paclitaxel (90 mg/m(2)) and carboplatinum (AUC 4) on d1 and d8 every 3 weeks were administered. Response rates were determined using RECIST and Gynaecological Cancer Intergroup (GCIG) CA 125 criteria. Platinum resistance was defined as progression during or within 6 months after platinum-based chemotherapy.

RESULTS

Thirty-three patients were included with a median number of prior treatment regimens of 2. Nine patients were platinum-resistant and 24 were platinum-sensitive. Three of 8 patients in the platinum-resistant group and 16 of 21 patients in the platinum-sensitive group achieved an evaluable response according to RECIST. According to the GCIG CA 125 criteria 3 of 7 patients in the platinum-resistant and 17 of 19 patients in the platinum-sensitive patients responded. In the entire patient population evaluable for response (n=29), the median progression-free survival (PFS) was 9 months; the median overall survival (OS) was 18 months. Median PFS was 6.75 months for the platinum-resistant and 10.5 months for the platinum-sensitive group. The median OS was 8 months in the platinum-resistant and not yet reached in the platinum-sensitive group. Toxicity was mostly bone marrow-related with neutropenia grade 3/4 in 34% and neutropenic fever in 2% of courses. Dose reduction was necessary in 25% of patients. Nausea and vomiting and fatigue were the most frequent non-hematological side effects.

CONCLUSION

Dose-dense paclitaxel and carboplatin offers a well-tolerated regimen with high response rates even in heavily pre-treated and platinum-resistant ovarian cancer.

Improvement in histologic response but not survival in osteosarcoma patients treated with intensified chemotherapy: a randomized phase III trial of the European Osteosarcoma Intergroup

BACKGROUND

Previous randomized controlled trials that used the two-drug chemotherapy regimen of cisplatin and doxorubicin as the conventional arm showed no evidence of benefit from an increase in the number of agents or the length of treatment. It was then proposed that survival could be improved by increasing the planned dose intensity of cisplatin and doxorubicin.

METHODS

Previously untreated patients with nonmetastatic, high-grade, central osteosarcoma of an extremity were randomly assigned to Regimen-C (conventional treatment with six 3-week cycles of cisplatin [100 mg/m2 by 24-hour infusion] and doxorubicin [25 mg/m2/day by 4-hour infusion for 3 days]) or to Regimen-DI (intensified treatment with identical total doses of cisplatin and doxorubicin, planned as six 2-week cycles supported by granulocyte colony stimulating factor (G-CSF). Surgery was scheduled for week 6 in both arms. Primary and secondary outcome measures were overall and progression-free survival, respectively. Intention-to-treat analyses were performed using standard survival analysis methods. Landmark analyses were performed in patients with known surgical details and centrally reviewed histologic response. All statistical tests were two-sided.

RESULTS

Between May 1993 and September 2002, treatment was randomly allocated to 497 eligible patients. Six cycles of chemotherapy were completed by 78% of patients in Regimen-C and 80% of patients in Regimen-DI. The delivered preoperative median dose intensity of cisplatin was 86% in Regimen-C and 111% in Regimen-DI (as the percentage of that planned for the conventional regimen). Postoperative median dose intensity of cisplatin was 82% in Regimen-C and 110% in Regimen-DI (the corresponding figures for doxorubicin dose intensity were similar). Regimen-DI was associated with lower risks of severe leucopenia and neutropenia and higher risks of thrombocytopenia and mucositis. Good histologic response (>90% tumor necrosis) was observed in 36% of Regimen-C patients and 50% of Regimen-DI patients (P = .003, chi2 test). There was no evidence of a difference in overall survival (hazard ratio [HR] = 0.94, 95% CI = 0.71 to 1.24; P = .64) or progression-free survival (HR = 0.98, 95% CI = 0.77 to 1.24; P = .83). Landmark analyses showed similar results.

CONCLUSIONS

Planned intensification of chemotherapy with cisplatin and doxorubicin increased received dose intensity and resulted in a statistically significant increase in favorable histologic response rate, but not in increased progression-free or overall survival. Our results call into question the use of histologic response as a surrogate outcome measure in trials of this disease.

Cancer pain and its impact on diagnosis, survival and quality of life

Cancer pain significantly affects the diagnosis, quality of life and survival of patients with cancer. During the past decade, preclinical and clinical data has begun to provide insight into the mechanisms that drive and mask cancer pain and the mechanisms by which anti-neoplastic agents induce peripheral neuropathy. Developing a mechanism-based understanding and mechanism-based therapies to treat cancer-associated pain and sensory neuropathy, and incorporating these into mainstream cancer research and therapy, will be crucial to improving the quality of life and survival of patients with cancer.

Evaluation of weekly low-dose paclitaxel and carboplatin treatment for patients with platinum-sensitive relapsed ovarian cancer

OBJECTIVE

Although paclitaxel and carboplatin therapy (TC) is an established effective standard regimen for patients with ovarian cancer, both treatment delay for hematologic toxicity and discontinuation of treatment due to neurotoxicity have occasionally been reported. To achieve therapeutic density, we evaluated the usefulness of weekly low-dose TC therapy (WTC) in patients with platinum-sensitive (median PFI was 11.4 +/- 2.7 months) recurrent epithelial ovarian cancer.

METHODS

A total of 25 patients were treated with paclitaxel at 60 mg/m(2) and carboplatin at AUC = 2 using 3 weekly courses with a 1-week break schedule. Eighteen patients had assessable tumors for response, and the other seven patients were evaluated by CA-125-based response. All of the patients were assessable for toxicity.

RESULTS

The overall response rate (OR) based on WHO criteria was 84.2% (95% CI; 0.65-0.98), including nine complete responses (CR); OR based on CA-125 was 85.7% (95% CI; 0.42-0.99), including 3 CR. The total response rate was 88.0% (95% C.I.; 0.68-0.97). The median progression-free survival of the patients was 13.5 months during the mean follow-up period of 21.9 +/- 9.2 months. No patients had grade 1 or higher thrombocytopenia, and although 44% of the patients developed neurotoxicity, all cases remained grade 1. Treatment delay of over 7 days due to toxicity was observed in only two patients (16.0%) and in six cycles (1.3%) in a total of 451 cycles.

CONCLUSION

WTC combination, as used in this study, produced a high response rate with acceptable toxicity, and the optimal combination in a weekly regimen remains to be determined.

Remaining controversies in the upfront management of advanced ovarian cancer

Ovarian cancer (OC) is one of the leading causes of cancer-related death in women. In the last decades, a lot of energy and resources have been put into a number of clinical trials, with some success. Nevertheless, the prognosis of patients diagnosed with advanced disease remains extremely poor. As research moved forward, some crucial questions with regard to the optimal upfront management of patients with advanced OC (AOC) have remained unanswered. In this article, we review the rationale behind these controversial issues, and provide the levels of evidence supporting the current recommendations for AOC management.

Weekly low-dose carboplatin and paclitaxel in the treatment of recurrent ovarian and peritoneal cancer

OBJECTIVES

Weekly paclitaxel alone has moderate activity in the salvage treatment of recurrent ovarian cancer and is associated with a favorable toxicity profile. Combination paclitaxel and carboplatin is a well-established first-line regimen for ovarian cancer. The purpose of this study was to evaluate weekly low-dose paclitaxel and carboplatin in recurrent ovarian or peritoneal cancer.

METHODS

Patients with recurrent ovarian or peritoneal cancer previously treated with between one and four chemotherapeutic regimens were eligible. Patients had measurable or assessable disease defined by clinical exam, radiographic studies, or serum CA-125 greater than 75 U/ml. One cycle of treatment consisted of carboplatin at an area under the curve of 2 and paclitaxel at 80 mg/m(2) on days 1, 8, and 15 on a 28-day cycle. Clinical responses were defined by established criteria.

RESULTS

Twenty-nine patients were included in this intent-to-treat study. The median number of prior treatment regimens was 2 (range 1 to 4). The overall response rate was 82.8% (16 complete clinical responses, 8 partial responses). Among 8 platinum-refractory patients, the response rate was 37.5%, while 21 platinum-sensitive patients had a 100% response rate. Median time to progression was 13.7 months among platinum-sensitive patients and 3.2 months among platinum-refractory patients. Overall median time to progression was 11.5 months and median-duration of response was 9.9 months. Hematologic toxicity was common (32% grade 3 neutropenia, no grade 4 neutropenia, 14.2% grade 3 or 4 thrombocytopenia) and managed by treatment delay, dose reduction of paclitaxel, or discontinuation of carboplatin.

CONCLUSION

Weekly low-dose carboplatin and paclitaxel has significant activity in both platinum-sensitive and platinum-resistant recurrent ovarian cancer with acceptable toxicity that is easily managed by dose adjustment.

Chemotherapy for advanced epithelial ovarian carcinoma

Advanced epithelial ovarian cancer (AOC) is the most common clinical presentation of ovarian cancer. Virtually all patients will require some form of chemotherapy with curative or palliative intent. Prognostic factors, first- and second-line therapy, as well as experimental approaches for AOC are reviewed.

Retreatment with dose-dense weekly cisplatin after previous cisplatin chemotherapy is not complicated by significant neuro-toxicity

Cisplatin induces a cumulative dose-dependent axonal sensory neuropathy. With a cumulative dose over 600 mg/m2, a significant percentage of patients will develop a moderate or severe neuropathy. We retreated patients with progressive or recurrent ovarian cancer after previous platinum-containing chemotherapy with weekly 50-70 mg/m2 cisplatin for six cycles. This group was prospectively followed for the development of neuropathy. Patients received six weekly cycles of either 50 or 70 mg/m2 cisplatin, combined with oral etoposide. Responding patients continued treatment with daily oral etoposide for nine months. Neurological toxicity was assessed with a sensory sum score, the sensory neuropathy common toxicity criteria (CTC) and quantitated sensory analysis of the vibration perception threshold (VPT). Neurological assessment was scheduled at baseline, after three cycles, at the end of cisplatin chemotherapy and at 3 monthly intervals until 1 year after the discontinuation of chemotherapy. The first evaluation carried out in the interval of 1-4 months after the end of weekly cisplatin therapy was taken as the principle evaluation for neurotoxicity because during this time interval the nadir of cisplatin neurotoxicity is to be expected. Of 89 patients evaluated for neurological toxicity, 80 patients were fully evaluable. Forty-nine had received prior cisplatin (median cumulative dosage 450 mg/m2); the others had received prior treatment with carboplatin. Cisplatin pretreated patients had slightly higher neuropathy scores at the start of weekly cisplatin. Almost all cisplatin pretreated patients received six cycles of cisplatin, 29 at 50 mg/m2 and 20 at 70 mg/m2 per cycle. Despite treatment up to an overall cumulative dose of 750-900 mg/m2 cisplatin, only 1 patient discontinued treatment due to neurotoxicity. One other patient developed a grade 3 neuropathy during follow-up. Only a marginal increase of neuropathic signs and symptoms were observed in all the other patients. In multiple regression analysis, the increase in VPT or the sensory sum score was not related to prior treatment (cisplatin or carboplatin). Patients with mild signs of neuropathy after prior treatment with cisplatin to a cumulative dose level of 400-450 mg/m2 can be retreated with weekly cisplatin to a cumulative dose of 420 mg/m2 (overall cumulative dose up to 800-900 mg/m2) with only a minimal risk of significant neurotoxicity.

Weekly platinum chemotherapy for recurrent ovarian cancer

British Journal of Cancer (2002) 86, 2–4. DOI: 10.1038/sj/bjc/6600062www.bjcancer.com

© 2002 The Cancer Research Campaign