Dose-effect study of carboplatin in ovarian cancer: a Danish Ovarian Cancer Group study

Experimental design approach for development of carboplatin loaded chitosan modified liposomal formulation with improved topical vaginal therapeutic potential

One of the most prevalent cancers affecting women globally is cervical cancer. Cervical cancer is thought to cause 570 000 new cases annually, and standard treatments can have serious side effects. In this work, the main aim is to design, fabrication, and evaluation of carboplatin loaded chitosan coated liposomal formulation (CCLF-I) for vaginal delivery in the treatment of cervical cancer. The particle size and polydispersity index of the CCLF-1 were observed at 269.33 ± 1.15 and 0.40 ± 0.002 nm, respectively. The in vitro mucin binding studies showed good adhesiveness of CCLF-I as compared to plain liposomes (CPLF-I), which was found at 23.49 and 10.80%, respectively. The ex-vivo percent drug permeation from plain liposomal formulation (CPLF-I) was found to be higher in comparison to chitosan coated liposomal formulation which was 56.33% while in CCLF-I it was observed 47.32% this is due to, higher retainability of delivery system (CCLF-I) on targeted site attained by coating of mucoadhesive polymer on liposomes. Ex vivo tissue retention studies exhibited 24.2% of CCLF-I in comparison to 10.34% from plain drug formulation (CPLF-I). The in vivo vaginal retention studies exhibited 14% of drug retention after 24 h from the novel formulation in comparison to 6% from the plain formulation. The developed CCLF-I formulation would open a new avenue in the cervical treatment.

Nanoscale drug delivery strategies for therapy of ovarian cancer: conventional vs targeted

Ovarian cancer is the second most common gynaecological malignancy. It usually occurs in women older than 50 years, and because 75% of cases are diagnosed at stage III or IV it is associated with poor diagnosis. Despite the chemosensitivity of intraperitoneal chemotherapy, the majority of patients is relapsed and eventually dies. In addition to the challenge of early detection, its treatment presents several challenges like the route of administration, resistance to therapy with recurrence and specific targeting of cancer to reduce cytotoxicity and side effects. In ovarian cancer therapy, nanocarriers help overcome problems of poor aqueous solubility of chemotherapeutic drugs and enhance their delivery to the tumour sites either by passive or active targeting, and thus reducing adverse side effects to the healthy tissues. Moreover, the bioavailability to the tumour site is increased by the enhanced permeability and retention (EPR) mechanism. The present review aims to describe the current conventional treatment with special reference to passively and actively targeted drug delivery systems (DDSs) towards specific receptors designed against ovarian cancer to overcome the drawbacks of conventional delivery. Conclusively, targeted nanocarriers would optimise the intra-tumour distribution, followed by drug delivery into the intracellular compartment. These features may contribute to greater therapeutic effect.

One-Step Solid Extraction for Simultaneous Determination of Eleven Commonly Used Anticancer Drugs and One Active Metabolite in Human Plasma by HPLC-MS/MS

Therapeutic drug monitoring for anticancer drugs could timely reflect in vivo drug exposure, and it was a powerful tool for adjusting and maintaining drug concentration into a reasonable range, so that an enhanced efficacy and declined adverse reactions could be achieved. A liquid chromatography-tandem mass spectrometry method had been developed and fully validated for simultaneous determination of paclitaxel, docetaxel, vinblastine, vinorelbine, pemetrexed, carboplatin, etoposide, cyclophosphamide, ifosfamide, gemcitabine, irinotecan, and SN-38 (an active metabolite of irinotecan) in human plasma from cancer patients after intravenous drip of chemotherapy drugs. One-step solid-phase extraction was successfully applied using an Ostro sample preparation 96-well plate for plasma samples pretreated with acetonitrile containing 0.1% formic acid. Chromatographic separation was achieved on an Atlantis T₃-C₁₈ column (2.1 × 100 mm, 3.0 μm) with gradient elution using a mobile phase consisting of acetonitrile and 10 mM ammonium acetate plus 0.1% formic acid in water, and the flow rate was 0.25 mL/min. The Agilent G6410A triple quadrupole liquid chromatography-mass spectrometry system was operated under the multiple reaction monitoring mode with an electrospray ionization in the positive mode. Linear range was 25.0-2500.0 ng for paclitaxel, 10.0-1000.0 ng for docetaxel and SN-38, 100.0-10000.0 ng for vinorelbine and pemetrexed, 10.0-10000.0 ng for vinblastine and irinotecan, 1.0-1000.0 ng for cyclophosphamide and ifosfamide, 50.0-5000.0 ng for carboplatin, etoposide, and gemcitabine. Linearity coefficients of correlation were >0.99 for all analytes. The intraday and interday accuracy and precision of the method were within ±15.0% and less than 15%. The mean recovery and matrix effect as well as stability of all the analytes ranged from 56.2% to 98.9% and 85.2% to 101.3% as well as within ±15.0%. This robust and efficient method was successfully applied to implement therapeutic drug monitoring for cancer patients in clinical application.

Basophil Activation Test is a Relevant Biomarker of the Outcome of Rapid Desensitization in Platinum Compounds-Allergy

BACKGROUND

Rapid drug desensitization (RDD) has become a cornerstone in the management of immediate drug hypersensitivity reactions (DHRs) to chemotherapeutic agents. Because of the inherent risk of anaphylaxis during RDD, biomarkers to predict patients at risk of developing such severe reactions are needed. The basophil activation test (BAT) has been used in DHRs as a diagnostic tool.

OBJECTIVE

We evaluated basophil CD63 and CD203c expression (BAT) as a biomarker to assess the safety and effectiveness of RDD in platinum compounds-allergic patients.

METHODS

Patients allergic to platinum compounds (n = 15) undergoing RDD were assessed through clinical history, skin testing, serum tryptase levels, and BAT. BAT was performed immediately before RDD, assessing CD203c and CD63 expression on basophils. BAT was also performed in 6 patients tolerant to platinum compounds and in 6 healthy volunteers.

RESULTS

BAT was positive to CD203c or CD63 in 11 out of 15 patients allergic to platinum compounds (73%), with increased expression of CD203c and CD63 in 11 (73%) and 6 (40%) patients, respectively. Increased CD63 expression tended to be associated with more severe initial reactions. All controls had negative test results. Reactions during RDD were associated with BAT positivity and increased tryptase levels. Only 1 of 4 patients with negative BAT had a mild reaction during RDD. BAT remained positive in multiple sequential RDD.

CONCLUSIONS

BAT identified patients allergic to platinum compounds with an increased risk of reactions during desensitization and higher CD63 expression was observed in severe reactions. Multiple RDDs to platinum compounds did not induce persistent hyporesponsiveness on basophils. BAT is a potential biomarker for RDD.

Enhanced Antiproliferative Effect of Carboplatin in Cervical Cancer Cells Utilizing Folate-Grafted Polymeric Nanoparticles

Carboplatin (CRB) possesses superior anticancer effect in cervical cancer cells with lower incidence of side effects compared to that of cisplatin. However, CRB suffers from severe side effects due to undesirable tissue distributions which contribute to the low therapeutic efficacy. Here, we report a unique folic acid-conjugated chitosan-coated poly(D-L-lactideco-glycolide) (PLGA) nanoparticles (FPCC) prepared for the selective delivery of carboplatin to the cervical cancer cells. The particles were nanosized and spherical shaped with size less than <200 nm. The presence of protective chitosan layer controlled the overall release rate of CRB from chitosan-coated PLGA nanoparticles (PCC) and FPCC. FPCC displayed a higher cellular uptake capacity in HeLa cells than compared to non-targeted nanoparticles. Selective uptake of FPCC was due to an interaction of folic acid (FA) with the folate receptors alpha (FRs-α) which is overexpressed on the HeLa and promoted active targeting. These results indicated that FPCC had a specific affinity for the cancerous, HeLa cells owing to ligand-receptor (FA-FR-α) recognition. Consistently, FPCC showed superior cytotoxic effect than any other formulations. The IC50 (concentration of the drug required to kill 50 % of the cells) value of FPCC was 0.65 μg/ml while it was 1.08, 1.56, and 2.35 μg/ml for PCC, PLGA NP, and free CRB, respectively. Consistent with the cytotoxicity assay, FPCC induced higher fraction of early as well as late apoptosis cells. Especially, FPCC induced nearly 45 % of early apoptosis cells and more than 35 % in late apoptosis. Therefore, we propose that folate-conjugated nanoparticles might have potential applications in cervical cancer therapy.

Retrospective analysis of the impact of platinum dose reduction and chemotherapy delays on the outcomes of stage III ovarian cancer patients

Background

Ovarian cancer is a common gynaecological malignancy still remaining a challenge to treat. The objective of this study was to evaluate the impact of platinum dose reduction and chemotherapy delays on progression free survival and overall survival in patients with stage III ovarian cancer and to analyze reasons for such chemotherapy scheme modifications.

Methods

Medical records of patients with FIGO stage III ovarian cancer were reviewed. Inclusion criteria involved FIGO stage III epithelial ovarian carcinoma; cytoreductive surgery performed and 6 courses of platinum-based chemotherapy completed; no neoadjuvant chemotherapy applied; and no history of previous malignancies. Progression free survival and overall survival were analyzed using Kaplan-Meier and Cox proportional hazards models.

Results

Significant 3.3 times higher death risk in patients who experienced only chemotherapy delays compared with patients who did not experience any chemotherapy scheme modifications was established (HR = 3.3, 95% Cl: 1.2 – 8.5, p = 0.016). Increased death risk in patients who experienced only chemotherapy delays compared with patients who experienced both chemotherapy delays and platinum dose reduction was also established (HR = 2.3, 95% Cl: 1.1 – 4.8, p = 0.021). Main reasons for chemotherapy scheme modifications (in decreasing order) were the following: neutropenia, modifications with no objective medical reasons, renal disorders, anaemia, poor performance status, gastrointestinal symptoms and neuropathy. Overall survival in patients who experienced chemotherapy scheme modifications with no objective medical reasons was non-inferior than in patients who did not experience any chemotherapy scheme modifications.

Conclusions

Chemotherapy delays in patients with FIGO stage III ovarian cancer caused lower overall survival. The most common reason for chemotherapy scheme modifications was neutropenia.

Encapsulation in nanoparticles improves anti-cancer efficacy of carboplatin

Poor cellular uptake contributes to high dose requirement and limited therapeutic efficacy of the platinum-based anticancer drug carboplatin. Delivery systems that can improve the cellular accumulation of carboplatin will, therefore, likely improve its therapeutic potential. The objective of this study was to evaluate nanoparticles composed of the biodegradable polymer, poly(D, L-lactide-co-glycolide), for carboplatin delivery to tumor cells. Carboplatin-loaded nanoparticles were formulated by double emulsion-solvent evaporation technique. Nanoparticles demonstrated sustained release of carboplatin over 7 days. Cellular uptake of carboplatin encapsulated in nanoparticles was several fold higher than that with free carboplatin in A549 (lung) and MA148 (ovarian) tumor cells. In vitro cytotoxicity studies showed that encapsulation of carboplatin in nanoparticles resulted in a remarkable reduction in the IC50 of carboplatin in several cell lines (up to 280-fold in some cells). Confocal microscopic analysis revealed the presence of carboplatin nanoparticles in several cellular compartments including lysosomes, cytoplasm, and the nucleus. These results demonstrate an enhanced cellular uptake of carboplatin through encapsulation in PLGA nanoparticles and suggest that improved therapeutic efficacy and reduced toxicity may be achieved with this approach.

What is the optimal treatment for obese patients with advanced ovarian carcinoma?

OBJECTIVE

The purpose of this study was to compare primary debulking surgery (PDS) vs neoadjuvant chemotherapy with interval debulking surgery (NACT-IDS) among obese patients.

STUDY DESIGN

Medical records of patients with a body mass index (BMI) of ≥30 kg/m(2) with ovarian/fallopian tube/primary peritoneal carcinoma between January 2005 and December 2010 were reviewed. Patients were separated by PDS or NACT-IDS. Preoperative characteristics, surgical procedures, and postoperative and oncologic outcomes were compared.

RESULTS

Of 117 patients, 95 women (81.2%) underwent PDS, and 22 women (18.8%) underwent NACT-IDS. Patients who underwent NACT-IDS were more likely to have stage IV disease (63.6% vs 26.3%; P = .001) and a low surgical complexity score (n = 14; 63.6%). There were no other differences between groups with respect to preoperative characteristics or postoperative morbidity. Compared with the NACT-IDS group, the PDS group had an improved progression-free survival (PFS; 15 vs 11 months; P = .006) and overall survival (OS; 53 vs 32 months; P = .036). Seventy-eight patients (66.7%) had a BMI of 30-34.9 kg/m(2). Within this subset of obese patients, the PDS group had an improved PFS (15 vs 10 months; P = .011) and OS (58 vs 32 months; P = .033), compared with the NACT-IDS group. Among patients with a BMI of ≥35 kg/m(2), there was no difference in PFS (14 vs 12 months; P = .316) or OS (38 vs 32 months; P = .640) when the PDS and NACT-IDS groups were compared.

CONCLUSION

Patients with a BMI of 30-34.9 kg/m(2) who undergo PDS have improved oncologic outcomes, compared with those women who undergo NACT-IDS. Patients with a BMI of ≥35 kg/m(2) who undergo PDS have similar oncologic outcomes to those who undergo NACT-IDS. Complication rates were similar at all BMIs, regardless of treatment approach.

Dose-dense paclitaxel with carboplatin for advanced ovarian cancer: a feasible treatment alternative

OBJECTIVE

Epithelial ovarian cancer is the leading cause of death from gynaecologic cancers in the Western world. If possible, initial cytoreductive surgery is the treatment of choice, followed by adjuvant chemotherapy, usually with a platinum/taxane combination. Increased survival has been recently reported in women who were given adjuvant chemotherapy weekly rather than at three-week intervals, which has been the standard. At our centre, we have been treating patients with advanced ovarian cancer with a dose-dense protocol since March 2010. Treatment is given in an outpatient setting on days 1, 8, and 15 of a 21-day cycle for six cycles. Carboplatin for an AUC of 5 mg/mL/min and paclitaxel 80mg/m² are given on day 1, followed by paclitaxel 80mg/m² on days 8 and 15. Our objective was to determine whether this protocol is a feasible alternative treatment in our population and whether or not the toxicity profile is acceptable.

METHODS

We performed a chart review of 46 patients undergoing treatment with dose-dense chemotherapy for advanced ovarian cancer. Demographic information, patient characteristics, adverse events, and treatment endpoints were recorded.

RESULTS

Sixty-one percent of women completed the six-cycle protocol as planned with minimal interruption, which is comparable to the only previously reported trial using this regimen. The most common side effects of treatment were fatigue, neuropathy, and neutropenia. Supplementation with regular magnesium and granulocyte colony-stimulating factor reduced delays.

CONCLUSION

Dose-dense paclitaxel with carboplatin chemotherapy for the treatment of advanced ovarian cancer shows promise in terms of progression-free and overall survival. We have shown this protocol to be practical and feasible in our population.

Immunohistochemical expression of platelet-derived growth factor receptors in ovarian cancer patients with long-term follow-up

Introduction. The well-documented role of the PDGF system in tumor growth and angiogenesis has prompted the development of new biological agents targeting the PDGF system. The aim of the present study was to analyze the expression of the PDGF-receptors in ovarian cancer and to investigate its relation to histopathological parameters and long-term overall survival. Methods. The immunohistochemical expression of PDGFR-α and PDGFR-β was investigated in tumor and stromal cells in 170 patients with histologically verified epithelial ovarian cancer. Results. Almost half of the tumor specimens showed high expression of PDGFR-α and PDGFR-β in tumor cells (43% and 41%) and in stromal compartments (32% and 44%). There was a significant association between high expression of PDGFR-α and high expression of PDGFR-β in both tumor and stromal cells. Coexpression of PDGFR-α and PDGFR-β in stromal cells was seen more often in serous adenocarcinomas than in nonserous adenocarcinomas. No clear correlation between PDGFR expression and longterm overall survival or clinical parameters was found. Conclusions. PDGFR-α and PDGFR-β were expressed in a subset of ovarian carcinomas but did not show significant prognostic importance in this material.

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.

Improved classification of epithelial ovarian cancer: results of 3 danish cohorts

OBJECTIVE

An increasing body of evidence has suggested that epithelial ovarian cancer (EOC) patients can broadly be divided into 2 groups on the basis of histopathologic parameters and molecular profiles. Type 1 tumors are slow-growing tumors with inherent mutations such as KRAS or BRAF mutations, whereas type 2 tumors are more rapidly growing tumors of which many contain TP53 mutations. In the present study, we performed a comprehensive study in a large Danish material to evaluate the clinical importance.

MATERIALS AND METHODS

A total of 512 tissue samples were included (430 EOCs, 34 borderline, 28 benign tumors, and 20 normal ovaries). KRAS mutations (codon 12/13) and BRAF codon 600 mutations were analyzed from formalin-fixed paraffin-embedded tissue by ARMS qPCR. p53 expression was examined by immunohistochemistry.

RESULTS

Of the EOC patients, 25% had histopathologically classified type 1 tumors, and of these, 44% were either KRAS or BRAF mutated. Of patients with histopathologic type 2 tumors, 66% showed p53 protein overexpression, whereas 4 (1.5%) patients contained a KRAS mutation. In a univariate survival analysis, a large difference in survival was seen between patients with type 1 and type 2 tumors. Patients with type histologic 2 tumors had significantly worse survival compared with patients with type 1 tumors (P < 10). International Federation of Gynecology and Obstetrics (FIGO) stage, tumor grade, residual tumor, and KRAS/BRAF mutation were independent predictors of overall survival in the multivariate analysis. Patients with KRAS/BRAF mutated carcinomas showed independent decreased overall survival with a hazard ratio of 2.01 (95% confidence interval, 1.13-3.57; P = 0.018).

CONCLUSIONS

KRAS/BRAF mutations are with very few exceptions constrained to patients with histopathologic type 1 tumors, whereas p53 overexpression is very frequent in type 2 tumors. KRAS/BRAF mutations had independent prognostic importance. The classification presented here should have a major therapeutic implication and serve as a hallmark of future clinical trials.

Continued chemotherapy after complete response to primary therapy among women with advanced ovarian cancer: a meta-analysis

BACKGROUND

Ovarian cancer (OC) is associated with a >75% risk of recurrence after completion of primary therapy. Several clinical trials have explored the role of continued therapy after complete response to primary adjuvant therapy to reduce the risk of recurrence; however, these trials have largely been underpowered, leading to inconclusive results.

METHODS

A systematic search strategy was initiated to identify all clinical trials involving consolidation or maintenance therapy regimens for OC in first complete remission. A meta-analysis was conducted to evaluate toxicity and progression-free (PFS) and overall survival (OS).

RESULTS

There were 37 publications meeting all eligibility criteria, representing 20 consolidation and 9 maintenance therapy trials. Consolidation and maintenance therapies were associated with improved PFS (hazard ratio [HR], 0.79 [P = .003] and HR, 0.82 [P = .02], respectively) and OS (HR, 0.68 [P = .0008] and HR, 0.68 [P = .007], respectively). This relationship remained statistically significant when the analysis was limited to randomized trials and across other sensitivity analyses.

CONCLUSIONS

Although individual studies have not yet convincingly shown a survival advantage with maintenance chemotherapy in OC, this meta-analysis demonstrates that continued chemotherapy after completion of primary therapy for OC improves PFS and OS. Benefits are greatest in patients with advanced stage OC who reach complete clinical or pathologic response after primary therapy.

Drug exposure: still an excellent biomarker

Relationships between plasma drug concentrations and clinical outcome have been defined for various chemotherapeutic agents, showing that drug exposure may be a marker of toxicity, mainly hematological and gastrointestinal toxicity, as well as efficacy, expressed as tumor response and survival. Biomarkers provide information for guidance in dosing and the minimization of interindividual variation in response. Drug exposure is commonly measured with parameters such as area under the plasma concentration-time curve, steady-state plasma or serum concentrations, peak concentrations and duration above a threshold concentration. In this review, we focus on drugs where pharmacokinetic/pharmacodynamic relationships as well as systemic exposure have been associated to toxicity and/or efficacy in solid and hematological tumors, these include: carboplatin, methotrexate, busulphan, 5-fluorouracil, etoposide, anthracyclines, irinotecan, vinorelbine and docetaxel.

Lack of relationship between TIMP-1 tumour cell immunoreactivity, treatment efficacy and prognosis in patients with advanced epithelial ovarian cancer

Background

Tissue inhibitor of metalloproteinase 1 (TIMP-1) is a natural inhibitor of the matrix metalloproteinases (MMPs) which are proteolytic enzymes involved in degradation of extracellular matrix thereby favoring tumour cell invasion and metastasis. TIMP-1 activity in tumour tissue may therefore play an essential role in the progression of a malignant tumour.

The primary aim of the present study was to evaluate TIMP-1 protein immunoreactivity in tissue from primary ovarian cancer patients and associate these findings with the course of the disease including response to treatment in the individual patient.

Methods

TIMP-1 was assessed by immunohistochemistry (in tissue micro arrays) in a total of 163 ovarian cancer specimens obtained from primary debulking surgery during 1991-1994 as part of a randomized clinical protocol.

Results

Positive TIMP-1 immunoreactivity was found in 12.3% of the tumours. The median survival time for the 143 patients with TIMP-1 negative tumours was 23.7 months [19.0-29.4] 95% CI, while the median survival time for the 20 patients with TIMP-1 positive tumours was 15.9 months [12.3-27.4] 95% CI. Although a difference of 7.8 months in median overall survival in favor of the TIMP-1 tumour negative patients was found, this difference did not reach statistical significance (p = 0.28, Kaplan-Meier, log-rank test). Moreover, TIMP-1 immunoreactivity was not associated with CA125 response (p = 0.53) or response at second look surgery (p = 0.72).

Conclusion

TIMP-1 immunoreactivity in tumour tissue from patients with primary epithelial ovarian cancer did not correlate with patient survival or response to combination platinum/cyclophosphamide therapy.

Trials with impact on clinical management: first line

INTRODUCTION

Advanced-stage epithelial ovarian cancer is generally managed with cytoreductive surgery and chemotherapy consisting of carboplatin and paclitaxel. Although initially responsive, most tumors recur and demonstrate progressive chemotherapy resistance. During the last 20 years, many thousands of women have participated in international front-line phase 3 trials that have contributed to our understanding of ovarian cancer biology and helped to define optimal treatment strategies. Emerging data from these trials need to be interpreted within an evolving paradigm of cancer biology, disease management, and availability of clinical resources.

METHODS

Survey of recent phase 3 trials and emerging principles of ovarian tumor biology.

RESULTS

There is no evidence that adding a third cytotoxic agent improves clinical outcomes. However, weekly dose-dense scheduling of paclitaxel appears superior to standard dosing.

CONCLUSION

Primary therapy with carboplatin and paclitaxel remains a well-tolerated standard regimen, including the option of weekly paclitaxel dosing. Data are awaited from completed trials incorporating bevacizumab. Emerging biological paradigms will contribute to individualized treatment options in the future.

Management of women with newly diagnosed ovarian cancer

Ovarian cancer is the leading cause of death from gynecologic cancers in the United States. Initial management is reviewed here and is best provided by a multidisciplinary team, including a gynecologic oncologist and a medical oncologist. Typically these patients are first treated with aggressive surgical debulking, followed by chemotherapy. Exceptions to this strategy, including those for patients adequately treated with surgery alone and those better served by neoadjuvant chemotherapy (NAC), are discussed. The history and rationale of current chemotherapy regimens, both intravenous (IV) and intraperitoneal (IP), are reviewed. Given the chemo-sensitive nature of this disease, as well as the fact that it remains largely incurable in advanced stages, efforts continue to be made to improve initial therapy. This disease represents an excellent target for new drug development, and some of the newer agents in trials for ovarian cancer are discussed.

Prognostic importance of vascular endothelial growth factor-A expression and vascular endothelial growth factor polymorphisms in epithelial ovarian cancer

INTRODUCTION

Vascular endothelial growth factors (VEGFs) play a central role in angiogenesis and consequently, in various steps of ovarian carcinogenesis. Gene polymorphisms within the VEGF system have revealed a correlation with prognosis in some malignancies. The aim of the present study was to examine the possible importance of 2 VEGF polymorphisms and VEGF-A expression in ovarian cancer.

METHODS

We investigated 2 single nucleotide polymorphisms VEGF +405G/C and VEGF -460C/T by polymerase chain reaction and also analyzed VEGF-A expression by immunohistochemistry in 159 women with ovarian cancer.

RESULTS

Vascular endothelial growth factor-A expression revealed a significant correlation with survival in a Cox proportional hazards regression model (P = 0.012). Germline polymorphisms were not correlated with clinicopathological parameters such as stage, type, and histology. Heterozygous genotype in VEGF +405G/C predicted a better survival compared with homozygous genotypes (P = 0.034), and the heterozygous genotype in VEGF -460C/T pointed to the same direction. A multivariate analysis also indicated that heterozygosity of either of the 2 polymorphisms held independent prognostic significance (P = 0.001).

CONCLUSIONS

Vascular endothelial growth factor polymorphisms +405G/C and VEGF expression seem to have independent prognostic importance.

Attitudes regarding the use of hematopoietic colony-stimulating factors and maintenance of relative dose intensity among gynecologic oncologists

OBJECTIVE

To assess the attitudes regarding the use of colony-stimulating factor (CSF) and the maintenance of relative dose intensity (RDI) by gynecologic oncologists during the administration of chemotherapy to patients with epithelial ovarian cancer.

METHODS

A nationwide survey of 608 gynecologic oncologists was performed using a 19-point questionnaire. The questionnaire assessed the following domains: (1) demographic information, (2) patterns of CSF use during first-line and relapse chemotherapies for patients with epithelial ovarian cancer, and (3) use of CSFs to maintain RDI.

RESULTS

The response rate to the survey was 42% (n = 255). Eighty-six percent (220/255) of the respondents routinely administer chemotherapy. In the first-line setting, 67% of physicians who routinely administer chemotherapy preferred to use CSFs for secondary prophylaxis after a neutropenic complication, whereas only 2% would use CSFs for primary prophylaxis. In the recurrent disease setting, physicians were more likely to administer a regimen with minimal myelosuppression (74% reported "likely" or "very likely"), to dose delay or modify if neutropenic complications occur (78%), or to administer CSFs for secondary prophylaxis (85%) than to dose attenuate upon initiation of chemotherapy (49%) or to administer CSFs for primary prophylaxis (46%). Most physicians would administer CSFs to maintain RDI in both the first-line (75%) and palliative settings (62%), and 49% would strive to maintain a dose intensity of more than 85%.

CONCLUSIONS

Most gynecologic oncologists use CSFs as secondary prophylaxis for neutropenic complications rather than as primary prophylaxis. Most gynecologic oncologists monitor RDI and use CSFs to maintain RDI in their patients with ovarian carcinoma.

Whole-body hyperthermia (WBH) in combination with carboplatin in patients with recurrent ovarian cancer - a phase II study

OBJECTIVE

Despite considerable progress in the front-line treatment in patient with advanced ovarian cancer, the outcome of patients with recurrent or refractory disease is still poor. Based on promising results of a pilot study, we initiated a phase II study with WBH and carboplatin in pretreated patients with advanced ovarian cancer to investigate the toxicity and efficacy of WBH in combination with carboplatin.

METHODS

47 patients with histologically confirmed epithelial ovarian carcinoma were enrolled in the study. Patients were pretreated with at least one palliative chemotherapy regimen. Of 47 patients 24 were classified as platinum refractory or resistant and 16 as platinum sensitive.

RESULTS

Main toxicity was hematological with grade 3/4 anaemia, leukopenia and thrombocytopenia occurring in 49%, 49% and 65%, respectively. Cardiac complications occurred with grade 1/2 in 22 of 47 (47%) patients and with grade 3 in 1 patient (2%). In 35 patients evaluable for response, the overall response rate was 45% [CR: 4/35 (11%), PR: 12/35 (34%), NC: 9/35 (26%]. In platinum refractory and resistant patients we observed CR in 6%, PR in 24% and NC in 24%. The median overall survival and progression free survival were 61.5 weeks and 29 weeks, respectively.

CONCLUSION

This study confirms that WBH in combination with carboplatin is an active salvage treatment option in patients with advanced ovarian cancer. However, significant hematological toxicity has to be considered and renders this regimen less suitable for palliative care setting. There is no evidence yet, that whole-body hyperthermia contributes to any clinical improvement beyond chemotherapy alone. This question can only be addressed in a randomized phase III trial.

Pharmaceutical management of ovarian cancer : current status

Over recent decades, truly impressive progress has been made in the outcome associated with the pharmacological antineoplastic management of women with advanced ovarian cancer. Following initial surgery, the large majority of patients with this malignancy will receive a chemotherapy regimen that includes a platinum drug (carboplatin or cisplatin) and a taxane (paclitaxel or docetaxel). Currently, objective responses are observed in approximately 60-80% of patients treated in the front-line setting, with documented improvements in overall survival compared with prior non-platinum and taxane programmes. Unfortunately, despite the high response rate to initial chemotherapy, the majority of women with advanced disease will experience recurrence of the malignant process and be candidates for a variety of possible second-line therapeutic options. It is well recognized that ovarian cancer patients who are documented to experience an initial response to platinum-based chemotherapy but where the disease recurs approximately 6 or more months following the completion of primary therapy, may have another clinically meaningful response (both objective and subjective) to a second platinum-based strategy. However, an optimal management approach in this setting remains to be defined. Furthermore, the malignant cell populations in all ovarian cancer patients who experience an initial relapse of the disease process will eventually be resistant to the platinum agents. In this setting, multiple drugs have been shown to be biologically active. Again, an optimal strategy to be employed in the platinum-resistant setting has yet to be demonstrated through the conduct of evidence-based trials. Reasonable goals of therapy in women with recurrent or resistant ovarian cancer are to improve overall survival, reduce the severity (and delay the occurrence) of symptoms and optimize overall quality of life.

Variability in chemotherapy delivery for elderly women with advanced stage ovarian cancer and its impact on survival

Given the survival benefits of adjuvant chemotherapy for advanced ovarian cancer (OC), we examined the associations of survival with the time interval from debulking surgery to initiation of chemotherapy and with the duration of chemotherapy. Among patients > or =65 years with stages III/IV OC diagnosed between 1991 and 2002 in the Surveillance, Epidemiology, and End Results-Medicare database, we developed regression models of predictors of the time interval from surgery to initiation of chemotherapy and of the total duration of chemotherapy. Survival was examined with Cox proportional hazards models. Among 2558 patients, 1712 (67%) initiated chemotherapy within 6 weeks of debulking surgery, while 846 (33%) began treatment >6 weeks. Older age, black race, being unmarried, and increased comorbidities were associated with delayed initiation of chemotherapy. Delay of chemotherapy was associated with an increase in mortality (hazard ratio (HR)=1.11; 95% CI, 1.0-1.2). Among 1932 patients in the duration of treatment analysis, the 1218 (63%) treated for 3-7 months had better survival than the 714 (37%) treated for < or =3 months (HR=0.84; 95% CI, 0.75-0.94). This analysis represents one of the few studies describing treatment delivery and outcome in women with advanced OC. Delayed initiation and early discontinuation of chemotherapy were common and associated with increased mortality.

What is the optimal approach to the administration of intraperitoneal chemotherapy in ovarian cancer?

Three well-designed and conducted randomized phase 3 trials have revealed that the intraperitoneal administration of cisplatin-based chemotherapy as primary treatment of small-volume residual advanced ovarian cancer improves both progression-free and overall survivals compared to an all intravenous cisplatin-based regimen. Based on very reasonable extrapolations from existing evidence-based data, a number of possible "options" can be proposed that use the intraperitoneal route for delivery of chemotherapy in this clinical setting.

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.

Weekly paclitaxel and carboplatin (PC-W) for patients with primary advanced ovarian cancer: results of a multicenter phase-II study of the NOGGO

OBJECTIVES

To study the toxicity and efficacy of weekly paclitaxel and carboplatin (PC-W) in women with primary ovarian cancer

METHODS

This investigation extended a phase-I dose finding study and was approved by the institutional review boards of all participating institutions. Between 1999 and 2003, women with radically resected ovarian cancer of FIGO stages II B to IV were enrolled at 17 German centres. Patients received weekly paclitaxel at a dose of 100 mg/m2, followed by carboplatin AUC 2. After a first treatment block consisting of six cycles of chemotherapy, patients had a treatment-free interval of 14 days, followed by a second block of six cycles. Treatment was completed by a 28-days break and a final block of six cycles.

RESULTS

Altogether, 129 women with a mean age of 59 +/- standard deviation 11 years entered the study. Most patients (82.9%) had serous papillary carcinoma of FIGO stage III (72.9%) and IV (20.9%). Participants received 1,851 cycles of chemotherapy; averaging 14.3 +/- 4.3 cycles each patient. PC-W produced low rates of peripheral neuropathy (grade 3: 2.3%, 95% confidence interval [CI] 0.5-6.6%), with rapid recovery after 3 months. However, 72 patients had grade III/IV anaemia (55.8%, 95% CI 46.8-64.5%). There were 36 events of grade III/IV leukopenia (27.9%, 95% CI 20.4-36.5%). One patient sustained neutropenic fever. CA-125- and objective response was noted in 73.9% (95% CI 64.7-81.8%) and 55.6% (95% CI 41.4-69.1%) of patients. Median progression free and overall survival was 21 and 43 months, respectively.

CONCLUSIONS

PC-W is feasible; a randomized study is warranted to compare this new regimen with conventional 3-weekly treatment.

The prognostic importance of cyclooxygenase 2 and HER2 expression in epithelial ovarian cancer

Both cyclooxygenase 2 (COX2) and human epidermal growth factor receptor 2 (HER2, also called c-erbB-2) overexpression have been related to a worse prognosis in epithelial ovarian cancer (EOC), but the data are conflicting and the percentage of tumors with overexpression varies widely in different studies. The aim of this study was to investigate the potential prognostic value of COX2 and HER2 expression in EOC. A further purpose was to investigate a possible coexpression of the two markers, and finally, to elucidate the agreement between fluorescence in situ hybridization (FISH) and immunohistochemistry (IHC) for evaluation of the HER2 status in EOC. Immunostaining was performed for COX2/HER2 together with FISH analysis for HER2 gene amplification in 160 patients with EOC, FIGO stages IIB-IV. Follow-up was more than 10 years. COX2 overexpression was found in 20.0% of the tumors. With HER2 staining, 64.4% were scored as 0, 24.4% as 1+, 6.9% as 2+, and 4.4% as 3+. Median survival time for COX2-negative tumors was 21.6 versus 36 months for COX2-positive tumors. The longer survival for COX2 positive was significant by both univariate analysis (P= 0.015) and multivariate analysis (P= 0.025). Positive immunostaining for HER2 was associated with poor overall survival (P= 0.03). Agreement between IHC and FISH was seen in all cases (P < 0.0000001). With long-term observation, patients with negative COX2 expression had significantly shorter survival compared to patients with COX2-positive tumors. Positive HER2 expression also notified a grave prognosis, but the low rate of overexpression reduces its potential clinical application.

Influence of interval between primary surgery and chemotherapy on short-term survival of patients with advanced ovarian, tubal or peritoneal cancer

OBJECTIVE

To investigate the impact on short-term survival of time between surgery and start of first chemotherapy cycle in patients with advanced ovarian cancer.

METHODS

This prospective, population-based study comprised 371 patients with epithelial ovarian, tubal or peritoneal cancer diagnosed in 2002-2003. All patients underwent primary surgery, followed at different intervals by chemotherapy. The data were derived from notifications to the Norwegian Cancer Registry and included medical, surgical and histopathological records. Kaplan-Meier plots were used to show differences in survival, and Cox regression analysis was used to show the effect of prognostic factors on survival, expressed as hazard ratios (HRs).

RESULTS

No difference in survival between patient groups was seen when time between surgery and start of chemotherapy was divided into quartiles. The group of patients with no residual disease and an interval between surgery and start of chemotherapy equal to or more than 6 weeks had non-significantly worse survival (unadjusted HR = 1.86; adjusted HR = 1.35) than those with an interval of less than 6 weeks. Patients with residual disease after surgery and chemotherapy at an interval of less than 6 weeks had worse short-term survival than patients without residual disease and the same interval before chemotherapy: unadjusted HR = 3.66 (95% CI, 2.09-6.40) and adjusted HR = 2.36 (95% CI, 1.22-4.57).

CONCLUSIONS

The interval between surgery and start of chemotherapy had no major impact on short-term survival after ovarian cancer. Patients might be included in chemotherapy trials when interval between surgery and start of chemotherapy is more than 6 weeks. Any further investigation of a possible effect of interval between surgery and start of chemotherapy should be performed as a randomized trial.

Treatment strategy for recurrent and refractory epithelial ovarian cancer: efficacy of high-dose chemotherapy with hematopoietic stem cell transplantation

According to population statistics in Japan, approximately 3,800 women die of ovarian -cancer annually, and approximately 6,000 are affected by this disease. Ovarian cancer is -referred to as a "silent tumor", since patients have few subjective symptoms and by the time symptoms are observed, the cancer has progressed to Stage III or IV in about half of the patients. The basic treatment for advanced epithelial ovarian cancer is to remove as much of the tumor as possible, and subsequently to perform anticancer therapy using drugs such as cisplatin, carboplatin and paclitaxel, all of which have been shown to be effective for epithelial ovarian cancer. However, the 5-year survival rate in advanced ovarian cancer patients is still only about 20%, and a treatment that leads to long-term survival has yet to be developed. Here, we review the available treatments for ovarian cancer, and present the results of high-dose chemotherapy (HDC) performed in our hospital for recurrent and refractory -ovarian cancer.

Relevance of chemotherapy dose and schedule to outcomes in ovarian cancer

The current standard of care in ovarian cancer is complete surgical cytoreduction followed by adjuvant (postoperative) platinum-based chemotherapy. Taxanes are frequently combined with platinum compounds in the adjuvant chemotherapy setting and, whether they are given in combination or sequentially, they produce greater progression-free and overall survival than historical combination regimens. Because the treatment of ovarian cancer relies on chemotherapy, this article reviews the evidence for a correlation between chemotherapy delivered at full dose on schedule (FDOS) and patient outcomes. Meta-analyses have suggested that the dose intensities of cisplatin and carboplatin correlate with survival. However, the findings in these hypothesis-generating analyses have not been confirmed in prospective trials. In addition, increasing the dose of cisplatin above a certain threshold is not recommended in ovarian cancer because of the greater toxicity with higher doses of platinum compounds. The delivered dose intensities of taxanes used as single agents have not been shown to correlate with patient outcomes, but adding a taxane to platinum compounds appears both to attenuate the toxicity of the platinum compounds and to facilitate the delivery of FDOS chemotherapy. In the literature on ovarian cancer there is no clear consensus on the benefit of maintaining FDOS chemotherapy. Clinical studies, especially a proposed trial of a dose-dense carboplatin and paclitaxel combination, may provide stronger evidence for the effect of FDOS chemotherapy in ovarian cancer.

Can we do a better job preventing clinically-relevant peripheral neuropathy resulting from carboplatin/paclitaxel chemotherapy?

Minor modifications in the standard "dose reduction" strategy commonly employed in the presence of developing carboplatin/paclitaxel-induced peripheral neuropathy may favorably impact the quality-of-life associated with use of this important combination chemotherapy regimen.

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.

Thrombocytopenia associated with second-line carboplatin-based chemotherapy for ovarian, fallopian tube, and primary peritoneal cavity cancers

PURPOSE

There are limited data available in the oncology literature regarding the risk of thrombocytopenia associated with carboplatin-based second-line treatment of ovarian cancer, outside the setting of patients participating in clinical trials.

METHODS

To examine this clinically-relevant issue, we conducted a retrospective review of the medical records of women with ovarian cancer treated in the Gynecologic Cancer Program of the Cleveland Clinic from 1994 through November 2003, who received >2 second-line carboplatin-based regimens.

RESULTS

A total of 176 second-line carboplatin-based programs were delivered to the 152 patients (median age 61 years; range 39-87 years) identified through this review. A total of ten (7%) patients experienced >grade 2 thrombocytopenia, with only four (3%) patients developing platelet count nadirs <50.0 x 10(9)/l. No patient required discontinuation of platinum-based therapy due to the development of thrombocytopenia.

CONCLUSION

Second-line carboplatin-based chemotherapy of ovarian cancer is associated with a low incidence of serious thrombocytopenia, if a strategy of selecting modest initial dose levels, and instituting rapid reductions in dose with the development of significant bone marrow suppression, is employed.

A phase II study of sequential carboplatin, paclitaxel and topotecan in patients with previously untreated advanced ovarian cancer

We evaluated the sequential use of carboplatin, paclitaxel and topotecan in patients with advanced, previously untreated ovarian cancer. In total, 43 patients with advanced ovarian cancer and >1 cm residual disease were treated with sequential carboplatin (area-under-the-curve (AUC) 5 days 1 and 22), paclitaxel (175 mg m⁻² days 43 and 64) and topotecan (1.5 mg m⁻² daily for 5 days from days 85, 106, 127 and 148). Median age of patients was 61 years. Median follow-up was 22.2 months (range 0.76–50.6 months). In all, 34 (79%) patients received all eight cycles of treatment and nine (21%) withdrew. Of the 29 evaluable patients, 19 (66%) responded according to WHO and 30 of 36 (83%) patients according to CA125. The best overall response (CA125 and/or WHO) was 77% (33 of 43 patients). The response rates to sequential drugs based on >50% fall in CA125 were as follows: carboplatin, 77% (30 of 39 patients); paclitaxel, 65% (15 of 23 patients); topotecan, 38% (five of 13 patients). Two patients responded to paclitaxel and one to topotecan after failure to respond to preceding chemotherapy. Median survival and time to progression was 22.24 and 10.61 months, respectively. This study demonstrates that sequential chemotherapy with just two initial courses of carboplatin is a reasonable way to introduce new agents into first-line therapy for poor prognostic ovarian cancer patients.

Experience with the management of neutropenia in gynecologic cancer patients receiving carboplatin-based chemotherapy

Objective. There exists limited information in the medical literature regarding the incidence and severity of carboplatin-associated neutropenia, outside the setting of a clinical trial. We wished to examine this issue in a large single institution experience involving patients receiving both single agent and combination carboplatin-based chemotherapy for management of a female pelvic malignancy. Patients and methods. The medical records of women with gynecologic cancers treated with carboplatin-based chemotherapy at the Cleveland Clinic from January 1, 1998 through December 31, 2002 were retrospectively reviewed to determine the incidence and severity of neutropenia. Results. During the time period encompassed by this analysis, a total of 323 patients received 2145 cycles of carboplatin-based chemotherapy (total of 441 courses; median cycles/patient: 6 [range 1-27]). The total number of each program utilized, and the incidence of grades 3 and 4 neutropenia observed (lowest nadir/regimen), were as follows: single agent carboplatin (178 courses; 5% grade 3, and <1% grade 4), carboplatin/paclitaxel (198; 23% and 6%), carboplatin/docetaxel (42; 17% and 73%) and carboplatin/paclitaxel/irinotecan (23; 39% and 61%). Febrile neutropenia was uncommon, and there was only a single neutropenic-related death. Conclusion. Both single-agent carboplatin and carboplatin/paclitaxel result in a very low incidence of grade 4 neutropenia. While combining docetaxel with carboplatin or adding a "third drug" to carboplatin/paclitaxel substantially increases the incidence of severe neutropenia, neutropenic fever, and required hospitalizations for septic episodes are uncommon. The prophylactic oral administration of a broad-spectrum antibiotic (e.g., ciprofloxicin) in the presence of grade 4 neutropenia appears to be an effective strategy to minimize the risk of subsequent febrile events.

Docetaxel and carboplatin as first-line chemotherapy in patients with advanced gynecological tumors. A phase I/II trial of the Arbeitsgemeinschaft Gynäkologische Onkologie (AGO-OVAR) Ovarian Cancer Study Group

OBJECTIVES

We performed a phase I-II study in patients with ovarian and other gynecological cancers to determine the dose-limiting toxicities, maximum tolerated dose (MTD) and efficacy of docetaxel/carboplatin.

METHODS

Thirty patients were treated in three cohorts with carboplatin (AUC 5) and escalating docetaxel (60, 75 and 90 mg/m2), administered intravenously on day 1, repeated every 3 weeks. Premedication consisted of 16 mg dexamethasone per os on day -1, and +1 and 4 mg intravenously before docetaxel.

RESULTS

A total of 6, 11 and 12 patients were eligible and treated on dose levels 1, 2 and 3, respectively. At docetaxel 90 mg/m2, febrile and prolonged neutropenia were dose-limiting, and 75 mg/m2 with carboplatin AUC 5 was considered the MTD. Prolonged neutropenia occurred in two, four and nine patients of dose levels 1-3, respectively, and febrile neutropenia in 2, 1, and 2 patients of dose level 1-3. Thrombocytopenia grade 4 was observed in one patient of dose level 1. Non-hematological toxicity including neuropathy was usually mild across all dose levels. Overall response rate was 73%. Median time to progression was 18.0 months, and median overall survival will exceed 24.4 months.

CONCLUSIONS

Docetaxel/carboplatin can be safely administered to patients with gynecological cancer despite substantial myelotoxicity and appears to be active in the treatment of ovarian cancer. Low neurotoxicity offers an option for comparison with paclitaxel-containing regimens.

Systemic treatment policies in ovarian cancer: the next 10 years

Over the past two decades, the development of treatment policies and practice standards has become formalized. In ovarian cancer, most attention has been focused on the development of policies for front-line systemic treatment, using survival as the major outcome that should drive change. This review summarizes the evidence that supported the emergence of paclitaxel-carboplatin as a widely used standard of care for front-line therapy and some of the contradictory data from randomized studies. Furthermore, recently completed or ongoing randomized studies of the addition of a third cytotoxic agent to paclitaxel-carboplatin are summarized. Finally, some novel noncytotoxic approaches are discussed. New standards of care and treatment policies in the next decade will be based on high-quality evidence of improved survival from controlled studies. Many such trials are now ongoing or planned.

Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study

PURPOSE

In randomized trials the combination of cisplatin and paclitaxel was superior to cisplatin and cyclophosphamide in advanced-stage epithelial ovarian cancer. Although in nonrandomized trials, carboplatin and paclitaxel was a less toxic and highly active combination regimen, there remained concern regarding its efficacy in patients with small-volume, resected, stage III disease. Thus, we conducted a noninferiority trial of cisplatin and paclitaxel versus carboplatin and paclitaxel in this population.

PATIENTS AND METHODS

Patients with advanced ovarian cancer and no residual mass greater than 1.0 cm after surgery were randomly assigned to receive cisplatin 75 mg/m2 plus a 24-hour infusion of paclitaxel 135 mg/m2 (arm I), or carboplatin area under the curve 7.5 intravenously plus paclitaxel 175 mg/m2 over 3 hours (arm II).

RESULTS

Seven hundred ninety-two eligible patients were enrolled onto the study. Prognostic factors were similar in the two treatment groups. Gastrointestinal, renal, and metabolic toxicity, as well as grade 4 leukopenia, were significantly more frequent in arm I. Grade 2 or greater thrombocytopenia was more common in arm II. Neurologic toxicity was similar in both regimens. Median progression-free survival and overall survival were 19.4 and 48.7 months, respectively, for arm I compared with 20.7 and 57.4 months, respectively, for arm II. The relative risk (RR) of progression for the carboplatin plus paclitaxel group was 0.88 (95% confidence interval [CI], 0.75 to 1.03) and the RR of death was 0.84 (95% CI, 0.70 to 1.02).

CONCLUSION

In patients with advanced ovarian cancer, a chemotherapy regimen consisting of carboplatin plus paclitaxel results in less toxicity, is easier to administer, and is not inferior, when compared with cisplatin plus paclitaxel.