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Praiss AM, Miller A, Smith J, Lichtman SM, Bookman M, Aghajanian C, Sabbatini P, Backes F, Cohn DE, Argenta P, Friedlander M, Goodheart MJ, Mutch DG, Gershenson DM, Tewari KS, Wenham RM, Wahner Hendrickson AE, Lee RB, Gray H, Secord AA, Van Le L, O'Cearbhaill RE. Carboplatin dosing in the treatment of ovarian cancer: An NRG oncology group study. Gynecol Oncol 2023; 174:213-223. [PMID: 37229879 PMCID: PMC10330633 DOI: 10.1016/j.ygyno.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To determine the effects of using National Comprehensive Cancer Network (NCCN) guidelines to estimate renal function on carboplatin dosing and explore adverse effects associated with a more accurate estimation of lower creatinine clearance (CrCl). METHODS Retrospective data were obtained for 3830 of 4312 patients treated on GOG182 (NCT00011986)-a phase III trial of platinum-based chemotherapy for advanced-stage ovarian cancer. Carboplatin dose per patient on GOG182 was determined using the Jelliffe formula. We recalculated CrCl to determine dosing using Modification of Diet in Renal Disease (MDRD) and Cockcroft-Gault (with/without NCCN recommended modifications) formulas. Associations between baseline CrCl and toxicity were described using the area under the receiver operating characteristic curve (AUC). Sensitivity and positive predictive values described the model's ability to discriminate between subjects with/without the adverse event. RESULTS AUC statistics (range, 0.52-0.64) showed log(CrClJelliffe) was not a good predictor of grade ≥3 adverse events (anemia, thrombocytopenia, febrile neutropenia, auditory, renal, metabolic, neurologic). Of 3830 patients, 628 (16%) had CrCl <60 mL/min. Positive predictive values for adverse events ranged from 1.8%-15%. Using the Cockcroft-Gault, Cockcroft-Gault with NCCN modifications, and MDRD (instead of Jelliffe) formulas to estimate renal function resulted in a >10% decrease in carboplatin dosing in 16%, 32%, and 5.2% of patients, respectively, and a >10% increase in carboplatin dosing in 41%, 9.6% and 12% of patients, respectively. CONCLUSION The formula used to estimate CrCl affects carboplatin dosing. Estimated CrCl <60 mL/min (by Jelliffe) did not accurately predict adverse events. Efforts continue to better predict renal function. Endorsing National Cancer Institute initiatives to broaden study eligibility, our data do not support a minimum threshold CrCl <60 mL/min as an exclusion criterion from clinical trials.
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Affiliation(s)
- Aaron M Praiss
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America.
| | - Austin Miller
- NRG Oncology Statistics and Data Center, Roswell Park Cancer Institute, Buffalo, NY, United States of America.
| | - Judith Smith
- McGovern Medical School, The University of Texas Health Science Center, Houston, TX, United States of America.
| | - Stuart M Lichtman
- Gynecologic Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Medicine, Weill Cornell Medical College, New York, NY, United States of America.
| | - Michael Bookman
- Department of Medical Oncology, Kaiser-Permanente Northern California, San Francisco, CA, United States of America.
| | - Carol Aghajanian
- Gynecologic Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Medicine, Weill Cornell Medical College, New York, NY, United States of America.
| | - Paul Sabbatini
- Gynecologic Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Medicine, Weill Cornell Medical College, New York, NY, United States of America.
| | - Floor Backes
- Department of Oncology, James Cancer Center, Ohio State University Comprehensive Cancer Center, Columbus, OH, United States of America.
| | - David E Cohn
- Department of Oncology, James Cancer Center, Ohio State University Comprehensive Cancer Center, Columbus, OH, United States of America.
| | - Peter Argenta
- Department of Obstetrics, Gynecology and Women's Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, United States of America.
| | - Michael Friedlander
- Department of Medical Oncology, Prince of Wales Hospital and Prince of Wales Clinical School, UNSW, Sydney, New South Wales, Australia.
| | - Michael J Goodheart
- Gynecologic Oncology, University of Iowa Hospitals, Iowa City, IA, United States of America.
| | - David G Mutch
- Gynecologic Oncology, Washington University, St. Louis, MO, United States of America.
| | - David M Gershenson
- Gynecologic Oncology, University of Texas, MD Anderson Cancer Center, Houston, TX, United States of America.
| | - Krishnansu S Tewari
- Gynecologic Oncology, University of California, Irvine Medical Center, Orange, CA, USA.
| | - Robert M Wenham
- Gynecologic Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, United States of America.
| | | | - Roger B Lee
- Gynecologic Oncology, Tacoma General Hospital, Tacoma, WA, United States of America
| | - Heidi Gray
- Gynecologic Oncology, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America.
| | - Angeles Alvarez Secord
- Gynecologic Oncology, Duke Cancer Institute, Duke University Medical Center, Durham, NC, United States of America.
| | - Linda Van Le
- Gynecologic Oncology, University of North Carolina, United States of America.
| | - Roisin E O'Cearbhaill
- Gynecologic Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Medicine, Weill Cornell Medical College, New York, NY, United States of America.
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Aigner KR, Gailhofer S, Aigner K. Hypoxic isolated abdominal perfusion breaks through chemoresistance in recurrent FIGO stage IIIC and IV ovarian cancer. Mol Clin Oncol 2021; 14:129. [PMID: 33981433 PMCID: PMC8108027 DOI: 10.3892/mco.2021.2291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 04/09/2021] [Indexed: 01/19/2023] Open
Abstract
To overcome drug resistance in relapsed ovarian cancer, an isolated perfusion system was used to generate a higher local exposure to cytostatic drugs. In addition to cisplatin as the cytostatic agent of choice, the present study combined adriamycin and mitomycin in a three drugs regime due to their increased cytotoxicity under hypoxia. A total of 107 patients, including 87 patients with relapses after previous platinum-containing therapies, 46 stage IIIC and 41 stage IV cases, were enrolled in the present study. A total of 25 patients were chemonaive, including 20 stage IIIC. The systemically pretreated patients in stage IIIC survived a median of 12.8 months, and those in stage IV 10.9 months. The overall clinical response rate of stages IIIC and IV combined was 69%. A complete decrease in ascites was found in 43% of all patients, a significant reduction in 19%. Toxicity and side effects were very mild and the bone marrow suppression was mostly grade I and never exceeded grade II. The primary clinical symptom in patients with post-therapeutic tumor necrosis, which occurred in 10-15% of all cases, was fever, fatigue and poor performance. The isolated hypoxic abdominal perfusion treatment is a potent instrument to break an existing chemoresistance without significant side effects with a good quality of life and comparatively long survival time.
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Affiliation(s)
- Karl R Aigner
- Department of Surgical Oncology, Medias Klinikum Burghausen, D-84489 Burghausen, Germany
| | - Sabine Gailhofer
- Department of Surgical Oncology, Medias Klinikum Burghausen, D-84489 Burghausen, Germany
| | - Kornelia Aigner
- Department of Surgical Oncology, Medias Klinikum Burghausen, D-84489 Burghausen, Germany
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Aigner KR, Selak E, Gailhofer S, Aigner K. Hypoxic Isolated Abdominal Perfusion (HAP) chemotherapy for non-operable advanced staged ovarian cancer with peritoneal carcinosis: an experience in 45 platinum-refractory ovarian cancer patients. Indian J Surg Oncol 2019; 10:506-514. [PMID: 31496601 PMCID: PMC6707993 DOI: 10.1007/s13193-019-00922-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/02/2019] [Indexed: 01/19/2023] Open
Abstract
In order to break through drug resistance in platinum-refractory ovarian cancer, augmented drug exposure was administered to the abdomen by means of an isolated perfusion system. Four cycles of isolated hypoxic abdominal perfusion with cisplatin, adriamycin, and mitomycin were conducted in 4-week intervals. Cisplatin and adriamycin were chosen because of their increased cytotoxicity under hypoxic conditions. Chemofiltration was performed for prophylaxis of cumulative toxicity of adriamycin and mitomycin. The study included 45 patients with recurrent epithelial ovarian cancer who had prior platinum containing therapies (3, stage Federation of Gynecology and Obstetrics (FIGO) IIIB; 20, stage FIGO IIIC; 22; stage FIGO IV). The median survival rate in stage FIGO IIIBC was 12 months, and in stage IV was 10 months. The tumor marker decreased to complete response or partial response at 17.8% and 55.6% of the patients. CT or MRI visualization showed complete response in 4.1%, and partial response was in 54.1%. Complete resolution of ascites was noted in 30% of cases and substantial reduction in another 43%. Toxicity was generally low. Quality of life was improved in the majority of cases. Bone-marrow suppression ranged between WHO grade 1 and 2, and in patients with previous third- or fourth-line chemotherapy, it was WHO grade 3. Isolated hypoxic abdominal perfusion with chemofiltration for patients with progressive and platinum-refractory stage III and IV ovarian cancer is an effective therapy, breaking through chemoresistance and offering comparably long survival at good quality of life.
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Affiliation(s)
- Karl Reinhard Aigner
- Department of Surgical Oncology, Medias Klinikum GmbH & Co KG, Krankenhausstr. 3a, 84489 Burghausen, Germany
| | - Emir Selak
- Department of Surgical Oncology, Medias Klinikum GmbH & Co KG, Krankenhausstr. 3a, 84489 Burghausen, Germany
| | - Sabine Gailhofer
- Department of Surgical Oncology, Medias Klinikum GmbH & Co KG, Krankenhausstr. 3a, 84489 Burghausen, Germany
| | - Kornelia Aigner
- Department of Surgical Oncology, Medias Klinikum GmbH & Co KG, Krankenhausstr. 3a, 84489 Burghausen, Germany
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4
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Trial-level analysis of progression-free survival and response rate as end points of trials of first-line chemotherapy in advanced ovarian cancer. Med Oncol 2017; 34:87. [DOI: 10.1007/s12032-017-0939-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 03/28/2017] [Indexed: 10/19/2022]
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Fukuhara H, Yagi M, Ando K, Tomita Y. Long-term administration of single-agent carboplatin (AUC 4) for advanced testicular seminoma safely achieved complete response in an 80-year-old man with chronic heart failure: A case report. Can Urol Assoc J 2015; 8:E931-3. [PMID: 25553172 DOI: 10.5489/cuaj.2089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Carboplatin is often used instead of cisplatin as an alternative treatment for advanced testicular cancer. However, the safety, optimal dose, and optimal duration of this agent are unclear in patients with cardiac complications. We report the safety and effectiveness of long-term single-agent carboplatin for the treatment of testicular cancer in a patient with chronic heart failure (CHF). An 80-year-old man was referred to our institution for evaluation of painless swelling of the left scrotum. Computed tomography revealed lung metastases. Left radical inguinal orchiectomy was performed, and pathologic examination revealed a pure seminoma. Because he had CHF, there was high possibility of onset of acute heart failure secondary to fluid administration. Thus, single-agent carboplatin (AUC 4) was selected for therapy. A complete response was achieved after 8 of 13 cycles, and no serious adverse events occurred, including cardiac problems. Neither recurrence nor metastasis was detected during the 6-month follow-up. Low-dose, long-term carboplatin is likely effective for patients who are unfit for cisplatin administration because of comorbidities, especially CHF.
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Affiliation(s)
- Hiroki Fukuhara
- Yamagata University Faculty of Medicine Department of Urology, Yamagata, Japan
| | - Mayu Yagi
- Yamagata University Faculty of Medicine Department of Urology, Yamagata, Japan
| | - Kaoru Ando
- Yamagata University Faculty of Medicine Departments of Cardiology, Pulmonology and Nephrology, Yamagata, Japan
| | - Yoshihiko Tomita
- Yamagata University Faculty of Medicine Department of Urology, Yamagata, Japan
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Argyriou AA, Kyritsis AP, Makatsoris T, Kalofonos HP. Chemotherapy-induced peripheral neuropathy in adults: a comprehensive update of the literature. Cancer Manag Res 2014; 6:135-47. [PMID: 24672257 PMCID: PMC3964029 DOI: 10.2147/cmar.s44261] [Citation(s) in RCA: 185] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Commonly used chemotherapeutic agents in oncology/hematology practice, causing toxic peripheral neuropathy, include taxanes, platinum compounds, vinca alkaloids, proteasome inhibitors, and antiangiogenic/immunomodulatory agents. This review paper intends to put together and discuss the spectrum of chemotherapy-induced peripheral neuropathy (CIPN) characteristics so as to highlight areas of future research to pursue on the topic. Current knowledge shows that the pathogenesis of CIPN still remains elusive, mostly because there are several sites of involvement in the peripheral nervous system. In any case, it is acknowledged that the dorsal root ganglia of the primary sensory neurons are the most common neural targets of CIPN. Both the incidence and severity of CIPN are clinically under- and misreported, and it has been demonstrated that scoring CIPN with common toxicity scales is associated with significant inter-observer variability. Only a proportion of chemotherapy-treated patients develop treatment-emergent and persistent CIPN, and to date it has been impossible to predict high-and low-risk subjects even within groups who receive the same drug regimen. This issue has recently been investigated in the context of pharmacogenetic analyses, but these studies have not implemented a proper methodological approach and their results are inconsistent and not really clinically relevant. As such, a stringent approach has to be implemented to validate that information. Another open issue is that, at present, there is insufficient evidence to support the use of any of the already tested chemoprotective agents to prevent or limit CIPN. The results of comprehensive interventions, including clinical, neurophysiological, and pharmacogenetic approaches, are expected to produce a consistent advantage for both doctors and patients and thus allow the registration and analysis of reliable data on the true characteristics of CIPN, eventually leading to potential preventive and therapeutic interventions.
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Affiliation(s)
- Andreas A Argyriou
- Department of Neurology, "Saint Andrew's" General Hospital of Patras, Greece ; Department of Medicine-Division of Oncology, University of Patras Medical School, Rion-Patras, Greece
| | | | - Thomas Makatsoris
- Department of Medicine-Division of Oncology, University of Patras Medical School, Rion-Patras, Greece
| | - Haralabos P Kalofonos
- Department of Medicine-Division of Oncology, University of Patras Medical School, Rion-Patras, Greece
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Abstract
Ovarian cancer is the leading cause of gynecologic cancer deaths and accounts for 4% of women's cancer diagnoses and 5% of all cancer mortalities. Despite the ability of current chemotherapy and cytoreductive surgery to put patients in remission, most patients with advanced cancer will eventually relapse. Many advances in the treatment of ovarian cancer have been reported in the past several years and a historical background is provided. Attention will then turn to analogs of current chemotherapeutic agents, new cytotoxic drugs, targeted molecular therapy, intraperitoneal therapy and immunotherapy. This review will give a perspective on current drugs, potential agents and upcoming clinical trials.
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Affiliation(s)
- Franco Muggia
- New York University Clinical Cancer Center, NY 10016-9196, USA.
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8
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Tookman L, Rashid S, Matakidou A, Phillips M, Wilson P, Ansell W, Jamal-Hanjani M, Chowdhury S, Harland S, Sarwar N, Oliver T, Powles T, Shamash J. Carboplatin AUC 10 for IGCCCG good prognosis metastatic seminoma. Acta Oncol 2013; 52:987-93. [PMID: 22943385 DOI: 10.3109/0284186x.2012.714078] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Metastatic seminoma is a highly curable disease. Standard treatment comprises of combination chemotherapy. The short- and long-term toxicities of this treatment are increasingly recognised and the possibility of over treatment in such a curable disease should be considered. We have therefore assessed the use of single agent carboplatin at a dose of AUC 10 in patients with good prognosis metastatic seminoma. MATERIALS AND METHODS Patients with good prognosis metastatic seminoma treated with carboplatin (AUC 10) were identified at our institution and affiliated institutions. Treatment was three weekly for a total of three or four cycles. Outcome and toxicities were analysed. RESULTS With a median follow-up of 36 months, 61 patients in total were treated with carboplatin AUC 10, all good prognosis by the IGCCCG criteria. Forty-eight percent had stage IIA/IIB disease and 52% had greater than stage IIB disease. Thirty-one patients (51%) had a complete response following treatment. Three-year survival was 96.3% with a three-year progression free survival of 93.2%. The main treatment toxicity was haematological with 46% having grade 3, 24% having grade 4 neutropenia and 54% experiencing grade 3/4 thrombocytopenia. There were no treatment related deaths. CONCLUSION Single agent carboplatin at a dose of AUC 10 is an effective treatment for good prognosis metastatic seminoma. The outcome compares favourably to previously published outcomes of combination chemotherapy. Although haematological toxicity is a concern, single agent carboplatin treatment for good prognosis metastatic seminoma could be considered a treatment option and is associated with less toxicity than combination regimens currently used.
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Affiliation(s)
- Laura Tookman
- Department of Medical Oncology, St Bartholomew's Hospital, West Smithfield, London, UK
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Hanna RK, Poniewierski MS, Laskey RA, Lopez MA, Shafer A, Van Le L, Crawford J, Dale DC, Gehrig PA, Secord AA, Havrilesky LJ, Lyman GH. Predictors of reduced relative dose intensity and its relationship to mortality in women receiving multi-agent chemotherapy for epithelial ovarian cancer. Gynecol Oncol 2013; 129:74-80. [DOI: 10.1016/j.ygyno.2012.12.017] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 12/08/2012] [Accepted: 12/11/2012] [Indexed: 12/01/2022]
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Markman M. Abandoning "TAP" as treatment of metastatic endometrial cancer: a serious example of the consequences resulting from the failure to adequately define the question being addressed in a phase 3 trial. Curr Oncol Rep 2012; 14:480-2. [PMID: 22923018 DOI: 10.1007/s11912-012-0264-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Maurie Markman
- Cancer Treatment Centers of America, Eastern Regional Medical Center, 1331 East Wyoming Avenue, Philadelphia, PA 19124, USA.
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11
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Laskey RA, Poniewierski MS, Lopez MA, Hanna RK, Secord AA, Gehrig PA, Lyman GH, Havrilesky LJ. Predictors of severe and febrile neutropenia during primary chemotherapy for ovarian cancer. Gynecol Oncol 2012; 125:625-30. [DOI: 10.1016/j.ygyno.2012.03.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Revised: 03/01/2012] [Accepted: 03/08/2012] [Indexed: 12/31/2022]
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Zahedi P, Yoganathan R, Piquette-Miller M, Allen C. Recent advances in drug delivery strategies for treatment of ovarian cancer. Expert Opin Drug Deliv 2012; 9:567-83. [DOI: 10.1517/17425247.2012.665366] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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13
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van der Burg MEL, Boere IA, Berns PMJJ. Dose-dense therapy is of benefit in primary treatment of ovarian cancer: contra. Ann Oncol 2012; 22 Suppl 8:viii33-viii39. [PMID: 22180397 DOI: 10.1093/annonc/mdr514] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- M E L van der Burg
- Department of Medical Oncology, Erasmus MC, University Medical Center Rotterdam, 's Gravendijkwal 230, Rotterdam, The Netherlands.
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14
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Hess LM, Rong N, Monahan PO, Gupta P, Thomaskutty C, Matei D. Continued chemotherapy after complete response to primary therapy among women with advanced ovarian cancer: a meta-analysis. Cancer 2011; 116:5251-60. [PMID: 20665885 DOI: 10.1002/cncr.25487] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Lisa M Hess
- Department of Public Health, Indiana University School of Medicine, Indianapolis, IN, USA.
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15
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Fruscio R, Garbi A, Parma G, Lissoni AA, Garavaglia D, Bonazzi CM, Dell'Anna T, Mangioni C, Milani R, Colombo N. Randomized Phase III Clinical Trial Evaluating Weekly Cisplatin for Advanced Epithelial Ovarian Cancer. J Natl Cancer Inst 2011; 103:347-51. [DOI: 10.1093/jnci/djq530] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Bookman MA. The addition of new drugs to standard therapy in the first-line treatment of ovarian cancer. Ann Oncol 2010; 21 Suppl 7:vii211-17. [PMID: 20943617 DOI: 10.1093/annonc/mdq368] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- M A Bookman
- Arizona Cancer Center, Tucson, AZ 85724-5024, USA.
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17
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Abstract
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.
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Affiliation(s)
- Michael A Bookman
- Arizona Cancer Center, 1515 N Campbell Avenue, Tucson, AZ 85724-5024, USA.
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Steimer JL, Dahl SG, De Alwis DP, Gundert-Remy U, Karlsson MO, Martinkova J, Aarons L, Ahr HJ, Clairambault J, Freyer G, Friberg LE, Kern SE, Kopp-Schneider A, Ludwig WD, De Nicolao G, Rocchetti M, Troconiz IF. Modelling the genesis and treatment of cancer: the potential role of physiologically based pharmacodynamics. Eur J Cancer 2010; 46:21-32. [PMID: 19954965 DOI: 10.1016/j.ejca.2009.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Revised: 09/30/2009] [Accepted: 10/09/2009] [Indexed: 12/01/2022]
Abstract
Physiologically based modelling of pharmacodynamics/toxicodynamics requires an a priori knowledge on the underlying mechanisms causing toxicity or causing the disease. In the context of cancer, the objective of the expert meeting was to discuss the molecular understanding of the disease, modelling approaches used so far to describe the process, preclinical models of cancer treatment and to evaluate modelling approaches developed based on improved knowledge. Molecular events in cancerogenesis can be detected using 'omics' technology, a tool applied in experimental carcinogenesis, but also for diagnostics and prognosis. The molecular understanding forms the basis for new drugs, for example targeting protein kinases specifically expressed in cancer. At present, empirical preclinical models of tumour growth are in great use as the development of physiological models is cost and resource intensive. Although a major challenge in PKPD modelling in oncology patients is the complexity of the system, based in part on preclinical models, successful models have been constructed describing the mechanism of action and providing a tool to establish levels of biomarker associated with efficacy and assisting in defining biologically effective dose range selection for first dose in man. To follow the concentration in the tumour compartment enables to link kinetics and dynamics. In order to obtain a reliable model of tumour growth dynamics and drug effects, specific aspects of the modelling of the concentration-effect relationship in cancer treatment that need to be accounted for include: the physiological/circadian rhythms of the cell cycle; the treatment with combinations and the need to optimally choose appropriate combinations of the multiple agents to study; and the schedule dependence of the response in the clinical situation.
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Abstract
The standard initial management of epithelial ovarian cancer consists of surgical staging, operative tumour debulking including total abdominal hysterectomy and bilateral salpingo-oophorectomy, and administration of six cycles of intravenous chemotherapy with carboplatin and paclitaxel. Extensive and largely retrospective experience has shown that optimum surgical debulking to leave residual tumour deposits that are less than 1 cm in size is associated with improved patient outcomes. However, 75% of patients present with advanced (stage III or IV) disease and, although more than 80% of these women benefit from first-line therapy, tumour recurrence occurs in almost all these patients at a median of 15 months from diagnosis. Second-line treatments can improve survival and quality of life but are not curative. Advances in screening and understanding of molecular pathogenesis of ovarian cancer and development of novel targeted therapies (eg, bevacizumab) and practical intraperitoneal techniques for drug delivery are most likely to improve patient outcomes.
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Affiliation(s)
- Bryan T Hennessy
- Department of Gynecologic Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Alvarez Secord A, Bae-Jump V, Havrilesky LJ, Calingaert B, Clarke-Pearson DL, Soper JT, Gehrig PA. Attitudes regarding the use of hematopoietic colony-stimulating factors and maintenance of relative dose intensity among gynecologic oncologists. Int J Gynecol Cancer 2009; 19:447-54. [PMID: 19407573 DOI: 10.1111/igc.0b013e3181a1a6c9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
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.
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Ingersoll SB, Patel S, Caballero L, Ahmad S, Edwards D, Holloway RW, Edwards JR. Synergistic cytotoxicity of interferonalpha-2b and interleukin-2 in combination with PBMC against ovarian cancer: development of an experimental model for cellular therapy. Gynecol Oncol 2008; 112:192-8. [PMID: 18995891 DOI: 10.1016/j.ygyno.2008.09.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Revised: 09/11/2008] [Accepted: 09/13/2008] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Current therapies for ovarian cancer (OC) patients have a modest impact on long-term survival justifying the need for novel treatment strategies. We developed in vitro and in vivo systems to test the effects of cytokines in combination with peripheral blood mononuclear cells (PBMC) on OC cells. METHODS Two OC cell-lines were transfected with a plasmid encoding Red Fluorescent Protein (SKOV3-RFP and CAR3-RFP). Proliferation of these lines in the presence of cytokines alone and in combination was assayed. Cytotoxicity of SKOV3-RFP cells mediated by PBMC and cytokines was determined by lactate dehydrogenase release. Mice were injected intraperitoneally (IP) with SKOV3-RFP cells; solid tumor and ascitic fluid were collected, analyzed, and cell lines were established. Tumor-derived cell lines were re-injected to produce a more tumorigenic line. RESULTS IFNalpha-2b showed an inhibitory effect on OC cell proliferation. The remaining cytokines, either alone or in combination, showed no significant effect. PBMC in combination with IL-2 showed clear dose-dependent cytotoxicity against SKOV3-RFP. IFNalpha-2b had a synergistic effect with IL-2 and PBMC increasing the cytotoxicity by an average of 20%. Using an animal model, SKOV3-RFP cells continue to express RFP when harvested from the peritoneum and are more tumorigenic when re-injected into mice. CONCLUSION These observations justify the use of IL-2, IFNalpha-2b, and PBMC in a xenograph animal model of OC to determine if combination cytokine and cellular therapy has an anti-tumor effect in vivo. This approach may prove useful as an in vivo system of IP cytokines administered in combination with cellular therapy.
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Affiliation(s)
- Susan B Ingersoll
- Cellular Therapy Laboratory, Florida Hospital Cancer Institute, Orlando, FL 32804, USA.
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Abstract
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.
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Affiliation(s)
- Maurie Markman
- Department of Gynecologic Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Tummala MK, Alagarsamy S, McGuire WP. Intraperitoneal chemotherapy: standard of care for patients with minimal residual stage III ovarian cancer? Expert Rev Anticancer Ther 2008; 8:1135-47. [PMID: 18588458 DOI: 10.1586/14737140.8.7.1135] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Epithelial ovarian cancer is the leading cause of death from gynecological cancer in most of the Western world, and long-term survival remains poor despite good initial response to systemic therapy after debulking surgery. Even after complete pathological response, the risk of recurrence in the first few years is substantial. The peritoneum is the predominant site of failure and the disease remains confined to the peritoneal cavity for much of its course. Efforts to improve clinical outcomes in this group of patients included investigation of intraperitoneal administration of active agents to expose the low-volume postoperative residual disease in the peritoneum to high concentrations of these drugs. In spite of three National Cancer Institute-sponsored randomized trials demonstrating clinical benefit with intraperitoneal therapy in patients with advanced ovarian cancer, the fact remains that it is not uniformly accepted by the gynecologic oncology community in the USA and is rarely used by clinicians in Europe. Intraperitoneal regimens are perceived to be too toxic for administration, although most of the toxicity is reversible. In this article we discuss the available evidence for intraperitoneal chemotherapy, challenges facing the gynecologic oncology community to make this modality more widely acceptable, the selection of patients most likely to tolerate intraperitoneal therapy and ongoing research in this field.
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Affiliation(s)
- Mohan K Tummala
- Clinical Research Fellow, Clinical Research Branch, National Institute on Aging/NIH & Greenebaum Cancer Center, University of Maryland, Baltimore, MD, USA.
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Wright JD, Tian C, Mutch DG, Herzog TJ, Nagao S, Fujiwara K, Powell MA. Carboplatin dosing in obese women with ovarian cancer: A Gynecologic Oncology Group study. Gynecol Oncol 2008; 109:353-8. [DOI: 10.1016/j.ygyno.2008.02.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Revised: 02/21/2008] [Accepted: 02/25/2008] [Indexed: 10/22/2022]
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Markman M. Evidence-based chemotherapy administration in advanced ovarian cancer: An impressive past, a disquieting present and an uncertain future. Gynecol Oncol 2008; 109:4-7. [DOI: 10.1016/j.ygyno.2007.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2007] [Accepted: 12/14/2007] [Indexed: 10/22/2022]
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Wright J, Doan T, McBride R, Jacobson J, Hershman D. Variability in chemotherapy delivery for elderly women with advanced stage ovarian cancer and its impact on survival. Br J Cancer 2008; 98:1197-203. [PMID: 18349836 PMCID: PMC2359630 DOI: 10.1038/sj.bjc.6604298] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Jd Wright
- Department of Obstetrics and Gynecology, Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, New York, NY 10032, USA
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Markman M. What is the optimal approach to the administration of intraperitoneal chemotherapy in ovarian cancer? Int J Gynecol Cancer 2008; 18 Suppl 1:36-9. [DOI: 10.1111/j.1525-1438.2007.01103.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
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
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Ovarian Cancer. Oncology 2007. [DOI: 10.1007/0-387-31056-8_52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cadron I, Leunen K, Amant F, Van Gorp T, Neven P, Vergote I. The “Leuven” dose-dense paclitaxel/carboplatin regimen in patients with recurrent ovarian cancer. Gynecol Oncol 2007; 106:354-61. [PMID: 17499348 DOI: 10.1016/j.ygyno.2007.04.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2007] [Revised: 04/02/2007] [Accepted: 04/02/2007] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Isabelle Cadron
- Division of Gynecological Oncology, Department of Obstetrics and Gynecology, University Hospitals Leuven, Katholieke Universiteit Leuven, Belgium
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Alberts DS, Markman M, Muggia F, Ozols RF, Eldermire E, Bookman MA, Chen T, Curtin J, Hess LM, Liebes L, Young RC, Trimble E. Proceedings of a GOG workshop on intraperitoneal therapy for ovarian cancer. Gynecol Oncol 2006; 103:783-92. [PMID: 17070570 PMCID: PMC1987372 DOI: 10.1016/j.ygyno.2006.09.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2006] [Accepted: 09/11/2006] [Indexed: 11/18/2022]
Abstract
Ovarian cancer is the leading cause of gynecologic cancer deaths in the U.S. The concept of intraperitoneal drug delivery for therapy of intraperitoneal cancers, such as ovarian cancer, arose in the 1960s. The field of intraperitoneal cisplatin therapy for ovarian cancer was initiated in the late 1970s and early 1980s. The markedly improved survival data resulting from a phase III trial of intraperitoneal cisplatin for ovarian cancer in early 2006 led to an NCI Clinical Announcement and a Gynecologic Oncology Group-sponsored workshop on intraperitoneal therapy in January, 2006, in San Diego, California. The proceedings of this workshop summarize both research trial results and practical implementation issues associated with intraperitoneal therapy discussed at this workshop.
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Affiliation(s)
- D S Alberts
- University of Arizona, Arizona Cancer Center, 1515 N. Campbell Avenue, POB 245024, Tucson, AZ 85724-5024, and Case Western Reserve University Hospital, USA.
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Basile S, Angioli R, Manci N, Palaia I, Plotti F, Benedetti Panici P. Gynecological cancers in developing countries: the challenge of chemotherapy in low-resources setting. Int J Gynecol Cancer 2006; 16:1491-7. [PMID: 16884356 DOI: 10.1111/j.1525-1438.2006.00619.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The epidemiologic pattern of cancers in developing countries differs in many aspects from that of industrialized nations. Cancer natural history, microbiologic environment, patient's immune system, and drug availability may differ as well. Four of five new cases of cervical cancer and most of cervical cancer deaths occur in developing countries. Where chemoradiation and supportive care facilities are unavailable, it would be logical to consider an inexpensive effective drug. In locally advanced cases, neoadjuvant chemotherapy followed by surgery should be considered the treatment of choice. For ovarian cancer, it may be reasonable to maintain a secure supply of platinum and/or taxanes. For endometrial cancer, platinum compounds are proved active chemotherapic single agents. Oral medroxyprogesterone acetate (MPA) may represent a good chance for treating an advanced or recurrent disease. For vulvar/vaginal cancer, the role of chemotherapy alone is currently considered limited, and it is mostly used as palliative treatment in advanced or recurrent cases. Whenever possible, standard western chemotherapic regimens should be applied in developing countries as well. When standard therapies are unavailable, drugs of choice should be easily accessible, inexpensive, and effective. The most commonly used drugs are cisplatin, cyclophosphamide, and MPA.
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Affiliation(s)
- S Basile
- Department of Obstetrics and Gynecology, La Sapienza University of Rome, Italy
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Markman M, Walker JL. Intraperitoneal chemotherapy of ovarian cancer: a review, with a focus on practical aspects of treatment. J Clin Oncol 2006; 24:988-94. [PMID: 16461779 DOI: 10.1200/jco.2005.05.2456] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Maurie Markman
- The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA.
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Argyriou AA, Polychronopoulos P, Iconomou G, Koutras A, Kalofonos HP, Chroni E. Paclitaxel plus carboplatin-induced peripheral neuropathy. A prospective clinical and electrophysiological study in patients suffering from solid malignancies. J Neurol 2005; 252:1459-64. [PMID: 16284715 DOI: 10.1007/s00415-005-0887-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2005] [Revised: 03/22/2005] [Accepted: 04/13/2005] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The current study intended to determine the incidence, severity and reversibility of paclitaxel plus carboplatin (CP)-induced peripheral neuropathy (CPPN) and to describe its clinical and electrophysiological features. PATIENTS AND METHODS We prospectively studied 21 adult patients scheduled to be treated with 6 courses of cumulative carboplatin plus paclitaxel (CP) regimens for a non-myeloid malignancy. They were followed-up by neurological examination and electrophysiological study during chemotherapy and 3 months after its discontinuation. The severity of neurotoxicity was assessed by means of a modified peripheral neuropathy (PNP) score. RESULTS Evidence of CPPN was recorded in 14 of the 21 patients (66.6 %). The sensory symptoms were present in the lower limbs first and then involved the upper limbs. No statistical significance, concerning the changes from baseline to subsequent mean scores in all motor conduction parameters examined,was revealed. By contrast, comparisons of the mean changes at baseline and each of the follow-up studies showed significant decrease in all sensory action potentials examined. The mean PNP scores for patients that manifested some grade of neurotoxicity were 17.9 +/- 9.8. The followup data 3 months after the discontinuation of chemotherapy showed that the CP-induced neuropathy was at least partially reversed. CONCLUSIONS CP-induced neuropathy was symmetrical, distal and predominantly sensory in character, though minor to moderate motor signs were only evident in severely affected patients. Reversibility of CP-induced neuropathy was partially observed after the suspension of chemotherapy.
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Affiliation(s)
- Andreas A Argyriou
- Dept. of Neurology, Laboratory of Clinical Neurophysiology, University of Patras Medical School, P.O. Box 1045, Rion, Patras, Greece.
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Guppy AE, Nathan PD, Rustin GJS. Epithelial Ovarian Cancer: A Review of Current Management. Clin Oncol (R Coll Radiol) 2005; 17:399-411. [PMID: 16149282 DOI: 10.1016/j.clon.2005.05.009] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Epithelial ovarian cancer is the most lethal gynaecological cancer among women worldwide, with 6000 new cases diagnosed in the UK each year. Most women present with advanced disease, but, despite a good initial response to treatment, most relapse. The overall 5-year survival rate is 46%, although this drops to about 13% in women with advanced disease. Transvaginal ultrasound and the tumour marker CA125 are being investigated for screening in ongoing randomised trials. Treatment of ovarian cancer is dependent on clinical stage, and should always be managed within a multidisciplinary team. Most cases will require a pelvic clearance and adjuvant chemotherapy. Current guidelines by the National Institute of Clinical Excellence (NICE) recommend that first-line chemotherapy should include a platinum-based regimen with or without paclitaxel. Relapsed ovarian cancer is incurable; however, chemotherapy can improve quality of life and survival. Gene therapy, immunotherapy and signal transduction inhibitors are all potential future therapies, and are being investigated in ongoing clinical research. In this paper we review the literature on the epidemiology, pathology, clinical features and the current treatment options in epithelial ovarian cancer.
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Affiliation(s)
- A E Guppy
- Department of Medical Oncology, Mount Vernon Cancer Centre, Northwood, Middlesex, UK
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36
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Herrington JD, Tran HT, Riggs MW. Prospective evaluation of carboplatin AUC dosing in patients with a BMI>or=27 or cachexia. Cancer Chemother Pharmacol 2005; 57:241-7. [PMID: 16133538 DOI: 10.1007/s00280-005-0012-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2004] [Accepted: 04/26/2005] [Indexed: 10/25/2022]
Abstract
When determining the carboplatin dosage from the Calvert formula, there are a lack of data when evaluating patients with cachexia or body mass index (BMI)>or=27. If the Cockcroft and Gault (C-G) creatinine clearance (CrCl) equation is utilized and substituted for glomerular filtration rate in the Calvert formula, the chance for inaccurate dosing occurs especially in these populations. Therefore, the purpose of this study is to evaluate and compare the target carboplatin area under the concentration (AUC) with the actual AUC achieved in cachectic or BMI>or=27 patients. In a prospective manner, we evaluated 19 patients with a BMI>or=27 and nine cachectic patients. In the C-G equation to determine creatinine clearance, the adjusted body weight was used for BMI>or=27 patients and serum creatinine value of 70.7 microM (0.8 mg/dl) for the cachectic patients. The carboplatin dose was calculated, administered to the patients, and subsequent carboplatin blood samples were obtained for pharmacokinetic determination. Once the AUC was determined, the results were compared with the expected outcomes from the modified C-G CrCl equation for the Calvert formula, Chatelut and Bénézet equations. The results demonstrated that the modified C-G CrCl equation for the Calvert formula had less bias and more precision than using actual weight in the C-G CrCl equation or using the Chatelut and Bénézet equations. Using the actual weight in overweight and especially obese patients and using a serum creatinine<70.7 microM in cachectic patients will lead to overestimation of the carboplatin clearance and thus AUC.
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Affiliation(s)
- Jon D Herrington
- Department of Clinical Pharmacy, Scott & White Memorial Hospital, 2401 South 31st Street, Temple, TX 76508, USA.
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McKeage MJ. New-generation platinum drugs in the treatment of cisplatin-resistant cancers. Expert Opin Investig Drugs 2005; 14:1033-46. [PMID: 16050795 DOI: 10.1517/13543784.14.8.1033] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Platinum drugs with altered stable ligands, such as oxaliplatin and satraplatin, produce a different DNA-adduct profile to cisplatin. This results in a distinct therapeutic profile, and clinical trials with these agents demonstrate significant anticancer activity in diseases with inherent or acquired resistance to cisplatin, such as colorectal and prostate cancers as well as previously treated ovarian and germ-cell cancer. An alternative approach to increasing the efficacy associated with platinum therapy is to enhance tumour delivery by coupling platinum drugs with a polymer or encapsulating the agent in a liposome. The early clinical trials of these novel delivery formulations are promising but, as yet, have not confirmed that the delivery of platinum to the tumour cell DNA is increased.
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Affiliation(s)
- Mark J McKeage
- Department of Pharmacology and Clinical Pharmacology, School of Medical Sciences, The University of Auckland, Auckland, New Zealand.
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Foreman NK, Schissel D, Le T, Strain J, Fleitz J, Quinones R, Giller R. A study of sequential high dose cyclophosphamide and high dose carboplatin with peripheral stem-cell rescue in resistant or recurrent pediatric brain tumors. J Neurooncol 2005; 71:181-7. [PMID: 15690136 DOI: 10.1007/s11060-004-1366-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To determine the maximum tolerated dose (MTD) of carboplatin with autologous hematopoietic stem-cell rescue, in children with poor-prognosis brain tumors. PATIENTS AND METHODS A previously determined dose of cyclophosphamide with stem-cell rescue was used as a first course. In a second course, carboplatin was given for 3 days with stem-cell rescue to 20 children. The starting dose of carboplatin was 400 mg/m2/day with increments of 75 mg/m2/day in subsequent cohorts. Toxicity and tumor response were recorded. RESULTS There were two grade IV toxicities at the dose level of 775 mg/m2/day. There were no toxic deaths. Thus, the MTD of carboplatin was 700 mg/m2/day for 3 days. There were six complete responses (33%, 95% confidence interval [CI], 13-59%), two partial responses (11%; 95% CI, 1-35%), four with stable diseases (22%; 95% CI, 6-48%) and six progressed (33%; 95% CI, 13-59%) out of 18 assessable. Seven of the eight responses were in primitive neuroectodermal tumors (PNETs) or Germinomas. One child with a metastatic anaplastic astrocytoma had a CR. The median duration of tumor response was 10 months (range: 1.5-87 months) with two children disease free at 66 and 87 months. Actuarial survival is 21%. Median follow-up of survivors is 35 months (range: 15-87 months). CONCLUSION The MTD of carboplatin with stem-cell rescue is 700 mg/m2/day for 3 days. Sequential stem-cell supported cyclophosphamide and carboplatin was tolerable in children with brain tumors and produced responses in PNETs and Germinomas.
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Affiliation(s)
- N K Foreman
- The Children's Hospital, Denver, and The University of Colorado, Health Sciences Center, Denver, Colorado 80218, USA.
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Donato ML, Aleman A, Champlin RE, Saliba RM, Wharton JT, Burke TW, Bodurka DC, Bevers MW, Levenback CF, Wolf JK, Bast RC, Freedman RS, Ippoliti C, Brewer M, Gajewski JL, Gershenson DM. Analysis of 96 patients with advanced ovarian carcinoma treated with high-dose chemotherapy and autologous stem cell transplantation. Bone Marrow Transplant 2005; 33:1219-24. [PMID: 15122311 DOI: 10.1038/sj.bmt.1704473] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The purpose of this study was to identify characteristics significant to survival and progression-free survival in patients with advanced ovarian cancer receiving high-dose chemotherapy. In all, 96 patients received autologous stem cell transplantation. Regimens included paclitaxel with carboplatin (PC), topotecan, melphalan, cyclophosphamide (TMC) and cyclophosphamide, BCNU, thiotepa (CBT). At the time of transplantation, 43% of patients were in clinical CR, 34% were in clinical PR, 18% had progressive disease and 5% had stable disease. There were no treatment-related deaths. The 6-year survival by Kaplan-Meier was 38%. For patients who received transplantation for remission consolidation, the 6-year survival was 53% with a PFS of 29%. On univariate analysis, the CBT regimen, clear cell histology and disease status other than CR prior to treatment were statistically significant adverse prognostic factors. This analysis has demonstrated that patients in clinical remission are most likely to benefit from autologous transplantation, with the exception of patients with clear cell histology. The TMC combination appeared to be superior to the PC and CBT combinations. Comparative studies of different consolidation approaches will be necessary to determine if autologous transplantation is the preferred treatment for this patient population.
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Affiliation(s)
- M L Donato
- Department of Blood and Marrow Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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Abstract
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.
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Affiliation(s)
- Franco M Muggia
- Division of Medical Oncology and Clinical Cancer Center, School of Medicine, New York University, New York, NY 10016, USA
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Markman M. Can we do a better job preventing clinically-relevant peripheral neuropathy resulting from carboplatin/paclitaxel chemotherapy? Cancer Invest 2004; 22:471-3. [PMID: 15493367 DOI: 10.1081/cnv-200029076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Maurie Markman
- The Department of Hematology/Medical Oncology, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Mano MS, Awada A, Minisini A, Atalay G, Lago LD, Cardoso F, Piccart M. Remaining controversies in the upfront management of advanced ovarian cancer. Int J Gynecol Cancer 2004; 14:707-20. [PMID: 15361178 DOI: 10.1111/j.1048-891x.2004.014502.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- M S Mano
- Unité de Chimiothérapie, Institut Jules Bordet, Brussels, Belgium.
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Markman M, Markman J, Webster K, Zanotti K, Kulp B, Peterson G, Belinson J. Thrombocytopenia associated with second-line carboplatin-based chemotherapy for ovarian, fallopian tube, and primary peritoneal cavity cancers. J Cancer Res Clin Oncol 2004; 130:741-4. [PMID: 15338296 DOI: 10.1007/s00432-004-0598-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2003] [Accepted: 06/04/2004] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Maurie Markman
- University of Texas M.D. Anderson Cancer Center, Houston, 77030, USA.
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Muggia FM. Sequential single agents as first-line chemotherapy for ovarian cancer: a strategy derived from the results of GOG-132. Int J Gynecol Cancer 2004; 13 Suppl 2:156-62. [PMID: 14656273 DOI: 10.1111/j.1525-1438.2003.13351.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
First-line chemotherapy for ovarian cancer during the past decade has evolved toward the use of carboplatin and paclitaxel combinations. This has been based on randomized trials showing that combinations of these two drugs lead to a outcome similar to that obtained using cisplatin and paclitaxel (that had, in turn, proven superior in progression-free survival and overall survival to cisplatin and cyclophosphamide) but with less toxicity. Surprisingly, taxane-platinum combinations were not superior to control arms in two studies (ICON3 and GOG-132) utilizing carboplatin or cisplatin as the comparators. This has renewed interest in the role of single agents in first-line chemotherapy - a concept also supported by a number of prior clinical trials with single-agent platinum compounds yielding results not inferior to combinations. Early 'pre-emptive' crossover (prior to the stipulated clinical progression) to paclitaxel or a paclitaxel-containing regimen, however, occurred in 24% of patients initially treated with cisplatin on GOG-132. This has led to the interpretation of this trial as a combination versus sequential design. Although not subscribing to this interpretation, the results of GOG-132 and ICON3 not only raise doubts over a clear superiority of combinations over single agents but also lead to a consideration of sequential treatment designs for first line. Advantages of such designs are: (a) ability to provide 'dose-dense' platinums followed by 'dose-dense' paclitaxel and, perhaps, other drugs; and (b) the potential of acquiring biological data linked to the antitumor effects of a specific drug. Mathematical modeling and recent positive results in breast cancer adjuvant therapy support the use of 'dose-dense' strategies, and these should be considered in the design of future trials in ovarian cancer.
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Affiliation(s)
- F M Muggia
- NYU School of Medicine & Cancer Institute, New York, NY 10016, USA.
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Guppy AE, Nelstrop AE, Foster T, Agarwal R, Seckl MJ, Rustin GJS. A phase II study of sequential carboplatin, paclitaxel and topotecan in patients with previously untreated advanced ovarian cancer. Br J Cancer 2004; 90:810-4. [PMID: 14970858 PMCID: PMC2410185 DOI: 10.1038/sj.bjc.6601618] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- A E Guppy
- Department of Medical Oncology, The Clocktower, Mount Vernon Centre for Cancer Treatment, Rickmansworth Road, Northwood, Middlesex HA6 2RN, UK
| | - A E Nelstrop
- Department of Medical Oncology, The Clocktower, Mount Vernon Centre for Cancer Treatment, Rickmansworth Road, Northwood, Middlesex HA6 2RN, UK
| | - T Foster
- Charing Cross Hospital, London W6 8RF, UK
| | - R Agarwal
- Charing Cross Hospital, London W6 8RF, UK
| | - M J Seckl
- Charing Cross Hospital, London W6 8RF, UK
| | - G J S Rustin
- Department of Medical Oncology, The Clocktower, Mount Vernon Centre for Cancer Treatment, Rickmansworth Road, Northwood, Middlesex HA6 2RN, UK
- Department of Medical Oncology, The Clocktower, Mount Vernon Centre for Cancer Treatment, Rickmansworth Road, Northwood, Middlesex HA6 2RN, UK. E-mail:
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Polee MB, Sparreboom A, Eskens FALM, Hoekstra R, van de Schaaf J, Verweij J, Stoter G, van der Gaast A. A Phase I and Pharmacokinetic Study of Weekly Paclitaxel and Carboplatin in Patients with Metastatic Esophageal Cancer. Clin Cancer Res 2004; 10:1928-34. [PMID: 15041708 DOI: 10.1158/1078-0432.ccr-03-0319] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine the maximum-tolerated dose, toxicity profile, and pharmacokinetics of a fixed dose of paclitaxel followed by increasing doses of carboplatin, given weekly to patients with advanced esophageal or gastric junction cancer. EXPERIMENTAL DESIGN Paclitaxel was administered on day 1 as a 1-h infusion at a fixed dose of 100 mg/m(2) followed by a 1-h infusion of carboplatin targeting an area under the curve (AUC) of 2-5 mg x min/ml, with cycles repeated on days 8, 15, 29, 36, and 43. RESULTS Forty patients [36 males; median (range) age, 57 (40-74) years] were enrolled. Dose-limiting toxicity was observed at a carboplatin AUC of 5 mg x min/ml and consisted of treatment delay attributable to myelosuppression. No grade 3/4 treatment-related nonhematological toxicity was observed. The highest dose intensity (>95% of the planned dose over time) was achieved with a carboplatin AUC of 4 mg x min/ml. The mean (+/-SD) AUCs of unbound (Cu) and total paclitaxel were 0.662 +/- 0.186 and 7.37 +/- 1.33 micro M x h, respectively. Clearance of Cu was 188 +/- 44.6 liter/h/m(2), which is not significantly different from historical data (P = 0.52). Cremophor EL clearance was 123 +/- 23 ml/h/m(2), similar to previous findings. Of 37 patients evaluable for response, 1 had complete response, 19 had partial response, and 10 had stable disease, accounting for an overall response rate of 54%. CONCLUSIONS This regimen is very tolerable and effective, and the recommended doses for additional studies are paclitaxel (100 mg/m(2)), with carboplatin targeting an AUC of 4 mg x min/ml.
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Affiliation(s)
- Marco B Polee
- Department of Medical Oncology and Laboratory of Translational and Molecular Pharmacology, Rotterdam, the Netherlands
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Markman J, Zanotti K, Webster K, Belinson J, Peterson G, Kulp B, Markman M. Experience with the management of neutropenia in gynecologic cancer patients receiving carboplatin-based chemotherapy. Gynecol Oncol 2004; 92:592-5. [PMID: 14766252 DOI: 10.1016/j.ygyno.2003.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2003] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Jonathan Markman
- Department of Hematology/Medical Oncology, Gynecology/Obstetrics, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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Biagi JJ, Eisenhauer EA. Systemic treatment policies in ovarian cancer: the next 10 years. Int J Gynecol Cancer 2003; 13 Suppl 2:231-40. [PMID: 14656285 DOI: 10.1111/j.1525-1438.2003.13356.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- J J Biagi
- Kingston Regional Cancer Centre, Kingston, ON, Canada.
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Ozols RF, Bundy BN, Greer BE, Fowler JM, Clarke-Pearson D, Burger RA, Mannel RS, DeGeest K, Hartenbach EM, Baergen R. 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. J Clin Oncol 2003; 21:3194-200. [PMID: 12860964 DOI: 10.1200/jco.2003.02.153] [Citation(s) in RCA: 1475] [Impact Index Per Article: 70.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Robert F Ozols
- Medical Science Department, Fox Chase Cancer Center, Philadelphia, PA, USA
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