Phase II evaluation of capecitabine in refractory nonsquamous cell carcinoma of the cervix: a Gynecologic Oncology Group Study

Systemic therapy for advanced cervical cancer: Leveraging the historical threshold of overall survival

Cervical cancer (CC) is a worldwide problem, especially in low- and middle-income countries, where patients are often diagnosed with locally advanced disease. Until recently, all chemotherapy drugs achieved low ORR and 12-month overall survival (12- month OS) for advanced CC after failure for platinum compounds. Advances in systemic therapy with immunotherapy, targeted therapy, and antibody-drug conjugates (ADC) have leveraged the 12-month OS limit. Recently, immunotherapy (pembrolizumab) has become the standard of care in first-line advanced CC combined with platinum and taxane and in second-line after platinum doublet failure.

Capecitabine in treating patients with advanced, persistent, or recurrent cervical cancer: an active and safe option?

Introduction: Advanced, persistent or recurrent cervical cancer in patients not amenable to curative surgery or radiotherapy predicts a dismal prognosis. Systemic chemotherapy based on paclitaxel/cisplatin ± bevacizumab is the current standard of care. However, once progression occurs, the possibility of alternative treatment options is very limited.Areas covered: The usefulness of capecitabine has been well-established against several cancer types, including head and neck, breast, and colorectal cancer. This review covers current literature evidence on the clinical efficacy and safety of capecitabine in cervical cancer treatment, either as monotherapy or combined with other agents or chemo-radiotherapy.Expert opinion: Recent clinical data, albeit scant, suggested a promising role for capecitabine both as monotherapy in patients with platinum-resistant cervical cancer and in combination with cisplatin in chemotherapy-naïve patients with metastatic or recurrent cervical cancer. In our opinion, capecitabine, especially in combination regimens, could represent a valid treatment option and further research is warranted to better understand its effectiveness in these challenging patients.

Safety and Efficacy of Pembrolizumab in Advanced, Programmed Death Ligand 1–Positive Cervical Cancer: Results From the Phase Ib KEYNOTE-028 Trial

Purpose

The KEYNOTE-028 trial ( ClinicalTrials.gov identifier: NCT02054806) was designed to assess the safety and efficacy of pembrolizumab in 20 programmed death ligand 1–positive, advanced solid tumor cohorts. Here, we present the results from the cohort of patients with advanced cervical cancer.

Methods

Patients were treated with pembrolizumab 10 mg/kg every 2 weeks for up to 24 months. Response was assessed every 8 weeks for the first 6 months and every 12 weeks thereafter. The primary end point was overall response rate per Response Evaluation Criteria in Solid Tumors, version 1.1, by investigator review. Safety was a secondary end point.

Results

Twenty-four patients were enrolled in the cervical cancer cohort. The median age was 42 years (range, 26 to 62 years), 22 patients (92%) had received prior radiation therapy, and 15 patients (63%) had received two or more lines of therapy, including bevacizumab (10 of 24 patients), for advanced disease. At the data cutoff, median follow-up duration was 11.0 months (range, 1.3 to 32.2 months). Overall response rate was 17% (95% CI, 5% to 37%); four patients (17%) achieved a confirmed partial response, and three patients (13%) had stable disease. Median duration of response for the four patients who achieved a partial response was 5.4 months (4.1 to 7.5 months). Treatment related adverse events (AEs) were experienced by 18 patients (75%); only rash (n = 5; 21%) and pyrexia (n = 4; 17%) and occurred in ≥ 10% of patients. Five patients experienced grade 3 treatment-related AEs. No grade 4 treatment-related AEs or deaths were observed.

Conclusion

In patients with programmed death ligand 1–positive advanced cervical cancer, pembrolizumab demonstrated antitumor activity and exhibited a safety profile consistent with that seen in other tumor types.

Emerging drugs for the treatment of cervical cancer

INTRODUCTION

Worldwide, most cervical cancer (CC) patients require the use of drug therapy either adjuvant, concurrent with radiation or palliative.

AREAS COVERED

This review briefly discusses the current achievements in treating CC with an emphasis in emerging agents.

EXPERT OPINION

Concurrent cisplatin with radiation and lately, gemcitabine-cisplatin chemoradiation has resulted in small but significant improvements in the treatment of locally advanced and high-risk early-stage patients. So far, only antiangiogenic therapy with bevacizumab added to cisplatin chemoradiation has demonstrated safety and encouraging results in a Phase II study. In advanced disease, cisplatin doublets yield median survival rates not exceeding 14 months. The first Phase III study of bevacizumab, added to standard chemotherapy cisplatin- or non-cisplatin-containing doublet, has shown significant increase in both overall survival and progression-free survival. Further studies are needed before bevacizumab plus chemotherapy can be considered the standard of care for advanced disease. The characterization of the mutational landscape of CC and developments of novel targeted therapies may result in more effective and individualized treatments for CC. The potential efficacy of knocking down the key alterations in CC, E6 and E7 human papilloma virus oncoproteins must not be overlooked.

Phase II Trial of Capecitabine and Cisplatin in Advanced, Persistent, or Recurrent Carcinoma of the Cervix

Purpose:

Platinum-based drugs are the most active agents in cervical carcinoma. The aim of this study was to assess the activity and toxicity of the association of cisplatin and capecitabine as first-line treatment in patients with advanced, persistent, or recurrent carcinoma of the cervix.

Patients and Methods:

Patients with histological proven primary carcinoma, presence of measurable tumors, age 18 years or older, performance status of 2 or less, and adequate bone marrow, renal, and hepatic functions were potentially eligible for this trial. Prior chemotherapy was allowed only in the context of radiosensitization. Treatment consisted of 50 mg/m2of intravenous cisplatin on day 1 with 2500 mg/m2oral capecitabine daily in 2 divided doses for 14 consecutive days in 21-day cycles. Responses were assessed using response evaluation criteria in solid tumors.

Results:

Between November 2004 and October 2007, 22 women were entered into the trial. Median age was 51 years (range, 37-70 years). Seventeen patients had prior radiotherapy, and 13 received a radiation sensitizer, whereas 2 patients underwent surgery exclusively and 3 patients had no prior treatment. A median of 5 cycles was administered (range, 2-8 cycles). There were one septic death, one grade 4 neutropenia, and one grade 4 anemia. Grade 3 fatigue, gastrointestinal toxicity, renal toxicity, and hand-foot syndrome were seen in 31.8%, 22.7%, 9%, and 9% of the patients, respectively. There were 1 complete response and 6 partial responses for an overall response rate of 31.8%. Seven patients (31.8%) each had stable disease, and 8 patients showed progression. The median time to progression was 7.6 months, with a median overall survival of 20 months.

Conclusion:

These results seem to suggest that the capecitabine-cisplatin combination is a moderately tolerated and active regimen in advanced, persistent, or recurrent cervical carcinoma patients. Further evaluation of this drug combination may be warranted.

Docetaxel, carboplatin and 5-fluorouracil (TCF) chemotherapy in patients with unresectable metastatic carcinoma of cervix

OBJECTIVES

This retrospective study evaluates the efficacy and safety of chemotherapy with docetaxel, carboplatin and 5-FU (TCF) in patients with metastatic cervical carcinoma.

METHODS

Between January 2006 and April 2007, 23 patients with metastatic cervical carcinoma were included in the study. Patients fulfilling the following criteria were enrolled: histologically confirmed metastatic cervical carcinoma; documented progressive disease (PD) after cisplatinum-based treatment if applicable; an Eastern Cooperative Oncology Group (ECOG) performance scale of 0-2; not candidates for local therapy; measurable metastatic lesions as assessed by the Response Evaluation Criteria in Solid Tumors (RECIST); and adequate hematologic, hepatic, and renal functions. Treatment consisted of intravenous docetaxel at 60 mg/m(2) diluted in 500 ml 5% glucose administered over 1 h on day 1, followed by carboplatin (AUC of 5 or 6) given as a 1-h intravenous infusion delivered on day 2, followed by 5-FU at 500 mg/m(2) diluted in 500 ml normal saline continuously infusion for 24 h for 2 days on day 2. Chemotherapy was repeated every 21 days, and a total of 1-5 courses were performed.

RESULTS

There were 3 (13%) complete responses; 4(17%) partial responses; 6 (26%) with stable disease, and 10 (43%) with disease progression. The overall response rate was 56%. After a median follow-up of 16 months, the median overall survival was 12 months. Neutropenia was the most severe toxicity.

CONCLUSIONS

The combination of docetaxel, carboplatin and 5-fluorouracil (TCF) appears to have activity in metastatic cervical carcinoma with acceptable toxicity profile.