Author Archives: Paul Cacciatore

Non-Platinum Topotecan Drug Combination Therapy Provides No Survival Advantage Over Topotecan Monotherapy

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“In women with recurrent ovarian cancer, treatment with topotecan along with etoposide or gemcitabine offers no survival advantage over topotecan monotherapy, German and Austrian researchers report in the July 1st issue of the Journal of Clinical Oncology.”

“In women with recurrent ovarian cancer, treatment with topotecan along with etoposide or gemcitabine offers no survival advantage over topotecan monotherapy, German and Austrian researchers report in the July 1st issue of the Journal of Clinical Oncology.

‘Combination therapies,’ lead investigator Dr. Jalid Sehouli told Reuters Health, ‘were associated with higher toxicity, but progression-free survival and overall survival were not significantly different.’

Dr. Sehouli, of Humboldt University in Berlin, and colleagues explain in their paper that although topotecan monotherapy is an established treatment, there was evidence to suggest that combination therapy may provide better results.

To investigate further, the researchers studied 502 women in whom ovarian cancer recurred following primary surgery and platinum-based chemotherapy. They were randomized to receive either topotecan alone or in combination with etoposide or gemcitabine.

Median overall survival was not significantly different among the groups: 17.2 months with topotecan alone, 17.8 months with the etoposide combination and 15.2 months with the gemcitabine combination. There were no differences in either median progression-free survival or objective response rates.

The researchers note that the incidence of thrombocytopenia was lower with monotherapy (13.5%) than with the etoposide combination (21.5%) or gemcitabine combination (31.3%), and they conclude that combination therapy increases toxicity and does not provide a survival advantage.

‘Based on our results,’ Dr. Sehouli warns, ‘physicians should not harm their patients with such combination regimens.’”

Quoted Source: Topotecan Combo No Extra Help in Ovarian Cancer, by David Douglas, Matria Healthcare News, July 28, 2008 (summarizing the findings of 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; Sehouli J et. al., J Clin Oncol. 2008 July;26(19):3176-82.

Additional Information:

A Requiem Hallelujah, But Don’t Let There Be a Hole in the World Tomorrow

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As many of you know, the H*O*P*E*™ weblog is dedicated to Libby, my 26 year old cousin. Libby was diagnosed with ovarian clear cell carcinoma in January 2007. I am deeply saddened to inform you that Libby lost her ovarian cancer battle this morning with her family at her side. Libby leaves behind her loving spouse, Steve, her mother Kathy, her father Dennis, and her sister Sara.

Libby and Steve are the inspiration behind H*O*P*E*™, and its contining campaign to make all women aware of the early warning signs and symptoms of ovarian cancer, as well as significant treatment developments relating to the disease. Upon hearing of Libby’s death this morning, my initial thought was to allow H*O*P*E*™ to go “dark” (from a post reporting perspective) for the next week in her honor. Immediately after that initial thought, two classic songs came to mind as a better way to honor Libby. I believe the song choices were inspired by Libby from a much better place.

The first song is a gospel ballad entitled “Hallelujah.” “Hallelujah” was written by Canadian singer-songwriter Leonard Cohen, who originally released it on his 1984 studio album entitled “Various Positions.” A general translation of the word “Hallelujah” in the Jewish and Christian faiths is “Great Praise to God.” The song “Hallelujah” is frequently used in television shows and movies during scenes involving death or heartbreak. The reason for this, I believe, is that the song evokes strong emotions that capture the struggle to love, pray, and live with faith in the midst of tragic human suffering. Libby experienced that same struggle throughout her treatment, yet continued her fight to the end with grace and courage.

“Hallelujah” has been covered by various singers more than 120 times (counting only recorded, not live, versions). American singer-songwriter Jeff Buckley recorded one of the best-known and emotionally moving covers of “Hallelujah” for his 1994 studio album entitled “Grace.” Buckley, not wholly satisfied with any one take, recorded the song more than twenty times. In September 2007, a poll of fifty songwriters conducted by Q Magazine listed “Hallelujah” among the all-time “Top 10 Greatest Tracks,” with John Legend calling Buckley’s version “as near perfect as you can get.” A hyperlink to Jeff Buckley’s cover version of “Hallelujah” is provided below as an acknowledgment of Libby’s courageous fight against ovarian cancer.

Jeff Buckley-Hallelujah

CLICK HERE TO VIEW VIDEO

The second song is “[There’s a] Hole in the World [Tonight], which was recorded by The Eagles, a legendary U.S. rock band. In August 2001, The Eagles returned to the U.S. upon completion of a successful European tour to record a new album. The band was scheduled to begin recording on September 11, 2001. “Hole in the World” was written by the band in five part harmony to express the fear, sorrow, and future hope stemming from that tragic day. The lyrics set forth in the first verse of the song are as follows:

“There’s a hole in the world tonight.
There’s a cloud of fear and sorrow.
There’s a hole in the world tonight.
Don’t let there be a hole in the world tomorrow.”

I believe that Libby would abide by the message set forth in the last two sentences of that verse. Today, our family has a hole in its world as a result of Libby’s death, but H*O*P*E*™ cannot allow that fear and sorrow to create a hole in the world of another woman and her family through the failure to move ahead with its educational mission. Libby would tell you that “education increases survival.”

A video of The Eagles singing “Hole in the World” is provided below, as inspiration for all individuals who are involved in the fight against ovarian cancer. This fight will require perseverance through medical research, advocacy, education and fundraising until ovarian cancer is vanquished.

As an enduring tribute to Libby, H*O*P*E*™ revised the weblog homepage caption to read “Libby’s H*O*P*E*™.” We love you Libby and will forever miss you, but we will continue the fight against ovarian cancer on your behalf.

The Eagles – Hole In the World

Source: Wikipedia descriptions of the word “Hallelujah,” and Leonard Cohen’s song entitled “Hallelujah.”

From Zero to Hero: HMGB1 Protein Found to Promote DNA Repair, Prevents Cancer

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“An abundant chromosomal protein [HMGB1] that binds to damaged DNA prevents cancer development by enhancing DNA repair, researchers at The University of Texas M. D. Anderson Cancer Center report online this week in the Proceedings of the National Academies of Science.”

“An abundant chromosomal protein that binds to damaged DNA prevents cancer development by enhancing DNA repair, researchers at The University of Texas M. D. Anderson Cancer Center report online this week in the Proceedings of the National Academies of Science.

The protein, HMGB1 [High mobility group box 1] , was previously hypothesized to block DNA repair, said senior author Karen Vasquez, Ph.D., associate professor in M. D. Anderson’s Department of Carcinogenesis at the Science Park – Research Division in Smithville, Texas.

Identification and repair of DNA damage is the frontline defense against the birth and reproduction of mutant cells that cause cancer and other illnesses.

Pinpointing HMGB1’s role in repair raises a fundamental question about drugs under development to block the protein, Vasquez said. The protein also plays a role in inflammation, so it’s being targeted in drugs under development for rheumatoid arthritis and sepsis.

‘Arthritis therapy involves long-term treatment,’ Vasquez said. ‘Our findings suggest that depleting this protein may leave patients more vulnerable to developing cancer.’

Long known to attach to sites of damaged DNA, the protein was suspected of preventing repair. ‘That did not make sense to us, because HMGB1 is a chromosomal protein that’s so abundant that it would be hard to imagine cell repair happening at all if that were the case,’ Vasquez said.

In a series of experiments reported in the paper, Vasquez and first author Sabine Lange, a doctoral candidate in the Graduate School of Biomedical Sciences, tracked the protein’s impact on all three steps of DNA restoration: access to damage, repair and repackaging of the original structure, a combination of DNA and histone proteins called chromatin.

First, they knocked out the [HMGB1] gene in mouse embryonic cells [HMGB1 knockout cells] and then exposed cells to two types of DNA-damaging agents. One was UV light, the other a chemotherapy called psoralen that’s activated by exposure to darker, low frequency light known as UVA. In both cases, the cells survived at a steeply lower rate after DNA damage than did normal cells.

Next they exposed HMGB1 knockout cells and normal cells to psoralen and assessed the rate of genetic mutation. The knockout cells had a mutation frequency more than double that of normal cells, however, there was no effect on the types of mutation that occurred.

Knock out and normal cells were then exposed to UV light and suffered the same amount of damage. However, those with HMGB1 had two to three times the repair as those without. Evidence suggests that HMGB1 works by summoning other DNA repair factors to the damaged site, Vasquez said.

The last step in DNA repair is called chromatin remodeling. DNA does not exist in a linear structure in the chromosome, but wraps around specialized histone proteins. This chromatin structure permits access to DNA when it is loose, or opened up, and blocks access when it is more tightly wrapped. Presence of HMGB1 resulted in a much higher rate of chromatin assembly in both undamaged and UVC-damaged cells.

Lange and Vasquez hypothesize that HMGB1 normally binds to the entrance and exit of DNA nucleosomes, so is nearby when DNA damage occurs. It then binds to and bends the damaged site at a 90-degree angle, a distortion that may help DNA repair factors recognize and repair the damage. After repair it facilitates restructuring of the chromatin.

Co-author with Lange and Vasquez is David Mitchell, Ph.D., professor of carcinogenesis.

The research was supported by grants from the National Cancer Institute and the National Institute of Environmental Health Sciences as well as an American Legion Auxiliary fellowship. 07/21/08”

Quoted Source: Once Suspect Protein Found to Promote DNA Repair, Prevent Cancer – M. D. Anderson scientists caution against targeting HMGB1 to treat other disease, M. D. Anderson News Release, July 21, 2008.

Fashion Really Can Make a Statement In the Fight Against Ovarian Cancer

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Kelly Ripa and Molly Sims are fighting for a cure by doing something they love — shop! It’s all a part of Super Saturday Live on QVC. QVC will offer designer clothing, jewelry, beauty products, and accessories at 30% to 50% off of the manufacturer’s suggested retail price. All of the net proceeds benefit the Ovarian Cancer Research Fund (OCRF).

The QVC Super Saturday Live event will take place on Saturday, July 26, 2008 from 2:00 P.M. to 4:00 P.M. E.D.T. In its 11th year, the QVC Super Saturday Live event program will be hosted in the Hamptons, which is a summer playground in New York for the rich and famous. Dubbed the “Rolls Royce of Garage Sales” by The New York Times, Super Saturday 11 promises an exciting line up of over 200 top designers. It is being broadcast live for the second year on QVC.

The Super Saturday Live product line will be available through QVC by calling (800) 345-1515 or visiting www.QVC.com while supplies last.  To read ovarian cancer survivor stories on the QVC Super Saturday blog, click here.

As an organization committed to finding better ways to detect, treat, and ultimately cure ovarian cancer, the OCRF believes that future advances in ovarian cancer research lie in the hands of researchers. To promote research advancement, the OCRF sponsors young researchers with promising projects. Since 1998, the OCRF has awarded over $23 million grants to 128 of the brightest women and men in the field today at over 40 leading medical centers across the country. A brief video that describes the OCRF is provided below.

Ovarian Cancer Research Fund

TP53 Gene Mutation Found in 80% of High Grade Ovarian Serous Carcinomas; TP53 Not Directly Involved In The Development of Drug Resistance

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“… [T]he [Johns Hopkins] research team concluded that the frequency of TP53 gene mutations using purified tumor DNA from ovarian serous carcinomas was 80.3%, which is much higher than previously reported in the medical literature. Furthermore, the research team found that TP53 is not directly involved in the development of drug resistance in high-grade ovarian serous carcinomas.”

The TP53 gene mutation frequency in ovarian serous carcinomas has been reported to range between 50% and 80%. A research team working at the The Sidney Kimmel Comprehensive Cancer Center of The Johns Hopkins Medical Institutions (Johns Hopkins) made several important findings regarding TP53 gene mutations with respect to high grade ovarian serous carcinoma, as reported in the International Journal of Gynecological Cancer. Ovarian serous carcinoma is the most common tumor subtype within the epithelial ovarian cancer histological classification.

According to the Johns Hopkins research team, a stringent analysis of the TP53 gene using purified epithelial tumor samples has not been performed to accurately assess the TP53 gene mutation frequency and its correlation to tumor histologic grade. The research team assessed the TP53 gene mutational profile in a relatively large series of high-grade (53 primary tumors and 18 recurrent tumors) and 13 low-grade ovarian serous tumors. All samples were affinity purified, and the tumor DNA was analyzed for TP53 mutations in exons 4 through 9. In addition, the ovarian serous tumors were subjected to in vitro drug resistance testing. In vitro drug resistance assays were performed on the same tumor samples using carboplatin, cisplatin, paclitaxel, and taxotere, and the results were correlated with the TP53 mutation status.

The reported study findings are as follows:

  • TP53 mutations were detected in 57 (80.3%) of 71 high-grade carcinomas and in one (7.8%) of 13; low-grade serous tumors (an invasive low-grade serous carcinoma);
  • The mutations were predominantly missense mutations (59.6%);
  • TP53 mutations were associated with high-grade serous carcinomas and recurrent disease; and
  • There was no statistically significant correlation between TP53 mutation status and drug resistance assays or clinical stage.

Accordingly, the research team concluded that the frequency of TP53 gene mutations using purified tumor DNA from ovarian serous carcinomas was 80.3%, which is much higher than previously reported in the medical literature. Furthermore, the research team found that TP53 was not directly involved in the development of drug resistance in high-grade ovarian serous carcinomas.

Source: Assessment of TP53 mutation using purified tissue samples of ovarian serous carcinomas reveals a higher mutation rate than previously reported and does not correlate with drug resistance; Salani R, et. al., Int J Gynecol Cancer. 2008 May-Jun;18(3):487-91. Epub 2007 Aug 10.

P.O.V. Documentary “In the Family”: One Woman’s Journey Through the Unpredictable World of Predictive Genetic Testing

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“At the age of 27, filmmaker Joanna Rudnick tested positive for the BRCA mutation. Joanna now faces an impossible decision: remove her healthy breasts and ovaries or risk incredible odds of developing cancer. Armed with a positive test result that leaves her essentially “a ticking time bomb,” she balances dreams of having her own children with the unnerving reality that she is risking her life by holding on to her fertility. IN THE FAMILY follows Joanna as she takes us on a journey through the unpredictable world of predictive genetic testing.

Turning the camera on herself, Joanna bares her conflicting emotions about preventative surgery and the potential consequences. Turning the camera on her new relationship, she and her partner capture a young couple falling in love in the shadow of the mutation. Turning the camera on the company that owns the patents to the BRCA genes, she questions their control over access to the test. Along the way, she looks to other women and families dealing with the same unbelievable information.

Intensely personal and timely, IN THE FAMILY is a groundbreaking investigation that attempts to answer the question: How much do you sacrifice to survive?”

_________________________________

Producer/Director: Joanna Rudnick

Co-production: Kartemquin Films and the Independent Television Service (ITVS).

Date of Completion: February 2008

Running Time: 90 Minutes

US Broadcast: PBS/P.O.V. will air the film on Wednesday, October 1, 2008 at 10:00 P.M. (to have a reminder sent to you by email, click here, then click on the “Send Me A Reminder” link)

Filmmaker’s Website: http://inthefamily.kartemquin.com

_________________________________

Quoted Source: IN THE FAMILY – How much do you sacrifice to survive? (Synopsis), Press Kit, IN THE FAMILY website, accessed July 16, 2008 (Adobe Reader PDF document).

Comment: Visit the filmmaker’s website for more information about the film and upcoming screenings, by clicking on the link above. A brief video excerpt of IN THE FAMILY is provide below.

POV Website Note: “Want to hold a screening of In the Family in your community? If you are an organizer, a teacher, a young person using media to reach your peers or a PBS station employee interested in planning free local screenings of P.O.V. films, apply through P.O.V.’s Community Network and we’ll loan you a copy of the film (for free!) along with a toolkit including a discussion guide.”

Additional Resources:

P.O.V. – In the Family by Joanna Rudnick | PBS 2008

M.D. Anderson Identifies TG2 As a Potential Target in Chemo-Resistant Ovarian Cancer

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“Scientists from The University of Texas M. D. Anderson Cancer Center have found overexpression of tissue type transglutaminase (TG2) in ovarian cancer is associated with increased tumor cell growth and adhesion, resistance to chemotherapy and lower overall survival rates. When researchers targeted and silenced TG2 in animal models, cancer progression was reversed, suggesting the protein may also provide a novel therapeutic approach for late-stage ovarian cancer.”

“Scientists from The University of Texas M. D. Anderson Cancer Center have found overexpression of tissue type transglutaminase (TG2) in ovarian cancer is associated with increased tumor cell growth and adhesion, resistance to chemotherapy and lower overall survival rates. When researchers targeted and silenced TG2 in animal models, cancer progression was reversed, suggesting the protein may also provide a novel therapeutic approach for late-stage ovarian cancer.

These findings in the July 15th issue of Cancer Research by a team of researchers led by Anil K. Sood, M.D., professor in the Departments of Gynecologic Oncology and Cancer Biology, and Kapil Mehta, Ph.D., professor in the Department of Experimental Therapeutics at M. D. Anderson, are among the first to explore TG2’s functionality in ovarian cancer.

‘TG2 appears to fuel different types of cancer through multiple molecular pathways, making it an important therapeutic target,’ said Mehta, whose lab also has connected TG2 overexpression to drug-resistant and metastatic melanoma, breast cancer and pancreatic cancer.

‘Drug resistance and metastasis are major impediments to the successful treatment of ovarian cancer and until now we had little information about the role TG2 played in ovarian cancer,’ Sood said. ‘We began to see its story unfold as we translated this data from tissue samples to cell lines to animal models.’

The American Cancer Society estimates 15,000 U.S. women will die from ovarian cancer this year. Most patients present with advanced stage disease that has spread beyond the primary tumor site. More than 70 percent of ovarian cancer patients will suffer a recurrence and eventually succumb to the disease.

Higher TG2, lower survival

The study, which examined 93 ovarian cancer samples of ranging stages, found that high levels of TG2 corresponded with significantly lower patient survival than those with low levels of TG2. Sixty-nine percent of high-stage ovarian cancers overexpressed TG2 compared with 30 percent of low-stage cancers. In-depth analysis demonstrated that tumors which overexpressed the protein tended to have an increased ability to invade healthy tissue and to survive or avoid the affects of chemotherapy.

‘From this investigation it became clear that TG2 activates the survival pathway p13K/Akt in these tumors, explaining the adverse, resistant behavior we observed on a molecular level,’ said Sood. ‘We then focused on whether silencing TG2 would block these effects.’

Researchers shut off TG2 with a small interfering RNA strand (TG2 siRNA) targeted to the protein, reducing the ability of the tumor cells to invade and killing them through programmed cell death, or apoptosis. ‘When exposed to this potent targeted therapy, ovarian cancer cells greatly reduced cancer cell proliferation and blood vessel development, while increasing apoptosis,’ said Sood.

Mouse model studies of chemotherapy-sensitive and chemotherapy-resistant models showed considerable antitumor activity both with TG2 siRNA alone and in combination with docetaxel chemotherapy. The combination therapy of TG2 siRNA with docetaxel reduced tumor weight by 86 percent, proving to have the greatest efficacy compared to control groups or those without chemotherapy.

‘While it remains to be seen if these results will translate in humans, looking ahead long term, it will be an attractive option against advanced ovarian cancer,’ said co-author Gabriel Lopez-Berestein, M.D. professor in the Department of Experimental Therapeutics at M. D. Anderson.

TG2 fuels pancreatic cancer differently

Sood and Lopez-Berestein, have developed siRNA therapy by packaging the gene-silencing strips of RNA in a fatty nanoparticle called a liposome and delivering it intravenously. TG2 is the third protein they have targeted in preclinical research. Sood and Mehta are moving TG2 siRNA toward Phase I clinical trials for ovarian and pancreatic cancers.

TG2 acts through different pathways in other types of cancer, Mehta noted. For example, TG2 overexpression causes the degradation of the tumor-suppressing protein PTEN in pancreatic cancer, Mehta and colleagues reported in Clinical Cancer Research in April. With PTEN out of the picture, pancreatic cancer is protected from a separate type of cell death called autophagy. In a separate paper, they showed that silencing TG2 with the siRNA liposome reduced tumor size, slowed metastasis and enhanced the effect of gemcitabine chemotherapy.

‘This aberrant protein is doing so many different things, you would have to develop a small-molecule drug to block each function,’ Mehta said. ‘Liposomal siRNA is exciting because it takes out TG2 completely, blocking everything that it does.’

Research was funded by grants from the National Cancer Institute, including M. D. Anderson’s Specialized Program in Research Excellence in Ovarian Cancer grant, a program project development grant from the Ovarian Cancer Research Fund, Inc., and the Zarrow Foundation.

In addition to Sood, Mehta and Lopez-Berestein, authors include Jee Young Hwang, M.D., Lingegowda S. Mangala, Ph.D., co-first authors, and Yvonne G. Lin, M.D., William M. Merritt, M.D., Whitney A. Spannuth, M.D., Alpa M. Nick, M.D., Derek J. Fiterman, M.D., and Robert L. Coleman, M.D., all of M. D. Anderson’s Department of Gynecologic Oncology; Jansina Y. Fok, also a co-first author, and Pablo E. Vivas-Mejia, Ph.D., both of the Department of Experimental Therapeutics; and Michael T. Deavers, M.D., of M. D. Anderson’s Department of Pathology. Hwang is also with the Department of Obstetrics and Gynecology, Dongguk University of College of Medicine, Kyung-ju, Korea. 07/15/08”

Quoted Source: TG2 Identified as Potential Target in Chemo-Resistant Ovarian Cancer – M. D. Anderson team silences protein with siRNA, implicates TG2 in fourth cancer, The University of Texas, M.D. Anderson Cancer Center News Release, July 15, 2008 (summarizing the findings of Clinical and biological significance of tissue transglutaminase in ovarian carcinoma; Sood, AK et. al,  Cancer Res. 2008 Jul 15;68(14):5849-58.)

Additional Information:

Understanding Cancer: A TV News Magazine

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Yesterday, we came across an informative online cancer TV news magazine entitled “Understanding Cancer.” Based upon its mission statement, the Understanding Cancer website provides:

  • Empowerment through reliable, understandable information about cancer and its treatment;
  • Inspiration through the stories of cancer survivors and their cancer journeys;
  • Information about community oncology practitioners who are dedicated to outstanding patient care;
  • Stress relief through a “Meditation Room;”
  • Tips for managing symptoms;
  • Tools for living life to its fullest;
  • Compassion and understanding;
  • Relaxation through its “Mindless Distractions” which include online games, and crafts;
  • And most of all…Hope!

If you would like to learn more about Understanding Cancer TV, click here to watch the Understanding Cancer Welcome video located under the H*O*P*E*™ Ovarian Cancer Video Archive posting dated July 10, 2008, or visit the Understanding Cancer website by clicking on the banner below.


www.UnderstandingCancer.tv

U.S. News & World Report Issues 2008 Best U.S. Hospitals List

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On July 10, 2008, U.S. News & World Report issued its 2008 list of the best U.S. hospitals (for adults). The University of Texas, M.D. Anderson Cancer Center was rated #1 in Cancer, Brigham and Women’s Hospital was rated #1 in gynecology, and Johns Hopkins was rated #1 overall. If you would like more information regarding the 2008 U.S. News & World Report best U.S. hospitals ranking, click here. To read “Your ‘Best Hospitals’ Questions Answered,” written by U.S. News & World Report’s Avery Comarow, click here.  U.S. News & World Report issued its 2008 “America’s Best Children’s Hospitals” last month.  If you would like to review the 2008 “America’s Best Children’s Hospitals” List, click here.

Top 10 U.S. Hospitals: Cancer

Top 10 U.S. Hospitals: Gynecology

Top 10 U.S. Hospitals (highest scores in at least six medical specialties)
1. Univ. of Texas M.D. Anderson Cancer Center, Houston, Texas Brigham and Women’s Hospital, Boston, Massachusetts Johns Hopkins Hospital, Baltimore, Maryland
2. Memorial Sloan-Kettering Cancer Center, New York, New York Johns Hopkins Hospital, Baltimore, Maryland Mayo Clinic, Rochester, Minnesota
3. Johns Hopkins Hospital, Baltimore, Maryland Mayo Clinic, Rochester, Minnesota Ronald Reagan UCLA Medical Center, Los Angeles
4. Mayo Clinic, Rochester, Minnesota Duke University Medical Center, Durham, North Carolina Cleveland Clinic, Cleveland, Ohio
5. Dana-Farber Cancer Institute, Boston, Massachusetts Univ. of California, San Francisco (UCSF) Medical Center Massachusetts General Hospital, Boston, Massachusetts
6. University of Washington Medical Center, Seattle, Washington New York-Presbyterian Univ. Hospital of Columbia & Cornell, New York, New York New York-Presbyterian Univ. Hospital of Columbia & Cornell, New York, New York
7. Massachusetts General Hospital, Boston, Massachusetts Magee-Womens Hospital of Univ. of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Univ. of California, San Francisco (UCSF) Medical Center
8. Univ. of California, San Francisco (UCSF) Medical Center Cleveland Clinic, Cleveland, Ohio -Brigham and Women’s Hospital, Boston, Massachusetts/-Duke University Medical Center, Durham, North Carolina
9. Stanford Hospital and Clinics, Stanford, California Vanderbilt Univ. Medical Center, Nashville, Tennessee
10. Ronald Reagan UCLA Medical Center, Los Angeles Ronald Reagan UCLA Medical Center, Los Angeles –Hospital of the Univ. of Pennsylvania, Philadelphia, Pennsylvania/-University of Washington Medical Center, Seattle, Washington

Increased Worldwide Focus on the Safety of Drugs Used To Treat Chemotherapy-Related Anemia

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Over the past month, there was considerable press coverage regarding the safety and proper use of epoetin alfa (marketed as Epogen® & Procrit®) and darbepoetin (marketed as Aranesp®). Both drugs are erythropoiesis-stimulating agents (ESAs).

This controvery began between December 2006 and February 2007, when the U.S. Food and Drug Administration (FDA) was made aware of several studies in cancer patients that showed higher mortality or shorter time to tumor progression in patients randomized to receive an ESA as compared to placebo. Some of the trials dosed patients in the ESA treatment group to achieve hemoglobin levels ≥ 12 g/dl (higher than recommended on the ESAs drug box labeling). Other trials included anemic patients who were not on chemotherapy or radiotherapy. These studies were discussed at a May 10, 2007 meeting of the Oncology Drug Advisory Committee of the FDA (ODAC). The ODAC recommended additional restrictions in the labeling for ESAs including: (i) specific tumor types for which adverse safety signals were observed with the use of an ESA, (ii) instructions for hemoglobin trigger level-based dose modification/suspension, and (iii) instruction to discontinue use of ESAs upon completion of chemotherapy.

With respect to cancer the FDA recommendations to healthcare professionals include the following:

  • ESAs shortened the overall survival and/or time-to-tumor progression in patients with various cancers;
  • Risks of shortened survival and tumor progression have not been excluded when ESAs are dosed with the intent to achieve hemoglobin levels <12g/dL;
  • Use the lowest dose of [Aranesp/EPOGEN/PROCRIT] needed to avoid red blood cell transfusions. Do not exceed the upper safety limit for hemoglobin levels of 12 g/dL;
  • Reduce the ESA dose by 25% when hemoglobin reaches a level needed to avoid transfusion;
  • Withhold dosing with an ESA when hemoglobin level exceeds 12 g/dL;
  • Restart dosing at 25% below the previous dose when the hemoglobin approaches a level where transfusions may be required;
  • Discontinue treatment with an ESA following the completion of a course of chemotherapy; and
  • Use of ESAs in cancer patients have not been demonstrated in controlled clinical trials to improve the symptoms of anemia, quality of life, fatigue, or well-being.

The FDA also provided patient counseling guidance to healthcare professionals with respect to the use of ESAs. As part of a risk minimization plan, the FDA announced that it is developing a patient “Medication Guide” to better communicate the risks and benefits of ESA use to patients. Physicians and other healthcare professionals were advised by the FDA to discuss the following talking points with their patients:

  • The primary goal of treatment with erythropoiesis stimulating agents (ESA) is to increase the number of red blood cells in order to avoid receiving blood transfusions.
  • ESAs require at least 2 weeks of treatment before there is an increase in the number of red blood cells and the dose may be adjusted periodically but not more often than every 4 weeks.
  • ESAs increase the patient’s chance of blood clots and the risk of dying may be greater in certain circumstances
  • Patients should keep appointments for blood tests so hemoglobin levels can be monitored.
  • Patients need to monitor their blood pressure and contact their doctor if there are any changes outside of the range that has been established for them.
  • Patients should contact their doctor if they experience any of the following symptoms:

o Pain and/or swelling in the legs;
o Worsening in shortness of breath;
o Increases in blood pressure;
o Dizziness or loss of consciousness;
o Extreme tiredness; and
o Blood clots in hemodialysis vascular access ports

On June 26, 2008 -in a surprising announcement – the European Medicines Agency (EMEA) urged oncologists to favor blood transfusions over ESAs. Although these popular drugs have been used to treat cancer-related anemia for close to 20 years and have become a mainstay of therapy, the new recommendation is encouraging clinicians to reverse this common practice. The EMEA committee for Medicinal Products for Human Use (CHMP) recommendation is based upon its review of new data from studies that showed an increased risk for tumor progression, venous thromboembolism, and shorter overall survival in patients who received ESAs. “In cancer patients with a reasonably long life expectancy, the benefit of using epoetins does not outweigh the risk of tumor progression and shorter overall survival,” the committee noted in a statement. There are many U.S. doctors who believe that there is simply not enough data to conclude that ESAs are unsafe. Despite that fact, the ESA controversy is likely to continue until definitive fact-based evidence is fully developed.

Sources:

The “Fight Back Express” – A Mobile Petition To Fight Cancer

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“The Fight Back Express is rolling across the nation, carrying the mobile message that Americans have the power to fight cancer in this country with their voices. The American Cancer Society Cancer Action Network (ACS CAN) is sponsoring the 6-month bus tour to highlight the crucial role elected officials play in supporting laws and policies that help people fight cancer. The ACS CAN Fight Back Express kicked off in Ohio in early May and will travel across the 48 continental United States through Election Day, Nov. 4 [2008].”

“The Fight Back Express is rolling across the nation, carrying the mobile message that Americans have the power to fight cancer in this country with their voices. The American Cancer Society Cancer Action Network (ACS CAN) is sponsoring the 6-month bus tour to highlight the crucial role elected officials play in supporting laws and policies that help people fight cancer. The ACS CAN Fight Back Express kicked off in Ohio in early May and will travel across the 48 continental United States through Election Day, Nov. 4 [2008].

‘If one person can fight cancer, then a nation can rise up and defeat it,’ said Daniel E. Smith, president of ACS CAN, the sister advocacy organization of the American Cancer Society. ‘As an essential partner in the fight against cancer, government has a critical role to play in enacting laws and policies that help people battle a disease that will kill an estimated 565,650 people in America this year.’ Scientific discovery alone will not defeat cancer. The federal government is by far the largest source of cancer research funding, but years of budget freezes and cuts are impeding progress.

Through the bus tour, ACS CAN is working to make cancer a higher national priority by educating the public, lawmakers, candidates and the media about the importance of government’s role in defeating cancer. Cancer patients, survivors, caregivers and their families gather at each stop to share their experience with the disease and to voice the need to make dramatic changes in this country’s approach to cancer. ‘We can make this disease history,’ said Bob Willman, an ACS CAN State Lead Ambassador Volunteer from Springfield, Ohio. ‘We know what we need to do to win the war on cancer. Now we need our elected officials to join us and support laws and policies that will help defeat this disease.’

The ACS CAN Fight Back Express is a mobile action center. At each bus stop visitors have the chance to share their story with their Members of Congress through the Picture A Cure program and sign a petition to support access to quality health care for all Americans. The ACS CAN Fight Back Express bus tour comes on the heels of a major public education campaign by ACS CAN and the American Cancer Society, raising awareness about the critical need for access to quality healthcare for all Americans. There has been tremendous progress in the fight against cancer, as evidenced by the reduction in death rates from cancer every year since 1991. But continued success is at risk if Americans don’t have access to cancer prevention, early detection and treatment. More than 47 million people in America are uninsured and countless millions more are underinsured, making them more likely to be diagnosed at later stages when cancers are more deadly. Too often, lifesaving cancer prevention, early detection, and treatment programs are not available to patients who need care the most.

ACS CAN supports evidence-based policy and legislative solutions for a number of cancer-related issues including:

  • Prevention and Early Detection: Regular screenings can catch cancer at its earliest, most treatable stages, but a federal program that offers low-income and uninsured women screenings for breast and cervical cancer only covers 1 in 5 eligible women. A similar program for colon cancer is now pending before Congress and needs to be created immediately as both of these programs have the potential to save lives.
  • Increased Funding for Cancer Research: Medical research could lead to the discovery of prevention and early detection tools for the most deadly cancers such as pancreatic and ovarian cancer, but federal research funding has been frozen or cut in recent years, threatening progress.
  • Tobacco Control: Tobacco is responsible for approximately one-third of all cancer deaths, but the federal government still lacks the ability to regulate tobacco products. At the state and local level, strong smoke-free policies could significantly reduce the number of tobacco-related cancer cases by protecting workers and patrons from the hazards of secondhand smoke.

The Fight Back Express is made possible by the contributions of millions of American Cancer Society and ACS CAN donors across the country whose lives have been touched by cancer. Additionally, the bus tour is made possible by a generous contribution from Pharmaceutical Research and Manufacturers of America (PhRMA). “Incredible progress has been made in recent years in the battle against cancer,” said PhRMA President and CEO Billy Tauzin. ‘America’s pharmaceutical research companies work hard every day to develop new medicines that will enable cancer patients to live longer, healthier, more productive lives. However, scientific research isbut one piece of the puzzle; improved prevention, early detection and access to quality healthcare are equally critical. Together, we can win this fight.’

To find out more about the ACS CAN Fight Back Express and how to make cancer a national priority log on to www.acscan.org. ACS CAN, the nonprofit, nonpartisan advocacy partner of the American Cancer Society, supports evidence-based policy and legislative solutions designed to eliminate cancer as a major health problem. ACS CAN works to encourage elected officials and candidates to make cancer a top national priority. ACS CAN gives ordinary people extraordinary power to fight cancer with the training and tools they need to make their voices heard. For more information, visit www.acscan.org.”

Quoted Source: National Bus Tour Rolls Across the Nation Urging Americans to Join the Fight to Defeat Cancer – American Cancer Society Cancer Action Network Effort Highlighting the Role of Elected Officials in the Fight Against Cancer, American Cancer Society Cancer Action Network Press Release, undated.

Comment: For additional information regarding the Fight Back Express including: (i) the purchase of miles to keep the bus on the road; (ii) the upcoming Fight Back Express stop locations; and (iii) stories from the roadtrip, please click here. A YouTube video regarding the ACS CAN Fight Back Express bus tour is provided below.

ACS CAN Fight Back Express Bus Tour

IL-7 Boosts Immune Response in Cancer Patients

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” … [Recombinant human interleukin-7] rhIL-7 appears to be an effective T cell growth factor with “immune rejuvenating” properties, suggesting that it is effective in augmenting immune reactivity in hosts with impaired immunity due to any number of factors, including age, chemotherapy, and infectious disease, the authors note. In patients with both intact and deficient immune systems, the capacity of rhIL-7 to augment responses to weak antigens and to increase T cell cycling without expanding T regulatory cells might be clinically exploitable in the context of immunotherapy regimens for cancer and/or chronic infection, they write.”

“Data from a preliminary study suggest that recombinant human interleukin (r-hIL)-7 can enhance and broaden immune responses in patients with impaired immunity due to lymphocyte depletion.

The results of the phase 1 trial, published online June 23 in The Journal of Experimental Medicine, showed that when given to cancer patients, rhIL-7 induced a dramatic polyclonal prolonged expansion of CD4+ and CD8+ T cells, which in turn caused a significant broadening of circulating T cell receptor repertoire diversity. These effects were mediated primarily through an increase in peripheral T cell cycling and augmented cell survival.

Lymphopenia induced by cytotoxic chemotherapy, or pathologies such as HIV infection, can significantly weaken immune function; as a physiologic immuno-enhancer, IL-7 can enhance the restoration of T cells. CD4+ T cell recovery in adults who have experienced severe depletion requires the reemergence of a pool of naive T cells, which generally takes 18 to 24 months and might only occur in people younger than 40 to 45 years. Thus, the authors note, a strategy that can accelerate or promote the recovery of a widely diverse T cell repertoire in older people might be useful for a large number of clinical applications.

‘We know that IL-7 can enhance tumor vaccines in animals, so that would be a clear avenue of research,’ said lead author Claude Sportès, MD, senior staff clinician at the National Cancer Institute‘s Center for Cancer Research, Experimental Transplantation and Immunology Branch, in Bethesda, Maryland. ‘But it wouldn’t only have to be tumor vaccines. Hopefully we will have a trial underway in the not-too-distant future looking at how it can enhance anti-viral and other immunizations, particularly in the elderly.’

Treatment with IL-7 therapy exerted a marked effect on T cell immune reconstitution during preliminary trials with animal models. It also appeared to augment effector and memory responses to vaccination in mice; in preclinical models, IL-7 therapy was able to augment anti-tumor responses that might improve survival when combined with anti-tumor vaccines.

‘In older individuals, therapy with IL-7 could lead to a rejuvenation of the phenotype,’ explained Dr. Sportès in an interview. ‘This in turn can lead to better vaccine responses in general and, in oncology, better tumor vaccine responses.’

The implications for rhIL-7 are potentially vast, and there are many promising therapeutic avenues. ‘But as often happens in medicine,’ he cautioned, ‘things can be very promising at this stage and then fizzle out.’

First Human Trial

In this phase 1 dose-escalation study, the first initiated in a human population, Dr. Sportès and colleagues evaluated the effects of IL-7 therapy on human lymphocytes in 16 patients, between the ages of 20 to 71 years, with nonhematologic, nonlymphoid refractory cancer. The doses, extrapolated from previous mouse and primate studies, were 3, 10, 30, and 60 μg/kg, and were administered by subcutaneous injection every other day for 14 days, for a total of 8 doses.

They found that after a very transient decrease, the numbers of circulating lymphocytes and CD4+ and CD8+ T cells increased in a dose-dependent manner. At the highest dose levels, increases approached 300% for CD4+ and exceeded 400% for CD8+ T cells. Overall, the treatment induced widespread T cell cycling and was able to expand the T cell pool in human patients while preserving T cell function.

Treatment with rhIL-7 also seems to have advantages over rhIL-2, explained Dr. Sportès. The expanded T cells retained significant functional capacity, and the CD4+ T cell expansion was not accompanied by a disproportionate increase in T regulatory cells, a phenomenon that has been observed after rhIL-2 therapy. Previous data have shown that in vivo IL-2 administration in humans has minimal effects on CD8+ T cell numbers, whereas rhIL-7 effects on CD8+ T cell expansion are at least comparable to the effects on CD4+ T cells.

The researchers noted that rhIL-7 increases T cell receptor repertoire diversity, and that although it appears to selectively expand CD4+ recent thymic emigrants, naive cells, and central-memory populations, it did not have the same effect on effector T cells.

The details of the clinical trial will be the focus of a separate paper, said Dr. Sportès. ‘But it was well tolerated and we went to full-dose escalation.’

“Immune Rejuvenating” Properties

rhIL-7 appears to be an effective T cell growth factor with “immune rejuvenating” properties, suggesting that it is effective in augmenting immune reactivity in hosts with impaired immunity due to any number of factors, including age, chemotherapy, and infectious disease, the authors note.

In patients with both intact and deficient immune systems, the capacity of rhIL-7 to augment responses to weak antigens and to increase T cell cycling without expanding T regulatory cells might be clinically exploitable in the context of immunotherapy regimens for cancer and/or chronic infection, they write.”

[Quoted Source: IL-7 Therapy Boosts Immune Response in Cancer Patients, by Roxanne Nelson, Medscape Medical News, Medscape Today, July 4, 2008 (summarizing the findings of Administration of rhIL-7 in humans increases in vivo TCR repertoire diversity by preferential expansion of naive T cell subsets; Sportes, C. et. al., J Exp Med. 2008 Jun 23. Epub ahead of print]

2008 ASCO Annual Meeting Abtracts Highlight Several Drugs That Show Promise Against Drug Resistant Ovarian Cancer

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There were several drugs highlighted in clinical trial abstracts presented at the 2008 American Society of Clinical Oncology (ASCO) Annual Meeting that demonstrated varying degrees of effectiveness against drug resistant (i.e., recurrence within 6 to 12 months after completion of first line treatment) and/or drug refractory (i.e., recurrence within 6 months after completion of first line treatment) ovarian cancer. By “effectiveness,” we mean generally that the drug or drug combination produced a complete response, partial response, and/or disease stabilization (and in a few cases, a significant drop in the CA-125 tumor marker) in ovarian cancer tumors. To better understand how to intrepret a medical study abstract, click here. The 2008 ASCO Annual Meeting was held in Chicago, Illinois on May 30 – June 3, 2008.

A list of the drugs/drug combinations is provided below. Any drug covered in depth through an earlier H*O*P*E*™ weblog post is noted. We also included 2008 ASCO Annual Meeting abstracts that provide “solid tumor” clinical trial results with respect to studies that enrolled patients with ovarian cancer tumors. When evaluating the potential enrollment in a clinical trial at various treatment points, an ovarian cancer survivor should evaluate trials dedicated to ovarian cancer patients in entirety, as well as general “solid tumor” trials that allow enrollment of ovarian cancer patients. Generally, a patient should give first priority to dedicated ovarian cancer trials and use the solid tumor trials as a “backup” to the ovarian cancer trials. All questions regarding the priority assigned to, or proper sequencing of, clinical trials should be discussed in detail with your doctor(s). Treatment priority and sequencing issues arise, for example, when enrollment in one clinical trial potentially disqualifies the patient for a subsequent second clinical trial based upon the protocol (i.e., inclusion/exclusion criteria) of the second trial. This example assumes that both clinical trials are currently enrolling patients when trial enrollment is being evaluated by you and your doctor.

Abbreviation Legend:

ABSTR=2008 American Society of Clinical Oncology Annual Meeting Abtract; ASCO=American Society of Clinical Oncology; CA-125=cancer antigen 125; CEA=Carcinoembryonic Antigen (Tumor Marker); CR=Complete Response; CT=Computed Tomography

CTC=Common Toxicity Criteria; DCE-MRI=Dynamic Contrast Enhanced Magnetic Resonance Imaging; DLT=Dose Limiting Toxicity; DP=Disease Progression; EOC=Epithelial Ovarian Cancer; G=Grade of Adverse Drug Effect;

GCIG=Gynecologic Cancer Intergroup; GOG–Gynecologic Oncology Group; MTD=Maximum Tolerable Dose; mg/m²=milligrams per metre squared; NCI=National Cancer Institute; OR=Objective Response; OS=Overall Survival;

PET=Positron Emission Tomography Scanning; PK=Pharmacokinetics; PO=Oral Administration; PR=Partial Response; PFS=Progression Free Survival; RECIST=Response Evaluation Criteria in Solid Tumors; RR=Response Rate; SD=Stable Disease

SNS-595 (Voreloxin®):

NOV-002 & Carboplatin (Paraplatin®):

  • NOV-002 plus carboplatin in platinum-resistant ovarian cancer (2008 ASCO Abstract #5593). Patients were heavily pretreated with 11/15 patients having received 3 prior [treatment] lines. Toxicity was mild-moderate with no G4 toxicity. There was no febrile neutropenia. The most common toxicities were nausea and fatigue, as well as abdominal pain and bowel obstruction thought to be related to underlying disease. To date, there is 1 patient with PR, 7 patients with SD and 5 patients with PD, with 1 patient off-trial for patient discretion. PFS is 14 weeks. Patients tolerated this regimen extremely well, with most toxicity attributable to carboplatin alone. Conclusion: The PFS was longer than expected, with a significant proportion of these platinum resistant patients achieving clinical benefit with prolonged stable disease. [61% disease control (CR+PR+SD) rate]

Picoplatin & Pegylated Liposomal Doxorubicin (Doxil®):

  • Final results of a phase I study of picoplatin and pegylated liposomal doxorubicin [e.g. Doxil™] in advanced solid tumor malignancies (2008 ASCO Annual Mtg. Abstr. #2568 ): Picoplatin is a novel, sterically hindered platinum(II) complex designed to circumvent mechanisms of platinum resistance. Given the single agent activity seen in multiple tumor types, we conducted a phase I study of picoplatin in combination with pegylated liposomal doxorubicin (PLD) in patients with advanced solid tumors. The Phase 1 trial enrolled 16 patients with advanced solid tumors who had received up to three prior regimens for metastatic disease. Patients were administered picoplatin followed by liposomal doxorubicin on day one of a 28-day cycle. Four dose levels of picoplatin and pegylated liposomal doxorubicin were tested: 100/20, 100/30, 100/40 and 120/40 (all mg/m2). A total of 62 courses of treatment were delivered to 16 patients with a median number of four cycles per patient. A total of 12 patients were evaluable for response. One patient experienced a CR (primary peritoneal cancer) and four experienced a PR (including three of five patients with ovarian cancer). Hematologic and non-hematologic toxicity were mild. Conclusion: This study suggests that picoplatin and liposomal doxorubicin is an active combination with promising results and can be given at standard dose levels with a minimal increase in toxicity. [41% disease control (CR+PR+SD) rate among evaluable patients]

Weekly Topotecan (Hycamtin™) Monotherapy:

  • Phase II study of weekly topotecan in recurrent ovarian cancer: duration of response based on a prolonged follow-up (ASCO Annual Mtg. Abstr. #16549). Nineteen patients (median age 52 yrs, range 45-72) with EOC who progressed after 3 (11/19 patients = 57.9%), 4 (7/19 patients= 36.8%) or 5 (1/19 patients= 5.3%) previous lines of chemotherapy were treated with Topotecan at the dose of 2.0 mg/m2 via a 30-minute intravenous infusion once every week until disease progression, unacceptable toxicity or when a stability of disease was reached. Results: All patients were evaluable for toxicity and clinical response. 16/19 patients enrolled (84.2%) had stage III-IV disease. Median number of chemotherapy cycles was 7 (range 3 – 12). A total of 107 cycles were administered. Dose reduction was necessary for 13% of the cycles. Main toxicities included anemia (G1-G2=57.9%), leucopenia (G1-G2=15.8%), thrombocytopenia (G1-G2=10.5%) and asthenia (20%). No one showed a CR, while 5/19 patients experienced a PR (26.4%), 6/19 patients experienced SD (31.5%), and 8/19 patients (42.1%) experienced DP. The median PFS was 12 weeks in patients with PR; SD was maintained for a median time of 14 weeks. Conclusion: The rate of patients with ongoing stable disease (31.5%) suggests that the clinical benefit of weekly topotecan may be expected also in patients with no other viable therapeutic options. [57% disease control (CR+PR+SD) rate among evaluable patients]

Azacitidine & Carboplatin:

Combretastatin A4 Phosphate (Zybrestat™) and Bevacizumab (Avastin™):

BSI-201:

Belinostat (PXD101):

SU11248/Sunitinib (Sutent®):

AZD2281 (KU-0059436):

  • AZD2281, a PARP (poly ADP-ribose polymerase) inhibitor with single agent anticancer activity in patients with BRCA deficient ovarian cancer: Results from a phase I study (2008 ASCO Annual Mtg. Abstr. #5510) Thirty-two patients with BRCA-deficient ovarian cancer (i.e., patients with BRCA gene mutations) the majority of whom were platinum resistant/refractory are so far evaluable for response. All evaluable patients had either received treatment for at least 8 weeks (2 cycles) or progressed prior to completion of 2 cycles. Fourteen patients have achieved PR, 13 patients meeting GCIG- CA125 criteria and 10 patients meeting RECIST criteria. Of the responders, 1 patient has been on drug > 56 weeks whilst 7 patients have maintained responses for > 24 weeks. SD was seen in an additional 8 patients, 7 of whom continue on drug and 3 patients had SD > 16 weeks. Responses were seen at all dose levels from 100mg bd and above. Conclusion: AZD2281 is well tolerated and has demonstrated compelling activity in patients with BRCA deficient ovarian cancer. Responses were seen in all patient groups including platinum resistant disease. Updated efficacy data, together with a correlation of potential predictive factors including platinum free interval will be presented on a total planned cohort of 46 patients with BRCA-deficient ovarian cancer. A randomised study in BRCA-deficient ovarian cancer has been planned. [68% disease control (CR+PR+SD) rate among evaluable patients]

Gemcitibine (Gemzar™) & Epirubicin (Ellence™):

Belinostat/PXD101, Carboplatin (Paraplatin®) & Paclitaxel (Taxol™):

Pegylated Liposomal Doxorubicin (Doxil®) & Gemcitabine (Gemzar®):

Pemetrexed/LY231514 (Altima®):

Sorafenib (Nexavar™):

  • Phase II trial of sorafenib in persistent or recurrent epithelial ovarian cancer (EOC) or primary peritoneal cancer (PPC): A Gynecologic Oncology Group (GOG) study (2008 ASCO Annual Mtg. Abstr. #5537). Sorafenib is a tyrosine kinase inhibitor targeting raf and other receptor kinases (VEGF-R, PDGF-R, Flt3, c-KIT). Sorafenib may have anti-angiogenic activity through inhibition of VEGF-R. This phase II study was conducted to assess the activity and tolerability of sorafenib in patients with recurrent EOC. Methods: This was an open label multi-institutional phase II study …. Eligible patients had persistent or recurrent EOC/PPC after 1-2 prior cytotoxic regimens, measurable or detectable (e.g. by CA125) disease, and GOG performance status < 2. Patients were required to have progressed within 12 months of completing platinum based therapy. Treatment consisted of sorafenib 400 mg orally bid until disease progression or prohibitive toxicity. Primary endpoints were PFS at 6 months and toxicity by NCI criteria. Secondary endpoints were tumor response and duration of PFS/OS. Results: 73 patients were enrolled from 10/04 to 5/07 and as of 12/2007, 68 patients are evaluable (2 ineligible and 3 too early) for toxicity. Median age was 60 (range 33-80) years and prior treatment consisted of 1 regimen in 40 patients and 2 regimens in 28 patients. Significant G3 and G4 toxicities included: rash (12 patients), metabolic (10 patients), gastrointestinal (3 patients), cardiovascular (2 patients), and pulmonary (2 patients). No treatment related deaths were recorded. Only patients with measurable disease were used to assess efficacy. Among the 59 patients with measurable disease, 12 survived PFS at least 6 months. Three patients are yet to be determined. Two patients had PR; 20 had SD; 30 had DP, and 7 could not have their tumor assessed. Conclusions: Preliminary results suggest that sorafenib is tolerated in patients with recurrent EOC with dermatologic and metabolic abnormalities being the most common toxicities. Efficacy data is expected to reach maturity and be analyzed in the spring of 2007, and comprehensive results will be presented. [42% disease control (CR+PR+SD) rate among evaluable patients]

Topotecan (Hycamtin™) & Bevacizumab (Avastin™):

  • Phase II prospective study of weekly topotecan and bevacizumab in platinum refractory ovarian cancer or peritoneal cancer (OC) (2008 ASCO Annual Mtg. Abstr. #5551). Patients (pts) with platinum refractory OC have limited treatment options. Bevacizumab, an anti-angiogenesis agent has demonstrated efficacy in recurrent ovarian cancer. Bevacizumab combined with chemotherapy in other solid tumors has improved efficacy compared with bevacizumab or chemotherapy alone. Topotecan, an active drug in recurrent OC has been used in a weekly fashion with less toxicity and more acceptability than a standard 5 day regimen. Topotecan and bevacizumab have non-overlapping toxicities. We studied the efficacy and tolerability of weekly topotecan and bevacizumab in patients with platinum refractory OC. Methods: The primary objectives of this study were to evaluate PFS, OS, OR rate and toxicity of this combination regimen. Eligible pts included those with platinum refractory OC (recurrence < 6 months of platinum therapy) who had received a maximum of 2 prior chemotherapy regimens. Results: Twenty-two pts have been enrolled to date, with 11 pts remaining on study and 18 now evaluable. Best responses for the 18 evaluable pts were: 22.2% PR (n=4), 27.8% SD (n=5), and 50% DP (n=9). Eleven pts went off study due to DP (based on CT scan RECIST criteria [n=6] or general deterioration and/or bowel obstruction [n=5]). Median duration on study for the 18 evaluable pts was 15 wks (range 5-63 weeks). Four pts have had PFS >5 months. The 18 evaluable pts received a total of 91 treatment cycles. No pt went off study due to treatment related toxicity or suffered a bowel perforation. Conclusions: Combination bevacizumab and topotecan administered in a weekly fashion demonstrate good activity in platinum refractory OC with acceptable toxicity. G3-G4 Hematologic or Hypertensive Toxicities. [50% disease control (CR+PR+SD) rate among evaluable patients]

Lapatinib (Tykerb™), Carboplatin (Paraplatin®) & Paclitaxel (Taxol™):

  • Phase I/II lapatinib plus carboplatin and paclitaxel in stage III or IV relapsed ovarian cancer patients (2008 ASCO Annual Mtg. Abstr. #5556). The purpose of this study was to establish the MTD and evaluate DLTs and response to therapy of combination therapy with carboplatin/paclitaxel and lapatinib, an oral dual tyrosine kinase inhibitor of both ErbB1 and ErbB2, in Stage III /IV relapsed ovarian cancer. Methods: This was an open-label, multicenter, phase I/II study of carboplatin/paclitaxel in combination with single agent lapatinib in Stage III/IV relapsed ovarian cancer patients. Measurable disease, adequate organ function and ECOG performance status of 0-2 were required. Results: 25 ovarian cancer patients are enrolled and four are too early to be evaluable. The median age is 57 (range 39-81). The median number of prior therapeutic regimens is 4 (range 1-10). GI toxicities were primarily < grade 2 and were successfully treated with aggressive bowel management. 10 patients (pts) experienced G3 toxicities. 4 pts- leukopenia, 2 pts-neutropenia, 2 pts-hyperglycemia, 2 pts-allergic reactions to carboplatin, 1 pt-thrombocytopenia, 1 pt-lymphopenia, 1 pt-hypokalemia, 1 pt-nausea, 1 pt-diarrhea, 1 pt-bowel obstruction. Response to therapy to date is: CR=21%, PR=29%, SD=29%, PD=21%. Two patients who were in complete remission both stopped IV chemotherapy and were maintained only with lapatinib. One is still in remission after six months and one relapsed. Conclusions: Lapatinib, an oral targeted molecular therapy which inhibits both EGFR 1 and 2 tyrosine kinase activity, can be safely administered with a weekly regimen of carboplatin and paclitaxel in heavily pretreated, ovarian cancer patients. The high response rates seen warrant further investigation. [79% disease control (CR+PR+SD) rate among evaluable patients]

Ifomide, Epirubicin, & Cisplatin:

NKTR-102 (Pegylated irinotecan):

  • Phase I dose finding and pharmacokinetic study of NKTR-102 (PEGylated irinotecan): Early evidence of anti-tumor activity (2008 ASCO Annual Mtg. Abstr. #13518 ). NKTR-102 is a novel pegylated form of irinotecan with superior efficacy against a range of xenografts compared with irinotecan. Sustained tumor inhibition is associated with increased SN38 exposure. A phase I trial of NKTR-102 was conducted to establish the MTD and to characterize safety and PK in patients (pts) with refractory solid tumors. No CTC Grade 4 toxicity was observed. G3 diarrhea was dose limiting. Other toxicities included transient uncomplicated G3 neutropenia and transient infusion related visual disturbance. PK data are available for 12 pts. Two partial responses were observed in pts with advanced cervical cancer and small cell lung cancer. Anti-tumor activity was seen in 4 other pts; ovarian: CA-125 decreased from 2557 to 518, Hodgkin’s disease: 28% radiologic improvement with symptomatic benefit, adrenocortical: cortisol levels normalized, metabolic response by PET, esophageal: CEA decreased from 35.5 to 13.6, metabolic response by PET. Conclusions: NKTR-102 shows early evidence of activity in a wide spectrum of tumors. Cumulative SN38 exposure is 1.2 to 6.5 fold higher than that predicted for irinotecan. Toxicity is manageable; diarrhea (not neutropenia) is dose limiting.

ON 01910.Na:

  • Phase I study of ON 01910.Na, a novel polo-like kinase 1 pathway modulator, administered as a weekly 24-hour continuous infusion in patients with advanced cancer (2008 ASCO Annual Mtg. Abstr. #2515). ON 01910.Na induces G2/M cell cycle arrest, apoptosis, and cell death in a broad spectrum of cancer cells, but not in non-neoplastic cells. In vitro, cell killing is dependent on drug exposure time. Based on these preclinical findings, a weekly 24hr continuous infusion (CI) study to determine safety and MTD of ON 01910.Na was initiated. Methods: Patients with advanced cancers received ON 01910.Na as a weekly 24hr CI. Twenty-three pts (7:16 M:F, 45-80 yrs) have received ON 01910.Na. G2 toxicities (2-grade increase over baseline) included fatigue (3 pts) and anorexia (1 pt). Fatigue (11/23 pts) was the most common side effect, with no G3 or greater fatigue observed. Overall, three G3 events occurred, none of which were drug-related. The best response was a pt with advanced ovarian cancer who maintained stable disease for 36 wks of treatment. Conclusions: ON 01910.Na is well tolerated as a weekly 24h continuous infusion. In the dose range studied, the drug exhibited non-linear kinetics with rapid attainment of plasma concentrations that are cytotoxic to cancer cells in vitro, but have limited end-organ toxicity in vivo. Study data continues to accrue, and we expect to recommend a phase II dose shortly. Further analysis and combination phase I studies are planned.

BAY 73-4506:

  • Phase I study of BAY 73-4506, an inhibitor of oncogenic and angiogenic kinases, in patients with advanced solid tumors: Final results of a dose-escalation study (2008 ASCO Annual Mtg. Abstr. #2558 ). BAY 73-4506 is a potent tyrosine kinase inhibitor of receptor tyrosine kinases (VEGFR, PDGF, RET, KIT, FGFR) and serine/threonine kinases (raf and p38MAPK). In tumor xenograft models, BAY 73-4506 demonstrated a broad spectrum antitumor activity. Methods: This phase I study was a dose-escalation trial investigating the safety, PK, and pharmacodynamic (PD) profile of BAY 73-4506, given orally in 21 days on/7 days off cycles, until discontinuation due to toxicity or tumor progression. PK was assessed on days 1 and 21 of cycle 1. PD markers including DCE-MRI, soluble VEGFR-2 (sVEGFR-2) and VEGF plasma levels were assessed at each cycle. Tumor response was evaluated as per RECIST. Results: 52 patients (pts) with solid tumors and progressive disease were enrolled and treated with doses of 10 to 220 mg once daily. Frequent tumor types included colorectal cancer (CRC) (31%), malignant melanoma (10%), and ovarian cancer (10%). The median treatment duration was 49.5 days (min. 3, max. 609). Drug-related adverse events (AEs) of all grades reported in >20% of pts were hoarseness (54%), dermatological toxicities (50%; CTC G3-G4: 13%), mucositis (35%), diarrhea (25%; CTC 3: 2%), fatigue (23%; CTC 3: 2%), and hypertension (23%; CTC 3: 6%). Treatment-related AEs leading to dose reduction, interruption or discontinuation were hand foot skin reaction (15%), diarrhea (8%), and thrombopenia (6%). Of the 33 evaluable pts, 9% achieved a partial response (PR), 64% had stable disease (SD), at least 7 weeks after start of treatment, and 48% had SD or PR for more than 11 weeks. Conclusions: The recommended phase II dose for BAY 73-4506 is 160 mg daily, using the 21 days on/7 days off treatment schedule. Clinical activity (PR+SD) has been demonstrated in 73% of the evaluable pts. An extension cohort (dose level 160 mg) has been started.

Let the Sunshine In!

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“People with a vitamin D deficiency are as much as twice as likely to die compared to people whose blood contains higher amounts of the so-called sunshine vitamin, Austrian researchers said on Monday. Their study — the latest to suggest a health benefit from the vitamin — showed death rates from any cause as well as from heart-related problems varied greatly depending on vitamin D. ‘This is the first association study that shows vitamin D affects mortality regardless of the reason for death,’ said Harald Dobnig, an internist and endocrinologist at the University of Graz in Austria who led the study. …Many doctors agree that people with low levels of vitamin D cannot make up for it safely by sitting in the sun, but should take supplements. ‘These results should prompt us to perform vitamin D measurements on a more frequent basis especially in populations at risk,’ Dobnig said.”

“People with a vitamin D deficiency are as much as twice as likely to die compared to people whose blood contains higher amounts of the so-called sunshine vitamin, Austrian researchers said on Monday. Their study — the latest to suggest a health benefit from the vitamin — showed death rates from any cause as well as from heart-related problems varied greatly depending on vitamin D. ‘This is the first association study that shows vitamin D affects mortality regardless of the reason for death,’ said Harald Dobnig, an internist and endocrinologist at the University of Graz in Austria who led the study.

The body makes vitamin D when the skin is exposed to sunlight, a reason for its nickname as the ‘sunshine vitamin.’ It is added to milk and fatty fish like salmon but many people do not get enough of it. Vitamin D helps the body absorb calcium and is considered important for bone health. In adults, vitamin D deficiency can lead to osteoporosis, and it can lead to rickets in children. A number of recent studies have also indicated vitamin D may offer a variety of other health benefits, including protecting against cancer, peripheral artery disease and tuberculosis. Last week, U.S. researchers said vitamin D may extend the lives of people with colon and rectal cancer.

Dobnig and colleagues, who reported their findings in the Archives of Internal Medicine, studied more than 3,200 people with an average age of 62 who were scheduled for a heart exam between 1997 and 2000. During an eight-year follow-up the researchers found that the quarter of volunteers with the lowest levels of vitamin D in their blood were at greater risk of dying. ‘Even when accounting for factors such as heart disease, exercise and other conditions, the researchers found that the risk was double for people with between 5 to 10 nanograms per millilitre of vitamin D in their blood,’ Dobnig said. ‘Most doctors believe people should have between 20 to 30 nanograms per millilitre of the vitamin in their blood,’ he added in a telephone interview.

What causes this effect is not clear, but Dobnig pointed to a host of studies suggesting links to high blood pressure, cancer and fractures as places to begin looking. ‘The potential health risk of low levels of vitamin D should also prod physicians to be more aware of the potential problem, especially for the immobile, elderly and others who spend a great amount of time indoors,’ he added. Many doctors agree that people with low levels of vitamin D cannot make up for it safely by sitting in the sun, but should take supplements. ‘These results should prompt us to perform vitamin D measurements on a more frequent basis especially in populations at risk,’ Dobnig said.”

[Quoted Source: Study shows more benefits of sunshine vitamin, by Michael Kahn, Reuters Health On-Line News Release, June 24, 2008 (summarizing the findings of Independent association of low serum 25-hydroxyvitamin d and 1,25-dihydroxyvitamin d levels with all-cause and cardiovascular mortality; Dobnig, H. et. al., Arch Intern Med. 2008 Jun 23;168(12):1340-9.)]

Additional Information:

Updates:

Vermillion Files FDA Pre-Market Application for OVA1 Ovarian Tumor Triage Test

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” …The OVA1 [Ovarian Tumor Triage Test] test will help assess the risk of malignancy in the hundreds of thousands of women who require surgery for ovarian tumors each year. ‘This information can be used to identify those who might benefit from referral to a gynecologic oncologist,’ said Fred Ueland, M.D., principal investigator of the study and Associate Professor of Gynecologic Oncology at the University of Kentucky. While most tumors are benign, numerous studies have shown that women with ovarian cancer have better overall outcomes when their surgery is performed by a gynecologic oncologist.”

“ FREMONT, Calif., June 25 /PRNewswire-FirstCall/ — Vermillion, Inc. (Nasdaq: VRML), a molecular diagnostics company, today announced that it has submitted a 510(k) pre-market notification application to the U.S. Food & Drug Administration (FDA) requesting regulatory clearance of its Ovarian Tumor Triage Test known as OVA1™.

As announced previously, the OVA1 prospective clinical trial met its primary endpoints, indicating that the test is capable of stratifying women with pelvic masses into high- and low-risk categories to help determine whether the patient should be referred to a specialist prior to surgery. The clinical trial was one of the largest ovarian cancer studies ever conducted and assessed more than 550 women with a confirmed adnexal mass at 27 clinical sites in the United States. Additionally, the trial was the culmination of more than eight independent studies in more than 2,500 women.

The OVA1 test will help assess the risk of malignancy in the hundreds of thousands of women who require surgery for ovarian tumors each year. ‘This information can be used to identify those who might benefit from referral to a gynecologic oncologist,’ said Fred Ueland, M.D., principal investigator of the study and Associate Professor of Gynecologic Oncology at the University of Kentucky. While most tumors are benign, numerous studies have shown that women with ovarian cancer have better overall outcomes when their surgery is performed by a gynecologic oncologist.

This is an important milestone for Vermillion and a significant step toward the commercialization of OVA1™. ‘We are pleased with the results of the trial and look forward to discussing the significance of our data and our commercialization strategy in an upcoming investor roundtable, planned for July,’ said Gail Page, President and CEO of Vermillion. ‘We also look forward to receiving regulatory clearance from the FDA and making OVA1 available to the hundreds of thousands of women who could benefit considerably from the test.’

Vermillion will host a roundtable teleconference to address the need for OVA1 on Tuesday, July 15. Fred Ueland, M.D., principal investigator of the OVA1 clinical study, will serve as the keynote speaker. Conference call details, including dial-in information and timing, are forthcoming.

About Vermillion’s Ovarian Cancer Diagnostic Program

In addition to developing a diagnostic test designed to distinguish between benign and malignant pelvic masses, Vermillion has a broad program of ovarian cancer diagnostic tests in development. Studies are underway to validate diagnostic tests developed to detect early-stage ovarian cancer, predict prognosis and recurrence, and identify women considered at high-risk for the disease.

Vermillion’s comprehensive diagnostic development program is being conducted with several leading collaborators at The Johns Hopkins School of Medicine, The University of Texas M.D. Anderson Cancer Center, Rigshospitalet (Copenhagen), and the University of Kentucky.

The Company’s OVA1 test is part of a strategic alliance with Quest Diagnostics to jointly develop and commercialize diagnostic tests.

About Vermillion

Vermillion, Inc. is dedicated to the discovery, development and commercialization of novel high-value diagnostic tests that help physicians diagnose, treat and improve outcomes for patients. Vermillion, along with its prestigious scientific collaborators, has diagnostic programs in oncology, hematology, cardiology and women’s health. Vermillion is based in Fremont, California. Additional information about Vermillion can be found on the Web at http://www.vermillion.com.”

[Quoted Source: Vermillion Files 510(k) Application With U.S. Food & Drug Administration for OVA1 Ovarian Tumor Triage Test – Significant Milestone Achieved Based on Compelling Clinical Studies, Vermillion, Inc. Press Release, June 25, 2008.]

Additional Information:  To learn more about molecular diagnostics and proteomics, see Understanding Cancer Series: Molecular Diagnostics, National Cancer Institute, September 1, 2006.