Improved Survival with Single-Agent Paclitaxel Consolidation/Maintenance Therapy in Advanced Ovarian Carcinoma

Prolonged remission of recurrent cervical carcinoma following paclitaxel and carboplatin chemotherapy with paclitaxel maintenance chemotherapy

Cervical cancer recurs in ~30% of cases, for which a favorable prognosis is often unattainable. We describe a cervical cancer patient who developed metastatic disease ~5 years after her initial diagnosis. She was subsequently treated with six cycles of paclitaxel (175 mg/m) and carboplatin area under the curve (AUC) 5 chemotherapy every 21 days, and paclitaxel (135 mg/m) maintenance therapy every 21 days; the patient has remained in clinical remission after more than 5 years of follow-up. Chemotherapy has not historically been effective in managing recurrent, persistent, or metastatic cervical cancer. However, our case study involving paclitaxel and carboplatin chemotherapy with maintenance chemotherapy represents one of the longest documented remission rates in association with the management of recurrent cervical cancer.

Current status of bevacizumab in advanced ovarian cancer

Ovarian cancer is the most lethal gynecological cancer, mainly because of the delay in diagnosis. Recently, much effort has been put into investigating and introducing novel targeted agents into clinical practice, with the aim of improving prognosis and quality of life. Angiogenesis is a possible target. The aim of this review is to investigate the most common molecular pathways of angiogenesis, which have provided novel targets for tailored therapy in patients with ovarian cancer. These therapeutic strategies include monoclonal antibodies and tyrosine-kinase inhibitors. These drugs have as molecular targets vascular endothelial growth factor, vascular endothelial growth factor receptors, platelet-derived growth factor, fibroblast growth factor, and angiopoietin. Bevacizumab was investigated in several Phase III studies, with interesting results. Today, there is strong evidence for introducing bevacizumab in the treatment of patients with advanced and recurrent ovarian cancer. Nevertheless, further investigations and large clinical trials are needed to understand the safety and effectiveness of bevacizumab, the optimal duration and timing of treatment, and activity in association with other chemotherapeutic and targeted agents. It also is necessary to identify biologic factors predictive of efficacy to choose the most appropriate antiangiogenic agent in the integrated treatment of epithelial ovarian cancer.

Feasibility study on biweekly paclitaxel treatment as maintenance chemotherapy in advanced müllerian carcinoma

AIM

To evaluate the feasibility of biweekly paclitaxel treatment as maintenance chemotherapy for patients with advanced müllerian carcinoma.

METHODS

Thirty patients with stage III or IV ovarian, fallopian tube, and peritoneal cancers who underwent primary optimal surgery and standard 6 cycles of carboplatin/taxane-based chemotherapy and exhibited a complete clinical response were entered in this study. Paclitaxel 80 mg/m(2) was administered biweekly for 12 cycles. Patients were evaluated monthly for treatment-related toxicity.

RESULTS

Four patients, including 3 disease progressions and 1 bone marrow suppression, came off the protocol therapy. Twenty-six (86.7%) patients received complete treatment. Although the major toxicity was neutropenia, most of those patients (27/30, 90.0%) did not experience grade 3 or 4 neutropenia. Twenty-four (80.0%) patients showed persistent grade 1 neuropathy and the remaining 6 (20.0%) did not as a result of prior therapy. However, none experienced neuropathy progression during or after the protocol therapy. Most (17/22, 77.3%) of the completely treated patients experienced a regression of symptoms during and after therapy.

CONCLUSION

Biweekly paclitaxel therapy is well tolerated by patients with advanced müllerian carcinoma and is therefore acceptable as a candidate for maintenance chemotherapy in these patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Heat shock proteins, cell survival and drug resistance: the mitochondrial chaperone TRAP1, a potential novel target for ovarian cancer therapy

BACKGROUND

Protein homeostasis is a highly complex network of molecular interactions governing the health and life span of the organism. Molecular chaperones, mainly heat shock proteins (HSP) and other stress-inducible proteins abundantly expressed in multiple compartments of the cell, are major modulators of protein homeostasis. TRAP1 is a mitochondrial HSP involved in protection against oxidant-induced DNA damage and apoptosis. It was recently described as a component of a mitochondrial pathway selectively up-regulated in tumor cells which antagonizes the proapoptotic activity of cyclophilin D, a mitochondrial permeability transition pore regulator, and is responsible for the maintenance of mitochondrial integrity, thus favoring cell survival. Interestingly, novel TRAP1 antagonists cause sudden collapse of mitochondrial function and selective tumor cell death, suggesting that this pathway may represent a novel molecular target to improve anticancer therapy. Preliminary data suggest that TRAP1 may be a valuable biomarker in ovarian cancers: in fact, TRAP1 levels are significantly higher in cisplatin-resistant ovarian tumors and ovarian carcinoma cell lines.

CONCLUSIONS

While major advances have been made in understanding the genetics and molecular biology of cancer, given the considerable heterogeneity of ovarian cancer, the introduction of novel targeted therapies and the consequent selection of treatments based on the molecular profile of each tumor may have a major impact on the management of this malignancy and might contribute to building a new era of personalized medicine.

A review of the current evidence for maintenance therapy in ovarian cancer

OBJECTIVES

Ovarian cancer (OC) typically is diagnosed at advanced stages, in which the primary goal of therapy is to prolong progression-free survival (PFS) and overall survival (OS). In recent years, maintenance therapy has been tested for this purpose in advanced OC (AOC). Literature on maintenance therapy in AOC was systematically reviewed to assess current knowledge regarding the impact of this therapeutic approach.

METHODS

A MEDLINE search was performed 2/2009 for articles published 1/2001-1/2009 pertaining to OC maintenance therapy guidelines, patterns, and outcomes. A second search used keywords specific to maintenance and included primary studies published in the last 10 years. Of 406 sources identified, 36 primary studies and 16 review articles were included in this systematic review. A third search used the keyword "consolidation" to find maintenance articles not identified through other searches; of 48 additional sources, 13 primary studies and 6 reviews were included. A fourth search of non-MEDLINE-indexed sources yielded 14 additional relevant publications from the same time period.

RESULTS

Among practice guidelines identified, only the National Comprehensive Cancer Network (NCCN) 2008 guidelines provide recommendations regarding maintenance therapy, assigning it a category 2B recommendation. No studies were identified that reported current treatment patterns or economic outcomes in maintenance therapy; quality of life data were reported in one study. A variety of agents have been tested for maintenance, with paclitaxel the most commonly evaluated. The Southwest Oncology Group-Gynecologic Oncology Group 178 trial has found that 12 cycles of paclitaxel extend PFS (by 7 months) compared to 3 months paclitaxel, but could not adequately evaluate OS.

CONCLUSIONS

Maintenance therapy may improve clinical outcomes in AOC, but additional research is needed to demonstrate an OS advantage. Future studies should investigate the long-term clinical benefit of maintenance treatment and its impact on resource utilization and health-related quality of life.

Future directions in the management of epithelial ovarian cancer

Epithelial ovarian cancer can be a difficult malignancy to manage, partially owing to its heterogenous biology. Whilst desirable, screening designed to reduce mortality has not yet proven effective, though results of ongoing studies are awaited. In this brief review, we attempt to highlight some important issues in the current management of primary and recurrent ovarian cancer, and to place these issues in the context of cutting-edge approaches to targeted therapy and its combination with chemotherapy, as well as other novel treatment strategies. It is hoped that this will lead to further improvements in progression-free and overall survival for patients with ovarian cancer, whilst maintaining their quality of life for as much of the disease journey as possible.

Are three additional cycles of chemotherapy useful in patients with advanced-stage epithelial ovarian cancer after a complete response to six cycles of intravenous adjuvant paclitaxel and carboplatin?

Background

To evaluate the efficacy of three additional cycles of chemotherapy in patients with the International Federation of Gynecology and Obstetrics Stage III or IV, who achieved a complete response after six cycles of intravenous adjuvant paclitaxel/carboplatin after surgery.

Methods

The clinical data of 94 patients with complete response after six cycles of adjuvant paclitaxel/carboplatin after surgery between January 1997 and March 2007 were reviewed retrospectively. Three additional cycles using the same chemotherapy were administered to 57 patients as consolidation chemotherapy (Group 1). Thirty-seven patients without the additional cycles served as controls (Group 2). Disease-free survival (DFS) and overall survival (OS) were evaluated using the Kaplan–Meier method with the log-rank test. The importance of consolidation chemotherapy as a prognostic factor affecting survival was examined using the Cox's proportional hazard analysis. The incidence of chemotherapy-induced hematological toxicities was compared between the two groups using chi-square test.

Results

Median DFS and mean OS were not significantly different between the two groups (15 versus 22 months, P = 0.703; 69 versus 73 months, P = 0.891, respectively). Consolidation chemotherapy was not a prognostic factor of survival although optimal debulking surgery and lower value of serum CA-125 levels after six cycles of the chemotherapy were prognostic factors improving DFS (P < 0.01). Grade 3 or 4 leukopenia was more common in patients treated with consolidation chemotherapy than in those not treated (50.9 versus 21.6%, P = 0.004).

Conclusion

Consolidation chemotherapy using paclitaxel/carboplatin may be inefficient and relatively toxic to advanced-stage epithelial ovarian cancer patients with complete response to six cycles of the same chemotherapy after surgery.