Sorafenib plus topotecan versus placebo plus topotecan for platinum-resistant ovarian cancer (TRIAS): a multicentre, randomised, double-blind, placebo-controlled, phase 2 trial

BACKGROUND

Antiangiogenic therapy has known activity in ovarian cancer. The investigator-initiated randomised phase 2 TRIAS trial assessed the multi-kinase inhibitor sorafenib combined with topotecan and continued as maintenance therapy for platinum-resistant or platinum-refractory ovarian cancer.

METHODS

We did a multicentre, double-blind, placebo-controlled, randomised, phase 2 trial at 20 sites in Germany. Patients (≥18 years) with platinum-resistant ovarian cancer previously treated with two or fewer chemotherapy lines for recurrent disease were stratified (first vs later relapse) in block sizes of four and randomly assigned (1:1) using a web-generated response system to topotecan (1·25 mg/m² on days 1-5) plus either oral sorafenib 400 mg or placebo twice daily on days 6-15, repeated every 21 days for six cycles, followed by daily maintenance sorafenib or placebo for up to 1 year in patients without progression. Investigators and patients were masked to allocation of sorafenib or placebo; topotecan treatment was open label. The primary endpoint was investigator-assessed progression-free survival, analysed in all patients who received at least one dose of study drug. This completed trial is registered with ClinicalTrials.gov, number NCT01047891.

FINDINGS

Between Jan 18, 2010, and Sept 19, 2013, 185 patients were enrolled, 174 of whom were randomly assigned: 85 to sorafenib and 89 to placebo. Two patients in the sorafenib group had serious adverse events before treatment and were excluded from analyses. 83 patients in the sorafenib group and 89 in the placebo group started treatment. Progression-free survival was significantly improved with sorafenib versus placebo (hazard ratio 0·60, 95% CI 0·43-0·83; p=0·0018). Median progression-free survival was 6·7 months (95% CI 5·8-7·6) with sorafenib versus 4·4 months (3·7-5·0) with placebo. The most common grade 3-4 adverse events were leucopenia (57 [69%] of 83 patients in the sorafenib group vs 47 [53%] of 89 in the placebo group), neutropenia (46 [55%] vs 48 [54%]), and thrombocytopenia (23 [28%] vs 20 [22%]). Serious adverse events occurred in 49 (59%) of 83 sorafenib-treated patients and 45 (51%) of 89 placebo-treated patients. Of these, events were fatal in four patients (5%) in the sorafenib group (dyspnoea and poor general condition, septic shock, ascites and dyspnoea, and sigma perforation) and seven (8%) in the placebo group (pulmonary embolism in two patients, disease progression in two patients, and one case each of sepsis with fever, pleural effusion, and tumour cachexia). Sorafenib was associated with increased incidences of grade 3 hand-foot skin reaction (three [13%] vs 0 patients) and grade 2 alopecia (24 [29%] vs 12 [13%]).

INTERPRETATION

Sorafenib, when given orally in combination with topotecan and continued as maintenance therapy, showed a statistically and clinically significant improvement in progression-free survival in women with platinum-resistant ovarian cancer. These encouraging results support the crucial role of antiangiogenesis as the treatment backbone in combination with chemotherapy, making this approach attractive for further assessment with other targeted strategies.

FUNDING

Bayer, Amgen, and GlaxoSmithKline.

Health-related quality of life during sequential chemotherapy with carboplatin followed by weekly paclitaxel in advanced ovarian cancer: a multicenter phase ii study of the North Eastern German Society of Gynecological Oncology

AIM

We describe the impact of a sequential dose-dense schedule of carboplatin and paclitaxel on the quality of life (QoL) of patients with ovarian cancer.

PATIENTS AND METHODS

In this multicenter phase II trial, four cycles of carboplatin followed by 12 cycles of weekly paclitaxel were applied after cytoreductive surgery. QoL was assessed using the QoL questionnaires EORTC QLQ-C30 and QLQ-OV28 before chemotherapy (baseline), after four cycles of carboplatin, at the end of treatment (EOT), and after 6, 12, and 24 months.

RESULTS

Out of 104 eligible patients 87 (84%) participated in at least one QoL assessment. At baseline, all QLQ-C30 scales and symptoms were significantly worse than age-adjusted values for the general population. Subsequently QoL improved in general. During chemotherapy with paclitaxel, most functioning scales and symptoms worsened slightly (not significantly). However, peripheral neuropathy and chemotherapy-related side-effects increased to clinically important levels. At the end of treatment, most QoL scores were similar to those of the general population, but physical functioning and fatigue were worse. Sexual functioning and peripheral neuropathy remained problematic.

CONCLUSION

QoL was affected mainly by the weekly paclitaxel schedule, but effects were in most cases only temporary. A dose-dense regimen using a sequential protocol may be favourable in terms of QoL.

Deterioration in quality of life (QoL) in patients with malignant ascites: results from a phase II/III study comparing paracentesis plus catumaxomab with paracentesis alone

BACKGROUND

Malignant ascites (MA) is associated with poor prognosis and limited palliative therapeutic options. Therefore, quality of life (QoL) assessment is of particular importance to demonstrate new treatment value. Following the demonstration of the superiority of catumaxomab and paracentesis over paracentesis on puncture-free survival, this analysis aimed at comparing deterioration in QoL between both the treatment options.

PATIENTS AND METHODS

In a randomised, multicentre, phase II/III study of patients with MA due to epithelial cell adhesion molecule (EpCAM) positive cancer, the QoL was evaluated using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 items (EORTC QLQ-C30) questionnaire at screening, 1, 3 and 7 months after treatment and in the case of re-puncture on the day of paracentesis. Time to first deterioration in QoL was defined as a decrease in the QoL score of at least five points and compared between the catumaxomab (n=160) and control (n=85) groups using the log-rank test and Cox proportional hazards models adjusted for baseline score, country and primary tumour type.

RESULTS

Deterioration in QoL scores appeared more rapidly in the control than in the catumaxomab group (median 19-26 days versus 47-49 days). The difference in time to deterioration in QoL between the groups was statistically significant for all scores (P<0.01). The hazard ratios ranged from 0.08 to 0.24 (P<0.01).

CONCLUSIONS

Treatment with catumaxomab delayed deterioration in QoL in patients with MA. Compared with paracentesis alone, catumaxomab enabled patients to benefit from better QoL for a prolonged survival period.

Topotecan Weekly Versus Conventional 5-Day Schedule in Patients With Platinum-Resistant Ovarian Cancer: a randomized multicenter phase II trial of the North-Eastern German Society of Gynecological Oncology Ovarian Cancer Study Group

PURPOSE

Weekly administration of topotecan (Tw) is less toxic and widely considered a better treatment option than conventional 5-day therapy (Tc) in women with platinum-resistant recurrent ovarian cancer. We conducted a randomized phase II trial (TOWER [Topotecan Weekly Versus Conventional 5-Day Schedule in Patients With Platinum-Resistant Ovarian Cancer]) to better define the ratio between benefits and risks with either treatment approach.

PATIENTS AND METHODS

Patients were randomly assigned to two independent two-stage protocols of Tw (4 mg/m(2)/wk administered on days 1, 8, and 15) or Tc (1.25 mg/m(2)/d on days 1 to 5). We evaluated risk ratios (RRs) for the primary end point of clinical benefit (complete response, partial response, and stable disease), the duration of progression-free survival (PFS) and overall survival (OS), associated hazard ratios (HRs), and RRs of toxicity with 95% CIs.

RESULTS

In total, 194 patients were randomly assigned at 54 centers to Tw (n = 97) or Tc (n = 97). Clinical benefit was observed in 36 of 76 (47%; 95% CI, 36% to 59%) Tw and 46 of 80 (58%; 95% CI, 46% to 68%) Tc patients (RR, 1.21; 95% CI, 0.90 to 1.64; P = .205). Patients in the Tw group had a slightly shorter PFS (HR, 1.29; 95% CI, 0.96 to 1.76) but similar OS (HR, 1.04; 95% CI, 0.74 to 1.45) compared with Tc. Tw was associated with significantly lower risks of anemia (RR, 0.35; 95% CI, 0.16 to 0.79), neutropenia (RR, 0.38; 95% CI, 0.23 to 0.65), and thrombocytopenia (RR, 0.23; 95% CI, 0.09 to 0.57).

CONCLUSION

With regard to effectiveness in terms of response and PFS, Tc remains the standard of care in patients with platinum-resistant recurrent ovarian cancer. However, comparable OS rates and a favorable toxicity profile make Tw another viable treatment option in this setting.

Clinical management of borderline tumours of the ovary - experience from the "Berlin online tumour conference for gynaecological malignancies"

Borderline ovarian tumour (BOT) represents a rare and special tumour entity. Despite a generally favourable prognosis for patients with BOT, the presence of invasive peritoneal implants decreases the survival rate to 30-50%. In contrast to ovarian cancer, only few data exist concerning the current clinical management of patients with BOT. For this reason, the present analyses were performed for patients with BOT who were admitted into our online tumor conference for patients with gynaecological malignancies. Based on the results discussed in this article, the current aspects and problems regarding the diagnostic, surgical and conservative treatment and aftercare management of patients with BOT are considered.

A phase-I trial of pemetrexed plus carboplatin in recurrent ovarian cancer

BACKGROUND

Carboplatin-based combinations are established in platinum-sensitive recurrent ovarian cancer. To improve the therapeutic index, new platinum-based combinations are required. Pemetrexed is a multi-targeted antifolate inhibiting thymidylate synthase. The aim of this study was to determine the maximally tolerated dose (MTD) and dose-limiting toxicity (DLT) and to characterize toxicities of the combination of pemetrexed (Pem) and carboplatin (Cb).

DESIGN

A standard three-patient cohort dose escalation was performed starting at Cb AUC-5 and Pem 500 mg/m(2). Patients with platinum-sensitive recurrent ovarian cancer were eligible. Two levels of Cb (AUC-5, 6) and five levels of Pem (500, 600, 700, 800, and 900 mg/m(2)) were evaluated. DLTs were based on cycle 1.

RESULTS

Twenty patients were enrolled. The median age was 57.4 years (37.3-75.3) and the median platinum-free interval was 26.2 months (7.2-124.4). There was one DLT at dose level 3 in cycle one. No serious adverse events related to the study therapy were observed. The 20 patients completed 112 cycles of Cb (104 were planned) and 115 cycles of Pem (112 were planned). The maximum dose level of Cb AUC-6 and Pem 900 mg/m(2) was well tolerated. Response rates in 19 patients were: CR: 63.2%; PR: 21.1%; SD; 5.3%, PD: 10.5%.

CONCLUSIONS

The combination carboplatin and pemetrexed is safe and well tolerated. A multicenter phase-II trial is currently underway.

Brain metastases from epithelial ovarian cancer: overview and optimal management

Central nervous system involvement is a rare finding in the management of epithelial ovarian cancer with an incidence between 1-2%. A sharp rise in the incidence has been widely and repeatedly proclaimed for nearly two decades now, but has to be treated with scepticism after a careful review of the current literature. Brain metastases from ovarian cancer are known to be related to a very poor prognosis. Since brain imaging is not part of the routine follow-up care for ovarian cancer patients, and since CA-125--one of the standard tools--cannot be relied upon to detect central nervous system relapse, brain lesions are mostly traced by unspecific neurological symptoms only. Several prognostic factors are still being discussed today. But only a high performance status and the absence of an extra cranial disease at the time of CNS relapse have been accepted throughout the current literature as having a highly significant positive impact on survival. In the past, therapeutic efforts have focused on symptom palliation with corticosteroids and whole-brain radiation therapy (WBRT). During the last years several other therapy options have evolved from encouraging efforts made by several study groups, including chemotherapy, neurosurgery and radiosurgery. It has been shown that a multi-modal approach, combining these strategies, promises the best prolongation of survival and in some cases even resulted in long-term remissions. The present article gives an overview of brain metastases in epithelial ovarian cancer and discusses the current treatment options.

Prediction of nutritional status and intestinal tumor involvement in patients with primary or recurrent ovarian cancer: Results of a prospective study

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Background: Global malnutrition is widespread among patients with ovarian cancer. The objective of this study was to investigate the influence of the nutritional status on the clinical outcome of patients with primary or recurrent ovarian and peritoneal cancer. Methods: In a two-year-period (January 2007 - December 2008) 152 consecutive patients were analysed. 79 (52%) of them had primary and 73 (48%) recurrent disease. At the time of admission for surgical therapy, the body composition was analysed with Bioelectrical Impedance Analysis (BIA) using phase angle alpha and ratio of extra-cellular mass and body cell mass (ECM/BCM). Serum protein parameters were registered. The risk of malnutrition was estimated by Nutritional Risk Score (NRS). During operation a standardised and validated tumor documentation tool (IMO) was performed. Nutritional parameters were correlated with IMO-parameters. Results: The median age of patients was 56 years (range 48–66) with median BMI 24.4 kg/m2 (range 21.8–27.3). In 23% primary and 14% recurrent cases a high nutritional risk was classified (NRS≥3). These patients had significantly lower serum albumin, pre-albumin and transferrin levels compared to patients with NRS<3 (p < 0.05). FIGO stage and NRS correlated negatively with phase angle alpha and positively with ECM/BCM in patients with primary diagnosis (p < 0.05). Patients with primary or recurrent disease who required surgical resection of small or large intestine, phase angle alpha and serum albumin level were significantly lower than in patients with no intestinal involvement (p < 0.05). Conclusions: Independent of tumor stage, the preoperative evaluation of BIA, especially phase angle α, is a valid method to predict surgical outcome in patients with ovarian and peritoneal cancer.

No significant financial relationships to disclose.

Current management of borderline ovarian tumors: A multicenter survey of 323 clinics in Germany, on behalf of the North-Eastern German Society of Gynecological Oncology (NOGGO)

e16568

Background: The aim of this survey was to analyze the standard of care in diagnostic, surgery, chemotherapy and aftercare management of patients with Borderline tumor of the ovary (BOT) in Germany. Methods: A structured questionnaire comprising different dimensions of treatment of BOT was sent to all 1,114 gynecological departments in Germany. The questionnaire could be returned anonymously. Results: The overall response rate was 29.0% (323 departments). The most departments were on secondary care (71.8%), tertiary care (23.2%) or university hospital (5.0%) level. The most clinicians performed not more than 5 BOT operations (89.2%) per year. 93.2% of the gynecological departments used additional preoperative diagnostic procedures to the classical bimanual examination and vaginal ultrasound in a case of unclear ovarian tumor: CA-125 or CEA detection (95%), CT-scan (76%), Doppler ultrasound (66%), MRI (36%), or PET-CT (1.7%) techniques. In university hospitals (87%), tertiary care (80%), secondary care (68%) and most of the general practitioners’ hospitals (64%) a regular fresh frozen section was the intraoperative diagnostic standard. For diagnosis of BOT mostly laparotomy (48%) and laparoscopy (15%) were performed, whereas 19% used a diagnostic laparoscopy, followed by laparotomy for completion in a second intervention or switch from laparoscopy to laparotomy in the primary surgical session (18%). In young women with desire to preserve fertility clinicians performed much seldom unilateral salpingo-oophorectomy (92%) and only in 53% biopsies of the contra lateral ovary and in 67% peritoneal biopsies. Generally biopsies of the contra lateral ovary were performed in 4% to 53% of all patients. Chemotherapy was the second therapy option (64%) after surgery (97%) for BOT, mostly favored in “high-risk” patients with tumor residual, micro invasion or invasive implants. Conclusions: These data demonstrate a high clinical unsureness in the clinical management of borderline tumors of the ovary.

No significant financial relationships to disclose.

Do patients with recurrent ovarian cancer benefit from relative tumor reduction? Results from a prospective study

e16541

Background: Primary cytoreduction is the cornerstone in the management of epithelial ovarian cancer (OC). However, the roles of salvage surgery and of tumor reduction are still discussed controversially. The present study was conducted to assess the impact of secondary tumor reduction surgery on progression-free survival and on overall survival. Methods: Between September 2000 and April 2006, 177 consecutive patients (pts) with a first relapse of OC underwent secondary tumor reduction surgery at our department. The achieved tumor reduction was categorized as 1/5 (20% tumor debulked), 2/5 (40%), 3/5 (60%), 4/5 (80%), or 5/5 (macroscopic tumor-free) and the maximal tumor diameter was also denoted (tumor free, < 1cm, ≥ 1cm). Results: The median age was 56 years (95% CI: 23–83), median follow-up was 10.8 months (95% CI: 1–65). In 79 pts (44.6%) complete macroscopic tumor resection was achieved (median overall survival (OAS) 60.6 months, 21.3–99.8 and median progression-free survival (PFS) 14.9 months, 11.7–18, p < 0.001). In 56 pts (31.6%) 4/5 of the tumor was removed (OAS 15.6 months, 10.3–20.8 and PFS 9 months, 7.2–10.7, p < 0.001), in 13 (7.3%) 3/5 (OAS 21.7 months, no interval and PFS 12 months, 0.0–24.5, p < 0.001) and in 7 (4%) each 2/5 tumor reduction (OAS was 14.2 months, 4.1–24.2 and PFS 11 months, 5.9–16, p < 0.001) and if 1/5 tumor reduction was achieved OAS was 11.1 months, 2–20.1 and PFS 7 months, 2.5–11.4, p < 0.001. Fifteen pts (8.5%) had a bulky unresected disease (OAS 4.7 months, 1.0–8.3 and PFS of 3.7 months, 0–7.6, p < 0.001). From these 98 (55.4%) pts without complete macroscopic tumor resection, 46 were left with <1cm tumor diameter (OAS 17.2 months, 13–21.4 and PFS 9 months, 7.4–10.6 p < 0.001) and 52 with ≥1cm tumor diameter (OAS 8.7 months, 4.2–13.2 and PFS 7 months, 5.8–8.2 p < 0.001). All in all, the median postoperative survival for pts with tumor residuals and any tumor reduction (4/5, 3/5, 2/5. and 1/5 tumor reduction) were better when compared to pts with no tumor reduction (24.8 months vs. 4.7, p < 0.001). Conclusions: Our data demonstrate a significant benefit for salvage surgery if a macroscopic complete tumor resection can be achieved. We could not see any effect of relative tumor reduction on PFS or OAS.

No significant financial relationships to disclose.

What do patients think about CA-125 monitoring in the follow-up? Results from a multicenter trial in 1,060 patients with ovarian cancer

5522

Background: In the clinical day CA-125 monitoring is frequently used as a part of follow-up care for patients with ovarian cancer (OC). However, the potential benefit of CA-125 controls in the absence clinical symptoms are still unclear.There is little known about the expectations and preferences of patients with OC. Therefore we have initiated a multi-institutional survey. Methods: A semi-structered consisting 15 questions was developed in a pilot-study of 20 patients. After this validation all gynecological departments and gynecological-oncological practices were invited to participate in this trial using an anonynomous print version of the questionaire Results: Between December 2006 and December 2007 a total of 1,060 patients were enrolled. The median age of the patients was 58 years (range 16–87). 60% of the patients had primary ovarian cancer, 40% had relapsed ovarian cancer. Routine follow-up visits were mostly performed by gynaecologists in a gynaecological practice (56.9%) and in hospitals (49.5%). Patients were informed about the procedures and goals of cancer care predominantly after primary surgery (62.5%) and in 15.7% after last cycle of first-line chemotherapy. 7.7% declared that they were informed only at the first follow-up visit, 9.2% stated that they have never received any information about their cancer care management. According the patient´s opinion the main objective for the follow-up is the early detection of relapse and a prolongation of overall survival (95.8%). About more than 90% get CA-125 measurements. These were the procedures with highest anxiety but also the most important procedure for the patient. Finally, most patients (89%) were satisfied from their management of cancer care. Conclusions: The present study is the largest survey about cancer care so far and provides several important data for physician-patient communication concerning the follow-up management of patients OC.

No significant financial relationships to disclose.

Topotecan weekly versus routine 5-day schedule in patients with platinum-resistant ovarian cancer (TOWER): A randomized, multicenter trial of the North-Eastern German Society of Gynecological Oncology (NOGGO)

5553

Background: In women with platinum-resistant recurrent ovarian cancer, weekly administration of topotecan (Tw) may be equally effective, but better tolerated than conventional 5-day dosing (Tc). We conducted a randomized multicenter trial to validate this assumption. Methods: The trial was pre-registered at clinicaltrials.gov ( NCT00170677 ). Women with platinum-resistant ovarian and fallopian tube cancers or primary peritoneal carcinoma, and measurable or assessable disease (GCIG criteria) were randomized to receive either Tw (d1,8,15/q28d, 4 mg/m2) or Tc (d1–5/q21d, 1.25 mg/m2). The predefined stopping rule, based on the primary endpoint of best CA-125 or tumor response, was not reached (presented at ASCO 2007, Abstract 5526). This permitted the accrual of 194 patients, 154 of whom could be assessed for CA-125 or tumor response (SD + CR + PR). We also compared progression-free (PFS) and overall survival (OS), as well as toxicity between trial groups. Results: Mean age was 61.8 (SD 9.8) years, and 59 women were on third-line treatment. Patients received a total of 809 cycles of chemotherapy. Demographic baseline characteristics, tumor stages and grades, and previous lines of chemotherapy were well balanced between treatment groups. There were 35 / 75 (47%) and 45 / 79 (57%) responses in the Tw and Tc groups, respectively (risk ratio [RR] 1.22, 95% CI 0.89–1.66). Median PFS and OS did not differ markedly between both regimens (3.2 versus 4.4 months, hazard ratio [HR] 1.30, 95% CI 0.96–1.77 and 9.8 versus 10.0 months, HR 1.08, 95% CI 0.77–1.52). The risk of grade III/IV hematological toxicity was significantly lower in the Tw group (anemia: RR 0.35, p = 0.007, neutropenia: RR 0.38, p = 0.0001, thrombopenia: RR 0.23, p = 0.0004). Conclusions: Weekly administration of topotecan shows no substantial difference in endpoints of effectiveness compared to conventional dosing, but is associated with a significantly lower likelihood of severe hematological toxicity. Weekly topotecan should be considered as a possible treatment alternative in women with platinum-resistant ovarian cancer because of its favourable benefit-risk-profile.

No significant financial relationships to disclose.

Nonplatinum Topotecan Combinations Versus Topotecan Alone for Recurrent Ovarian Cancer: Results of a Phase III Study of the North-Eastern German Society of Gynecological Oncology Ovarian Cancer Study Group

Purpose

The management of recurrent ovarian cancer remains controversial. Single-agent topotecan is an established treatment option, and preliminary evidence suggests improved tumor control by combining topotecan with etoposide or gemcitabine.

Patients and Methods

Women with relapsed ovarian cancer after primary surgery and platinum-based chemotherapy were randomly assigned to topotecan monotherapy 1.25 mg/m2/d, topotecan 1.0 mg/m2plus oral etoposide 50 mg/d, or topotecan 0.5 mg/m2/d plus gemcitabine 800 mg/m2on day 1 and 600 mg/m2on day 8 every 3 weeks. Patients were stratified for platinum-refractory and platinum-sensitive disease according to a recurrence-free interval of less or more than 12 months, respectively. The primary end point was overall survival. Secondary end points included progression-free survival, objective response rates, toxicity, and quality of life (as measured by the European Organisation for Research and Treatment of Cancer [EORTC] 30-item Quality-of-Life Questionnaire).

Results

The trial enrolled 502 patients with a mean age of 60.5 years (± 10.2 years), 208 of whom were platinum resistant. Median overall survival was 17.2 months (95% CI, 13.5 to 21.9 months) with topotecan, 17.8 months (95% CI, 13.7 to 20.0 months) with topotecan plus etoposide (log-rank P = .7647), and 15.2 months (95% CI, 11.3 to 20.9 months) with topotecan plus gemcitabine (log-rank P = .2344). Platinum-sensitive patients lived significantly longer than platinum-refractory patients (21.9 v 10.6 months). The median progression-free survival was 7.0, 7.8, and 6.3 months, respectively. Objective response rates were 27.8%, 36.1%, and 31.6%, respectively. Patients under combined treatment were at higher risk of severe thrombocytopenia.

Conclusion

Nonplatinum topotecan combinations do not provide a survival advantage over topotecan alone in women with relapsed ovarian cancer.

Biweekly pegylated liposomal doxorubicin as second-line treatment in patients with relapsed ovarian cancer after failure of platinum and paclitaxel: results from a multi-center phase II study of the NOGGO

BACKGROUND

Pegylated liposomal doxorubicin (PLD) is one of the most effective cytotoxic agents in recurrent ovarian cancer. Palmar-plantar erythrodysesthesia (PPE) is a typical and commonly noted adverse event and often represents the dose-limiting toxicity. The purpose of this multicenter study was to determine the efficacy of this regimen as second-line therapy for patients with recurrent ovarian cancer.

PATIENTS AND METHODS

Patients with recurrent epithelial ovarian cancer after surgery and initial treatment with carboplatin and paclitaxel were enrolled. Eligible patients were required to have an ECOG performance status of < or =2, and sufficient organ function. PLD was administered at a dose of 20 mg/m2 every two weeks.

RESULTS

Twenty patients were recruited into this trial. Overall, 155 cycles of chemotherapy with a median of six courses (range 4-24) were administered. The median patient age was 64 years (range, 41-77 years). The hematological and non-hematological toxicity profile was favorable. No grade IV toxicity was observed. PPE grade III toxicity was noted in only one patient. Median overall survival was 19.2 months (range 1.8 to 39 months; 95% confidence interval (CI) 14.2-29.7 months) Progression-free survival was 3.3 months (range 1.38 to 36.4 months; 95% CI 1.84-13.4 months).

CONCLUSION

Biweekly PLD is an effective second-line treatment for patients with relapsed ovarian cancer. Toxicity incidence with this treatment schedule does not appear to be associated with the number of previous chemotherapies. Our data supports the need for a randomized study comparing biweekly with conventional monthly administration of 40 mg/m2 or 50 mg/m2 PLD to determine the best therapeutic index for PLD.

Role of multivisceral cytoreductive surgery in patients (pts) with recurrent ovarian cancer (ROC): Who will not benefit from radical tumor debulking?

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Background: Despite improvement in surgery and adjuvant chemotherapy most pts with ovarian cancer (OC) experience a relapse within 2 years after first diagnosis. For primary OC a standard concensus on optimal staging and surgical guidelines is established. The role of radical tumor debulking surgery in ROC is not clearly defined. Aim of this study was to analyze clinical parameters for prediction of operability and impact on overall survival in ROC. Methods: Within the framework of the international project “Tumor bank Ovarian Cancer“ (TOC) a systematic prospective surgical and histomorphological tumor documentation for ROC was performed. Results: Between september 2000 and december 2006, 307 multivisceral operations on 254 pts with ROC were performed consecutively in our department. Median age was 55 years (19–83), median follow-up 15 months (1–75). 34.8% of pts experienced first relapse of OC. Overall, 96.3% of pts received a platinum-based first-line chemotherapy, whereas 73.4% were platinum sensitive. In 55% of pts first relapse surgery was performed. In 41.4% of pts complete macroscopic tumor resection was achieved, associated with a significantly better recurrence-free (median 20.6 vs 13.2, p=0.001) and overall survival (median 42 vs 12 months, p<0.001) compared to pts with any postoperative residual tumor. In multivariate analysis, complete tumor resection was associated with the absence of tumor burden in the upper abdomen (p=0.001) and absence of ascites (p=0.05). Prognostic factors for postoperative survival were: tumor resection (0 cm vs > 0 cm, p<0.001), intraoperative volume of ascites (0 ml vs > 0 ml, p=0.006) and response to platinum-based first-line therapy (platinum sensitive vs platinum-resistant, p=0.006). Conclusions: Radical tumor debulking in patients with ROC is associated with a low postoperative morbidity and mortality. Complete mascroscopic tumor resection is correlated with a significant better long-term prognosis and influenced by tumor spread and presence of ascites. Pts with ROC will not benefit from multivisceral cytoreductive surgery in case of platinum resistance to first-line chemotherapy, presence of intraoperative ascites and postoperative residual tumor.

No significant financial relationships to disclose.

Topotecan weekly versus routine 5-day schedule in patients with platinum-resistant ovarian cancer (TOWER): A randomized, two-stage phase-II study of the North-Eastern German Society of Gynaecological Oncology (NOGGO)

5526

Background: Optimizing the therapeutic index (that is, maintaining drug effectiveness while reducing toxicity) is a major goal in chemotherapy for platinum-resistant ovarian cancer. Early phase-I/II studies suggest that weekly topotecan (T) might be effective and apparently better tolerated than the established 5-day regimen. As yet, no randomized comparison of both regimes was attempted. To prove the hypothesis of an improved therapeutic index with weekly T, we conducted a randomized, multicenter, two-stage phase-II trial, and herein present the data of the planned interim analysis. Methods: Pts with platinresistent ovarian and fallopian tube cancers or primary peritoneal carcinoma, measurable or assessable disease (GCIG-CA-125 response criteria), were eligible. Pts were randomized to receive either weekly T (d1,8,15/q28d, 4 mg/m2) or T from d1–5/q21d at a dose of 1.25 mg/m2. According to Gehan’s two-stage-design, both arms were handled as independent studies. Overall response rate (CR + PR) was defined as primary study endpoint, secondary endpoints of the interim analysis were toxicity and safety. Results: 28 pts in the weekly and 21 pts in the conventional group, enrolled at 38 centers form the basis of this report. 230 cycles of chemotherapy were evaluated for toxicity analyses. Median age was 61 years (range, 36 - 82 years). Demographic baseline characteristics, including tumor stage and grade were well balanced between treatment arms. There were 2/28 and 5/21 responses in weekly and the conventional arm, respectively (Risk Ratio [RR] 0.30, 95% confidence interval [CI] 0.06 - 1.40, p=0.122). The risk of early treatment termination due to tumor progression (RR 1.39, 95%CI 0.75 - 2.56), haematological (RR 0.20, 95% CI 0.01 - 3.97) or non- hematological toxicities (RR 1.96, 95% CI 0.18 - 20.83) did not differ significantly between groups. The only three events of neutropenic fever occurred in the conventional arm (RR 1.70, 95% CI 0.99 - 1.16). Conclusions: Weekly T is well tolerated and potentially active. The second stage of this study will require additional 46 patients each arm. Complete enrolment is expected to be accomplished in May 2007.

No significant financial relationships to disclose.

Sequential therapy with carboplatin (C) followed by paclitaxel (P) as first-line chemotherapy in 105 patients with advanced ovarian cancer (AOC): Results of a multicenter phase II study of the Northeastern German Society of Gynecological Oncology

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Background: For the adjuvant setting of AOC after primary radical surgery the combination of paclitaxel and platinum in a three weeks schedule has emerged as the current standard. Exposition duration of the drug is important for cell death. In animal model additional anti-angionetic effects of low dose paclitaxel infusion was observed. A sequential schedule of these agents can potentially yield in an improved therapeutic index. Methods: In this multicenter-phase II trial after primary radical surgery 4 cycles of Carboplatin at a dose of AUC 5 (d1/q21d) followed by 12 cycles weekly paclitaxel at a dose of 80mg/m2 (d1/q7d) was applied. All patients with haemoglobin levels < 12mg/dl get primary erythropoietin. No primary use of other growth factors were allowed. Eligibility criteria were: AOC (FIGO IIb-IV), ECOG performance status 0–2, normal organ functions. Results: Between 07/2003 and 05/2005, 105 patients from 27 institutions were enrolled. The median age was 60 years (23–80). FIGO-stages were: II: 11.4%, III: 67.6%, IV: 14.2%. 1,441 cycles were analyzed and in median 16 courses were applied (range 0–16). The incidence of non-hematological toxicities was very low. 25 % of all patients experienced alopecia (grade 1–2). Neurotoxicity and nausea/vomiting (grade III-IV) occurred in no patients. Grade 3–4 hematological toxicity (% of all pts) included: thrombocytopenia (16 %), anemia (3%), leucopenia (22%), neutropenic fever (0%). 96% received erythropoietin. Thromboembolic events (5%) were not increased in patients who received erythropoietin. After a median follow-up interval of 10 months (range: 1–27 months) 20 patients died, the median overall survival is already not reached. The progression free survival is 19 months (range:10–23 months). Conclusions: These results suggest that this sequential regimen using weekly paclitaxel represents an efficacious and well-tolerated regimen. A randomized study comparing this new schedule with the conventional 3-week protocol is warranted. (Supported by Bristol Myers Squibb Germany and Ortho Biotech Germany)

No significant financial relationships to disclose.

Topotecan (T) and carboplatin (C) in the treatment of platinum sensitive relapsed ovarian cancer (ROC): Results of a multicenter phase I/II study

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Background: Despite of the effectiveness of radical surgery and first-line chemotherapy, most patients (pts) with advanced ovarian cancer will relapse. Paclitaxel (P) in combination with C as second-line treatment improves the outcome of pts with platinum-sensitive ROC in comparison to C monotherapy. Due to polyneuropathy and alopecia this regimen can not be offered to all pts. Therefore, other platinum-combinations are required. We conducted a phase I/II study to define the dose limiting toxicities (DLT) and the tolerability of combination therapy with T and C. Methods: Pts with platinum-sensitive ROC and primary standard therapy were stratified according to treatment-free interval (TFI): 6–12 months (A) and ≥12 months (B). Following dose regimens were analysed: T 1mg/m2/d1–3 + C AUC5/d3 and T 0.75 mg/m2/d1–3 + C AUC5/d3, q21d. DLT was based on the first 4 courses and defined as: CTC grade 3/4 hematological and grade 2 non-hematological toxicity (excepted alopecia, vomiting), treatment delay >7d. Primary endpoints were DLT and tolerability. Secondary endpoints were remission rate (RR) and progression-free survival (PFS). Results: From 06/04 to 08/05, 28 pts were enrolled, 26 pts (A:13 pts, B:13 pts) were eligible. Median age was 61.5 years. A total of 141 cycles were analysed, median number of cycles was 6 (range A:2–8, B:1–10). DLTs were: leucopenia (n = 5) and thrombocytopenia (n = 1). MTD was reached at dose: T: 0.75mg/m2 and C: AUC5. Overall, grade 3/4 hematologic toxicities (in% of all cycles), for (A) and (B) respectively, were: anemia 4% vs. 4%, leucopenia 34% vs. 13%, neutropenia 30% vs. 31%, thrombocytopenia 7% vs. 6%. Febrile neutropenia 4.3% vs. 0%. Darbepoetin alfa was given in 13.5% of all cycles. Overall, grade 3/4 non-hematologic toxicities were infrequent (< 5%). Overall RR (95% CI) was 50% (29.7–70.1) [A: 30.8% (0.1–61.1), B: 69.3% (38.7–90.9)]. Median follow-up was 5.8 mo, median PFS (95% CI) was 7.7 mo (1.3–9.4) [A: 6.2 (1.3–7.2), B: 8.0 (7.3–9.4)]. Median overall survival was not reached. Conclusions: TC is a feasible and effective chemotherapy regimen for platinum sensitive ROC. Tolerability is not associated to TFI. The recommended dose for subsequent studies is T:0.75 and C:AUC5.

No significant financial relationships to disclose.

What do adjuvant and metastatic breast cancer patients (BC) expect from their doctors? Final results of a german survey in 617 patients:

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Background: An increasing number of breast cancer patients in western countries are accessing the Internet for medical information. The following study was condcuted to explore the information needs and preferences with special focus on doctor-patient communication. Methods: A questionnaire was developed and validated in a phase-I study and was than administered to breast cancer patients both via internet (online) or via a print-version consisting of 62 questions. Results: A total of 617 patients were interviewed, 552 by online version (online group) and 65 by printed questionnaire (print group). The median age of the online group was 47 years (21–85), for the print group 53 years (40–92). 65% of the patients were treated with the intention of cure, 35% of the patients had a metastatic disease. The median time of consultation communicating the information “You have breast cancer”, was 15 minutes (0–300). The most effective and “patient-relevant source of information and explanations of treatment options was the consultation with their physician (84%). When asked to suggest areas for improvement, most frequent answers were: more alternative therapies should be offered by physician (54%); physicians should have more time for explanations (51%); cooperation between involved physicians should be optimized (39%). Most relevant questions for patients are: “Do I receive the adequate treatment?” (89%); “How many patients with my disease does my physician treat?” (46%); “Can I be enrolled into a trial?” (46%). An independent second opinion centre was desired by 94% of the patients, but only 20% know such an institution. Conclusions: This study underlines the need to give patients with breast cancer all details on treatment options and cancer managements.

No significant financial relationships to disclose.