Month: November 2010

Oncoprescribe Blog Improving Progression Free Survival with Bevacizumab in Ovarian Cancer patients

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Taxanes were first introduced in the mid 1990’s for the first line treatment of ovarian cancer. There has since been no real progress made. However recent data presented at ESMO (European Society for Medical Oncology) 2010, shed light on the benefit of adding Bevacizumab to standard chemotherapy. In the ICON 7 trial, 1,528 women with high risk, early or advanced stage ovarian cancer were randomized to receive either 6 cycles of standard chemotherapy with Carboplatin and Paclitaxel or Carboplatin and Paclitaxel given along with Bevacizumab, followed by maintenance Bevacizumab for an additional 12 cycles.

There was a significant improvement in the median progression free survival in the Bevacizumab group. Patients with poor risk features benefited the most. So, after over 15 years of drought, we are now seeing progress made, in the treatment of ovarian cancer. It is not clear at this time however, if this three drug combination will improve Overall Survival.

Oncoprescribe Blog Denosumab approved for bone metastases in solid tumors

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Denosumab (Xgeva) was approved by the FDA for the prevention of  Skeletal Related Events (SRE’s) in patients with bone metastases from solid tumors. Denosumab is a monoclonal antibody targeting a protein called RANKL (Receptor Activator for Nuclear Factor kappa B Ligand). RANKL also known as  ODF (osteoclast differentiation factor) is an important molecule necessary for maintaining bone homeostasis. Overproduction of RANKL leads to increased osteoclastic activity resulting in bone resorption. Accelerated bone resorption can not only result in osteoporosis, but has also been implicated in the development of tumor related bone metastases. Denosumab binds to RANKL negating the formation, function and survival of osteoclasts.

Two international randomized studies demonstrated the superiority of Denosumab over Zoledronic acid in patients  with bone metastases, secondary to Breast Cancer and Castrate Resistant Prostate Cancer. In a third study involving patients with other solid tumors with bone metastases, Denosumab was found to be non-inferior to Zoledronic acid.

Denosumab, a RANK ligand inhibitor is a welcome addition to IV bisphosphonates, Pamidronate (Aredia) and Zoledronic acid (Zometa).

Oncoprescribe Blog Eribulin improves survival in metastatic Breast Cancer

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Eribulin is a non taxane inhibitor of microtubule dynamics and is a synthetic analog of halichondrin B, a product derived from a a sea sponge Halichodria okadai. The EMBRACE trial is a randomized open label phase III study involving 762 heavily pretreated patients with locally recurrent or metastatic breast cancer. Patients were randomized to either Eribulin (508 patients) or to an approved treatment of their physician’s choice and this could be single agent chemotherapy, hormonal therapy, biological therapy or palliative radiation therapy (254 patients). There was a statistically significant improvement in overall survival in the Eribulin group 13.12 months compared to 10.65 months in the control group. This statistically significant benefit was also seen in the overall response rates.

We now have another agent with a distinct survival advantage for heavily pretreated metastatic breast cancer patients.

Oncoprescribe Blog Nab-Paclitaxel in Non Small Cell Lung Cancer

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A randomized phase III trial data was presented at ASCO 2010 by Dr. Socinski and colleagues, involving chemonaïve patients with stage IIIb and stage IV non small cell lung cancer patients. Five hundred and twenty five (525) patients received Nab-Paclitaxel (Abraxane) without any pre medications at 100 mg/m2 on days 1, 8 and 15 along with Carboplatin given on day 1 at an AUC of 6. The control group of 525 patients received standard Paclitaxel 200mg/m2 and Carboplatin at an AUC of 6 on day 1. The major end point was response rate. The Nab-Paclitaxel group had a response rate of 33% compared to 25% for the standard Paclitaxel group. When broken down by histology, the response rates in those with squamous cell carcinoma was 41% in the Nab-Paclitaxel group versus 24% in the standard Paclitaxel arm whereas the non squamous subtypes had a response rate of 26% versus 25% in the Nab-Paclitaxel and Paclitaxel group respectively. It is hypothesized that the superior response rates in squamous cell histology may be due to the overexpression by this sub type of Caveolin–1, which is a protein which may facilitate a higher intratumoral drug concentration.

So, here is something for squamous cell histology. Choosing therapy based on histology is here to stay.

Oncoprescribe Blog Anticancer therapy with bisphosphonates

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Parenteral therapy with bisphosphonates in patients with skeletal metastases has significantly decreased the risk of skeletal related events and need for radiation therapy. Evolving data suggests that bisphosphonates in general and one of the more commonly used bisphosphonates Zoledronic acid (Zometa) has been shown to induce apoptosis, inhibit angiogensis, inhibit tumor metastases and exhibit synergy with certain anticancer agents in early stage Breast Cancer.

In the Z-FAST and ZO-FAST trials, Zoledronic acid improved disease free survival in hormone receptor positive early stage breast cancer. This intriguing data regarding the benefits of bisphosphonates in early stage breast cancer is likely to move this class of agents into the adjuvant setting, to become a part of adjuvant therapy.

Oncoprescribe Blog Newer agents for hard-to-treat cancers. Sorafenib to the rescue

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It was once Renal Cell Carcinoma and then Malignant Melanoma, but now we are about to conquer Hepatocellular carcinoma (HCC). In the SHARP trial published in the NEJM, patients with Hepatocellular carcinoma were randomized to receive either Sorafenib, a raf-kinase inhibitor or placebo. The outcomes were quite striking. Sorafenib significantly improved overall survival with a 31% reduction in the risk of death.

It is important to realize that patients with HCC already have a damaged liver secondary to cirrhosis and the patients in this study predominantly belonged to  Child-Pugh category A .  Sorafenib is presently being studied in combination with Doxorubicin for the treatment of HCC. As we learn more about the pathobiology of a malignancy, drug development to target the molecular mechanism of the disease is becoming a reality.

Oncoprescribe Blog Is Warfarin on its way out?

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May be, but not quite. Warfarin is one of the most dangerous oral prescription drugs and is in the top 10 drugs with serious adverse events as has been reported by the  FDA’s Adverse Event Reporting System. The risk of bleeding complications with warfarin is as high as 10%-16%. ( www.archinternmed.com). For this reason FDA has mandated “black box” product warning of bleeding complication for warfarin, in October 2006. Further this drug requires frequent blood monitoring to ensure efficacy and safety. Interaction with other drugs and dietary products is a major drawback of warfarin. First approved for use in the early 1950’s,  warfarin is the most widely prescribed anticoagulant drug in the USA and has remained largely unchallenged until now.

The new players  on the stage are Dabigatran (Pradaxa) and Rivaroxaban (Xarelto). These agents are oral direct thrombin inhibitors. Unlike warfarin, laboratory monitoring is not necessary and drug interactions are uncommon with these agents. The FDA recently approved Dabigatran for stroke prevention in patients with atrial fibrillation. We will soon have these agents also available for the prevention and treatment of Deep Vein Thrombosis (DVT).  This is welcome news for patients on warfarin, who get  stuck at least once a month for laboratory monitoring and have to follow stringent dietary habits to reap the benefits of warfarin.

Oncoprescribe Blog Personalized Therapy based on HPV status in patients with Head and Neck Cancer

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Even though long term use of alcohol and tobacco has been implicated as major risk factors for the development of head and neck cancers, it appears that oral HPV (Human Papilloma Virus) 16 accounts for 60% of oropharygeal cancers in the USA. The biology of HPV positive head and neck cancers is different in that it is often seen in younger individuals who do not smoke or drink and tends to originate in the orpharynx and frequently is poorly differentiated with a basaloid nonkeratinizing histopathology. These patients do better that those who are HPV negative.

In an RTOG study, HPV associated oropharynx head and neck cancers responded best to chemoradiation and several retrospective studies have demonstrated a 60% reduction in the risk of death from HPV positive head and neck cancers compared to patients with HPV negative head and neck cancers. Therefore analyzing the tumor for HPV 16 by FISH may be of value in predicting who will benefit best from chemoradiation. In fact ECOG has a study underway evaluating the optimal treatment intervention for HPV positive head and neck cancer patients with the goal of reducing treatment related morbidity but without compromising efficacy.

Armed with this information, we should be able to soon pursue a kinder and gentler approach when treating HPV positive patients with head and neck cancers.

Oncoprescribe Blog More on Romiplostim for ITP

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In the November 11, 2010 issue of the NEJM, David Kuter and colleagues reported the results of an open label randomized trial comparing 52 weeks of Romiplostim (Nplate) to “standard of care” in patients with ITP ( Immune Thrombocytopenic Purpura). In this study, Romiplostim was associated with superior platelet response rates, lower rates of treatment failure, improved quality of life and even more importantly, no significantly increased adverse events compared to the standard of care.

In the “Research Regimens”  section at www.oncoprescribe.com, we have a detailed write up on a previous study on Romoplostim by the same author published in Lancet 2008. The Oncoprescribe Blog also has a brief write up on the REMS program.

Romiplostim was approved by the FDA on August 22, 2008 for the treatment of thrombocytopenia in patients with chronic Immune  Thrombocytopenic Purpura (ITP) who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy. Armed with the recently published data, it is likely that Romiplostim for ITP could be taking the front row seat.

Oncoprescribe Blog Personalized medicine for prostate cancer patients

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Prolaris is a molecular diagnostic tool developed by Myriad Genetics, Inc. This 46 gene panel is capable of predicting  aggressiveness of prostate cancer and can be used in conjunction with Gleason score and PSA. By measuring the  expression level of genes involved with cell cycle progression, this test is able to differentiate indolent from aggressive prostate cancers and therefore predict disease outcome.

In a retrospective analysis of 366 patients who had undergone radical prostatectomy and 337 patients with clinically localized prostate cancer, this gene panel was able to give a favorable and unfavorable score to patient subsets and thus predict clinical outcomes. This prognostic information will allow clinicians to recommend appropriate therapy at the time of diagnosis of prostate cancer.

So we have gene signature assays for breast cancer, colon cancer, lung cancer (oncoprescribe blog) and now for prostate cancer as well. In the end, patients benefit.