09 state of the art of the management of advanced and recurrent ovarian cancer
TRANSCRIPT
Fernando Cotait Maluf
Chairof Medical OncologyDepartment
São José Hospital
São Paulo São Paulo Brazil
•Advancedstagesatdiagnosis (~75%)
•Highlychemotherapy-sensitive
• Complete clinicalresponse to platinum-based CT: 70-85%
•Stage III: 20-25% of complete remissionat 5y
• 81 studies
• 6885 patients
•StageIIIandIV
•Cytoreductivesurgeryfollowedbyplatinum-based CT
Bristowet al. J ClinOncol, 2002
• CT platinum-basedversus CT NON platinum-based1,2
• HR death: 0.88 [0.79 – 0.98]
OvarianCancerMeta-Analysis Project (GynecolOncol, 2002) 1
AdvancedOvarianCancerTrialistsGroup (2002) 2
OvarianCancerMeta-Analysis Project (J ClinOncol, 1991) 3
•CT anthracyline-basedversus CT NON anthracyline-based3
•Absolutesurvivalbenefit: 5% ( p = 0.02)
•CisplatinversusCarboplatin1,2
• HR death: 1.02 [0.93 – 1.12]
•Platinum-dosenotassociatedwithsurvivalbenefit3
•MONOCT platinum-basedversus POLICT platinum-based1,2
• HR death: 0.91 [0.75 – 1.05]
OvarianCancerMeta-Analysis Project (GynecolOncol, 2002) 1
AdvancedOvarianCancerTrialistsGroup (2002) 2
ICON 3: CarboplatinvsCarboplatin + Paclitaxel
GOG 111 andOV 10(Intergroup)
McGuireetal, N Eng J Med, 1996;
n=386,suboptimalcytoreduction III/IV
SLPSG
PT 18m 38m
PC 13m 24m
Piccartetal, J Nat CancerInst, 2000;
n=668, debulkingsurgery, II-IV
SLPSG
PT 17m 35m
PC 12m 25m
Standard arm IV
D1 D2
IV IV
D1 Paclitaxel IV 135mg/m2/24hs
D2 CisplatinIV 75mg/m2
D1 D2 D8
IVIP IP
Experimental arm IV/IP D1 Paclitaxel EV 135mg/m2/24hs
D2 CisplatinIP100mg/m2
D8 PaclitaxelIP60mg/m2
GOG 172
Armostrong e al, NEJM, 2006;
N=429, optimaldebulkingsurgery, stage III
SLPSG
PT IV 19m 50m
PT IV/IP 24m 65m
Only 42% ofptscompletedtreat. IV/IP arm
GOG randomized studies: IV vs IP
PFS (m) %Advantage OS (m) %Advantage
IV IP IV IP
Alberts -- -- 41 49
Markman 22 28 27 52 63
Armstrong 19 24 20 50 65 25
* Statisticallysignificant : p < 0.05
AdvancedOvaria
nCancer
(n = 637)
RANDOMIZATION
CarboplatinAUC 6 + Paclitaxel
180mg/m2
q 21 days x 6 cycles
Katsumata N, Lancet: 374, 2009
CarboplatinAUC 6 + Paclitaxel
80mg/m2 d1,8,15
q 21 days x 6 cycles
Katsumata N, Lancet: 374, 2009
Progression-freeSurvival Overall Survival
AdvancedOv
arianCancer
(III/IV)
(n = 718)
RANDOMIZATION
PrimaryCitoreduc
tion
Vergote I, NEJM: 363 2010
Platinun-CT
x 3 cycles
IntervalCytored
uction
Platinun-CT
x 3 cycles
Platinun-CT
x 6 cycles
Vergote I, NEJM: 363 2010
OverallSurvival Overall Survivalvs Residual Disease
Vergote I, NEJM: 363 2010
Citoreduction CT CT Citoreduction
Complete resection
20.4% 50.0%
Vergote I, NEJM: 363 2010
Citoreduction CT
CT Citoreductio
n
Pos-op Death 2.5% 0.7%
Hemorraghe G III/IV 7.1% 4.1%Infection 8.1% 1.7%
DVT/PE 2.5% 0%
GOG-0218: Scheme
Stratification
• PS
• Stage/Citoreduction BEV 15 mg/kg
15 months
Paclitaxel (P) 175 mg/m2
Carboplatin(C) AUC 6
Carboplatin(C) AUC 6
Paclitaxel (P) 175 mg/m2
Carboplatin(C) AUC 6
Paclitaxel (P) 175 mg/m2
Placebo
PlaceboBEV 15 mg/kg
First-line : Epithelial
OV, PP or F
• Stage III optimal
• Stage III suboptimal
• Stage IV
n=1800 (planned)
R
A
N
D
O
M
I
Z
E
I
II
III
Arm
1:1:1
GOG-218: Progression-Free SurvivalArm I
CP
(n=625)
Arm II
CP + BEV
(n=625)
Patients with event, n (%)423
(67.7)
418
(66.9)
Median PFS, months 10.3 11.2
Stratified analysis HR
(95% CI)
0.908
(0.759–1.040)
One-sided p-value (log rank) 0.080a
+ BEV (Arm II)CP (Arm I)
+ BEV → BEV maintenance (Arm III)Pro
po
rtio
n s
urv
ivin
g p
rog
ress
ion
fre
e
Months since randomization
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0 12 24 36
Arm III
CP + BEV BEV
(n=623)
360
(57.8)
14.1
0.717
(0.625–0.824)
<0.0001a
Adverse event (grade when limited), n (%)
Arm I
CP
(n=601)
Arm II
CP + BEV
(n=607)
Arm III
CP + BEV BEV
(n=608)
GI eventsa (grade ≥2) 7 (1.2) 17 (2.8) 16 (2.6)
Hypertension (grade ≥2) 43 (7.2)b 100 (16.5)b 139 (22.9)b
Proteinuria (grade ≥3) 4 (0.7) 4 (0.7) 10 (1.6)
Pain (grade ≥2) 250 (41.7) 252 (41.5) 286 (47.1)
Neutropenia (grade ≥4) 347 (57.7) 384 (63.3) 385 (63.3)
Febrile neutropenia 21 (3.5) 30 (4.9) 26 (4.3)
Venous thromboembolic event 35 (5.8) 32 (5.3) 41 (6.7)
Arterial thromboembolic event 5 (0.8) 4 (0.7) 4 (0.7)
CNS bleeding 0 0 2 (0.3)
Non-CNS bleeding (grade ≥3) 5 (0.8) 8 (1.3) 13 (2.1)
RPLS 0 1 (0.2) 1 (0.2)
GOG-218: Select Adverse EventsOnset between cycle 2 and 30 days after date of last treatment
RPLS = reversible posterior leukoencephalopathy syndromeaPerforation/fistula/necrosis/leak
bp<0.05
ICON 7: Scheme
• Open-label study
• Endpoints
– primary: PFS
– secondary: RR, OS, safety, QoL, cost effectiveness, translational
• Stratification
– FIGO stage/surgery; time since surgery; GCIG group
Paclitaxel 175mg/m2 q3w
CarboplatinAUC6* q3w
Bevacizumab 7.5mg/kg q3w
Paclitaxel 175mg/m2 q3w
CarboplatinAUC6* q3w
18 cycles
Stage I or IIa (grade
3 or clear cell) or
stage IIb–IV EOC,
PP, FTC
(n=1,520)
ICON 7: Progression-Free Survival
Control Experimental
Events, n (%) 130 (17) 111 (15)
Log-rank p=0.098
Hazard ratio (95% CI) 0.81 (0.63–1.04)
Sobrevida 1-ano, % 93 95
1.00
0.75
0.50
0.25
0
Pro
port
ion s
urv
ivin
g
Time (months)
0 3 6 9 12 15 18 21 24 27 30
ICON 7: Select Adverse Events
6.2
2.5 2.1 1.3 0.4
11.6
4.1
1.50.4 0
29.1
2.0
9.2
25.9
4.4 5.0
1.7 1.3
39.6
6.7
3.6
0.4 0
28.3
2.8
12.5
0
5
10
15
20
25
30
35
40
45Control (n=753)
Research (n=745)
ATE = arterial thromboembolism; CHF = congestive heart failure; RPLS = reversible posterior leucoencephalopathy syndrome; VTE = venous thromboembolism
Patients
(%
)
GOG 218 and ICON 7: Comparison of TrialsTrial GOG-0218 ICON7
Number of patients 1,800 1,520
Setting/design •Double-blinded, placebo-controlled
•First-line setting
•3-arm study:
Arm I: CT + placebo
Arm II: CT + Bevacizumab (5 cycles)
Arm III: CT + Bevacizumab (extended)
•Bevacizumab continued for 16 months
•Bevacizumab dose: 5mg/kg/week
•Rigid AUC for carboplatin
• Open-label
•First-line setting
• 2-arm study:
Arm A: carboplatin/paclitaxel (CT)
Arm B: CT + Bevacizumab
•Bevacizumab continued for 12 months
•Bevacizumab dose: 2.5mg/kg/week
•Flexibility in AUC for carboplatin
Patient population Post-cytoreductive surgery
Sub-optimally debulked stage III/IV
Macroscopic optimally debulked stage III
Post-cytoreductive surgery
I or IIa (grade 3 or clear-cell histology)
IIb–IV (all grades and histological types)
Target disease Epithelial ovarian, fallopian tube or primary
peritoneal cancer
Epithelial ovarian, fallopian tube or primary
peritoneal cancer
Stratification • PS (0–1 vs 2)
• Stage (III vs IV)
• FIGO stage
• ≤ vs>4 weeks after surgery
• GCIG group
Primary endpoint • Investigator-assessed PFS data
• Exploratory: IRC-assessed PFS data
• Investigator-assessed PFS data
P
R
I
M
A
R
Y
T
R
E
A
T
M
E
N
T
0 3 6 12 18 24
Refractory
Resistent
Sensitive
Highlysensitive
Months
70
60
50
40
30
20
10
0
12
33
59
< 6 months
12-18 months
> 18 months
Overall ResponseRate (%)
Intervalfrom prior platinumtreatment (months)
Platinum-
Sensitive
Platinum-
ResistantorRefrac
tory
Platinum-
basedTherapy
Platinum-sensitiveovariancancer
ΔT >6 m
RANDOMIZATION
CarboplatinAUC 5 a 6 EV
OR
Cisplatin75mg/m2 EV
q 21 days
CarboplatinAUC 5 EVOR
Cisplatin50mg/m2 EV+
Paclitaxel 175mg/m2 EVQ 21 days
Parmar MK, Lancet: 361, 2003
ICON-4/AGO-OVAR-2.2 Trial
Parmar MK, Lancet: 361, 2003
Overall Survival
ICON-4/AGO-OVAR-2.2 Trial
Pujades E etal, J ClinOncol, 2010
Inclusion Criteria:
• Platinum-sensitive (> 6 m)
• 1 or 2 prior platinum-based CT
• Measurable disease (image or CA125)
RANDOMIZATION
CarboplatinAUC 5 EV + Paclitaxel 175
mg/m2 IV 3
q21dx6 cycles
CarboplatinAUC 5 EV + DoxoLipossomal
30 mg/m2 IV 1 h
q 28 days x6 cycles*
*or until PD in patients with stable disease or response
CALYPSO: Scheme
Pujades E etal, J ClinOncol, 2010
CALYPSO: Progression-Free Survival
•Endpoints
– primary: PFS
– secondary: ORR, OS, response duration, safety
– exploratory: IRC, CA125 response, ascites
•Stratification: time to recurrence, cytoreductive surgery
Gemcitabine 1000mg/m2
days 1 and 8 q3w
CarboplatinAUC4 q3w
Gemcitabine 1000mg/m2
days 1 and 8 q3w
CarboplatinAUC4 q3w
Bevacizumab 15mg/kg
Placebo
EOC = epithelial ovarian; PP = primary peritoneal; FTC = fallopian tube carcinoma
PD
PD
Bev.
15mg/kg
Pretreated
platinum-sensitive,
EOC, PP or FTC
(n=480)
Placebo
OCEANS: Scheme
OCEANS: Patients Characteristics
CharacteristicCG + PL
(n=242)
CG + BV
(n=242)
Median age, years
(range)
61
(28−86)
60
(38–87)
Age ≥65 years, % 38 35
Race, %
White
Other
92
8
90
10
ECOG PS 0, % 76 75
Histologic subtype, %
Serous
Mucinous/clear cell
Other
84
3
14
78
5
17
Platinum-free interval, %
6–12 months
>12 months
42
58
41
59
Cytoreductive surgery for recurrent disease, % 10 12
OCEANS: Progression-free SurvivalCG + PL
(n=242)
CG + BV
(n=242)
Events, n (%) 148 (61) 119 (49)
Median PFS,
months (95% CI)
8.6
(8.3–10.2)
12.3
(10.7–14.6)
Stratified analysis
HR (95% CI)
Log-rank p-value
0.451
(0.351–0.580)
<0.0001
1.0
0.8
0.6
0.4
0.2
0
Pro
po
rtio
n p
rog
ress
ion
fre
e
0 6 12 18 24 30
242 168 31 8 3 0CG + PL242 195 73 22 7 0CG + BV
MonthsNo. at risk
OCEANS: Progression-free Survival vs Subgroups
Median PFS
(months)
Baseline risk factorNo. of
patientsCG + PL
(n=242)
CG + BV
(n=242) HR (95% CI)
CG + BV
better
CG + PL
better
All patients 484 8.4 12.4 0.49 (0.40–0.61)
Platinum-free interval,
months6–12 202 8.0 11.9 0.41 (0.29–0.58)
>12 282 9.7 12.4 0.55 (0.41–0.73)
Cytoreductive surgery
for recurrent diseaseYes 54 7.5 16.7 0.50 (0.24–1.01)
No 430 8.4 12.3 0.49 (0.39–0.62)
Age, years <65 306 8.5 12.5 0.47 (0.36–0.62)
≥65 178 8.4 12.3 0.50 (0.34–0.72)
Baseline ECOG PS 0 367 8.6 12.5 0.47 (0.36–0.60)
1 116 8.3 10.6 0.61 (0.39–0.95)
HR0.2 0.5 1 2 5
OCEANS: Response Rate
Duration of response CG + PL
(n=139)
CG + BV
(n=190)
Median, months 7.4 10.4
HR (95% CI) 0.534
(0.408–0.698)
p<0.0001a
100
80
60
40
20
0
%
78.5
57.4 PR = 61
PR = 48
CR = 17CR = 9
Difference: 21.1%
p<0.0001
aCompared for descriptive purposes only
CG + PL
(n=242)
CG + BV
(n=242)
Median PFS
(months)
Baseline risk factorNo. of
patientsCG + PL
(n=242)
CG + BV
(n=242) HR (95% CI)
CG + BV
better
CG + PL
better
All patients 484 8.4 12.4 0.49 (0.40–0.61)
Platinum-free interval,
months6–12 202 8.0 11.9 0.41 (0.29–0.58)
>12 282 9.7 12.4 0.55 (0.41–0.73)
Cytoreductive surgery
for recurrent diseaseYes 54 7.5 16.7 0.50 (0.24–1.01)
No 430 8.4 12.3 0.49 (0.39–0.62)
Age, years <65 306 8.5 12.5 0.47 (0.36–0.62)
≥65 178 8.4 12.3 0.50 (0.34–0.72)
Baseline ECOG PS 0 367 8.6 12.5 0.47 (0.36–0.60)
1 116 8.3 10.6 0.61 (0.39–0.95)
HR0.2 0.5 1 2 5
Median PFS
(months)
Baseline risk factorNo. of
patientsCG + PL
(n=242)
CG + BV
(n=242) HR (95% CI)
CG + BV
better
CG + PL
better
All patients 484 8.4 12.4 0.49 (0.40–0.61)
Platinum-free interval,
months6–12 202 8.0 11.9 0.41 (0.29–0.58)
>12 282 9.7 12.4 0.55 (0.41–0.73)
Cytoreductive surgery
for recurrent diseaseYes 54 7.5 16.7 0.50 (0.24–1.01)
No 430 8.4 12.3 0.49 (0.39–0.62)
Age, years <65 306 8.5 12.5 0.47 (0.36–0.62)
≥65 178 8.4 12.3 0.50 (0.34–0.72)
Baseline ECOG PS 0 367 8.6 12.5 0.47 (0.36–0.60)
1 116 8.3 10.6 0.61 (0.39–0.95)
HR0.2 0.5 1 2 5
Platinum-
Sensitive
Platinum-
ResistantorRefrac
tory
Retrospectiveanalysis: 111 pts
Recurrence< 3m orØ Response
Median OS 6
months
SV <4months 32%
SV <12months 73%Markmanet al. GynecolOncol, 2004
LiposomalDoxorrubicin
Gemcitabine
Paclitaxel (weekly)
Docetaxel
Topotecan
Etoposide (oral)
Vinorelbine
Ifosfamide
AURELIA/MO22224: Scheme
Physician’s choice:
Bevacizumab
15mg/kg q3w or
SOC
•Endpoints
– primary: PFS
– secondary endpoints: ORR (RECIST and/or CA125), biological progression-free interval, OS, QoL, safety
•FPI: October 2009 (recruitment: 24 months)EOC = epithelial ovarian; PP = primary peritoneal; FTC = fallopian tube carcinoma; PLD = pegylated liposomal doxorubicin;
SOC = standard of care
Bevacizumab 10mg/kg q2w or
15mg/kg q3w+
chemotherapy (physician’s
choice, as in control arm)
SOC
Progression
Progression
Chemotherapy alone
(physician’s choice):
paclitaxel 80mg/m2qw or
topotecan4mg/m2 days 1, 8 and 15
q4w or 1.25mg/kg days 1–5 q3wor
PLD 40mg/m2 q4w
EOC, PP or FTC
that relapsed
within <6 months
after platinum-
based
chemotherapy
(n=300)
PARP inhibitors
Randomized Phase II trial: (Ledermann et al, ASCO , 2011)
N = 265
CTOlaparibvs Placebo
PFS: 8.4 vs 4.8 months (p< 0.00001)
Phase II trial: (Penson et al, ASCO , 2011)
N = 41
Carboplatin + Gemcitabine + Iniparib
OR: 70%
Convidados
Internacionais