Analysis of survivorship in high-risk patients on treated on GOG-218

Is there a "low-risk" patient population in advanced epithelial ovarian cancer?: a critical analysis

Ovarian cancer is the leading cause of gynecologic cancer-related death in the United States. Historically, studies have demonstrated that ovarian cancer is a heterogeneous disease with several patient and oncologic characteristics, including BRCA status and residual disease at surgery, known to be predictive of clinical outcomes. However, during the last decade, the discovery and approval of bevacizumab and poly(adenosine diphosphate-ribose) polymerase inhibitors have moved the frontline treatment paradigm beyond platinum-doublet therapy for women with advanced ovarian cancer. Subsequently, investigators have sought to assess the therapeutic efficacy of these agents in women who are considered "high" risk and "low" risk to determine which patients may benefit the most from aggressive therapy and in whom additional treatment may be avoided. We reviewed historic and contemporary definitions of "high-risk" and "low-risk" ovarian cancer and how this has been incorporated into the subset analyses of randomized, clinical trials of therapeutic agents, including bevacizumab and poly(adenosine diphosphate-ribose) polymerase inhibitors. Next, we provided an in-depth discussion of landmark trials for frontline maintenance therapy with bevacizumab and/or poly(adenosine diphosphate-ribose) polymerase inhibitors, focusing on the impact of treatment efficacy according to a "high-risk" and "low-risk" paradigm. Furthermore, we highlighted that recent data have challenged this dichotomous classification, notably from the Gynecologic Oncology Group-0218, ICON7, SOLO-1, and PAOLA-1 trials. Although some studies have suggested that certain populations of women with advanced ovarian cancer may have a more favorable prognosis and be considered "low risk," the risk of progression and death remains unacceptably high in all women. Furthermore, in many cases, those considered the lowest risk have the most treatment benefit from maintenance therapy with poly(adenosine diphosphate-ribose) polymerase inhibitors and/or bevacizumab. From these data, we have advocated that virtually all women with advanced ovarian cancer are high risk and that the use of our most effective therapies in the frontline setting holds promise for potentially curing more patients. Lastly, we critically discuss the practice of using subanalyses in clinical trials, with emphasis that although this practice is important for hypothesis generation, caution must be taken before accepting findings from subanalyses as actual treatment effects.

A comprehensive systematic review and network meta-analysis: the role of anti-angiogenic agents in advanced epithelial ovarian cancer

The efficacy of anti-angiogenic agents (AAAs) in epithelial ovarian cancer (EOC) remains unclear. Therefore, we conducted a systematic review and network meta-analysis (NMA) to synthesize evidence of their comparative effectiveness for improving overall survival (OS) among EOC patients. We searched six databases for randomized controlled trials (RCTs) from their inception to February 2021. We performed an NMA with hazard ratios (HRs) and 95%-confidence intervals (CIs) to evaluate comparative effectiveness among different AAAs in chemotherapy-naïve and recurrent EOC. P-score was used to provide an effectiveness hierarchy ranking. Sensitivity NMA was carried out by focusing on studies that reported high-risk chemotherapy-naïve, platinum-resistant, and platinum-sensitive EOC. The primary outcome was OS. We identified 23 RCTs that assessed the effectiveness of AAAs. In recurrent EOC, concurrent use of trebananib (10 mg/kg) with chemotherapy was likely to be the best option (P-score: 0.88, HR 1.67, 95% CI 0.94; 2.94). The NMA indicated that bevacizumab plus chemotherapy followed by maintenance bevacizumab (P-score: 0.99) and pazopanib combined with chemotherapy (P-score: 0.79) both had the highest probability of being the best intervention for improving OS in high-risk chemotherapy-naïve and platinum-resistant EOC, respectively. AAAs may not play a significant clinical role in non-high-risk chemotherapy-naïve and platinum-sensitive EOC.

The Use of Targeted Agents in the Treatment of Gynecologic Cancers

OPINION STATEMENT

Patients with advanced and recurrent ovarian, uterine, and cervical cancers have limited efficacious treatment options and poor outcomes. The development of agents that target DNA repair mechanisms, angiogenesis, immune checkpoints, and hormone receptor expression provides additional options for these patients. Many available targeted therapies have limited efficacy as single agents, so clinical trials investigating combination therapies as well as continued identification and validation of predictive biomarkers are critical. Many novel small molecule therapies, antibody drug conjugates, and therapeutic vaccines are also in development. This review will focus on recent evidence supporting the use of clinically available targeted therapies for gynecologic cancer.

Current and emerging treatment options in the management of advanced ovarian cancer

INTRODUCTION

Epithelial ovarian cancer is the most lethal gynecologic malignancy. Recent advances in understanding the biology and its molecular and histological diversity have led to mechanism based therapeutic strategies such as poly-ADP-ribose polymerase inhibitors (PARP) targeting homologous recombination deficient tumor cells and anti-angiogenic therapies. Clinical trial designs in ovarian cancer have to evolve to incorporate assessment of the genomic complexity and identify predictive biomarkers to improve precision of treatment and outcome.

AREAS COVERED

This review summarizes present-day strategies used in the management of ovarian cancer and novel promising therapeutic approaches in development. The article is based on English peer-reviewed articles located on MEDLINE and related abstracts presented at major international meetings.

EXPERT OPINION

Two types of molecular targeted therapies, anti-angiogenics and PARP inhibitors, have been shown to be active in randomized clinical trials and approved by regulatory agencies. Management of ovarian cancer is poised to change with the continued advancement of precision medicine that is founded upon improved understanding of disease biology; separation into histologically and molecularly defined subgroups; and the incorporation of this new knowledge into early phase drug development and novel clinical trial design.