First-line chemotherapy with epirubicin, paclitaxel, and carboplatin for advanced ovarian cancer: a phase I/II study of the Arbeitsgemeinschaft Gynäkologische Onkologie Ovarian Cancer Study Group

Profile of erlotinib and its potential in the treatment of advanced ovarian carcinoma

The epidermal growth-factor receptor (EGFR) is overexpressed in the majority of epithelial ovarian cancers and promotes cell proliferation, migration and invasion, and angiogenesis, as well as resistance to apoptosis. This makes EGFR an attractive therapeutic target in this disease. A number of strategies to block EGFR activity have been developed, including small-molecular-weight tyrosine kinase inhibitors such as erlotinib. Erlotinib has been evaluated as a single agent in recurrent ovarian cancer, as well as in combination with chemotherapeutic agents in the first-line and recurrent settings, and in combination with the antiangiogenic agent bevacizumab in the recurrent setting, as well as in the maintenance setting after completion of first-line chemotherapy. Unfortunately, erlotinib has shown only minimal efficacy as a single agent, and it has not enhanced the effects of chemotherapy or bevacizumab when combined with these agents. Ongoing and future studies of erlotinib and other agents blocking EGFR will need to define mechanisms resulting in resistance to such interventions, and to validate biomarkers of response to identify patients most likely to benefit from such approaches.

A phase II study of erlotinib (OSI-774) given in combination with carboplatin in patients with recurrent epithelial ovarian cancer (NCIC CTG IND.149)

OBJECTIVES

Approximately 50% of ovarian cancers have elevated levels of epidermal growth factor receptor (EGFR) which correlates with a poor prognosis. Preclinical evidence suggests that EGFR tyrosine kinase inhibitors (TKIs), such as erlotinib (OSI-774), may potentiate the anti-tumour effects of cytotoxic agents, including carboplatin. Blocking EGFR could thus potentially reverse drug resistance. The primary objective of the study was to assess the response rate to the addition of erlotinib in patients with recurrent ovarian cancer who were receiving carboplatin.

METHODS

Patients enrolled on this study had either local or advanced recurrent ovarian cancer with measurable disease. They may have had up to 2 prior chemotherapy regimens, one of which must have contained platinum, and they must have responded to prior platinum therapy. Patients were stratified by platinum sensitivity and were treated with erlotinib 150 mg daily on a continuous dosing schedule, and carboplatin at an AUC of 5 every 21 days.

RESULTS

Fifty patients with recurrent ovarian cancer entered the study, 33 in the platinum-sensitive arm and 17 in the platinum-resistant arm. Of patients evaluable for response, there were 14 partial responses (PR) of 30 evaluable for response (57% objective response rate (ORR)) in the platinum-sensitive arm, and 1 PR of 14 evaluable for response (7% ORR) in the platinum-resistant arm.

CONCLUSIONS

The combination of erlotinib and carboplatin was active in patients with platinum-sensitive disease, but not in platinum-resistant disease. The toxicities seen were those expected with carboplatin and erlotinib.

First-line treatment of advanced ovarian cancer: current research and perspectives

Epithelial ovarian cancer is the fourth biggest cause of cancer-related death in women. Over recent decades, improvements have been made in treatment outcome in terms of response rate and survival. To date, intensive surgical staging and cytoreduction, followed by primary chemotherapy with the carboplatin-paclitaxel regimen, are considered the gold standard for the management of this disease. Nevertheless, despite good initial response to systemic therapy after optimal debulking surgery, the long-term survival remains poor, with a high risk of recurrence. Furthermore, medical therapy of ovarian cancer impacts quality of life owing to the common occurrence of chemotherapy side effects, such as alopecia, neurotoxicity and fatigue. In order to improve the efficacy and reduce the toxicity of first-line chemotherapy, more than 10,000 women have been involved in worldwide randomized trials in the last 10 years. Several treatment alternatives have been investigated, such as intraperitoneal chemotherapy, alternative doublets and triplet regimens, in the effort to find an optimal first-line treatment strategy. In this review we discuss the results of these trials, the recent progresses and the most important ongoing studies, including those with emerging target and biological agents.

Southwest Oncology Group Trial S9912: intraperitoneal cisplatin and paclitaxel plus intravenous paclitaxel and pegylated liposomal doxorubicin as primary chemotherapy of small-volume residual stage III ovarian cancer

OBJECTIVE

While primary cisplatin-based intraperitoneal chemotherapy has been shown to favorably impact survival in small-volume residual advanced ovarian cancer, there is a need to develop strategies that improve the effectiveness of this approach.

METHODS

A multi-center phase 2 trial was conducted that added intravenous pegylated liposomal doxorubicin (day 8; 30-40 mg/m(2)) to a regimen of intraperitoneal cisplatin (day 2; 75 mg/m(2)) and intravenous (day 1; 135 mg/m(2)) plus intraperitoneal (day 8; 60 mg/m(2)) paclitaxel. Treatment was initially delivered on an every 3-week schedule, but was modified to an every 4-week program due to excessive toxicity. Patients were to receive 6 cycles of this regimen.

RESULTS

Of 68 patients entering this trial, 63 patients were eligible and evaluable, of whom 39 (62%) completed 6 cycles. Overall, 32 (51%) experienced at least 1 grade 4 or worse toxicity (most commonly hematologic) including 5 treatment-related deaths. Median progression-free survival (PFS) was 25 months (2-year PFS: 52%) and median overall survival 51 months, an outcome similar to previous reports of cisplatin-based intraperitoneal chemotherapy in comparable patient populations. Seventeen patients (27% of all eligible patients) were without evidence of disease recurrence >4 years following entry into the trial.

CONCLUSION

Both the overall trial outcome, and specifically the excessively severe systemic toxicity of this regimen would prevent its future development in this exact form. The provocative PFS in a subset of individuals should encourage the development of alternative strategies designed to optimize the delivery of regional therapy in ovarian cancer management.

A phase II randomised clinical trial comparing cisplatin, paclitaxel and ifosfamide with cisplatin, paclitaxel and epirubicin in newly diagnosed advanced epithelial ovarian cancer: long-term survival analysis

To test the feasibility and efficacy of epirubicin and ifosfamide added to first-line chemotherapy with cisplatin and paclitaxel in a phase II randomised clinical trial. Patients with histologically proven epithelial ovarian cancer were randomly assigned to receive first-line polychemotherapy with cisplatin/paclitaxel/epirubicin (CEP) or cisplatin/paclitaxel/ifosfamide (CIP) for six cycles every 21 days. Two hundred and eight patients were randomised between the two treatment arms and the median number of cycles per patient was six. Toxicity was predominantly haematological with both regimens; however, anaemia, leucopaenia, neutropaenic fever and use of granulocyte colony-stimulating factors and transfusion were significantly more frequent in the CIP treatment arm. Response rates were 85% (95% confidence interval (CI) 77-93%) in the CIP arm and 90% (95% CI 84-96%) in the CEP arm; complete response rates were 48 and 52%. After a median follow-up of 82 months, median overall survival (OS) was 51 and 65 months; 5-year survival rates were respectively 43 and 50%. In this clinical trial, both regimens showed good efficacy, but toxicity was heavier with the CIP regimen. Considering that more than 50% of patients were suboptimally debulked after the first surgery, OS seems to be longer than is commonly reported. This unexpected finding might be a consequence of the close surgical surveillance and aggressive chemotherapeutic approach.

Focal adhesion kinase targeting using in vivo short interfering RNA delivery in neutral liposomes for ovarian carcinoma therapy

PURPOSE

Focal adhesion kinase (FAK) plays a critical role in ovarian cancer cell survival and in various steps in the metastatic cascade. Based on encouraging in vitro results with FAK silencing, we examined the in vivo therapeutic potential of this approach using short interfering RNA (siRNA) in the neutral liposome 1,2-dioleoyl-sn-glycero-3-phosphatidylcholine (DOPC).

EXPERIMENTAL DESIGN

Therapy experiments of FAK siRNA with or without docetaxel were done using human ovarian cancer cell lines SKOV3ip1, HeyA8, and HeyA8MDR in nude mice. Additional experiments with a cisplatin-resistant cell line (A2780-CP20) were also done. Assessments of angiogenesis (CD31), cell proliferation (proliferating cell nuclear antigen), and apoptosis (terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling) were done using immunohistochemical analysis.

RESULTS

A single dose of FAK siRNA-DOPC was highly effective in reducing in vivo FAK expression for up to 4 days as assayed by Western blot and immunohistochemical analysis. Therapy experiments were started 1 week after injection of the ovarian cancer cells. Treatment with FAK siRNA-DOPC (150 mug/kg twice weekly) reduced mean tumor weight by 44% to 72% in the three cell lines compared with the control group (Ps < 0.05 for HeyA8, A2780-CP20, and SKOV3ip1). When FAK siRNA-DOPC was combined with docetaxel, there was even greater reduction in mean tumor weight in all models (all Ps < 0.05). Similar results were observed in combination with cisplatin. Treatment with FAK siRNA-DOPC plus docetaxel resulted in decreased microvessel density, decreased expression of vascular endothelial growth factor and matrix metalloproteinase-9, and increased apoptosis of tumor-associated endothelial cells and tumor cells.

CONCLUSIONS

Taken together, these findings suggest that FAK siRNA-DOPC plus docetaxel or platinum might be a novel therapeutic approach against ovarian cancer.

Paclitaxel, carboplatin and pegylated liposomal doxorubicin in ovarian and peritoneal carcinoma: a phase I study of the Gynecologic Oncology Group

PURPOSE

Based on the activity and tolerability of liposomal doxorubicin in platinum- and paclitaxel-resistant ovarian carcinoma, we conducted a phase I trial of pegylated liposomal doxorubicin with paclitaxel and carboplatin to determine the maximum tolerated dose (MTD) in chemotherapy naive ovarian, peritoneal and tubal carcinoma patients.

METHODS

Three schedules were studied: paclitaxel, carboplatin and pegylated liposomal doxorubicin every 28 days; paclitaxel and carboplatin every 21 days with liposomal doxorubicin every 42 days; and weekly paclitaxel, carboplatin (AUC=5) every 21 days and liposomal doxorubicin every 42 days. The paclitaxel dose was 175 mg/m(2) over 3 h on an every 3-4 week schedule and 60 mg/m(2) when administered weekly. Based on the frequency of neutropenic sepsis, grade 4 thrombocytopenia and > or =grade 3 non-hematologic toxicity, the starting dose of liposomal doxorubicin of 20 mg/m(2) was escalated to determine the MTD.

RESULTS

A total of 210 (21-day) cycles were administered to 37 patients. Dose-limiting toxicity (DLT) occurred when liposomal doxorubicin was administered at 40 mg/m(2). Because of treatment-related delays resulting in decreased paclitaxel/carboplatin dose intensity, administration was modified to be given every 21 days, with liposomal doxorubicin given every 42 days. Since neutropenia was the DLT of this schedule, the schema was further modified to administer paclitaxel weekly; however, weekly administration was inconsistent because of toxicity.

CONCLUSION

Paclitaxel 175 mg/m(2), carboplatin (AUC=5) and pegylated liposomal doxorubicin 30 mg/m(2) are tolerable without supportive therapy. The usual dose intensity of paclitaxel/carboplatin was maintained by administering liposomal doxorubicin every other cycle.

Addition of Epirubicin As a Third Drug to Carboplatin-Paclitaxel in First-Line Treatment of Advanced Ovarian Cancer: A Prospectively Randomized Gynecologic Cancer Intergroup Trial by the Arbeitsgemeinschaft Gynaekologische Onkologie Ovarian Cancer Study Group and the Groupe d'Investigateurs Nationaux pour l'Etude des Cancers Ovariens

Purpose

Despite the progress that has been achieved, long-term survival rates in patients with advanced ovarian cancer are still disappointing. One attempt to improve results could be the addition of non–cross-resistant drugs to platinum-paclitaxel combination regimens. Anthracyclines were among the candidates for incorporation as a third drug into first-line regimens.

Patients and Methods

We performed a prospectively randomized phase III study comparing carboplatin-paclitaxel (TC; area under the curve 5/175 mg/m2, respectively) with epirubicin 60 mg/m2 added to the same combination (TEC) in previously untreated patients with advanced epithelial ovarian cancer. All drugs were administered intravenously on day 1 of a 3-week schedule for a planned minimum of six courses.

Results

Between November 1997 and February 2000, 1,282 patients were randomly assigned to receive either TC (635 patients) or TEC (647 patients), respectively. Grade 3/4 hematologic and some nonhematologic toxicities (nausea/emesis, mucositis, and infections) occurred significantly more frequently in the TEC arm. Accordingly, quality-of-life analysis showed inferiority of TEC versus TC. Median progression-free survival time was 18.4 months for the TEC arm and 17.9 months for the TC arm (hazard ratio [HR], 0.95; 95% CI, 0.83 to 1.07; P = .3342). Median overall survival time was 45.8 months for the TEC arm and 41.0 months for the TC arm (HR, 0.93; 95% CI, 0.81 to 1.08; P = .3652). Similar nonsignificant differences were observed when strata were analyzed separately.

Conclusion

Addition of epirubicin to TC did not improve survival or time to treatment failure in patients with advanced epithelial ovarian cancer; therefore, it cannot be recommended for clinical use in this population.

Role of chemotherapy in the management of epithelial ovarian cancer

The management of ovarian cancer continues to provide major challenges and debates about optimal treatment. For first-line therapy there remain discussions about optimal chemotherapy for early disease, the use of taxanes as standard for advanced newly diagnosed patients, whether there is a definite role for neoadjuvant chemotherapy and the question of maintenance treatment. For relapsed disease, the management hinges around the distinction between platinum-sensitive and -resistant cancer, and the recent AGO-2.5 and ICON-4 studies suggest that treating with carboplatin and paclitaxel or carboplatin and gemcitabine is recommended. Intraperitoneal chemotherapy remains an enigma with at least three studies showing survival advantage; however, there has been no move to incorporate it into standard management of those patients who achieve complete remission after first-line chemotherapy. Finally, neoadjuvant chemotherapy prior to debulking surgery is the subject of several ongoing clinical trials and may turn out to be one of the most important developments since the concept of interval debulking surgery was established and proven in Europe.

Future options for first-line therapy of advanced ovarian cancer

The current standard of treatment for patients with advanced ovarian cancer has been established in light of the results from various clinical trials. After debulking surgery, a combination of carboplatin and paclitaxel is considered to be the best treatment option in terms of survival and quality of life. However, since most patients on this chemotherapy modality will experience relapse, several studies have explored, and continue to do so, various modifications and alternatives to standard therapy in order to attain improved efficacy. Various modifications of dose, schedule, or route of standard regimens have shown no benefit, apart from intraperitoneal therapy, which has produced mixed results and would benefit from a definitive trial. Studies of maintenance/consolidation therapy have been mainly negative, although a small number of trials have produced enough positive data to prompt two new studies powered to detect survival benefits. Various phase II trials have investigated "targeted therapies," but until now no positive results have been recorded. Translational studies are needed to identify patients who will benefit from such specific treatment strategies. The current most evaluated modification of standard therapy is the addition of a third non-cross-resistant drug to carboplatin and paclitaxel. Data for the addition of anthracyclines have either been negative (epirubicin) or not yet analyzed (pegylated liposomal doxorubicin), while evaluable data are shortly expected for the addition of topotecan. Data on the addition of gemcitabine are eagerly awaited from two phase III trials.

First-line treatment of ovarian cancer FIGO stages IIb-IV with paclitaxel/epirubicin/carboplatin versus paclitaxel/carboplatin

The objective of this study was to compare the safety and efficacy of carboplatin plus epirubicin and paclitaxel (TEC) to carboplatin and paclitaxel (TC), in the treatment of epithelial ovarian, peritoneal, or tubal carcinoma. Between March 1999 and August 2001, 887 patients were randomized to receive six to nine cycles of paclitaxel (175 mg/m2, 3 h intravenously) followed by carboplatin (AUC 5, Calvert formula) with or without epirubicin (75 mg/m2 intravenously prior to paclitaxel), on a 3-weekly schedule. The primary endpoint was progression-free survival. Demographic information: Residual disease <1 cm was reported on 41% of patients. At the end of treatment, 65% in the TEC and 55% in the TC arm had achieved a clinical complete response, and 18 and 25% a clinical partial response resulting in an overall response rate of 83% in the TEC and 80% in the TC arm, whereas 7 and 9% had progressive disease, respectively. The three-drug combination produced a markedly higher myelotoxicity, resulting in a higher frequency of febrile neutropenia (12.5% of the TEC and 1.5% of the TC patients) and a higher number of dose reductions and treatment delays. Cycle prolongation above seven days was seen in 7 and 5% of cycles in the TEC and TC arm, respectively. Stomatitis > or = grade 3 was also higher with TEC (4% TEC and 0.5% TC). Reductions in left ventricular ejection fraction of more than 15% after six courses were slightly more common with the TEC regimen (3% versus 1.5%), but the difference was not statistically significant (P = 0.2). In conclusion, treatment with the TEC combination produced a higher rate of complete responses than treatment with the TC combination. Toxicity was manageable. Long-term survival data are awaited.

The predictive and prognostic value of serum CA 125 half-life during paclitaxel/platinum-based chemotherapy in patients with advanced ovarian carcinoma

OBJECTIVES

Serum CA 125 kinetics during early chemotherapy has a strong predictive and prognostic relevance for patients with advanced ovarian carcinoma who received a first-line platinum-based regimen, whereas the ability of serum CA 125 assay to reflect the response to paclitaxel-based chemotherapy has not yet been defined. The aim of the present paper is to calculate the serum CA 125 half-life during first-line paclitaxel/platinum-based chemotherapy in patients with advanced ovarian carcinoma and to correlate this kinetic parameter with the response to treatment, progression-free survival and overall survival.

METHODS

This retrospective investigation assessed 71 patients with stages IIc-IV ovarian carcinoma who underwent initial surgery followed by paclitaxel/platinum-based chemotherapy and who had serum CA 125 > 35 U/ml before the first cycle of chemotherapy. Only epithelial ovarian cancers were included.

RESULTS

The 25%, 50%, and 75% quantiles of serum CA 125 half-life during early chemotherapy were 10, 14, and 20 days, respectively. Taking the value corresponding to the 50% quantile (i.e., 14 days) as cutoff limit, serum CA 125 half-life was an independent prognostic factor for the chance of achieving a complete response to treatment as well as for progression-free survival and overall survival. In detail, patients with serum antigen half-life <== 14 days had a 3.362 times as great probability to achieve a complete response and a 3.113 times as low probability to die when compared to those with a longer half-life.

CONCLUSIONS

Serum CA 125 assay represents a reliable biochemical tool for the management of advanced ovarian carcinoma patients who receive a first-line paclitaxel/platinum-based chemotherapy.

Improving first-line therapy of advanced ovarian cancer - the AGO Ovarian Cancer Study Group perspective

This review displays the AGO Ovarian Cancer Study Group approach towards evaluation of improvement options in first-line therapy of advanced ovarian cancer. Prospectively randomized phase III trials evaluating the addition of newer drugs to standards carboplatin-paclitaxol (TC) as well as pilot trials evaluating new treatment modalities like anti-idiotype CA 125 antibodies or epidermal growth factor receptor (EGFR) modulation are presented.

Escalating doses of paclitaxel and epirubicin in combination with cisplatin in advanced ovarian epithelial carcinoma: a phase I-II study

Our objective was to identify a new active three-drug combination regimen consisting of paclitaxel (PTX), epirubicin (EPI) and cisplatin as first-line line chemotherapy for advanced ovarian carcinoma. A phase I study was carried out to evaluate the dose-limiting toxicity (DLT) and the maximally tolerated dose (MTD) of PXT and EPI in combination with a fixed dose of cisplatin every 4 weeks. Side-effects were recorded according to the NCI Common Toxicity Criteria. Patients were treated in cohorts of three with fixed-dose cisplatin 80 mg/m2 and EPI 80-->100 mg/m2 and PXT 100-->160 mg/m2 until DLT was reached. Once MTD was identified, a single-step phase II study was therefore carried out to test the clinical activity and panel of toxicity of such regimen. Objective responses were recorded according to the WHO criteria. Time to progression and overall survival (OS) were secondary endpoints. The DLT was myelosuppression and, in more detail, febrile neutropenia, which occurred at the fifth dose level (PTX 140 mg/m2, EPI 100 mg/m2 and cisplatin 80 mg/m2) in two out of three patients. Other side-effects were grade 3 mucositis in two out of three patients and grade 3 anemia in one case. The combination of cisplatin 80 mg/m2 plus EPI 80 mg/m2 and PCT 140 mg/m2 every 4 weeks was considered as the MTD. In the phase II study a complete response was observed in six patients (33%) and a partial response in nine cases (50%) for an overall response rate of 83% [95% confidence limits (CL) 59-96%]. Median time to progression of patients with measurable disease was 16.4 months. Median OS was not reached after a follow-up of 42 months. This study demonstrated that PTX and EPI can be safely administered in combination with cisplatin to fit patients with advanced epithelial ovarian carcinoma. The three-drug regimen of cisplatin 80 mg/m2, EPI 80 mg/m2 and PTX 140 mg/m2 every 4 weeks is very active, at least in terms of objective response rate. This level of activity overlaps with the 95% CL of the activity of cisplatin alone; however, it does encourage future trials of the combination.

First-line chemotherapy with epidoxorubicin, paclitaxel, and carboplatin for the treatment of advanced epithelial ovarian cancer patients

OBJECTIVE

A combination of carboplatin (CBDCA) and paclitaxel (TAX) is the standard treatment in advanced ovarian cancer (AOC) patients. Epidoxorubicin (EDX) is an active treatment in AOC and exhibits nonoverlapping toxicities with CBDCA and TAX; moreover, when added to platinum-based chemotherapy, it improves long-term survival. We have therefore conducted a phase II study to evaluate the tolerability and antitumor activity of an EDX/TAX/CBDCA (ETC) triplet in AOC patients.

METHODS

Patients with histologically confirmed suboptimal stage III-IV ovarian cancer who had not previously received cytotoxic drugs were treated with TAX (175 mg/m(2) in a 3-h iv infusion), CBDCA (AUC 6, Calvert formula), and EDX (75 mg/m(2) iv bolus) all given on day 1 every 28 days for a maximum of six courses on an outpatient basis. EDX dosage was chosen after a pilot phase I study.

RESULTS

Fifty-five patients were registered, of whom 5 were determined ineligible bacause of age. Forty-two of the 50 are evaluable for response; 27 (64%) achieved a clinical complete response (CR) and 9 (21%) a partial response (PR) for a response rate of 86% (95% CI 71-94%). Thirty-three patients underwent a secondary debulking procedure after a median of 6 courses (range 2-6). Pathological CR and PR were observed in 9 (27.3%) and 21 (63.6%), respectively; among patients with persistent disease a successful cytoreduction (<1 cm) was obtained in 53.8% of patients. At a median follow up of 35.6 months (range 0-55.5) median progression-free survival is 19.5 months and median overall survival is 36 months. The most common adverse effects were G3-4 leukopenia and thrombocytopenia which occurred in 59 and 37% of patients, respectively.

CONCLUSIONS

The ETC combination given according to the outlined doses and schedule is highly active in AOC patients with poor prognostic factors and deserves further study.

Phase I study of carboplatin, doxorubicin and weekly paclitaxel in patients with advanced ovarian carcinoma

BACKGROUND

Doxorubicin is an active compound in epithelial ovarian cancer (EOC), but adding it to carboplatin-paclitaxel causes toxicity. Toxicity can be reduced by weekly administration. We examined the tolerability of weekly paclitaxel in combination with carboplatin and doxorubicin.

PATIENTS AND METHODS

Chemotherapy naïve patients with EOC were treated with doxorubicin (50 mg/m(2) day 1), carboplatin (AUC 6 day 1) and paclitaxel (days 1, 8, 15, 21), 28-day cycle. Three patients were treated at each paclitaxel dose level, starting at 60, 75 and 90 mg/m(2)/week. If more than two patients in a cohort experienced dose-limiting toxicity (DLT) three more patients were treated at the dose level below.

RESULTS

Twelve patients with advanced EOC received a median of six cycles (range 2-6) of the three-drug combination. DLT occurred at dose level 3: prolonged grade 4 febrile neutropenia, 1 patient; grade 3 peripheral neuropathy, 1 patient. All six patients treated at dose level 2 experienced short-lived grade 4 neutropenia, which led to dose modifications resulting in an actual delivered dose of paclitaxel of 64 mg/m(2)/week. Eight out of 12 patients had measurable disease on CT scan: four obtained a partial remission; three had stable disease.

CONCLUSIONS

The combination of carboplatin, doxorubicin and paclitaxel in patients with EOC is active and its main toxicity is myelosuppression. Dose intensity of paclitaxel can be maintained in a three-drug combination through weekly administration (65 mg/m(2)).

Ovarian cancer: progress and continuing controversies in management

Ovarian cancer is the most lethal of the gynaecological cancers, affecting approximately 1 in 75 women in the developed world. In most cases (>75%), the disease is disseminated beyond the ovary at diagnosis. For patients with stage III-IV disease, many clinicians agree that standard treatment should comprise six cycles of paclitaxel-carboplatin. Randomised trials over the past 10 years have indicated the superiority of paclitaxel-based treatment and that carboplatin is equivalent to cisplatin, but better tolerated. A recent trial has suggested that docetaxel may be a better option than paclitaxel, with reduced neurotoxicity and comparable efficacy. Overall treatment results remain unsatisfactory, since the median survival for these patients is 2-3 years. Future progress may be made by addressing the following issues: Would sequential regimes be more effective? Intriguing results from two large randomised trials (ICON-3 and GOG-132) indicate that single agent platinum might well be incorporated into such regimes. Additionally, a range of other agents could be tested as part of first-line regimes, having demonstrated activity in relapsed patients; these include topotecan, gemcitabine and liposomal doxorubicin. Newer agents, such as cell signalling inhibitors have shown potential as single agents, but may be particularly effective in combination with current drugs. Real progress can be expected when a better understanding is achieved of the mechanisms underlying clinical drug resistance in ovarian cancer, and a close laboratory-clinical interaction is crucial.

Chemotherapy for advanced epithelial ovarian carcinoma

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

Anthracyclines in the treatment of gynecologic malignancies

OBJECTIVE

The purpose of this article is to present a summary of the pharmacology of anthracyclines as well as to review the results of clinical trials including patients with gynecologic malignancies treated with anthracycline-based therapy.

METHODS

We performed a MEDLINE literature search of relevant clinical trials for the scope of this review that evaluated anthracycline-based therapy in gynecologic malignancies.

RESULTS

Doxorubicin has established activity in carcinomas that arise in the ovary, uterine cervix, and endometrium as well as in uterine sarcomas. However, doxorubicin has structural characteristics that limit its efficacy and safety. Newer anthracyclines with distinct structure, pharmacokinetics, pharmacodynamics, and toxicity profiles have been developed to overcome the limitations of doxorubicin and to further exploit the activity of anthracyclines. Epirubicin is characterized by a structural formula that confers similar cytotoxic antitumor activity with fewer associated side effects than its analogue. Most recently, pegylated liposomal formulations, with distinct pharmacokinetic properties and a favorable toxicity profile, have shown antitumor activity as salvage therapy in ovarian cancer. Intraperitoneal mitoxantrone is also associated with activity in ovarian cancer; however, its clinical use is limited by the severity of local adverse effects.

CONCLUSIONS

The role of anthracyclines in the management of advanced gynecologic malignancies is important as part of first-line therapy or as a salvage approach. Newer anthracycline agents such as epirubicin and pegylated liposomal doxorubicin are associated with a more favorable toxicity profile. Clinical trials are under way to further explore the role of newer anthracycline-based regimens as first-line or salvage treatment in gynecologic malignancies.

Ovarian cancer

Ovarian cancer remains the most lethal gynecologic malignancy in women in the United States. Studies from this year's American Society of Clinical Oncology more clearly defined the role of chemotherapy in women with early stage disease and now suggest that essentially all women with invasive disease should receive chemotherapy that contains carboplatin. Studies in women with advanced disease continue to support the use of carboplatin and paclitaxel in the treatment of women with newly diagnosed disease although early data suggest that carboplatin and docetaxel might be an acceptable alternative. Platinum-resistant disease remains a therapeutic challenge. Small molecules that inhibit the function of the epidermal growth factor receptor, such as OSI-774, and novel classes of chemotherapeutic agents, including the acylfulvene MGI-114 and epothilone B and its analogue, BMS247550, all warrant further study in this disease.

Phase I trial of escalating doses of paclitaxel combined with fixed doses of cisplatin and doxorubicin in advanced endometrial cancer and other gynecologic malignancies: a Gynecologic Oncology Group study

PURPOSE

The primary objective of this phase I trial was to determine the feasibility of administering a combination of paclitaxel, cisplatin, and doxorubicin with or without granulocyte colony-stimulating factor (G-CSF) in patients with advanced endometrial and other gynecologic cancers.

PATIENTS AND METHODS

Patients were chemotherapy-naive. Doxorubicin was administered as a brief infusion, paclitaxel for 3 hours, and cisplatin for 60 minutes. Treatments were repeated every 3 weeks. For most dose levels, the cisplatin and doxorubicin were fixed at 60 mg/m(2) and 45 mg/m(2), whereas the paclitaxel was escalated in successive cohorts from 90 to 250 mg/m(2). Patients who had received previous radiotherapy to the whole pelvis were escalated separately from those who had not.

RESULTS

Eighty patients received 320 cycles of therapy. When G-CSF was not used, myelosuppression prevented escalation beyond the starting dose for patients with or without previous pelvic radiotherapy. When G-CSF was added, neurotoxicity became dose-limiting for both groups. Ten patients were removed from the study for asymptomatic declines in ejection fraction, but no symptomatic congestive heart failure was observed. Major antitumor responses occurred in 46% of patients (six of 13) with measurable endometrial carcinoma and 50% of patients (eight of 16) with measurable cervical carcinoma.

CONCLUSION

The combination of paclitaxel, doxorubicin, and cisplatin at relevant single-agent doses is active and feasible with the addition of G-CSF. A regimen of cisplatin 60 mg/m(2), doxorubicin 45 mg/m(2), and paclitaxel 160 mg/m(2) with G-CSF support is recommended for further testing.

Paclitaxel, cisplatin, and epirubicin first-line chemotherapy in stage III and IV ovarian carcinoma: long-term results of a phase II study

BACKGROUND

The combination of paclitaxel with cisplatin or carboplatin has become the preferred chemotherapy regimen in the treatment of epithelial ovarian carcinoma. Anthracyclines also have activity in this disease. We conducted a Phase II study by using the combination of paclitaxel, cisplatin, and epirubicin for the treatment of advanced ovarian carcinoma.

METHODS

Forty consecutive patients with optimally (n = 7) or suboptimally (n = 33) debulked advanced ovarian carcinoma (International Federation of Gynecology and Obstetrics (FIGO) Stage III or IV) were treated with paclitaxel, 135 mg/m(2), as a 3-hour intravenous infusion, cisplatin 75 mg/m(2) intravenously (i.v.), and epirubicin 50 mg/m(2) i.v. every 3 weeks on an outpatient basis. Granulocyte-colony stimulating factor was administered at a dose of 5 microg/kg/day on Days 5-9.

RESULTS

Among 28 patients with measurable disease, 24 (86%%) achieved an objective response including 19 complete and 5 partial responses. Among 18 patients who underwent reassessment laparotomy, pathologic complete response was confirmed in 9 patients. At a minimum follow-up of 40 months, the median overall survival had not been reached whereas the median time to progression for all patients was 18.7 months. The median remission duration for women with measurable disease who responded to treatment was 14 months. The treatment was well tolerated without toxic deaths; the most common toxicity was Grade 3/4 neutropenia that occurred in 30% of patients. Significant neuropathy (Grade 2 or higher) developed in only 8% of patients.

CONCLUSIONS

The combination of paclitaxel, cisplatin, and epirubicin is a well tolerated outpatient regimen with significant activity in the treatment of advanced epithelial ovarian carcinoma.

Optimum chemotherapy for ovarian cancer

A series of prospective randomized trials recently have defined the new standard of care for chemotherapy patients with ovarian cancer. The current preferred regimen consists of carboplatin (dosed to an area-under-the-curve [AUC] of 5.0-7.5) plus paclitaxel (175 mg/m2-3 h infusion). This is an outpatient regimen that does not require growth factor support and six cycles are administered on a 21-day schedule. There is no evidence that any type of additional therapy impacts upon survival, including additional cycles of the same chemotherapy or switching to an alternative intravenous chemotherapy, high-dose chemotherapy with hematologic support, intraperitoneal chemotherapy, or whole abdominal radiation. The majority of patients will achieve a clinical complete remission with the regimen although the relapse rate remains high. Current trials are exploring new schedules of drug delivery as well as new combinations which include new agents such as gemcitabine and topotecan.

New cytotoxics and non-cytotoxics in epithelial ovarian cancer

Several new cytotoxic agents with activity in relapsed ovarian cancer are being combined with paclitaxel plus platinum as the first step to assess their impact in randomized trials against the standard treatment. These include topotecan, gemcitabine, epirubicin, and liposomal doxorubicin. Because of overlapping toxicities, there have been challenges in combining some of these agents in full dose with combination paclitaxel plus platinum. These have been overcome by use of sequenced administration. In addition to these new agents, novel non-cytotoxic drugs targeting specific signaling molecules or the tumor microenvironment provide additional avenues for clinical investigation. Many of these agents are rational to assess in ovarian cancer where laboratory research has pinpointed a number of alterations in molecules involved in cell signaling and cell cycle control. Examples include the antibody to HER 2/neu, agents targeting protein kinase C alpha, the p53 gene, and matrix metalloproteinase inhibitors. The challenges facing their assessment include how to determine adequate dosing when toxic effects are minimal and how to assess evidence of antitumor activity, short of conducting randomized studies. Finally, how best to use such agents together with conventional chemotherapy, in combination or in sequence, is unknown. Large clinical studies with some of these agents will provide some answers to their impact and how best to use them in the first-line management of advanced epithelial ovarian cancer.